Relative importance of sexuality and quality of life in patients with prostatic symptoms. Results of an international study

OBJECTIVE

Benign prostatic hyperplasia (BPH) and its treatment can impair the quality of life (QoL) of patients with the condition. Among the BPH-specific instruments available for assessing QoL, no consensus has emerged on the concepts that should be measured, particularly for aspects of sexual life. The objective of this study was to determine which aspects of QoL were most affected by prostatic symptoms and which patients considered the most important.

METHOD

After an extensive literature review, we drew up a self-administered questionnaire composed of an exhaustive list of concepts found in the available QoL/BPH measures. In a cross-sectional study, 73 French and 44 English patients with an International Prostate Score (I-PSS) > 7 were asked to fill in this 89-item questionnaire. The level of interference of the symptoms with each aspect of QoL and the importance of the problem were reported by the patients.

RESULTS

The aspects reported to be most affected and to be the most important were sleep, anxiety and worry about the disease, mobility, leisure, daily activities, sexual activities and satisfaction with sexual relationships. French patients considered all sexual aspects of life more important than English patients.

CONCLUSION

This study confirms that QoL is an important outcome in BPH. The major concepts identified by the patients to be important include sexual ones. These results suggest the importance of including the assessment of sexual functioning and behavior in any further evaluations of BPH treatments effects on QoL.

The Quebec Task Force classification for Spinal Disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis

STUDY DESIGN

A prospective cohort study of patients in Maine with sciatica and lumbar spinal stenosis treated surgically and nonsurgically.

SUMMARY OF BACKGROUND DATA

In 1987, the Quebec Task Force on Spinal Disorders proposed a diagnostic classification to help make clinical decisions, evaluate quality of care, assess prognosis, and conduct research.

OBJECTIVES

To assess the Quebec Task Force classification's ability to stratify patients according to severity and treatment at baseline, and to assess changes over time in health-related quality of life, including symptoms, functional status, and disability.

METHODS

Five hundred sixteen patients participating in the Maine Lumbar Spine Study who completed baseline and 1-year follow-up evaluations were classified successfully according to the Quebec Task Force classification. Patient characteristics and treatments were compared across Quebec Task Force classification categories. Changes in health-related quality of life over 1 year were assessed according to Quebec Task Force classification category and type of treatment.

RESULTS

Among patients with sciatica (n = 370), higher Quebec Task Force classification categories (from 2, pain radiating to the proximal extremity, to 6, sciatica with evidence of nerve root compression) were associated with increased severity of symptoms at baseline. There was no association between Quebec Task Force classification and baseline functional status. Quebec Task Force classification was associated strongly with the likelihood of receiving surgical treatment (P < or = 0.005). Among patients with sciatica treated nonsurgically, improvement at 1 year in back-specific and generic physical function increased with higher Quebec Task Force classification category (P < or = 0.05). Only a nonsignificant trend was observed for surgically treated patients. Patients with lumbar spinal stenosis (Quebec Task Force classification 7, n = 131) had baseline features and outcomes distinct from patients with sciatica.

CONCLUSIONS

For patients with sciatica, the Quebec Task Force classification was highly associated with the severity of symptoms and the probability of subsequent surgical treatment. Nonsurgically treated patients in Quebec Task Force classification categories reflecting nerve root compression had greater improvement than those with pain symptoms alone. Among surgical patients, the Quebec Task Force classification was not associated with outcome. These results provide validation for the classification and its wider adoption. Nonetheless, improved diagnostic classifications are needed to predict outcomes better in patients with sciatica who undergo surgery.

Measuring health and health state preferences among critically ill patients

OBJECTIVE

a) to examine the EuroQol instrument's ability to assess a patient's state of health prior to admission to an ICU; b) to describe a patient's health-related quality of life (HRQoL) before the onset of the condition leading to admission to the ICU, and prior to discharge; c) to compare patients' preferences for a "common core" of EuroQol health states with preferences from healthy individuals.

DESIGN

Patients in a step-down unit (SDU) retrospectively rated their health states prior to admission to the ICU, their current states of health and the "common core" of hypothetical EuroQol states of health. Proxies rated the patients' health states prior to admission to the ICU. Patients' preferences for EuroQol states of health were compared with the preferences obtained from a retrospective cohort of healthy individuals.

SETTING

An SDU at the University Hospital of Bellvitge, Barcelona, Spain.

