The INTERMED: a screening instrument to identify multiple sclerosis

PAPER

The INTERMED: a screening instrument to identify

multiple sclerosis patients in need of multidisciplinary

treatment

E L J Hoogervorst, P de Jonge, B Jelles, F J Huyse, I Heeres, H M van der Ploeg,

B M J Uitdehaag, C H Polman

.............................................................................................................................

J Neurol Neurosurg Psychiatry

2003;74:20–24

Objective: To analyse the value of the INTERMED, a screening instrument to assess case complexity,

compared with the Expanded Disability Status Scale (EDSS) and the Guy’s Neurological Disability

Scale (GNDS) to identify multiple sclerosis (MS) patients in need of multidisciplinary treatment.

Methods: One hundred MS patients underwent INTERMED, EDSS, and GNDS examinations. Patient

care needs were assessed by a multidisciplinary team and a goal oriented treatment plan was defined.

Correlations between INTERMED, individual INTERMED domains, EDSS, GNDS sum score, and total

number of proposed disciplines involved in the treatment plan were studied.

Results: Mean (SD) age was 40.6 (10.1) years. Median scores were 14.0 for the INTERMED, 4.0 for

the EDSS, and 13.5 for the GNDS sum score. Moderate correlations were found between the

INTERMED sum score and EDSS (

=0.59) and GNDS sum score (

=0.60). The number of disciplines as

proposed by the multidisciplinary team showed the highest statistically significant correlation with the

INTERMED sum score (

=0.41) compared with EDSS (

=0.32) and GNDS sum score (

=0.34). No sig-

nificant or only weak correlations were found between the psychological domain of the INTERMED and

EDSS or GNDS.

Conclusion: The findings in this study show that there is an additional value of the INTERMED com-

pared with the EDSS and GNDS in identifying MS patients in need of multidisciplinary treatment. The

INTERMED domains show the area of the patient’s vulnerability and care needs: especially the

INTERMED’s psychological and social domains may guide the clinician to deal with specific problems

that complicate healthcare delivery.

ultiple sclerosis (MS) is the most common cause of

neurological disability in young people.

Characteris-

tically, the course of the disease is highly variable and

unpredictable, although, with time, about two thirds of

patients pass into a progressive phase where a gradual

accumulation of wide ranging, and often complex, disabilities

occurs. These disabilities have a huge impact on the patient,

family and society, affecting mood, relationships, employ-

ment, and social interaction. Not surprisingly, this results in

huge cost to the society, much of which relates to indirect

effects of the disease, including loss of employment for both

patient and carer.

The recent development of disease modifying drugs has not

eliminated the need for rehabilitative strategies in the

management of MS. Rehabilitative techniques must be used

to reduce disability and handicap and should include a wide

range of interventions such as education, improving coping

strategies, physical rehabilitation, or the set up of a network of

community support. It is crucial to identify the optimal

approach for individual patients, but so far there are few sys-

tematic data to guide patient referral.

In most specialised centres the required patient care needs,

as well as the required treatment input and rehabilitation

goals for individual patients, are based on a detailed

assessment of physical, psychological, and social functioning

by a multidisciplinary team. Such a team is, however, usually

limited in the number of patients it can assess. Therefore, in

many places access to a multidisciplinary team is restricted or

only possible through long waiting lists. As a consequence, a

simple and short instrument that would screen patients with

respect to their needs and that could guide referral to the

multidisciplinary team, would be most welcomed and might

increase the (cost) effectiveness of the assessment procedure.

Neither the Expanded Disability Status Scale (EDSS)

nor

the Guy’s Neurological Disability Scale (GNDS),

two instru-

ments that measure disability in MS patients, give guidance

with respect to rehabilitative strategies required. Despite the

fact that the EDSS and GNDS are not developed to give guid-

ance to rehabilitative strategies, we used these measures in

this study for comparing with the INTERMED because the

EDSS is an often applied outcome measure in clinical trials of

MS and it seems possible that there is a connection between

more disability (EDSS), especially self reported disability

(GNDS), and the need for multidisciplinary treatment. In

contrast with the EDSS and GNDS, the INTERMED has been

deﬁned to give guidance to the kind of (multidisciplinary)

treatment a patient needs.

