International Journal for Quality in Health Care, 2018, 30(4), 265–270

doi: 10.1093/intqhc/mzx203
Advance Access Publication Date: 27 January 2018
Article

Article

Assessing functional status after intensive care

unit stay: the Barthel Index and the Katz Index
LEDA TOMIKO YAMADA DA SILVEIRA1,2, JANETE MARIA DA SILVA3,
JÚLIA MARIA PAVAN SOLER4, CAROLINA YEA LING SUN4,
CLARICE TANAKA1,5, and CAROLINA FU1
1
Department of Physiotherapy, Communication Science & Disorders, Occupational Therapy – Medical School of
the University of São Paulo, Rua Cipotânea 51, Cidade Universitária, 05360-000 São Paulo-SP, Brazil, 2University
Hospital, University of São Paulo, Av. Prof. Lineu Prestes, 2565, Cidade Universitária, 05508-000 São Paulo-SP,
Brazil, 3JMS Ciência e Saúde. Rua Manuel Augusto de Alvarenga 136, Vila Marari, São Paulo, SP 04402-050,
Brazil, 4Institute of Mathematics and Statistics, University of São Paulo, Rua do Matão, 1010, Cidade Universitária,
05508-090 São Paulo-SP, Brazil, and 5Clinical Hospital, Faculty of Medicine, University of São Paulo, Av. Dr. Enéas
de Carvalho Aguiar, 255, Cerqueira César, 05403-000 São Paulo-SP, Brazil

Address reprint requests to: Carolina Fu, Department of Physiotherapy, Communication Science & Disorders,
Occupational Therapy – Medical School of University of São Paulo, Rua Cipotânea 51, Cidade Universitária, 05360-000
São Paulo-SP, Brazil. Tel: +55-11-30918421; Fax: +55-11-30917459; E-mail: carolfu@usp.br
Editorial Decision 6 December 2017; Accepted 9 January 2018

Abstract
Objective: To assess the functional status of post-ICU patients using the Barthel Index (BI) and the
Katz Index (KI) and to assess which is more suitable for this population.
Design: Retrospective longitudinal study.
Setting: Public tertiary hospital in São Paulo (Brazil).
Participants: Patients aged ≥18 years old, admitted to ICU, who were treated with mechanical ven-
tilation (MV) ≥ 24 h and were discharged to ward.
Exclusion criteria: Inability to answer the BI and the KI; limiting neurological or orthopaedic condi-
tions; ICU stay ≥90 days. Patients transferred to or from other hospitals or who died in the wards
were not analysed.
Intervention: BI and KI were scored pre-ICU and post-ICU and the variation was calculated.
Main Outcome Measures: BI and KI scores were compared using analysis based on item response
theory (IRT), using degree of difficulty and discriminating items as parameters.
Results: Median age was 52 years old, median APACHE II score was 15. Median ICU stay was 11
days and median MV duration was 4 days. BI variation was 44% and KI variation was 55%. In IRT
analysis, BI considered a larger number of items with different levels of difficulty.
Conclusion: Both the BI and the KI revealed significant deterioration of functional status after ICU
discharge. The IRT analysis suggested that the Barthel Index might be a better scale than the Katz
Index for the assessment of functional status of patients discharged from ICU, since it presented
better discrimination of the ability to carry out the tasks.

Key words: intensive care, activities of daily living, recovery of function, outcome assessment

