MCID: Minimal Clinically Important Difference
If memories of your statistics course bring forth hazy images of decimal points and acronyms, you may be ready for a little refresher course on Minimal Clinically Important Difference. As physical, occupational, speech and mental health therapists, part of our responsibility to use evidence-based care includes reading research studies and using measurable data with sound psychometric properties.
Summary
- MCID for therapists focuses on clinical significance, not just statistics. The minimal clinically important difference (MCID) helps therapists determine whether a change in a client’s outcome score reflects a meaningful improvement from the client’s perspective.
- MCID supports better goal setting and progress tracking. Using MCID values allows clinicians to set treatment goals that are tied to real-world functional improvement rather than small, statistically significant changes.
- MCID differs from minimal detectable change (MDC). While MDC reflects the smallest change that exceeds measurement error, MCID reflects the smallest change that actually matters to the client.
- Client values remain central. Even when MCID thresholds are met, therapists should integrate client feedback and clinical judgment to interpret progress and guide care. Clinicians can keep track of their treatment goals through an EHR like TheraPlatform.
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One evidence-based tool commonly seen in healthcare specialties is standardized outcome measures. A standardized outcome measure is a set of subjective questions or objective exam items administered in a specific manner to standardize the interpretation of the results.
We frequently use these measures to quantify our clients’ current presentation, track changes over time and set goals for improvement. They are also an important tool for justifying a client’s need for ongoing care and to inform our treatment decisions.
Whether you are a rehabilitation or mental health professional, the number of standardized outcome measures continues to grow. Understanding how to choose, administer and interpret the correct measure is a skill set in and of itself. One important step in selecting an outcome measure is evaluating the psychometric data. Psychometric properties include concepts such as validity, reliability, bias, normative data and more.
According to a 2023 study on psychometric principle development published in Frontiers in Psychology, “[u]sing measurement instruments with poor reliability, validity, or feasibility, or those that are not appropriate for the target diagnostic group or construct/dimension under consideration, may be unfavorable for clients, unproductive, and hinder empirical advancement.”
These principles are a language of their own, and when you understand them, they can tell you a great deal about the test itself, including its utility.
While entire books have been written on psychometric principles, in this article, we will focus on a useful value that can help you determine when your client has made a meaningful change.
This property is called the minimal clinically important difference (MCID). In this article, we will investigate the MCID and outline how to use this value in your clinical decision-making.
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Minimal Clinically Importance Difference
Trends in research statistics have been shifting from a focus on statistical significance to one of clinical significance. A highly powered study with generally beneficial results is likely to reach statistical significance; that is, the measured change is unlikely to be due to chance alone.
It begs the question, however, whether a change that reaches statistical significance is equivalent to one that reaches clinical significance?
Clinical significance in healthcare and psychology implies that a treatment, disease or disorder has a meaningful impact on a client’s health and well-being. Research studies are undoubtedly important, but at the end of the day, most practitioners care that their treatments positively impact the humans they support.
The MCID is a statistic that can help you understand the clinical significance of an intervention or a change in symptom or disease presentation. The MCID defines a change in score that represents the smallest benefit of value to clients. In other words, a change in score equal to the MCID suggests the client experienced the smallest meaningful change in the outcome of interest.
Score changes smaller than the MCID suggest the change is too small to be beneficial, whereas changes larger than the MCID suggest a greater benefit to the client. The MCID can be calculated through different methods and is often specific to client demographics, like age or disease process.
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Centering the client experience
The MCID is intended to be a client-centered concept. This statistic represents the magnitude of improvement a client experienced in response to a treatment intervention, while also considering the value the client places on that change.
Let’s look at an example: The Modified Fatigue Impact Scale (Fisk et al., 1994) provides an assessment of the effects of Multiple Sclerosis-related fatigue on physical, cognitive and psychosocial functioning. The total score for this outcome measure is 84 points, with higher scores indicating greater impacts of fatigue.
Several research studies aiming to determine the psychometric properties of this outcome measure have established an MCID of four points. This means that a change in score of only four points can lead to a meaningful difference in the impact of fatigue for clients with MS.
The Geriatric Depression Scale, on the other hand, has no established MCID. How many points must an individual’s score improve to equal a noticeable or meaningful change in their depression? Without this statistic, it is difficult to know.