In this study we have investigated the INTERMED, an

instrument that has been developed in the past years as a

method to assess case complexity in order to organise coordi-

nated and integrated health care.

It is based on observations

that comprehensive understanding of patients’ needs in-

creases effectiveness of healthcare delivery in several patient

populations.

8–11

The INTERMED is an observer rated instru-

ment that classiﬁes information from a str uctured and proto-

colled medical history taking into four domains: biological,

psychological, social, and health care. Each domain is assessed

in the context of time (history, current state, and prognosis),

.............................................................

Abbreviations: MS, multiple sclerosis; EDSS, Expanded Disability Status

Scale; GNDS, Guy’s Neurological Disability Scale

See Editorial Commentary

See end of article for

authors’ affiliations

.......................

Correspondence to:

Dr E L J Hoogervorst, VU

Medical Centre,

Department of Neurology,

Post box 7057, 1007 MB

Amsterdam, Netherlands;

[email protected]

Received 23 April 2002

Accepted in revised form

15 August 2002

.......................

www.jnnp.com

which results in 20 variables (table 1). The different domain

scores of the INTERMED show the area of the patient’s

vulnerability and care needs and give a direction for an

integrated treatment plan. The speciﬁc variables force the cli-

nician who rates the INTERMED to think about speciﬁc prob-

lems that complicate healthcare delivery, such as compliance,

alcohol misuse, coping problems, need for social support

and/or help at home, and psychiatric comorbidity. Giving glo-

bal guidance with respect to therapeutic interventions

required has been one of the important goals in the develop-

ment of the INTERMED.

In the process of its development, attention has been

directed to the reliability,

validity,

and the clinical utility

13–17

of the INTERMED. Reliability has been studied in terms of

inter-rater agreement, as another important goal of the

INTERMED was to improve communication between health

care professionals. A ﬁrst inter-rater reliability study

sug-

gested that some improvements should be made, which has

led to a ﬁnal version now being used in a number of studies. A

recent study of the inter-rater reliability of this ﬁnal version in

a heterogeneous sample of patients with somatic illnesses,

with two independent raters—a psychologist and a clinician

nurse specialist—blindly rating patients based on a joint

interview, resulted in a κ of 0.85, indicating very good

agreement.

Inter nal consistency has been studied as well as reliability

coefﬁcients (Cronbach’s α), ranging from 0.75 to 0.92 in

different patient samples.

Applications in other patient populations with somatic and

psychosocial comorbidities, such as diabetes and advanced

cancer have demonstrated the INTERMED’s utility as measure

for case complexity and resulting care needs.

13 15

Furthermore,

the INTERMED can be used to detect patients with a risk of

decreased response to standard biomedical treatment, to

design multimodal treatment, and to control for confounding

variables.

The objective of this study was to analyse the additional

infor mation obtained by the INTERMED in a cohort of MS

patients compared with neurologist rating of neurological

examination abnormalities (EDSS) and patient self report

(GNDS), and to study correlations between these measures

and healthcare needs as deﬁned by a professional multidisci-

plinary team.

METHODS

Patients

One hundred consecutive newly referred patients fulﬁlling

diagnostic criteria for MS,

who consulted the neurological

outpatient clinic of the VU Medical Centre in the period March

1999 to November 2000 were included in this study. During

this time period newly referred MS patients were referred to

the multidisciplinary team without taking into account

whether it was felt at the ﬁrst visit there was a need for multi-

disciplinary assessment or not. Patients were diagnosed as

having relapsing-remitting (RR) (n=56), secondary-

progressive (SP) (n=24), or primary-progressive (PP) (n=20)

MS.

Procedure

Patient care needs were assessed according to a standard pro-

cedure and discussed in a multidisciplinary team consisting

of: neurologist, MS nurse, doctor of rehabilitation medicine,

physiotherapist, occupational therapist, psychologist, and

social worker. For each individual patient the multidiscipli-

nary team deﬁned a goal oriented treatment programme. In

“simple cases” it would consist of continued care by only the

neurologist and the MS nurse; in more complicated cases

input of at least one of the other participating disciplines

would be recommended, resulting in a really multidisciplinary

rehabilitation approach.

