Health-related quality of life in persons with acquired immune deficiency syndrome

Assessing health-related quality of life in persons infected with human immunodeficiency virus (HIV) is extremely important, but most available scales are too long, contain items that are not relevant for such persons, or do not assess important signs and symptoms of HIV infection. This study presents a new set of scales for assessing the symptoms and functioning of persons infected with HIV and reports data on their reliability and validity collected in face-to-face interviews with 189 patients receiving primary care. This study also assesses the associations among systems, functional impairment, and global health assessments. The scales are easy to administer, are reliable, and serve as valid measures of quality of life. Fatigue, functional status, and average severity of all symptoms were the best predictors of overall perceived health status. Psychological well-being and perceived health status were the best predictors of overall perceived health status. Psychological well-being and perceived health status were the strongest correlates of life satisfaction. When assessing the health-related quality of life of persons infected with HIV, this study recommends utilizing a comprehensive set of measures that allows one to examine both discrete symptoms and the more diffuse impact of illness on functioning, mental health, and quality of life.

Discussion of preferences for life-sustaining care by persons with AIDS. Predictors of failure in patient-physician communication

OBJECTIVES

To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician.

DESIGN AND SETTING

Structured patient interview at a staff-model health maintenance organization (HMO), an internal medicine group practice at a private teaching hospital, and an AIDS clinic at a public hospital.

PATIENTS

289 persons with AIDS.

MAIN RESULTS

Only 38% of patients had discussed their preferences for resuscitation with their physician. Using logistic regression, we found that patients were less likely to have discussed resuscitation with their physician if they were nonwhite (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24 to 0.99), had never been hospitalized (OR, 0.52; 95% CI, 0.27 to 0.99), or were cared for in the HMO (OR, 0.44 relative to the private teaching hospital; 95% CI, 0.23 to 0.82). Patients were more likely to have discussed their preferences if they were not currently taking zidovudine (OR, 1.76; 95% CI, 1.02 to 3.03) and if they had decided to defer life-sustaining therapy (OR, 2.30; 95% CI, 1.35 to 3.91). Among nonwhites, those with a nonwhite physician were more likely to have discussed resuscitation (OR, 4.38; 95% CI, 1.13 to 16.93). Of patients who had not discussed their preferences for life-sustaining care, 72% wanted to do so. Patient desire for discussion of this issue did not vary by race, severity of illness, hospitalization status, use of zidovudine, or site of care.

CONCLUSIONS

A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.

Depressive symptoms in blood donors notified of HIV infection

OBJECTIVES

Understanding more about the psychological state of persons notified of human immunodeficiency virus (HIV) infection is critical for designing notification and counseling programs that will have the most positive effect.

METHODS

The subjects were blood donors who had been notified of HIV infection by the New York Blood Center. A nurse elicited a medical history, performed a limited medical examination, and asked the subjects to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. The subjects completed another questionnaire approximately 2 weeks later.

RESULTS

The average depressive symptom scores for both men and women were substantially higher than scores typically found in representative population samples. More than a quarter of the men and more than a third of the women reported seeking psychological or psychiatric services in the first few weeks following notification.

CONCLUSIONS

Anticipating and meeting individuals' psychological needs may be necessary if HIV screening programs are to address effectively the needs of persons infected with HIV.

The course of transient hypochondriasis

OBJECTIVE

This study examined the longitudinal course of patients known to have had a previous episode of transient hypochondriasis.

METHOD

Twenty-two transiently hypochondriacal patients and 24 nonhypochondriacal patients from the same general medical clinic were reexamined after an average of 22 months with the use of self-report questionnaires, structured diagnostic interviews, and medical record review.

RESULTS

The hypochondriacal patients continued to manifest significantly more hypochondriacal symptoms, more somatization, and more psychopathological symptoms at follow-up. They also reported significantly more amplification of bodily sensations and more functional disability and utilized more medical care. These differences persisted after control for differences in medical morbidity and marital status. Only one hypochondriacal patient, however, had a DSM-III-R diagnosis of hypochondriasis at follow-up. Multivariate analyses revealed that the only significant predictors of hypochondriacal symptoms at follow-up were hypochondriacal symptoms and the tendency to amplify bodily sensations at the baseline evaluation.

