A comparative review of generic quality-of-life instruments

What do patients think? Results of a mixed methods pilot study assessing sciatica patients' interpretations of satisfaction and improvement

BACKGROUND

Little is known about the issues low back pain patients take into account when deciding their satisfaction with care, the importance placed on such satisfaction, or the factors they consider when assessing their overall improvement.

OBJECTIVE

The purpose of this study was to explore these issues and to assess the feasibility of implementing qualitative research methods within a clinical trial.

METHODS

Study participants were volunteers taking part in a randomized clinical pilot study comparing nonsurgical treatments for sciatica. Face-to-face interviews were conducted, transcribed, and analyzed using content analysis.

RESULTS

All 31 individuals who participated in the pilot study were interviewed. When asked which issues they considered when deciding their satisfaction with care, the most frequently identified themes were change in pain, personnel, and the treatment experience. When assessing their overall improvement, all participants considered whether their pain had changed. In response to the question asking participants which outcomes they considered to be most important, severity of pain and quality of life were most commonly cited.

CONCLUSION

This study demonstrated that a "mixed methods" approach using qualitative research methods within a clinical trial is not only feasible but can provide interesting and useful information for trial interpretation and future study design. By providing insight to the multidimensional nature of patients' beliefs and perceptions, this technique may not only shape but also redefine the focus of patient-oriented research and health care for low back pain conditions.

Quality of life of patients with type I diabetes mellitus

The objective of this study was to assess health related quality of life (QOL) in patients with type I diabetes mellitus (DMT1) and to compare their QOL with the QOL of persons of comparable age in the general population. Furthermore we wanted to investigate which factors mostly influence QOL. In a Dutch cohort of 281 patients with DMT1 QOL was assessed using two generic instruments: the EuroQol and the RAND-36. We performed regression analyses to investigate relationships between several demographic (e.g. sex, age, marital status) and diabetes-specific variables (e.g. HbA1c, frequency of insulin injection, presence of acute and chronic complications) and QOL. The Spearman rank correlations between RAND-36 domains and EuroQol were analysed. RAND-36 results showed, for almost all domains, a QOL comparable with persons of comparable age in the general population. In contrast the QOL measured with the EuroQol was lower for subjects with DMT1. Hyperglycaemic complaints and macrovascular complications had a profound negative influence on QOL. Most correlations between the RAND-36 results and the EuroQol results corresponded with our expectations. Longitudinal data and comparison with results of several diabetes-specific questionnaires should help to establish which instrument might be most appropriate to measure QOL in patients with DMT1.

Areas of decrement in health-related quality of life (HRQL): comparing the SF-12, EQ-5D, and HUI 3

BACKGROUND

Different measures of health status and health-related quality of life (HRQL) have been advocated for different purposes at the clinical and population level. Relatively little is known about how these measures function in relationship to one another. We examined the relationship between the Short-Form 12 (SF-12), EQ-5D, and Health Utilities Index (HUI) Mark 3 for overall scores and in analogous domains of health. A convenience sample was obtained through surveying patients at an inner-city community health center.

MEASUREMENTS AND MAIN RESULTS

The sample was comprised primarily of low-income racial/ethnic minorities; 393 patients were approached and 301 patients (77%) participated. The three measures had correlations between overall scores that ranged from 0.41 to 0.69 and correlations between similar domains from different measures that ranged from 0.42 to 0.59. For the HUI 3, 'any' impairment most frequently was noted with pain, vision, cognition, and emotion. For the EQ-5D, pain/discomfort and anxiety/depression were reported as impaired most often. Compared to published population scores, participants reported impairments with increased frequency and at a greater level.

CONCLUSIONS

Participants demonstrated consistency with responses to similar types of items and correlations between related aspects of health were moderate to strong. Domains of health most often reported as impaired resembled those noted in national surveys. Despite differences in the structure of the measures, all three instruments capture information about decrements in broadly analogous domains of health.