In parallel, patients underwent INTERMED, EDSS, and

GNDS examinations; the team did not know the results of

these examinations at the moment they deﬁned the treatment

programme.

Detailed test procedures

The INTERMED form was ﬁlled in by the MS nurse on the

basis of a structured medical history from the nurse’s point of

view. The four domain scores of the INTERMED (table 1) were

obtained by adding the scores (0–3) of the ﬁve variables for

each domain; the total INTERMED score is the sum score of

the four domain scores (range 0–60). An independent

psychologist (PdeJ) calculated the INTERMED (domain)

scores and these were actively kept away from the multidisci-

plinary team.

Disability on the EDSS was assessed by well trained medi-

cal doctors under carefully standardised conditions; the EDSS

is divided in 20 half points ranging from 0 (normal) to 10

(death attributable to MS). The GNDS score was based on a

patient interview; each subcategory of the GNDS was scored

separately, ranging from 0 (normal) to 5 (maximum help

required). For creating the GNDS score, the sum score of the

12 subcategories was used, with a range from 0 (normal) to 60

(maximum possible disability).

Data analysis

To study the relation between the scores on the various

instruments and the patient healthcare needs, the recom-

mended number of disciplines in the treatment programme as

proposed by the multidisciplinary team was used. Analysis of

difference in INTERMED, EDSS, GNDS sum score, and

number of recommended disciplines for two different disabil-

ity strata (EDSS<4.0 v EDSS>4.0) was done using one way

analysis of variance. Spearman’s rank correlation coefﬁcients

(r) were calculated to assess the relation between the

INTERMED sum score, its domain scores, EDSS, GNDS sum

score, and total number of disciplines involved. In addition,

Spear man’s rank correlations were studied between age and

Table 1 INTERMED

Domains History Current state Prognoses

Biological - Chronicity - Severity of illness - Complications and life threat

- Diagnostic uncertainty - Diagnostic uncertainty

Psychological - Restrictions in coping - Resistance to treatment - Mental health threat

- Premorbid psychiatric dysfunctioning - Severity of psychiatric symptoms

Social - Restrictions in social integration - Residential instability - Social vulnerability

- Social dysfunctioning - Restrictions in social network

Health care - Intensity of prior treatment - Organisational complexity - Care needs

- Prior treatment experience - Appropriateness

Huyse Lyons Stiefel Slaets de Jonge 1997, with permission of Elsevier.

The INTERMED and multiple sclerosis patients 21

www.jnnp.com

disease duration and number of involved disciplines. To

account for the multiple correlations tested, we considered p

values <0.01 as statistically signiﬁcant and p values <0.05 as

a trend only.

RESULTS

Patient characteristics, INTERMED sum scores, INTERMED

domain scores, EDSS, and GNDS sum scores and number of

disciplines involved are summarised in table 2 for the total

population and for different disability strata. Sixty three

patients had mild disability (EDSS<4.0) and 37 patients were

moderate to severely disabled (EDSS>4.0). Mean (SD) age

was 40.6 (10.1) years; 33% were male and 67% female, mean

(SD) disease duration 8.0 (7.8) years. Median scores were 4.0

for the EDSS, 13.5 for the GNDS sum score, and 14.0 for the

INTERMED. Signiﬁcant differences were found between the

two disability strata (mild or more disability) for GNDS sum

score (p<0.001), INTERMED sum score (p<0.001), the

INTERMED domains biological, social, and health care (for all

three domains p<0.001), and number of proposed disciplines

by the multidisciplinary team (p<0.001).

For a total of 61 patients, at least one other healthcare dis-

cipline besides neurologist and MS nurse was included in the

treatment recommendation plan by the multidisciplinary

team. Table 3 shows the median scores of the INTERMED sum

score, EDSS, and GNDS sum score per number of disciplines

proposed. As expected EDSS, GNDS sum score, and

INTERMED sum scores were higher when more disciplines

were involved.

Table 4 shows the median scores on the different

INTERMED domains, INTERMED sum score, EDSS, and

GNDS sum score per proposed discipline. Of the different dis-

ciplines, the intervention of a psychologist was most often

recommended in the treatment plan of individual patients (in

29 cases), in these cases the median scores on the psychologi-

cal domain of the INTERMED and the INTERMED sum score

were highest and, remarkably, median EDSS and GNDS sum

scores were lowest compared with cases when treatment

intervention of another discipline was recommended.