PATIENTS

103 critical medical and surgical patients were interviewed.

INTERVENTION

The EuroQol questionnaire, a non-disease specific instrument to evaluate HRQoL.

MEASUREMENTS AND MAIN RESULTS

Agreement between patients and proxies regarding their prior health state was moderate to good in physical and pain areas (kappa: 0.43-0.58), fair for mood (kappa: 0.38) and almost identical for prior overall health (65.9 vs 66.3). Compared with their prior HRQoL, patients had deteriorated in all physical areas and overall health at discharge from the SDU. Preferences for the worst health states varied significantly between patients and healthy individuals.

CONCLUSION

The EuroQol can be reliably used with proxies to determine the state of health of patients prior to admission to the ICU. Preferences between healthy individuals and ICU patients differed.

Evaluating quality-of-life and health status instruments: development of scientific review criteria

The Medical Outcomes Trust is a depository and distributor of high-quality, standardized, health outcomes measurement instruments to national and international health communities. Every instrument in the Trust library is reviewed by the Scientific Advisory Committee against a rigorous set of eight attributes. These attributes consist of the following: (1) conceptual and measurement model; (2) reliability; (3) validity; (4) responsiveness; (5) interpretability; (6) respondent and administrative burden; (7) alternative forms; and (8) cultural and language adaptations. In addition to a full description of each attribute, we discuss uses of these criteria beyond evaluation of existing instruments and lessons learned in the first few rounds of instrument review against these criteria.

The mental health patient profile: does it change primary care physicians' practice patterns?

BACKGROUND

We conducted a prospective trial randomizing 75 physicians to either a control or intervention arm to evaluate the impact of providing patient-reported information on anxiety and other mental health symptoms and disorders to primary care physicians.

METHODS

Five hundred seventy-three patients of the study physicians who met entry criteria were randomized to either usual care or usual care supplemented with feedback of patient-reported mental health information to physicians. This mental health information was derived from initial patient-reported questionnaires completed in waiting rooms of physicians contracted to a mixed-model health maintenance organization in Colorado. Main outcome measures included impact of intervention on rates of (1) chart notation of anxiety, depression, or other mental health diagnoses or symptoms; (2) referral to mental health specialists; (3) prescription of psychotropic medications; (4) hospitalization; and (5) office visits during a 5-month observation period.

RESULTS

Physicians receiving feedback on previously unrecognized and untreated anxiety patients were more likely to make chart notations (adjusted odds ratio [AOR] = 2.51, 95 percent confidence interval [CI] = 1.62-3.87), to make referrals to mental health specialists (AOR = 3.86, 95 percent CI = 1.63-9.16), and to see patients for more frequent outpatient visits (AOR = 1.73, 95 percent CI = 1.11-2.70). Use of psychotropic medications and rate of hospitalizations did not differ significantly.

CONCLUSIONS

Providing patient-reported mental health information to primary care physicians resulted in increased recognition and referral rates for previously unrecognized and untreated anxiety patients, plus an increase in primary care visits, without concomitant increases in the use of psychotropic medications or rate of hospitalizations.

A new instrument to assess the long-term quality of life effects from migraine: development and psychometric testing of the MSQOL

Quality of life is important to persons experiencing migraine. This study discusses the development of a migraine-specific quality-of-life measure (MSQOL). Participants, who included migraineurs from both tertiary care centers and the community, were screened using the International Headache Society migraine criteria prior to enrollment. Internal consistency of the MSQOL was high (alpha 0.92). Reproducibility over an average of 24 days was high (intraclass correlation 0.90). Construct validity was determined by convergent validity and known groups validity. The MSQOL was compared to two other frequently used health status questionnaires; results indicate that the MSQOL more closely resembles well-being than functional status. Results also indicate that migraineurs with more symptoms, medical appointments per year to treat migraines, and migraine episodes per year have a significantly worse quality of life. The MSQOL proved valid and reliable as a self-administered measure and will be a useful tool in clinical migraine research. The information gained from its use in the clinical environment should provide important additional information about the impact of migraine on quality of life and the potential benefits of therapeutic interventions.