Health related quality of life in individuals with asthma related symptoms

BACKGROUND

Where evidence is required for disease-area prioritisation (e.g. by national policymakers), impact on health related quality of life (HRQoL) can be considered equitably across diseases using quantitative data from generic HRQoL instruments. Before this can take place, it must be shown that the instrument captures HRQoL impairment associated with each disease area.

AIM

To ascertain whether the HRQoL impairment associated with respiratory disease can be represented by responses to EQ-5D, a generic HRQoL questionnaire.

METHOD

EQ-5D and a respiratory health questionnaire were sent to 10,471 adults registered with two general practices in Manchester, UK. EQ-5D examines 5 domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) and includes an overall rating via visual analogue scale. Societal valuations of domain responses were also considered.

RESULTS

HRQoL was substantially reduced in respondents who were likely to have obstructive airways disease (mean EQ-5D(index) 0.63 compared to 0.82, t-test P < 0.001; mean EQ-5D(vas) 62.7 compared to 77.6, t-test P < 0.001) and was negatively associated with respiratory symptoms, older age and female gender. The association with respiratory problems remained following stratification by age and gender. The deficit in HRQoL associated with increasing age was more pronounced in those likely to have obstructive airways disease.

CONCLUSION

HRQoL measured using EQ-5D is substantially reduced in respondents with respiratory symptoms enabling use of the instrument in inter-disease comparisons.

Effects of olanzapine alone and olanzapine/fluoxetine combination on health-related quality of life in patients with bipolar depression: Secondary analyses of a double-blind, placebo-controlled, randomized clinical trial

BACKGROUND

Improving patients' health-related quality of life (HRQOL) could be a treatment goal for bipolar depression.

OBJECTIVES

The objectives of these secondary analyses of a previous report were to determine the benefits of olanzapine alone and olanzapine-fluoxetine combination (OFC) for improving HRQOL in patients with bipolar depression using both a generic and a depression-specific HRQOL instrument, and to examine the association between the 2 HRQOL instruments and the construct validity of the depression-specific HRQOL instrument.

METHODS

This was a double-blind, placebo-controlled, 83-site, international, randomized trial. Adults with bipolar I disorder, most recent episode depressed (according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), were randomly assigned to receive olanzapine (6-20 mg/d), OFC (6/25, 12/25, or 12/50 mg/d), or placebo for 8 weeks. HRQOL improvement was calculated as last-observation-carried-forward changes in dimension and component summary scores on Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and total score on the Quality of Life in Depression Scale (QLDS).

RESULTS

Patients were assigned to receive olanzapine (n = 370), [corrected] OFC (n = 86), or placebo (n = 377) [corrected] for 8 weeks. Of 833 enrolled patients, 454 discontinued (olanzapine, 191/370 [51.6%] [corrected]OFC, 31/86 [36.0%]; and placebo, 232/377 [61.6%]) [corrected] Compared with placebo, olanzapine-treated patients exhibited greater improvements on SF-36 mental component summary (MCS) score ( P=0.002) and 3 of 8 SF-36 dimension scores (mental health [P=0.015], role-emotional [P=0.046], and social functioning [P=0.006). OFC-treated patients exhibited greater improvements on MCS score ( P<0.001) vs both placebo and olanzapine), 5 SF-36 dimension scores (general health perception (P<0.001) vs placebo; (P<0.001) vs olanzapinel, mental health [ P=0.001] vs both placebo and olanzapine], role-emotional [ P<0.001] vs placebo; [P=0.007] vs olanzapine], social functioning [ P=0.001] vs placebo; [P=0.032] vs olanzapine], and vitality [P=0.002] vs placebo; [P=0.011] vs olanzapine]), and QLDS total score ( P<0.001] vs both placebo and olanzapine). Changes in SF-36 scores of mental health, social functioning, role-emotional, and vitality were highly correlated to changes in the QLDS total score (all p < -0.5).

CONCLUSIONS

Based on these analyses, patients with bipolar depression receiving olanzapine or OFC for 8 weeks had greater improvement in HRQOL than those receiving placebo. OFC treatment was associated with greater improvement in HRQOL than olanzapine alone. The correlation results support the construct validity of the QLDS.