Moderate correlations were found between the INTERMED

sum score and both the EDSS (r=0.59; p<0.01) and the GNDS

sum score (r=0.60; p<0.01) as well as the number of proposed

disciplines (r=0.41; p<0.01) for the total population. The

Table 2 Patient characteristics, age, and disease duration expressed as mean (SD). EDSS, GNDS sum score,

INTERMED, INTERMED domains, and number of disciplines (besides neurologist and MS nurse) expressed as median

(interquartile range)

Total Mild* More disability†

Total 100 63 37

M 331914

F 674423

Age 40.6 (10.1) 37.0 (8.8) 46.7 (9.3)

Disease duration (y) 8.0 (7.8) 4.9 (5.7) 12.2 (8.4)

EDSS‡ 4.0 (2.0–6.0) 2.5 (1.5–3.5) 6.5 (5.3–7.0)

GNDS§ sum score 13.5 (7.3–22) 10.0 (5.0–14.0) 23.0 (19.0–26.0)

INTERMED 14.0 (10.3–18.0) 12.0 (10.0–15.0) 18.0 (13.0–23.0)

Biological 7.0 (6.0–8.0) 7.0 (6.0–8.0) 8.0 (7.0–8.0)

Psychological 2.0 (1.0–4.0) 2.0 (1.0–3.0) 3.0 (1.0–5.0)

Social 1.0 (0.0–4.0) 0.0 (0.0–1.0) 4.0 (2.5–5.0)

Health care 3.0 (2.0–4.0) 2.0 (1.0–3.0) 4.0 (2.5–5.0)

Number of disciplines 1.0 (0.0–1.0) 1.0 (0.0–1.0) 1.0 (0.0–2.0)

*Mild disability = EDSS <4.0; †More disability = EDSS >4.0; ‡EDSS = Expanded Disability Status Scale; §GNDS = Guy’s Neurological Disability Scale.

Table 3 Median scores on EDSS, GNDS sum score, and INTERMED per number of involved disciplines besides

neurologist and MS nurse (interquartile range)

Number of disciplines 0 n=39 1 n=41 2 n=13 3 n=7

EDSS* 2.5 (1.5–4.5) 4.0 (2.8–5.8) 4.0 (1.8–5.5) 6.5 (6.0–7.5)

GNDS† sum score 10.0 (4.0–18.0) 12.0 (8.0–22.0) 17.0 (10.0–21.5) 26.0 (26.0–28.0)

INTERMED 12.0 (10.0–15.0) 15.0 (11.0–18.0) 17.0 (13.0–22.0) 20.0 (15.0–23.0)

Biological 7.0 (6.0–8.0) 7.0 (6.0–8.0) 8.0 (7.0–8.0) 8.0 (8.0–8.0)

Psychological 2.0 (1.0–3.0) 3.0 (1.0–5.0) 3.0 (2.0–3.5) 3.0 (1.0–5.0)

Social 0.0 (0.0–2.0) 1.0 (0.0–4.0) 3.0 (0.5–5.5) 4.0 (2.0–7.0)

Health care 2.0 (1.0–3.0) 3.0 (2.0–4.0) 4.0 (2.5–5.0) 4.0 (4.0–5.0)

*EDSS = E xpanded Disability Status Scale; †GNDS = Guy’s Neurological Disability Scale.

Table 4 Median scores on the INTERMED domains, EDSS, GNDS sum score, and INTERMED sum score per discipline

involved (interquartile range)

Biological Psychological Social Health care INTERMED EDSS* GNDS† sum score

Psychologist (n=29) 7.0 (7.0–8.0) 4.0 (3.0–5.0) 1.0 (0.0–4.0) 4.0 (2.5–4.5) 27.0 (13.0–20.5) 4.0 (3.0–6.3) 14.0 (7.5–24.5)

Social worker (n=9) 8.0 (8.0–8.0) 3.0 (2.0–5.0) 5.0 (4.0–6.5) 4.0 (3.5–4.5) 19.0 (18.0–23.0) 6.0 (1.8–7.0) 23.0 (7.5–29.0)