Hostility, aggression and the association with hypertension in post-menopausal women

In order to determine whether a hostile attitude is associated with hypertension in post-menopausal women, we conducted a cross-sectional study of a sample of post-menopausal women enrollees from the Group Health Cooperative (Seattle, Washington). Out-patient medical records were reviewed for all subjects. Hypertension was defined as a recorded diagnosis of hypertension and treatment with an anti-hypertensive drug. Borderline hypertensives were excluded. Women were interviewed by telephone and asked the 14 questions comprising the Hostile-Affect (HOS) and Aggressive-Responding (AGGR) factors of the Cook-Medley hostility scale. Scores were grouped into high vs low HOS and AGGR. The AGGR score was available for 430 hypertensives and 628 normotensives. The HOS score was available for 436 hypertensives and 616 normotensives. High AGGR scores had a borderline association with hypertension (Odds Ratio (OR) = 1.26; 95% Confidence interval (CI) = 0.97-1.62). HOS was not associated with hypertension. Adjusting for age, physical activity, diabetes mellitus, cholesterol level, tobacco and alcohol use, weight and race, changed the association of AGGR with hypertension only slightly (OR = 1.22; CI = 0.92-1.63). We found a weak association between the prevalence of treated hypertension and AGGR in post-menopausal women. There was no association between the HOS component and hypertension. The results of this study support the need for prospective studies of the role of psychological factors in the development of hypertension in post-menopausal women. If this association is confirmed, AGGR measures may help identify women at high-risk who are most likely to benefit from hypertension screening and primary prevention.

The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica

STUDY DESIGN

The Maine Lumbar Spine Study is a prospective cohort study of patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine.

OBJECTIVE

To assess 1-year outcomes of patients with sciatica believed to be due to a herniated lumbar disc treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

Lumbar spine surgery rates vary by geographic region and may reflect uncertainty about optimal clinical use.

METHODS

Eligible consenting patients participated in a baseline interview performed by study personnel and then were mailed follow-up questionnaires at 3, 6, and 12 months. Clinical data were obtained from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, disability, quality of life, and satisfaction with care.

RESULTS

Five hundred seven patients with sciatica, 275 treated surgically and 232 treated nonsurgically initially, were enrolled. Surgically treated patients, on average, had more severe symptoms and had more severe physical and imaging findings than nonsurgically treated patients at entry. Although few surgically treated patients had mild symptoms and few nonsurgically treated patients had severe symptoms, about half in each treatment group had symptoms that fell into a moderate category. At the 1-year evaluation, improvement in symptoms, functional status, and disability were found in both treatment groups. However, surgically treated patients reported significantly greater improvement. For the predominant symptom, either back or leg pain, 71% of surgically treated and 43% of nonsurgically treated patients reported definite improvement (P < 0.001). This effect was even greater after adjustment for differences between treatment groups at entry (relative odds of definite improvement, 4.3; P < 0.001). For patients with moderate symptoms and abnormal physical examination findings, surgical treatment also resulted in greater improvement than nonsurgical treatment. However, there was little difference in the employment or workers' compensation status of patients treated surgically versus nonsurgically (5% vs. 7% unemployed at 1-year follow-up if employed at entry [P = 0.68]; 46% vs. 55% receiving workers' compensation at 1-year follow-up if receiving it at entry [P = 0.30] for surgical and nonsurgical management, respectively). For patients with mild symptoms, the benefits of surgical and nonsurgical treatment were similar.

CONCLUSIONS

Although surgically treated patients were on average more symptomatic at entry, there was substantial overlap in symptoms between surgically treated and nonsurgically treated patients. Surgically treated patients with sciatica reported substantially greater improvement at 1-year follow-up. However, employment and compensation outcomes were similar between the two treatment groups, and surgery appeared to provide little advantage for the subset of patients with mild symptoms. These results should be interpreted cautiously, because surgical treatment was not assigned randomly. Long-term follow-up will determine if these differences persist.

Cross-cultural development of a quality of life measure for men with erection difficulties

Erection difficulties have a profound effect on a man's quality of life, however, the emotional consequences are often overlooked in quantitative research where most sex-related questionnaires focus on a man's functional ability. Consequently, we developed a cross-cultural instrument to measure quality of life specific to male erection difficulties (QOL-MED). The items in the QOL-MED originated from interviewing forty men with erection difficulties In Seattle and Boston. Twelve men in the USA and 29 men in England helped us refine the instrument. Testing the QOL-MED's psychometric properties involved two administrations over a two-week period in the USA (n = 40) and the UK (n = 29). For discriminant validity, we predicted quality of life would worsen with increased self-perceived severity of the condition. After controlling for years with erection difficulties in a linear regression model, we found a significant negative association between self-perceived severity and quality of life for men in the UK only (p < 0.01). The expectation that the measure would produce evidence for convergent validity by being more closely correlated to well-being than functional status was not confirmed. Both the USA and UK instruments were internally consistent (Cronbach's alpha = 0.94 and 0.96, respectively), and reproducible (0.78 and 0.95, respectively). This instrument provides a promising tool for studying therapies and understanding quality of life in patients with erectile dysfunction.

