Revisiting the Barthel Index ― A Common Language for Activities of Daily Living With Timeless Value in the Digital Era ―
Article ID: CJ-25-0443
Details
Article ID: CJ-25-0443
Background: In aging societies, shared tools are needed to assess and communicate activities of daily living (ADL). The Barthel Index (BI) is widely used in administrative data but remains underutilized in discharge planning.
Methods and Results: We analyzed 605 older cardiovascular patients discharged from a regional hospital, classifying functional levels by BI ambulation, total score, and 6-minute walk distance. Higher levels corresponded with greater ADL independence across BI items.
Conclusions: The BI reflects structured functional tiers and serves as a common language in care coordination.
Japan’s aging population has expanded the role of hospitals beyond treating disease to supporting daily life through recovery and care coordination.1 Therefore, a shared language for describing activities of daily living (ADL) is essential across professions. The Barthel Index (BI),2 a long-established, easy-to-use tool for assessing ADL, has been formally adopted in national databases such as the Diagnosis Procedure Combination (DPC),3 and the Long-Term care Information system For Evidence (LIFE),4 but despite routine administrative use, its clinical value in discharge planning is under recognized.
This report illustrates how BI scores can reflect structured patterns of ADL performance and functional levels in older cardiovascular inpatients.
We analyzed 764 patients aged ≥65 hospitalized for cardiovascular disease at Niigata Minami Hospital (2019–2021). Among the 667 discharged alive, 605 with complete BI scores at discharge were included in the study. Their mean age was 84.3±9.8 years, 43.3% were male, and hospital stay averaged 44.7±27.2 days. BI is routinely assessed at discharge; the 6-minute walk distance (6MWD) is performed in rehabilitation patients when clinically indicated. Following DPC guidelines, BI evaluates ADL – not potential ability.
We retrospectively constructed 3 functional levels based on discharge BI and 6MWD patterns to explore a practical framework for post-discharge planning. We examined how these levels corresponded with BI item independence to assess their clinical relevance as structured ADL representations.
Higher discharge functional levels were associated with greater independence across other BI domains.
Level 1, defined as walking out of the hospital (BI ambulation ≥10), often showed independence in feeding and toileting, suggesting minimal need for home-based care (Figure). Level 2, defined by a total BI score ≥85, showed near-complete independence, indicating stable home life with little support and potential for instrumental ADL.5 Level 3 included patients with full scores on most BI items, where further gradation is limited by ceiling effects. In such cases, improvement in peak oxygen uptake may become the next clinical goal, and the 6MWD was used as a supplementary measure for stratification.
Functional levels and Barthel Index (BI) independence patterns. (Left) Patients were grouped into 3 discharge-planning levels, representing increasing ADL capacity, shown as a functional hierarchy with METs and V˙O2. (Right) Proportion of patients fully independent in each BI item. Blue: full independence; red: partial dependence. Numbers indicate those meeting each criterion evaluated. ADL, activities of daily living.
The thresholds for the 3 levels are intended as a conceptual framework derived from functional patterns observed in this cohort. They are not proposed as clinical standards or rigid classifications, and should be interpreted flexibly according to clinical context and population characteristics. Our findings support viewing the BI not only as a score but also a structured indicator of functional tiers; that is, a common language for discharge and interprofessional coordination. Even in the digital era, the BI remains clear, concise, and grounded. Although overlaps across levels are inevitable, rehabilitation goals should reflect clinical judgment, not single metrics.
Although prognostic outcomes were not assessed, our prior research showed that discharge ADL levels strongly correlate with long-term survival in older heart failure patients,1 underscoring the value of BI-based stratification for individualized care planning.
T. Inomata is an Editorial Board member of Circulation Journal.
This study used existing clinical data approved by the ethics committees of Niigata University (2022-0118) and Niigata Minami Hospital (1909), in accordance with the Declaration of Helsinki. Informed consent was obtained through opt-out. The study was funded by the Ministry of Health, Labour and Welfare of Japan (22FA1021) and the Niigata Health Foundation. The authors declare no conflicts of interest. Data are unavailable due to ethics restrictions and lack of secondary use approval.