Physiotherapist (n=14) 7.5 (6.0–8.0) 2.5 (1.0–3.5) 1.0 (0.0–3.0) 3.0 (2.8–5.0) 15.0 (10.0–17.8) 4.3 (3.4–6.0) 16.0 (10.0–26.0)

Occupational therapist (n=25) 8.0 (7.0–8.0) 2.0 (1.0–3.0) 3.0 (0.0–4.5) 3.0 (1.0–4.0) 16.0 (12.5–19.5) 5.0 (3.3–6.5) 17.0 (12.5–26.0)

Rehabilitation (n=9) 8.0 (7.5–8.0) 3.0 (1.0–5.5) 3.0 (0.5–4.5) 4.0 (2.5–5.0) 16.0 (12.0–23.0) 6.0 (4.5–6.3) 23.0 (19.5–27.0)

No other disciplines (n=39) 7.0 (6.0–8.0) 2.0 (1.0–3.0) 0.0 (0.0–2.0) 2.0 (1.0–3.0) 12.0 (10.0–15.0) 2.5 (1.5–4.5) 10.0 (4.0–18.0)

*EDSS = E xpanded Disability Status Scale; †GNDS = Guy’s Neurological Disability Scale.

22 Hoogervorst, de Jonge, Jelles, et al

www.jnnp.com

number of disciplines showed lower correlations with both

EDSS (r=0.32; p<0.01) and GNDS sum score (r=0.34;

p<0.01).

All four INTERMED domains showed good correlations

with the INTERMED sum score. Good correlations were also

found between the social domain and both EDSS and GNDS

sum score, and moderate cor relations were found between the

biological and healthcare domains and both EDSS and GNDS

sum score. The psychological domain however showed no sta-

tistically signiﬁcant correlation with the EDSS and only a

weak but signiﬁcant correlation with the GNDS sum score

(table 5).

No statistically signiﬁcant correlation was found between

the number of proposed disciplines and age, whereas a weak

cor relation was found with disease duration (r=0.31;

p<0.01).

DISCUSSION

In this cross sectional study we analysed the potential role of

the INTERMED as an instrument that would help to screen

individual patients to provide information to guide future

interventions, by comparing it with the traditionally used

neurologist rating of neurological examination abnormalities

(EDSS), patient self report (GNDS), and the number of differ-

ent disciplines being recommended in the treatment plan

indicated by a multidisciplinary team.

Our data conﬁrm that the INTERMED indeed gives

complementary information when compared with the EDSS

and the GNDS, especially because the INTERMED includes

domains (that is, psychological and social) not or only

partially represented in either EDSS or GNDS.

We found that the INTERMED was the best predictor for

treatment decisions in a multidisciplinary rehabilitation

focused approach. The INTERMED sum score showed the best

cor relation (r=0.41) with the total number of disciplines

involved in the treatment plan of MS patients as indicated by

the multidisciplinary team compared with both EDSS and

GNDS. However, an overlap in the INTERMED sum score and

number of disciplines involved existed, for example at

INTERMED sum score 10 as well as 17 the number of

proposed disciplines was 0, 1, or 2.

Analysing the four individual domains of the INTERMED

showed an additional value of the INTERMED, especially the

psychological domain, which is only partially or not at all rep-

resented in either the GNDS or the EDSS. This is shown by the

fact that a weak, but statistically signiﬁcant, correlation was

found between the psychological domain and the GNDS and a

trend only with the EDSS, whereas a good correlation was

found with the INTERMED sum score.

It was striking to ﬁnd the weak or even absent statistically

signiﬁcant correlations between the psychological domain

score, and the GNDS sum score or the EDSS, especially in the

light that the psychologist was the discipline most often

recommended in the treatment plan as proposed by the

multidisciplinary team. These weak or absent correlations are

most probably because of the fact that, mainly in early

diagnosed MS patients who still have low disability (low EDSS

and GNDS scores), psychological aspects, like acceptance of

diagnose and coping strategies, are important features for

which intervention by a psychologist can be indicated.

