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Comparing the Different Sets of Item-Level Diagnostic Criteria of the Coma Recovery Scale-Revised (CRS-R): A
Serena Caselli1, Matilde Leonardi2, Francesca Giulia Magnani2
1Unità Operativa Complessa di Medicina Riabilitativa, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy.
Objectives:
(1) To replicate the assessment of the internal construct validity of the Coma Recovery Scale-Revised (CRS-R) within the Rasch Measurement Theory framework using a larger multicenter sample size and (2) to compare the different sets of item-level diagnostic criteria against the measurement ruler constructed from Rasch analysis to understand how those criteria relate to the overall level of persons' consciousness.
Design:
Multicenter retrospective study.
Setting:
Seven centers.
Participants:
A total of 380 inpatients with a disorder of consciousness with one or more observations, for a total sample of 1460 observations.
Interventions:
Not applicable.
Main Outcome Measure:
CRS-R.
Results:
We created 2 subsamples: a validation subsample of 1 randomized assessment per subject (N=380) and a confirmation subsample using the further available assessments per subject (N=347). The Rasch analyses, conducted on the validation subsample and replicated on the confirmation one, demonstrated adequate satisfaction of all the model's requirements, including monotonicity, unidimensionality, local independence, invariance (χ2df=40.224; P=.020), and absence of significant differential item functioning across all person factors explored, including etiology. The reliability (Person Separation Index>0.870) was sufficient for individual person measurement, with the distinction of five Distinct Levels of Performance Ability. The CRS-R rulers based on the Rasch calibration allowed the visual comparison of the various sets of disorder of consciousness diagnostic criteria available, suggesting the possibility of a further refinement of these criteria.
Conclusions:
This study improved the results of a previous Rasch analysis published in 2013. It delivered a new stable Rasch calibration of the CRS-R within the largest multicenter sample size available to date and without any differential item functioning by patient's etiology. The adopted measurement-based approach provided further insights into the diagnostic meaning of several score categories of the CRS-R, confirming previous findings and suggesting that "automatic motor response" (item: motor function) and "object recognition" (item: visual function) are likely to represent behavioral manifestations of MCS+ and eMCS, respectively.