There are two common methods for determining the MCID. At this time, there is no certain agreement on which approach is best, but there are benefits and drawbacks to each.
The first method relies on a distribution-based approach. In this approach, the MCID is referenced to a measure of variability like the standard error of the mean or an effect size in the measure of interest.
The second method is an anchor-based method. This method references the MCID to an external assessment of change in the measure of interest. Some researchers propose using multiple methods to help “triangulate” the value of the MCID.
Minimal detectable change
When searching for the MCID of a certain outcome measure, you may come across the term “MDC.” While similar looking, the MDC (minimal detectable change) and MCID are quite different.
Unlike MCID, which describes both the magnitude of change and the value of a change in score, the MDC simply describes the minimum change in a client’s score that can be detected. This ensures the change is not simply the result of measurement error.
Like the MCID, the MDC has not been established for all outcome measures but can be useful when evaluating the change in a client’s score. A change smaller than the MDC has no real meaning clinically.
Putting the MCID into practice
As you can see, the MCID is a useful statistic. It should be used for goal setting and progress tracking. After administering a standardized outcome measure, use the MCID to help set a goal for change.
Aim to structure your long-term goals to meet or exceed the MCID value to ensure that your client is experiencing a clinically significant change, not just a statistically significant one. You can use the MCID as a jumping-off point, combining it with other numbers such as normative values and important cut-off scores.
Many new EHR systems, like Theraplatform, incorporate automatic outcome measure scoring tools and progress trackers to make this easier.
Regularly tracking outcome measure results serves several purposes:
- Informs your plan of care and alerts you when to stay the course or take a new approach
- Motivates your client to participate in their rehabilitation program by viewing their ongoing progress
- Helps you set short and long-term goals for your treatment plan
- Justifies discharge or continued care to payers and referring providers
- Plays an important role in evaluating disease progression, determining the need for equipment or referral to other providers and evaluating the effectiveness of multidisciplinary care
Though the MCID will not be available for every useful outcome measure, when it is, use it. This value can help ensure your work makes a meaningful impact on the clients you treat but it is important to remember that each person’s experience is unique.
Reaching the MCID may feel like a very meaningful change to one person and less so to another, so engaging your clients in open dialogue and client-directed goal setting is always a good choice.
In summary, trends in statistical research have been supporting the importance of clinical significance over statistical significance. Values like the minimal clinically important difference combine the magnitude of a change in score with the value a client will find in that change.
Combining objective changes with client values helps to guide better clinical decision-making and client-centered care. Most therapists incorporate standardized outcome measures into their practice but may have never considered the value of using the MCID to set goals and evaluate the effectiveness of their care.
Through a little research and practice with these values, however, we can all elevate our client care and clinical decisions.
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References
Geriatric depression scale. (2013, April 12). Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/geriatric-depression-scale
Malec, J. F., & Ketchum, J. M. (2020). A Standard Method for Determining the Minimal Clinically Important Difference for Rehabilitation Measures. Archives of physical medicine and rehabilitation, 101(6), 1090–1094. https://doi.org/10.1016/j.apmr.2019.12.008
Minimal clinically important difference: defining what really matters to clients. (n.d.). McGraw Hill Medical. https://jamaevidence.mhmedical.com/content.aspx?bookid=2742§ionid=233567395
Modified Fatigue Impact Scale. (n.d.). Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/modified-fatigue-impact-scale
Statistical terms & use. (2016, October 27). Shirley Ryan AbilityLab. https://www.sralab.org/statistical-terms-use
Swan K, Speyer R, Scharitzer M, Farneti D, Brown T, Woisard V and Cordier R (2023) Measuring what matters in healthcare: a practical guide to psychometric principles and instrument development. Front. Psychol. 14:1225850. doi: 10.3389/fpsyg.2023.1225850
FAQs about Minimal Clinically Important Difference
What is the minimal clinically important difference (MCID)?
The MCID is the smallest change in an outcome measure score that represents a meaningful improvement from the client’s perspective.
How is MCID different from minimal detectable change (MDC)?
MDC reflects the minimum change that exceeds measurement error, while MCID reflects a change that is both measurable and clinically meaningful.
How can therapists use MCID in practice?
Therapists can use MCID to set treatment goals, evaluate progress, justify continued care, and ensure that interventions lead to meaningful functional change.