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
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 266
Introduction
Interest in the assessment and treatment of weakness acquired in
intensive care units (ICU) has grown in the past years. Functional
status has been associated with ICU-acquired weakness and post-
hospital mortality and hospital readmission [1]. It may contribute to
post-intensive care unit syndrome, which is a result of a combin-
ation of factors, such as the illness itself, bed rest, drugs and other
therapeutic-related agents in ICU, and it has a close relationship
with functional decline [2, 3]. Survival rates after hospital discharge
have increased, but functional decline and delayed recovery have
been reported around the world [2–5].
Several instruments have been proposed for the assessment of
physical function and mobility during and after ICU stay, but the
most valid and sensitive tool to be used with ICU patients is
unknown [4]. The Barthel Index (BI) and the Katz Index (KI) assess
the ability to perform activities of daily living (ADL). They are fre-
quently used for clinical decision-making [6] and in scientific papers
[7]. They have previously been compared in elderly patients [6], but
not in post-ICU patients. The BI has been compared with the
Functional Independence Measure (FIM®) in traumatic brain injury
patients during rehabilitation [8].
The objective of the present study was to assess the functional
status of patients after ICU discharge in a tertiary hospital in Brazil,
using the BI and the KI and to assess which instrument is more suit-
able for this population.
Methods
Retrospective longitudinal study performed in all the ICU, surgical
and non-surgical, of a public tertiary hospital in São Paulo (Brazil).
It was part of a larger project (research protocol number 1159/07)
that aimed to study many aspects of critically ill patients. It was
approved by the Ethics Committee for Research Projects Analysis
(CAPPesq) of the Clinical Hospital, Faculty of Medicine, University
of São Paulo.
Inclusion criteria: patients aged ≥18 years old admitted to an ICU
bed in the Clinical Hospital, who were treated with invasive mechan-
ical ventilation (IMV) for at least 24 h, and had been discharged to the
ward. Exclusion criteria: any condition that made them unable to
answer the BI and KI questionnaires, such as aphasia or cognitive
impairments; any condition that might affect their physical function
other than ICU-acquired weakness, such as delirium or other cognitive
impairment; neurological disorders including acute, chronic and degen-
erative central nervous system diseases; limb amputation; medical pre-
scription for bed rest and any clinical conditions that were
impediments to performing ADL, such as lower limb external fixation
and peritoneostomy. Patients with ICU stay longer than 90 days and
those transferred to or from other hospitals were not analysed.
A daily visit to the ICU was performed in order to identify the
patients to be selected for the study. After discharge to the ward, a
researcher explained the study to the patients and responsible relatives
and checked for any exclusion criteria not mentioned before; then the
patients signed a consent form. Data collection included demographical
and clinical data and measurement of functional independence.
Demographical and clinical data
Some information was collected from patients’ records: age; gender;
body mass index (BMI); cause of hospital admission; cause of ICU
admission; Acute Physiology and Chronic Health Evaluation
(APACHE II) classification at the day of ICU admission; the
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Silveira et al.
Charlson index adjusted by age; cause of intubation; use of seda-
tives, neuromuscular blocking agents, vasoactive drugs, corticoster-
oids and antibiotics during the ICU stay; complications during the
ICU stay; and length of stay (LOS) in the ICU, ward and hospital.
Measurement of functional independence
Functional independence was assessed by the BI and the KI, applied
within 48 h after ICU discharge. Patients were interviewed about the
month before hospitalization (pre-ICU) and current condition (post-
ICU). Interviews were chosen because they are easier and faster than
other methods. Previous studies have shown good reliability for dif-
ferent types of administration, including self-report assessment [9].
Self-reporting should be used with care with patients with cognitive
impairment or confusion, but those patients were excluded from the
current study. All patients were interviewed by the same researcher,
in order to avoid bias caused by the way questions are asked [9].
The Barthel Index
The BI has previously been validated. It was initially developed for
use in the assessment of patients with neuromuscular and musculo-
skeletal disorders, but its use spread to the assessment of functional
changes in the rehabilitation of people who have suffered strokes
and in other populations as well. Some authors consider this the
best choice among the most common ADL scales [6].
The BI is composed of 10 ADL [10], which are scored according
to the level of assistance required by patients to perform the activ-
ities; the lower the value, the more dependent the patient. Bathing
and personal hygiene are scored 0 or 5; feeding, dressing, bowel
control, bladder control, using the toilet, and stair climbing are
scored 0, 5 or 10; chair/bed transfer and ambulation are scored 0, 5,
10 or 15. The item scores are totalled to provide the total BI score,
which may vary from 0 (total dependence in performing ADL) to
100 (fully independent in performing ADL).
The Katz Index
The KI was developed as a standardized quantitative measure for
use in the evaluation, treatment, prognosis and functional change
assessment in older people and people with chronic illness in institu-
tionalized settings [6, 11]. Along with the BI, it has been widely used
for ADL evaluation of patients regardless of their medical condition.
Some authors have described it as the most appropriate scale to
assess patients’ ability to perform ADL independently [6, 12].
The KI evaluates ability to perform six ADL [13]. Using a Likert
scale [13], the scores on the items range from 0 to 3: 0 reflects total
independence; 1 indicates the need for non-human assistance; 2 indi-
cates the need for human help; and 3 indicates total dependence. Item
scores are totalled, for a total score ranging from 0 to 18. Higher
scores indicate higher levels of dependence in performing ADL.
Statistical analysis
Clinical and demographic data were analysed by descriptive statistics
and presented as median (interquartile range) or number of observa-
tion (%). The BI and KI scores were calculated based on the sum of
the scores in each analysed activity. The relative variation between pre-
ICU and post-ICU scores was also calculated as follows:
Relative variation for Barthel index
(Pre ICU score − Post ICU score)
=
Pre ICU score
 Barthel/Katz index after ICU • Patient Outcomes 267