The Maine Lumbar Spine Study, Part I. Background and concepts

STUDY DESIGN

This paper describes the background and factors that led to the development and implementation of the Maine Lumbar Spine Study, a prospective cohort study of patients undergoing surgical and nonsurgical treatment of herniated lumbar disc with sciatica and symptomatic spinal stenosis.

OBJECTIVES

To define the factors leading to the study and the methods of designing and implementing a community-based effectiveness study to evaluate the outcomes of herniated lumbar intervertebral disc and spinal stenosis.

SUMMARY OF BACKGROUND DATA

Variations in the utilization of surgery for these conditions and physicians' uncertainty regarding the best way to manage them resulted in support of a community-based study of the effectiveness of treatment alternatives.

METHODS

A prospective cohort design was used. Methods of patient enrollment, data collection, management, and analysis are described. An innovative method of ascertaining the representativeness of the enrolled versus nonenrolled patient population is presented.

RESULTS

The importance of developing community-based networks of physicians is discussed.

CONCLUSIONS

These networks play an important role in analyzing practice pattern variations and in stimulating and participating in effectiveness research. Because effectiveness studies must be conducted at the community level, mechanisms must be developed with which to support and implement these efforts.

The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis

STUDY DESIGN

A prospective cohort study of patients with lumbar spinal stenosis recruited from the practices of orthopedic surgeons and neurosurgeons throughout Maine.

OBJECTIVE

To assess 1-year outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

No randomized trials and few nonexperimental studies have compared surgical and nonsurgical treatment of patients with lumbar spinal stenosis. The authors' goal was to assess 1-year outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically.

METHODS

Eligible, consenting patients participated in baseline interviews and were then mailed follow-up questionnaires at 3, 6, and 12 months. Clinical data were obtained from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, disability, and satisfaction with care.

RESULTS

One hundred forty-eight patients with lumbar spinal stenosis were enrolled, of whom 81 were treated surgically and 67 treated nonsurgically. On average, patients in the surgical group had more severe imaging findings and symptoms and worse functional status than patients in the nonsurgical group at entry. Few patients with mild symptoms were treated surgically, and few patients with severe symptoms were treated nonsurgically. However, of the patients with moderate symptoms, a similar percent were treated surgically or nonsurgically. One year after study entry, 28% of nonsurgically and 55% of surgically treated patients reported definite improvement in their predominant symptoms (P = 0.003). For patients with moderate symptoms, outcomes for surgically treated patients were also improved compared with those of nonsurgically treated patients. Surgical treatment remained a significant determinant of 1-year outcome, even after adjustment for differences between treatment groups at entry (P = 0.05). The maximal benefit of surgery was observed by the time of the first follow-up evaluation, which was at 3 months. Although few nonsurgically treated patients experienced a worsening of their condition, there was little improvement in symptoms and functional status compared with study entry.

CONCLUSIONS

At a 1-year evaluation of patient-reported outcomes, patients with severe lumbar spinal stenosis who were treated surgically had greater improvement than patients treated nonsurgically. Comparisons of outcomes by treatment received must be made cautiously because of differences in baseline characteristics. A determination of whether the outcomes observed persist requires long-term follow-up.

Application of outcomes research in occupational low back pain: the Maine Lumbar Spine Study

Outcomes research represents an expansion of traditional clinical research to include issues of cost and quality of care in usual clinical practice, emphasizing outcomes that matter most to patients. In low back disorders, outcomes research has focused on the lack of reliable information to support much of clinical practice and has demonstrated marked variability in the treatment of these common problems. The Maine Lumbar Spine Study represents an example of an outcomes research study to investigate the treatment of patients with sciatica in usual clinical practice. Because low back symptoms are a frequent cause of occupational disability, Workers' Compensation patients were explicitly oversampled. Baseline features were significantly different in those patients who were receiving Workers' Compensation versus those who were not. Efforts to compare outcomes by disability status need to control for these differences. Whereas most Workers' Compensation patients were still receiving disability compensation regardless of treatment at 6 months, patients who were treated surgically were more likely to have come off disability and returned to work than nonsurgically treated patients. Long-term follow-up is necessary to determine whether these differences persist.

