Clinical grading and the effects of scaling

In clinical practice, there has been a need to grade the magnitude or the severity of the functions and qualities that are assessed in the examination. It is popular to use a four-step grading scale to categorize the severity of clinical findings. The authors discuss clinical grading scales and their influence on the clinician's ability to detect change. These principles have been applied to grades or measures derived from either objective measuring instruments, subjective tests, or techniques in which the clinician makes subjective judgments. A hypothetical data set was used to show the problems associated with using grading scales that are too coarse. The authors presented a mathematic model that helps to estimate the benefits of using use of a finer scale. Data were presented from two separate studies, one on visual acuity measurement and the other on grading nuclear opacity, to show the advantages of using finer scales to enhance the sensitivity of clinical measurement. High levels of concordance between independent observations indicated that the grading scale was too coarse and that these scales needlessly reduced the clinician's ability to detect change in the parameter being assessed. For moderate sensitivity, the size of the scale increments should not exceed one standard deviation of the discrepancy so that the concordance of paired comparisons would not exceed 37%. For fine clinical sensitivity, the size of the scale increments should not exceed one third of the standard deviation of the discrepancy, in which case the concordance of paired comparisons would not exceed 13%. The theory and evidence presented here could prompt re-evaluations of common methods of clinical grading.