Relative variation for Katx index Table 1 Clinical and demographic data
Post ICU score − Pre ICU score
= N = 249
18 − Pre ICU score
Age, years 52 (36–61)
Since some of the tasks on the BI and KI had more than two possible
BMI, kg/cm2 23.9 (23.8-23.7)
answers, the responses for each task of the BI and KI were categorized.
Gender, male, n (%) 133 (53)
Thus, patients were categorized into ‘able to do,’ if they were totally APACHE II score on ICU admission day 15 (11–21)
independent in perform the task, and ‘not able to do,’ if they presented Charlson index adjusted for age 3 (1–5)
any level of dependence or were unable to perform the task at all. Need for renal replacement therapy, n (%) 162 (65)
Additional analysis of the BI and KI pre-ICU and post-ICU was Type of hospital admission, n (%)
carried out, using item response theory (IRT) [14, 15] to assess Non-surgical 94 (38)
whether one of the indexes was preferable for post-ICU patients. Emergency surgery 71 (28)
Analysis based on IRT is a statistical technique that allows identify- Elective surgery 42 (17)
ing which items present a higher degree of difficulty, and which Clinical emergency 42 (17)
Cause of hospital admission
items are able to discriminate the investigated population. The IRT
Respiratory 40 (16)
model included two parameters – difficulty and discrimination –
Gastrointestinal 49 (20)
considering the dichotomous answers ‘able to do’ and ‘not able to Pre-surgery 42 (17)
do,’ as mentioned above. The latent variable was functional status. Trauma 23 (9)
The characteristics of each scale were verified using visual Cardiovascular 20 (8)
graphic analysis in IRT. The flatter the curve, the more discrimin- Infection 18 (7)
atory the item. The projection of the central point of the curve (loca- Neurological 14 (6)
tion parameter, that represents the latent score value needed to get a Clinical investigation 10 (4)
50% probability of being able to do the item) reflects the difficulty Others* 33 (13)
of the item. Item characteristic curves show how the probability of Cause of ICU admission, n (%)
Post-operative** 106 (43)
responding in each item changes with the values of the latent vari-
Respiratory insufficiency 64 (26)
able (ability), as well as with the difficulty parameters of the items.
Shock 40 (16)
For curves with positive slope (positive discrimination parameter), Coma 17 (7)
when the projection of the central point of the curve is to the right Renal insufficiency 11 (4)
of the graph, the difficulty of the task is higher. Statistical analysis Monitoring*** 5 (2)
was performed with the statistical software R, version 3.1.3 [16]. Cardiorespiratory arrest 3 (1)
Liver insufficiency 3 (1)