Will uninsured people volunteer for voluntary health insurance? Experience from Washington State

OBJECTIVES

In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should be mandatory or voluntary. This study describes characteristics of low- income people who were more likely or less likely to be covered by a voluntary plan.

METHODS

Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics.

RESULTS

There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance.

CONCLUSIONS

If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care.

Quality of life of persons with urinary incontinence: development of a new measure

OBJECTIVES

Our objective was to develop a self-report quality of life measure specific to urinary incontinence (I-QOL) that could be used as an outcome measure in clinical trials and in patient care centers.

METHODS

The I-QOL was developed from interviews of 20 individuals with urinary incontinence. Refining the questionnaire was accomplished by structured interviews of 17 individuals with urinary incontinence. Testing the I-QOL's psychometric properties involved two administrations (n = 62) along with measures of psychologic well-being and functional status.

RESULTS

The rigorous development process ensured that the measure was complete and understandable. The I-QOL proved to be internally consistent (alpha 0.95) and highly reproducible (r = 0.93; 18 days; SD 4). For discriminant validity, severity of incontinence (P < 0.0001) and number of medical appointments in the past year to treat incontinence (P < 0.0001) significantly predicted I-QOL scores. Convergent validity analyses confirmed our predictions that the I-QOL scores were more closely related to overall well-being than bodily pain.

CONCLUSIONS

The I-QOL proved to be valid and reproducible as a self-administered measure for assessing quality of life of patients with urinary incontinence.

Reproducibility and responsiveness of the VF-14. An index of functional impairment in patients with cataracts

OBJECTIVES

To assess the test-retest reliability and responsiveness of the VF-14, which is an index of functional impairment in patient with cataracts.

DESIGN

Observational longitudinal study. Patients were enrolled prior to undergoing their first cataract surgery between July 15 and December 15, 1991, and they were followed up for 1 year after surgery.

SETTING

Patients were recruited from 72 ophthalmologists' practices in three US cities.

PATIENTS

Five hundred fifty-two patients who had undergone a surgical procedure in only one eye by the 4-month postoperative follow-up (responsiveness analyses) and a subset of these (n = 426) who had not subsequently undergone surgery for the second eye by the 12-month postoperative follow-up (reproducibility analyses).

MAIN OUTCOME MEASURES

Two health status measures (the VF-14 and the Sickness Impact Profile, two global measures of a patient's trouble and satisfaction with his or her vision, and best corrected visual acuity in each eye.

RESULTS

The VF-14 is highly reproducible, with an intraclass correlation coefficient of .79 when patient-rated criteria are used to define stable patients. The intraclass correlation coefficient was lower (.57 to .71) when various measures of visual acuity were used to define stable patients. The VF-14 is also about three times more responsive to a change in vision than the Sickness Impact Profile, which is a generic health status measure (effect size of approximately 1.00 vs 0.30). Estimates of the responsiveness of the VF-14 and the Sickness Impact Profile were not associated with preoperative visual acuity in the operated on or better eye. Responsiveness of the VF-14, however, was higher in patients with greater self-rated trouble with vision preoperatively.

CONCLUSIONS

The VF-14 was reproducible in stable patients during an 8-month period, and it was more responsive to clinically significant changes in vision than was a generic health status measure (ie, the Sickness Impact Profile).

The cost-effectiveness of lung transplantation. A pilot study. University of Washington Medical Center Lung Transplant Study Group

OBJECTIVE

Lung transplantation is one of the fastest-growing solid organ transplant procedures in the world, yet its cost-effectiveness is unknown. We compared the costs and outcomes of the first 25 patients who received lung transplants at the University of Washington with 24 patients currently on the lung transplant waiting list.

DESIGN

Inpatient and outpatient charges were obtained from the hospital billing service and home health agencies. Quality-adjusted life year scores (QALYs) were computed from the following: (1) utility scores obtained through standard gamble interviews, and (2) published survival data from an international lung transplant registry and from studies of patients on lung transplant waiting lists.