CONCLUSIONS

Hypochondriacal symptoms appear to have some temporal stability: patients who experienced hypochondriacal episodes at the beginning of the study were significantly more hypochondriacal 2 years later than comparison patients. They were not, however, any more likely to develop DSM-III-R-defined hypochondriasis. Thus, hypochondriacal symptoms may be distinct from the axis I disorder. The data are also compatible with the hypothesis that preexisting amplification of bodily sensations is an important predictor of subsequent hypochondriacal symptoms.

Using patient reports to assess health-related quality of life after total hip replacement

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Socio-demographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a response rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.

The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement. Comorbidity and outcomes after hip replacement

Co-existent or comorbid diseases are appreciated as prognostic factors in studies of quality and effectiveness of care when mortality is the end point. The need to measure and adjust for comorbidity in studies of postoperative hospital complications or long-term recovery from surgery has not been documented. In this study, we determined the impact of co-existent disease on post-operative complications and 1-year health-related quality of life in patients hospitalized for a total hip replacement. The study population consisted of a cohort of 356 patients who were hospitalized in four teaching hospitals in California and Massachusetts for a total hip replacement. Patients' medical records were reviewed to collect information regarding severity of illness, co-existent disease, and postoperative complications. The kind and amount of baseline preoperative co-existent disease was measured from medical record information at admission using a four level Index of co-existent Disease (ICED). Approximately 12 months after hospital discharge, 283 (80%) of the patients were surveyed by questionnaire. The presence and amount of co-existent disease were significant predictors of postoperative complications. The complication rates ranged from 3% to 41% between the lowest and highest levels of the ICED. Patients treated at the four study hospitals differed in functional outcomes 1 year after surgery. Functional outcomes were strongly related to ICED scores: patients in Level 4 ICED scored 26.8 points lower in instrumental activities of daily living than patients in Level 1. After controlling for gender, age, education, and marital status, ICED remained a significant predictor of functional status at 1 year. Furthermore, differences among hospitals in functional outcomes disappeared when the ICED was included in the model to adjust for patient characteristics at the time of surgery. A measure of co-existent disease was crucial in explaining differences among hospitals in recovery from total hip replacement patients.

The perception of cardiac activity in medical outpatients

This study compared several measures of cardiac perception and related them to patient' spontaneous reports of palpitations. One hundred and forty-five ambulatory patients referred for Holter monitoring for the evaluation of palpitations were compared with 70 asymptomatic nonpatients. Reports of palpitations during monitoring were compared with the ECG to determine whether they coincided with an arrhythmia. Subjects also completed a heartbeat detection task to determine whether they were accurately aware of cardiac systole while at rest. 20.7% of palpitation patients and 4.7% of asymptomatic controls demonstrated an accurate awareness of resting heartbeat (p = 0.01). Performance was unrelated to bodily amplification, somatization, hypochondriacal symptoms, ECG findings, or psychiatric morbidity. 34.3% of palpitation patients reported symptoms that consistently coincided with arrhythmias on ECG. These accurate patients had significantly lower levels of amplification, somatization, hypochondriacal symptoms, and psychiatric morbidity. Accuracy of symptom reporting and accuracy of heartbeat awareness were not statistically associated.(ABSTRACT TRUNCATED AT 250 WORDS)

Using patient reports to assess hospital treatment of persons with AIDS: a pilot study

Providing efficacious, compassionate, and efficient medical care to persons with HIV infection is one of the greatest challenges that will face US hospitals this decade. Unfortunately, there have been almost no studies of how organizational arrangements are related to the quality of care. We developed an interview protocol and conducted a pilot study to evaluate the instrument's ability to detect differences in selected interpersonal aspects of care provided to persons with AIDS. We evaluated the care received in two different treatment models in a major teaching hospital: a designated AIDS unit and general medical beds. We assessed several areas of patient care that are clinically important and that patients can evaluate: communication between patients and providers, patient education, respect for patient preferences, emotional support, involvement of family and friends, trust and confidence, physical care, pain management, AIDS knowledge, perceived segregation, confidentiality, and financial information. Patients generally were very satisfied with their hospital care, but many reported problems with certain aspects of their care. The instrument used detected differences between the care reported by patients treated in general hospital beds and in a designated AIDS unit in several specific aspects of care.