Results
A total of 858 patients were assessed for eligibility. Excluded
patients were 183 patients with cognitive impairment, 102 patients
with neurologic disease after hospital admission, 71 patients with
aphasia or communication impairment, 63 patients were trans-
ferred, died or were discharged <48 h after ICU discharge, 40
patients could not be assessed within 48 h after ICU discharge, 53
patients presented lower limb amputation or bed rest prescription,
44 patients presented previous neurologic or neuromuscular disease,
8 patients presented ICU stay >90 days, 24 patients refused to par-
ticipate, 9 patients were transferred to another hospital, 7 patients
died and 5 patients were discharged to long-term institutes.
Therefore, 249 patients were included in the study.
Tables 1 and 2 present the population characteristics. The
median age was 52 years old, so this was a non-elderly population,
and median APACHE II score within the first 24 h of ICU admission
was 15 points. Comorbidity, evaluated by the Charlson index
adjusted by age, presented a median of 3 points. The main cause of
ICU admission was post-surgery. The median ICU length of stay
was 11 days and the median MV duration was 4 days.
Table 3 presents total scores on the BI and KI. Patients suffered
deterioration of functional status after ICU stay. Fig. 1 provides
more detail about this observation. Before ICU admission, the pro-
portion of patients who were unable to do any of the tasks on the BI
and KI was no more than 3.2%. After ICU discharge, the smallest
percentage of patients who were unable to perform a task was
33.6%. Depending on the task, the percentage of patients who were
incapable of doing it was even greater. For example, 88.3% of
patients were not able to climb stairs.
BMI: body mass index; APACHE II: Acute Physiology and Chronic Health
Evaluation; ICU: intensive care unit. Data are expressed as n (%), where indi-
cated, or median (1st−3rd interquartile). *Others: refers to other grouped
causes of hospital admission and includes: renal, metabolic, haematological,
exogenous intoxication, bleeding, skin disease, tetanus. **Surgery for patients
admitted to the ICU in post-operative routine were the following: abdominal
or gastrointestinal surgery (39 patients, 37%); vascular surgery (24 patients,
23%); liver transplantation (21 patients, 20%), head and neck surgery
(11 patients, 10%); urogynecology surgery (4 patients, 4%); neurological sur-
gery (3 patients, 3%); soft tissue surgery (2 patients, 2%); thoracic surgery
(1 patient, 1%) and kidney transplantation surgery (1 patient, 1%).
***Monitoring refers to patients admitted to the ICU with clinical deterior-
ation, but without known diagnosis.
Before ICU admission, all items of both questionnaires presented
the same level of difficulty for most of the tasks, since the curves pre-
sent the same position – except for the item ‘feeding.’ This item is
located in a position to the left of the other curves, indicating that
the probability of being able to do this task is lower for those
patients who present lower scores according to the IRT scale.
After ICU discharge, the curves became more flattened than at
ICU admission. This indicates that the patients are now less homo-
geneous regarding the ability to perform the tasks. Also, the projec-
tion of the central point of the curves changes, showing that the
items take on different levels of difficulty. This was observed in both
questionnaires, but mostly for the BI. This suggests that after ICU
discharge, the BI considers a larger number of items with different
levels of difficulty than before ICU admission. Thus, it may be a bet-
ter tool for the assessment of the type of population involved in this
study. This is illustrated in Fig. 2.

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 268 Silveira et al.