Although the EDSS and the GNDS do not incorporate the

issue of social problems, their correlation with the social

domain score of the INTERMED was statistically signiﬁcant,

even though not so high as for the INTERMED sum score. We

assume that this is attributable to the fact that this domain

reﬂects the level of functioning—that is, having a job or stable

housing situation—, which is often correlated to disability. If

a patient does not have a job (which is more probable at higher

EDSS scores), this inﬂuences the variable restrictions in social

integration (at least 2 points) and restrictions in network (at

least 1 point).

The social domain turned out to be a determinant for the

total number of disciplines involved in the treatment of MS

patients as advised by the multidisciplinary team. This is

shown by the fact that the social domain score was higher

when more disciplines were recommended. More speciﬁc, the

social domain score seemed to be a predictor for a requirement

of intervention by a social worker (table 4).

The biological domain of the INTERMED showed relatively

high median scores as well as ceiling effects with little varia-

tion and a small interquartile range between the different dis-

ability strata as well as the total number and kind of

disciplines recommended in the treatment plan as indicated

by the multidisciplinary team. This is a result of the scoring

rules of the INTERMED and the fact that MS patients suffer

from at least one chronic condition that directly inﬂuences

their scores on chronicity (at least a score of 2) and biological

prognosis (at least a score of 2), therefore a score lower than 4

on the biological domain would not have been possible.

Another problem is the fact that, for example, communication

problems or dysphagia are scored in the biological domain and

as there is ceiling effect, consequently these problems are not

shown by the biological domain score. Communication and

swallowing problems, however, were rare in our patient popu-

lation (median scores on both GNDS subcategories speech and

swallowing were 0.0 (IQR 0–1) and 1.0 (IQR 0–2) for the

Brainstem Functional System of the EDSS).

In addition, most of the patients have experienced a period

of diagnostic uncertainty, which is reﬂected in past or present

diagnostic complexity in this domain. Obviously, this domain

does not add new information as compared with the EDSS or

the GNDS.

In conclusion, our study shows that the INTERMED

(domain) scores provide complementary information when

compared with either EDSS or GNDS. Speciﬁc domains of the

INTERMED show the area of the patient’s vulnerability and

care needs, whereas the speciﬁc variables, especially the

psychological and social domain, may guide the clinician to

deal with speciﬁc problems that complicate healthcare

Table 5 Spearman rank correlations between INTERMED, EDSS, GNDS sum score

and INTERMED sum score, INTERMED domains, and number of involved disciplines

for the total population

INTERMED sum

score EDSS† GNDS‡ sum score

INTERMED sum score – 0.59** 0.60**

Biological 0.75** 0.52** 0.58**

Psychological 0.63** 0.24* 0.27**

Social 0.84** 0.61** 0.62**

Health care 0.81** 0.46** 0.47**

Number of disciplines 0.41** 0.32** 0.34**

**Correlation is significant at the 0.01 level; *correlation is significant at the 0.05 level; †EDSS = Expanded

Disability Status Scale; ‡GNDS = Guy’s Neurological Disability Scale.

The INTERMED and multiple sclerosis patients 23

www.jnnp.com

delivery. We would like to emphasise, however, that even

though the INTERMED clearly is a promising screening

instrument, it does not replace the need for multidisciplinary

assessment: even though it identiﬁes problem areas, it does

not exactly indicate what the speciﬁc problems are and how

they might be tackled.

To demonstrate the clinical usefulness of the INTERMED in

MS patients in more depth, further studies will be necessary—

that is, relating INTERMED scores to clinical decision making,

to health care utilisation, and to outcome of intervention.

ACKNOWLEDGEMENT

The authors acknowledge Professor Alan Thompson, London, UK, for

critically reviewing a previous version of this manuscript.

.....................

Authors’ affiliations

E L J Hoogervorst, B Jelles, I Heeres, B M J Uitdehaag, C H

Polman, Department of Neurology, VU Medical Centre, Amsterdam,

Netherlands

P de Jonge, F J Huyse, Department of Psychiatry, VU Medical Centre

H M van der Ploeg, Department of Medical Psychology, VU Medical

Centre

B M J Uitdehaag, Department of Clinical Epidemiology and Biostatistics,

VU Medical Centre

P de Jonge, Department of Psychiatry, University of Groningen,

Netherlands

Competing interests: none declared.