Comparison of patient-reported outcomes after elective coronary artery bypass grafting in patients aged greater than or equal to and less than 65 years

Older patients represent a growing proportion of patients undergoing coronary artery bypass grafting (CABG). Although functional benefits after CABG have been demonstrated, most assessments of outcomes have involved patients aged less than 65 years. Therefore, little is known concerning the impact of CABG on older patients compared with that on younger ones. A number of postsurgical (6 months) health-related quality-of-life outcomes (e.g., symptoms, cardiac functional class, instrumental activities of daily living, and emotional and social functioning) reported by patients aged less than 65 (n = 169) and greater than or equal to 65 (n = 99) years who underwent elective CABG at 4 major teaching hospitals in Massachusetts and California were compared. The proportion of patients reporting cardiac-related symptoms after surgery did not vary by age, and quality-of-life outcome scores of younger and older patients did not differ even after adjustment for clinical and demographic characteristics. The exception to this was mental health status, an outcome for which older patients reported better functioning than did younger ones. On average, patients in the 2 age groups reported equivalent improvement over preadmission status in instrumental activities of daily living, and emotional and social functioning. The independent relation of clinical and sociodemographic factors to quality-of-life outcomes was also investigated. Patients who functioned better before admission, those with less severe co-morbid disease, and married patients reported better functioning after discharge. In general, older patients who underwent elective CABG reported functional benefits similar to those reported by younger ones, and the factors associated with better functioning did not vary by age group.

Determinants of perceived health status of medical outpatients

The aim of this study was to examine the relative contributions made by medical morbidity, psychiatric disorder, functional status, and hypochondriacal attitudes to medical patients' opinions of their overall health status. The study was conducted in the general medical clinic of a large academic teaching hospital. Consecutive clinic visitors on randomly selected days were screened with a hypochondriasis self-report questionnaire, since the overall project was designed as a study of hypochondriasis. A random sample of the patients below a pre-established cutoff (n = 100), along with all those exceeding the cutoff (n = 88), returned to undergo a research battery. For this analysis, a representative sample of the entire clinic was reconstituted by weighting the data from patients above and below the screening cutoff in proportion to their prevalence in the clinic. Measures of psychiatric disorder (the Diagnostic Interview Schedule), personality disorder, functional status and disability, medical morbidity (from physician ratings and medical record audit), and hypochondriacal attitudes were obtained. Patient self-ratings of global health status were significantly correlated with aggregate medical morbidity (r = 0.36; P less than 0.001); psychiatric morbidity (r = 0.48; P less than 0.001); functional disability (for intermediate activities of daily living, r = 0.62; P less than 0.001); hypochondriacal attitudes (r = 0.79; P less than 0.001); and with the tendency to somatize (r = 0.77; P less than 0.001). Using multiple regression analysis, the most powerful correlates of perceived global health were hypochondriasis, somatization and disability (model R2 = 0.762).(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related item nonresponse in surveys of recently discharged patients

We examined item nonresponse in questionnaires that assessed the physical functioning, emotional status, and satisfaction with care of surgical patients recently discharged from the hospital following coronary artery bypass graft surgery (CABG; N = 267), total hip replacement (THR; N = 283), and transurethral prostatectomy (TURP; N = 292). For all conditions, the total number of missing responses did not vary with age. More functional and healthier CABG and THR patients generated fewer missing responses than less healthy patients, whereas less educated TURP patients responded to items less frequently than more educated patients. The correlates of specific item nonresponse varied across samples. Most often, perceived health status, assistance with completion of the questionnaire, and patient-reported confusion all related to whether or not specific items were missing. The influence of these variables, however, varied by surgical condition. These results indicate that a proportion of elderly and sick respondents may not respond to at least some items, but it is possible to achieve a high level of data completeness if multiple item scales are used and questions are carefully designed to be salient to the population studied.