Table 2 Use of specific medications, duration of mechanical Discussion

ventilation and length of stay
The present data from a tertiary public hospital in a developing coun-
N = 249 try showed substantial impairment in functional status for patients
immediately after ICU discharge. Since patients who presented other
Use of medications, n (%)
causes for functional decline were excluded, such as a neurological dis-
Antibiotics 245 (98)
orders, cognitive impairment or prescriptions for bed rest, the decline
Sedatives 228 (92)
Vasoactive drugs 199 (80) in functional status may reflect disability caused by ICU stay.
Corticosteroids 124 (50) One of the inclusion criteria was the use of IMV; therefore, most
Neuromuscular blocking agents 14 (6) patients were given sedatives, although the median duration of sed-
Duration of medication use, days ation was low: 3 (2–6) days, as well as IMV duration: 4 (3–9) days.
Antibiotics 11 (7–18) Only 6% of the patients were given neuromuscular blocking agents;
Sedatives 3 (2–6) however, nearly 50% of the patients were given corticosteroids. The
Vasoactive drugs 4 (2–6) role of these drugs in ICU-acquired weakness is still unclear [2].
Corticosteroids 7 (4–12) A Brazilian study [17] assessed the BI three months after ICU
Neuromuscular blocking agents 1 (1–2)
discharge, and also found a significant decline for 49.5% of all eval-
MV duration, days 4 (3–9)
uated patients: The median BI score three months before ICU admis-
Length of stay, days
In hospital before ICU admission 1 (0–7) sion was 90.7 points (SD 16.6); three months after ICU discharge, it
ICU stay 11 (6–19) was 79.1 (SD 29.5). Age and IMV were independently associated
Ward after ICU discharge 10 (5–17) with poorer functional status.
Total hospital stay 34 (20–53) Although age seems to be related to ICU-acquired weakness
[2], it is noteworthy that the population in the present study was
ICU: intensive care unit; MV: mechanical ventilation. Data are expressed not elderly: the median age was 52 (36–61) years old. Still, a sig-
as n (%), where indicated, or median (1st−3rd interquartile).
nificant decline in functional status was observed: the BI presented
a relative variation of 0.44 (0.11–0.67); for the KI, the observed
Table 3 Functional status of the evaluated patients on Barthel relative variation was 0.55 (0.30–0.80). The present study was
Index and Katz Index conducted in a tertiary care hospital that is a reference hospital
in the region and receives severe trauma patients, for example.
N = 249
Moreover, only patients who had been mechanically ventilated for
Barthel Index at least 24 h were included, not the total ICU population. These
Pre-ICU 100 (100–100) facts may help explain why the median age of the study population
Post-ICU 55 (30–80) was different from other ICU studies.
Relative variation 0.44 (0.11–0.67) The BI and KI presented distinct behaviour when analysed by
Katz Index IRT. The IRT analysis considers the difficulty of each task to pre-
Pre-ICU 0 (0-0)
dict the patient’s ability to perform it. The results suggest that in
Post-ICU 8 (2–12)
the pre-ICU condition, the BI and KI were similar for assessment of
Relative variation 0.55 (0.30–0.80)
patients, as shown in Fig. 2. Before ICU admission, a very small
ICU: Intensive Care Unit. Data are expressed as median (1st−3rd inter- proportion of the patients presented loss of functional status, and
quartile). Relative variation for Barthel and Katz indexes is calculated as the sample was homogeneous. After ICU discharge, the BI seemed
follows: to be better than the KI in discriminating patients for the assess-
ment of functional status. In contrast to this finding, the KI has
Relative variation for Barthel index =
(Pre ICU score − Post ICU score )
.
been previously proposed for the evaluation of severely ill patients
Pre ICU score and in long-term hospital settings [6].
Although interest in functional status assessment for ICU matters
has grown in the recent years [4] there have been no previous studies
Post ICU score − Pre ICU score
Relative variation for Katx index = . comparing the BI and KI in this kind of population, or immediately
18 − Pre ICU score
after ICU discharge. A study comparing these two tools [6] for eld-
erly patients based on a comparative review found that the BI mea-
sures patients’ functional ability and provides information about
The scores on the ability to do the tasks in the BI and KI were their status or outcomes, and is useful for therapeutic planning.
calculated by the IRT analysis in the pre-ICU and post-ICU condi- The BI has been considered too simple and unresponsive since
tions. This included evaluation of the correlation between the ori- the development of other functional scales. However, a study with
ginal scores for the BI and KI and the scores of the IRT analysis traumatic brain injury patients suggested that the BI was not inferior
regarding the ability to do the tasks. Original scores were obtained to the Functional Independence Measure (FIM®) [8] and it is quicker
by the sum of item scores for each questionnaire. The correlation for to apply [9]. Another study suggested that the BI may be obtained
the pre-ICU condition was 0.59 and −0.73 for the BI and KI, by self-report, direct observation and consulting professionals who
respectively. For post-ICU scores, the correlation was higher: 0.95 have provided care to patients [10]. Additionally, both the BI and
and −0.94 for the BI and KI, respectively. This analysis shows that KI are still extensively used in current studies, including those
there is a fair correspondence between the original scores and the involving hospitalized, elderly and non-elderly patients [18–22].
scores calculated by the IRT analysis, especially in the post-ICU con- It has been suggested that the BI masks responsiveness at high
dition, in which patients presented poor functional status. levels of functioning [8]. In fact, before ICU admission, more than