REFERENCES

1 Dean G. How many people in the world have multiple sclerosis?

Neuroepidemiology

1994;13:1–7.

2 Sadovnick AD, Ebers GC. Epidemiology of multiple sclerosis: a critical

overview.

Can J Neurol Sci

1993;20:17–29.

3 Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an

expanded disability status scale (EDSS).

Neurology

1983;33:1444–52.

4 Sharrack B, Hughes RA. The Guy’s Neurological Disability Scale

(GNDS): a new disability measure for multiple sclerosis.

Multiple

Sclerosis

1999;5:223–33.

5 Sharrack B, Hughes RA. Scale development and Guy’s Neurological

Disability Scale.

J Neurol

1999;246:226.

6 Huyse FJ, Lyons JS, Stiefel FC,

et al

. “INTERMED”: a method to assess

health service needs. I. Development and reliability.

Gen Hosp Psychiatry

1999;21:39–48.

7 Huyse FJ, Lyons JS, Stiefel FC. Operationalizing the biopsychosocial

model: the INTERMED.

Psychosomatics

2001;42:1–9.

8 Aubert RE, Herman WH, Waters J,

et al

. Nurse case management to

improve glycemic control in diabetic patients in a health maintenance

organization. A randomized, controlled trial.

Ann Intern Med

1998;129:605–12.

9 Bernabei R, Landi F, Gambassi G,

et al

. Randomised trial of impact of

model of integrated care and case management for older people living in

the community.

BMJ

1998;316:1348–51.

10 Harris LE, Luft FC, Rudy DW,

et al

. Effects of multidisciplinary case

management in patients with chronic renal insufficiency.

Am J Med

1998;105:464–71.

11 Stewart S, Marley JE, Horowitz JD. Effects of a multidisciplinary,

home-based intervention on unplanned readmissions and survival among

patients with chronic congestive heart failure: a randomised controlled

study.

Lancet

1999;354:1077–83.

12 Stiefel FC, de Jonge P, Huyse FJ,

et al

. “INTERMED”: a method to assess

health service needs. II. Results on its validity and clinical use.

Gen Hosp

Psychiatry

1999;21:49–56.

13 de Jonge P, Huyse FJ, Ruinemans GM,

et al

. Timing of psychiatric

consultations: the impact of social vulnerability and level of psychiatric

dysfunction.

Psychosomatics

2000;41:505–11.

14 de Jonge P, Huyse FJ, Stiefel FC,

et al

. Intermed-a clinical instrument for

biopsychosocial assessment.

Psychosomatics

2001;42:106–9.

15 Fischer CJ, Stiefel FC, de Jonge P,

et al

. Case complexity and clinical

outcome in diabetes mellitus. A prospective study using the INTERMED.

Diabetes Metab

2000;26:295–302.

16 Mazzocato C, Stiefel F, de Jonge P,

et al

. Comprehensive assessment of

patients in palliative care: a descriptive study utilizing the INTERMED.

Journal of Pain and Symptom Management

2000;19:83–90.

17 Stiefel FC, de Jonge P, Huyse FJ,

et al

. INTERMED—an assessment and

classification system for case complexity. Results in patients with low back

pain.

Spine

1999;24:378–84.

18 de Jonge P, Latour C, Huyse FJ. Interrater reliability of the INTERMED in

a heterogeneous somatic population.

J Psychosom Res

2002;52:25–7.

19 Huyse FJ, de Jonge P, Lyons JS,

et al

. INTERMED: a tool for controlling

for confounding variables and designing multimodal treatment.

Psychosom Res

1999;46:401–2.

20 Poser CM, Paty DW, Scheinberg L,

et al

. New diagnostic criteria for

multiple sclerosis: guidelines for research protocols.

Ann Neurol

1983;13:227–31.

21 Lublin FD, Reingold SC. Defining the clinical course of multiple sclerosis:

results of an international survey. National Multiple Sclerosis Society

(USA) Advisory Committee on Clinical Trials of New Agents in Multiple

Sclerosis.

Neurology

1996;46:907–11.

24 Hoogervorst, de Jonge, Jelles, et al