The inpatient AIDS unit: a preliminary empirical investigation of access, economic, and outcome issues

An AIDS unit model ("cluster beds") and a general inpatient placement model ("scatter beds") in a major teaching hospital were compared to determine whether they differed on several dimensions of care. After controlling for severity of illness, (the major predictor of admission to the AIDS unit), length of stay, charges, and inpatient mortality rates did not differ between the two settings. Equal proportions of White, Hispanic, male, and privately insured patients were found in both settings. Nursing staff turnover rates were comparable to those of other sites. However, the data raise new issues regarding access to AIDS units for older, Black, and female patients.

Risk factors for delirium in hospitalized elderly

OBJECTIVE

To determine risk factors for delirium in elderly hospitalized patients.

DESIGN

Cohort analytic study. Using a reliable and valid instrument for detection of delirium, we prospectively followed up a cohort of elderly patients admitted to an acute care hospital. Using standardized criteria, we collected risk factor data from patient medical records.

SETTING

General medical and surgical wards of a tertiary-care hospital.

PATIENTS

Patients (n = 325) were 65 years of age or older, from either a geographically defined community or a long-term-care institution. We studied those patients (n = 291) not delirious on first evaluation. Fifty-seven patients or their families refused participation.

MAIN OUTCOME MEASURES

Incidence of delirium and risk factors calculated as adjusted odds ratios (ORs).

MAIN RESULTS

Delirium developed in 91 patients. By stepwise logistic regression, the independent risk factors for in-hospital delirium included prior cognitive impairment (OR, 8.97; 95% confidence interval [CI], 3.99 to 20.14), age over 80 years (OR, 5.22; 95% CI, 2.60 to 10.46), fracture on admission (OR, 6.57; 95% CI, 2.23 to 19.33), symptomatic infection (OR, 2.96; 95% CI, 1.42 to 6.15), and male sex (OR, 2.40; 95% CI, 1.19 to 4.84). Among medication groups, only neuroleptic use (OR, 4.48; 95% CI, 1.82 to 10.45) and narcotic use (OR, 2.54; 95% CI, 1.24 to 5.18) were independently associated with delirium. Anticholinergic use was not associated with delirium.

CONCLUSIONS

Delirium in hospitalized patients is most closely associated with factors already present on admission such as prior cognitive impairment, advanced age, and fracture. In the hospital, use of neuroleptics and narcotics and the presence of infection are less strongly associated with this syndrome.

The relationship between reported problems and patient summary evaluations of hospital care

A nationwide telephone survey of 6,455 adult medical and surgical patients discharged from 62 general hospitals focused on aspects of hospitalization that affected patients' overall evaluation of their care. Eighty percent reported the care they received was excellent or very good. The strongest predictors of patients' evaluations were reported health status and the number of problems reported. Most of the associations between patient characteristics and summary evaluations were explained by differences in the number of problems reported. However, controlling for number of reported problems, the associations between evaluations and age, health status, and preferences were still statistically significant.

Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients

We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition--defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent.

A structured diagnostic interview for hypochondriasis. A proposed criterion standard

We developed a structured diagnostic interview for DSM-III-R hypochondriasis (SDIH) that is the first such clinician-administered instrument. The SDIH was administered to 88 general medical outpatients who scored above a predetermined cutoff on a hypochondriacal symptom questionnaire, and to 100 comparison patients randomly chosen from among those below the cutoff. Using the joint assessment method, interrater agreement on the DSM-III-R diagnostic criteria was 88% to 97% and agreement on the diagnosis was 96%. Concurrent validity was suggested by a significant correlation between the interview and the primary care physicians' ratings of hypochondriasis. A measure of external validity was demonstrated in that several clinical characteristics thought to be ancillary features of hypochondriasis were significantly more prevalent in interview-positive patients than in interview-negative patients. Finally, the SDIH appeared to have discriminant validity in that patients diagnosed as hypochondriacal had several other clinical features that distinguished them from the patients who scored above the cutoff on hypochondriacal symptomatology, but failed to be diagnosed as hypochondriacal with the SDIH.