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 Barthel/Katz index after ICU • Patient Outcomes 269

Figure 1 Proportion of patients ‘able to do’ or ‘not able to do’ each activity of daily living of Barthel Index and Katz Index, considering dichotomous answers.
ICU: Intensive Care Unit.

Figure 2 Characteristic curve of each item for Barthel Index and Katz Index before (above) and after (below) ICU admission. The curve on the left side of the
graphics for before ICU admission represents the task ‘feeding.’ This figure indicates that before ICU admission, if the patient presented a lower Barthel Index
score, they presented lower probability of being able to perform the task ‘feeding.’ All the other curves presented the same level of discrimination and difficulty.
After ICU discharge, the curves become more flattened and the projection of the central point of the curves change, mostly for the Barthel Index. It is possible to
observe that the curves are more scattered for the Barthel Index than for the Katz Index.

90% of the study population for the present research presented and the KI were able to detect this fact. These tools have also
maximum independence scores. However, post-ICU patients pre- been shown to be associated with long-term prognosis in some
sented substantial impairment in functional status. Both the BI patients [17, 23, 24].

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 270
In contrast with most studies, in which assessment of functional
status occurred some time after ICU discharge [1, 5, 6], it was evalu-
ated immediately after ICU discharge in the present study. This may
be useful for the identification of patients whose functional status is
most impaired, who thus might need a higher level of assistance
after ICU discharge.
The transference of information regarding patients’ status at the
time of ICU discharge ensures that critical information is provided to
the care teams that are going to receive the patients [25]. One study
showed that 80% of nurses and doctors included information such as
patients’ condition and action plans during handover [26], and func-
tional status information may be helpful for both. Functional status
scales provide quantitative information that can be used for evaluation
of patients’ evolution during hospital stay. Finally, functional status
assessment can help in the optimization of human resource allocation
and, consequently, improve patient care and safety. It can also help in
rehabilitation planning in the hospital after ICU discharge. Improving
rehabilitation may reduce long-term restrictions in ADL [5].
Limitations of the present study: the IRT analysis did not take
into account different levels of assistance; even so, it was able to
show different behaviour for the BI and KI and point out which
scale would be more suitable for post-ICU patients. The study only
evaluated patients who had been submitted to IMV, which is related
to bed rest and, thus, to functional decline. Patients who presented
conditions such as delirium, aphasia, and previous or current neuro-
logical disorders were excluded because the focus of the study was
evaluating the impact of the ICU stay itself on the functional status
of the patients. Therefore, the results should be limited to the studied
population. Finally, assessment of the BI and KI previous to hospital
admission was made retrospectively. Although the BI and KI con-
cern very simple tasks, this could cause information bias.
In conclusion, in a tertiary public hospital in a developing coun-
try, patients presented a significant decline in functional status after
ICU discharge. Both the BI and KI were able to detect functional sta-
tus impairment, and the item response theory analysis suggested that
the BI might be a better scale than the KI for the assessment of func-
tional status in this situation.
Acknowledgements
We thank José Marcelo e Souza Mafra, Michele de Cássia Santos Ramos, Cauê
Padovani and Bruna Peruzzo Rotta, who all helped with data collection.
Funding
There was no funding for this study.
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