RESULTS

Transplantation charges averaged $164,989 (median, $152,071). Average monthly charges posttransplant were $11,917 in year 1 and $4,525 thereafter, vs $3,395 for waiting-list patients. Posttransplant utility scores were significantly higher than waiting-list scores (0.80 vs 0.68; p < 0.001). Life expectancy was not greater for lung transplant vs waiting-list patients (5.89 vs 5.32 years; p > 0.05), although quality-adjusted life expectancy did improve significantly. After converting charges to costs, the incremental cost per QALY gained for posttransplant compared with waiting-list patients was $176,817.

CONCLUSIONS

Lung transplantation is very expensive, although it can substantially improve quality of life. Two-thirds of care costs are incurred after transplantation. The principal barriers to cost-effectiveness at present are the high cost of postrecovery care and marginal gains in life expectancy compared with conservative care.

Advance care planning: eliciting patient preferences for life-sustaining treatment

Patient autonomy is a guiding principle in medical decision-making in America. This is challenging when patients become mentally incapacitated and cannot express their preferences. Advance care planning (ACP) addresses this challenge. ACP is a deliberative and communicative process that helps people formulate and communicate preferences for future medical care in the event of mental incapacity. Advance directives are mechanisms for communicating and/or documenting ACP, and are either instructional (e.g. statement of treatment preferences in living wills) or proxy types (e.g. appointment of another person to speak on the patient's behalf). ACP discussions between patients and health care providers and patient-orientated educational ACP materials often ignore insights from 2 related activities, health promotion and human information processing. More effective ACP should occur with greater attention to the concepts of stages of change and self-efficacy, the Health Belief Model, and the necessary requisites for cognitive integration.

Improvement in quality of life after lung transplantation: a preliminary study. The University of Washington Medical Center Lung Transplant Study Group

BACKGROUND

Lung transplantation is an expensive therapeutic option for a number of endstage conditions. Improving health-related quality of life is an important objective of transplantation.

METHODS

We report quality of life measurements in 21 waiting list patients and 23 patients after transplantation with seven different pulmonary conditions using two standardized instruments: the Sickness Impact Profile and the standard gamble.

RESULTS AND CONCLUSIONS

This cross-sectional study indicates the following: (1) overall quality of life improves significantly after transplantation; (2) although most dimensions of functional disability improve after transplantation, some aspects may suffer; (3) quality of life gains after transplantation may not be equal for all pretransplantation conditions.

Comparing the performance of health status measures for healthy older adults

OBJECTIVES

The specific goals of the study were to compare three health status measures among older adults for their correlations with similar scales and to examine whether extreme (positive) health states might lead to measurement problems. We also report on practical administration and response problems among older adults.

DESIGN

Eligible and randomly selected health plan enrollees aged 65 and older were sent a baseline survey about their health. A random sample of persons who returned this survey was recruited to participate in the comparative study. Additional questionnaires were completed by mail and telephone interviews. Measures were repeated at a 1-year follow-up mailing.

SETTING

This study was conducted at Group Health Co-operative (GHC) of Puget Sound, a large prepaid health maintenance organization.

PARTICIPANTS

Subjects were 200 of the 283 older adults selected (68.2% response). Mean age was 72.5 years.

MEASUREMENTS

The primary measures were the Sickness Impact Profile (SIP), the Quality of Well-being Scale (QWB), and three scales of the Medical Outcomes Study Short-Form 36 (SF-36). Also included were a stress scale, the Positive Affect Scale, and the Chronic Disease Score (CDS) computed from the automated pharmacy data.

RESULTS

SIP scores showed a very strong skew toward low (good health) scores with a mean of 3.4% (+/- SD 4.4). The QWB scores ranged from .50 to .90 (mean .73 +/- .09). For the MOS SF-36 scales, scores of 100 (good health) were common for both of the physical health scales but not for general health. Analyses showed the SIP, QWB, and MOS SF-36 scales were moderately to strongly correlated with similar measurement scales and with the independent measure of chronic disease and psychosocial health. Scales repeated at 1 year were highly correlated: intraclass correlation coefficients between baseline and 1 year ranged from an r = .51 to .73.

CONCLUSIONS

Our results suggest that the SIP is not a useful tool for rating healthy, community-dwelling older adults. Two MOS SF-36 measures used in this study showed some tendency for "ceiling" measurement effects. The QWB demonstrated an acceptable distribution of scale scores; however, it is the most complex of the three measures to administer. Among the broad range of older adults, no one tool appears to apply to every situation.