The delirium symptom interview: an interview for the detection of delirium symptoms in hospitalized patients

To study delirium in hospitalized elderly, a delirium symptom interview (DSI) was developed by an interdisciplinary group of investigators. This interview was administered in an acute care hospital to 50 patients who were over the age of 65 years. Results from the interview were compared to assessments of major symptoms of delirium made independently by a neurologist and a psychiatrist. This interview had good validity and reliability. The sensitivity of the DSI was .90 and the specificity was .80, when compared with the clinical judgment of a psychiatrist and neurologist. Interrater reliability, using lay interviewers, was .90 for the detection of major symptoms of delirium. These results indicate that the DSI could be used by lay interviewers to assess reliably the symptoms of delirium.

Behavior changes after notification of HIV infection

BACKGROUND

To learn more about how people who did not volunteer for testing react to information about HIV infection, we assessed short-term behavior changes in HIV-positive blood donors.

METHODS

Blood donors who were notified at the New York Blood Center that they were HIV positive were asked to participate in a study. A nurse elicited a medical history, performed a limited medical examination, and asked participants to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. Participants were asked to return in 2 weeks to complete another questionnaire.

RESULTS

Many fewer men and women reported engaging in unsafe sexual behaviors in the 2 weeks preceding the follow-up visit than had reported such behaviors prior to notification. These changes were greater than those other investigators have reported, but about 40% of the participants still reported unsafe sexual activity at the follow-up interview.

CONCLUSIONS

To make nonvolunteer screening programs for HIV infection more effective in reducing the spread of HIV infection, we need to learn more about how to help people change their high-risk behaviors.

Health-related quality of life among patients undergoing percutaneous transluminal coronary angioplasty

A randomized clinical trial was recently conducted to investigate whether a new antiplatelet agent could prevent restenosis in patients who had undergone percutaneous transluminal coronary artery angioplasty (PTCA). Approximately 1,200 patients were enrolled at 13 separate clinical sites. To assess the impact of this intervention on health-related quality of life, a patient questionnaire for telephone administration was developed. This questionnaire focused attention on several specific dimensions likely to be important in this patient population: physical well-being, perceived health, emotional well-being, home management, work, recreation, and social and sexual functioning. This paper describes the instrument that was used in this trial and reports on its psychometric [corrected] properties based on completed interviews with approximately 500 patients at study entry and 1 month after PTCA.

Assessing quality of life after surgery

Researchers and clinicians increasingly are recognizing the importance of assessing a wide range of outcomes when evaluating the efficacy of medical therapies or procedures. We developed and evaluated a set of self-report scales that assessed both generic and condition-specific aspects of health-related quality of life before and after surgery. We report data from a study of patients having one of four types of surgery at six teaching hospitals in California and Massachusetts. The four surgical conditions studied were: total hip replacement, transurethral prostatectomy, cholecystectomy, and coronary artery bypass graft surgery. All the outcome scales, except for those assessing cognitive functioning and fatigue, had internal consistencies greater than 0.70. The pattern of correlations between the scales and other measures of health status are similar to those reported in other studies and provide evidence of their construct validity. The scales also appeared to be sensitive to differences between presurgical and postsurgical health-related quality of life. The results suggest that the scales used were easy to administer, reliable, valid, and offered important information about outcomes of surgery that is not provided by more traditional clinical indicators.

Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California

OBJECTIVES

--To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes.

DESIGN

--We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire.

SETTING

--Six teaching hospitals in California and Massachusetts.

PATIENTS

--A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire.

OUTCOME MEASURES

--In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed.

RESULTS

--Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care.

CONCLUSION

--More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care.