Assessing health-related quality of life in patients with sciatica

STUDY DESIGN

This study analyzed health-related quality-of-life measures and other clinical and questionnaire data obtained from the Maine Lumbar Spine Study, a prospective cohort study of persons with low back problems.

OBJECTIVE

For persons with sciatica, back pain-specific and general measures of health-related quality-of-life were compared with regard to internal consistency, construct validity, reproducibility, and responsiveness in detecting small changes over a 3-month period.

SUMMARY OF BACKGROUND DATA

Data were collected from 427 participants with sciatica. Baseline in-person interviews were conducted with surgical and medical patients before treatment and by mail at 3 months.

METHODS

Health-related quality-of-life measures included symptoms (frequency and bothersomeness of pain and sciatica) functional status and well-being (modified back pain-specific Roland scale and Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and disability (bed rest, work loss, and restricted activity days).

RESULTS

Internal consistency of measures was high. Reproducibility was moderate, as expected after a 3-month interval. The SF-36 bodily pain item and the modified Roland measure demonstrated the greatest amount of change and were the most highly associated with self-rated improvement. The specific and generic measures changed in the expected direction, except for general health perceptions, which declined slightly. A high correlation between clinical findings or symptoms and the modified Roland measure, SF-36, and disability days indicated a high degree of construct validity.

CONCLUSIONS

These measures performed well in measuring the health-related quality-of-life of patients with sciatica. The modified Roland and the physical dimension of the SF-36 were the measures most responsive to change over time, suggesting their use in prospective evaluation. Disability day measures, although valuable for assessing the societal impact of dysfunction, were less responsive to changes over this short-term follow-up of 3 months.

Socioeconomic status and exercise self-efficacy in late life

Self-efficacy, or assessments about one's ability to carry out particular tasks, has been shown to play a central role in the adoption and maintenance of exercise. The relationship between exercise self-efficacy and socioeconomic status (SES), however, has not been formally developed or tested, and the implications of SES for exercise interventions are not known. We hypothesize pathways through which income, education, and occupation affect self-efficacy and capitalize on the availability of responses from 1944 older HMO enrollees to investigate the direct and indirect associations of SES indicators with exercise self-efficacy. Direct associations of age and education are found. Indirect associations of age, income, education, and occupation operate primarily through previous exercise experience, satisfaction with amount of walking, depression, and outcome expectations. The potentially modifiable nature of exercise outcome expectations (i.e., belief in the benefits of exercise) in combination with its strong association with exercise self-efficacy argue in support of greater consideration of its role in attempts to improve exercise self-efficacy.

A psychiatrist-rated battery of measures for assessing the clinical status of psychiatric inpatients

Despite the increasing demand for outcome assessment measures, no published reports have provided a standardized way to assess psychiatric inpatients that includes diagnosis and observer ratings of psychopathology. This paper reviews general principles for selecting outcome assessment measures, proposes a battery of instruments based on already available measures to assess clinical status in psychiatric inpatients, reviews methods of implementing the battery in an academic inpatient psychiatric setting, and presents preliminary data on its interrater reliability, construct validity, and range of response to acute hospitalization. Preliminary results suggest that the battery may be useful for resident and medical student education and for enhancing quality assurance and continuous quality improvement.

Medicare reimbursement for preventive care. Changes in performance of services, quality of life, and health care costs

A randomized, controlled trial was conducted to assess the effects of a financial and office systems intervention to increase preventive care in physicians' offices for patients aged 65 years or older. A total of 1,914 patients from 10 primary-care medical practices in central North Carolina were randomized within practices to an intervention and a usual-care control group. The intervention consisted of full Medicare reimbursement to physicians for preventive care and health promotion packages (thus making these services free for patients), regular prompting of physicians to routinely schedule preventive care visits, a new office system in which nurses carried out many preventive procedures, and a form for charting preventive care. The performance of screening tests dramatically increased in the intervention group relative to control (P < 0.001), but there was evidence of lack of follow-up of abnormal findings by physicians. At the 2-year follow-up, there were minimal differences between intervention and control groups in health-related quality-of-life indicators. Relative to the $294 per patient 3-year cost to Medicare for waivered services, the intervention was reimbursed-cost neutral or slightly cost reducing ($190 over 3 years) for Medicare. It is concluded that adding reimbursement for preventive services to Medicare--even with the office systems changes made in this study--will not by itself lead to effective implementation of preventive services in community medical practices. To enhance patient benefit from preventive services, greater attention needs to be focused on an organized approach to patient follow-up.