Outcome measures in osteoarthritis: Randomized controlled trials

Accepted outcome measures in randomized controlled trials (RCTs) in osteoarthritis (OA) include patient-reported assessments of physical function and health-related quality of life (HRQOL). Available data can inform treatment decisions when statistically significant changes are viewed in terms of clinically important improvements. Patient-reported outcomes validated in OA include global assessments of pain, disease activity, and disease-specific and generic measures of physical function and HRQOL. Definitions of minimum clinically important differences (MCID) have been derived from RCTs with physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 selective agents. Definitions of MCID should serve only as guidelines based on mean changes in a treatment group, and do not necessarily reflect clinically meaningful improvements for an individual patient. They help to interpret data across treatments and patient populations. Definitions of MCID may differ for the type of intervention assessed; additional methodologic issues must be addressed when evaluating nonpharmacologic treatments. Based on RCTs in OA evaluating physical therapy, cyclooxygenase-2 agents, and NSAIDs, the Western Ontario and McMaster Osteoarthritis Index is valid, reliable, sensitive to change, and correlates closely with the generic Medical Outcomes Survey Short-Form 36 measure of HRQOL. When evaluating RCT data, understanding derivation and MCID values of outcome measures facilitates informed therapeutic decisions regarding therapeutic interventions.

The Arthritis, Diet and Activity Promotion Trial (ADAPT): design, rationale, and baseline results

Osteoarthritis (OA) of the knee leads to restrictions of physical activity and ability to perform activities of daily living. Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability. The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was developed to test the efficacy of lifestyle behavioral changes on physical function, pain, and disability in obese, sedentary older adults with knee OA. This controlled trial randomized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups: Healthy Lifestyle Control; Dietary Weight Loss; Structured Exercise; or Combined Exercise and Dietary Weight Loss. The weight-loss goal for the diet groups was a 5% loss at 18 months. The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory. Exercise training consisted of aerobic and strength training for 60 minutes, three times per week in a group and home-based setting. The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index. Other measurements included timed stair climb, distance walked in 6 minutes, strength, gait, knee pain, health-related quality of life, knee radiographs, body weight, dietary intake, and cost-effectiveness of the interventions. We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks. The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA.

Guide to outcomes measurement for patients with low back pain syndromes

The Guide for Physical Therapist Practice states that the physical therapist determines the expected outcomes for each intervention and engages in outcomes data collection and analysis. Outcomes tracking provides a systematic way for therapists to monitor treatment effectiveness and efficiency. A familiarity with outcome measures for the patient with low back pain is indispensable for therapists in the outpatient orthopaedic setting, where patients with lumbar pain often comprise the majority of the caseload. The therapist must be able to evaluate and choose appropriate measurement tools and understand the clinical meaning of measurements to successfully employ these instruments. The purpose of this article is to review measurement instruments for patients with low back pain and to offer practical guidelines for selection and use of outcome measures for this population. The reliability, validity, sensitivity to change, and utility of common outcome measures are discussed. An overview of generic, disease-specific, and patient-specific tools is provided with specific commentary on the use of the SF-36, SF-12, Oswestry Questionnaire, Roland-Morris Questionnaire, and patient-specific tools. Practical guidelines for utilizing outcome measures in clinical practice and the overall benefits of outcomes tracking are highlighted.

Health-related quality of life as outcome parameter in haemophilia treatment

Health-related quality of life (HRQoL) is increasingly used as an outcome parameter in haemophilia treatment. Currently, only generic HRQoL instruments are used, as disease-specific instruments for haemophilia are not available. The most widely used generic instruments are the descriptive SF-36 questionnaire and the EQ-5D questionnaire for assessment of utilities, ie preference-based HRQoL. Results of both instruments show significant correlation. All haemophilia prophylaxis studies using HRQoL as an outcome report a decreased HRQoL compared with the general population, a positive effect of prophylactic treatment and a negative effect of age. Generic instruments for measuring HRQoL are able to pick up differences between groups of patients with haemophilia and enable us to make comparisons across diseases. However, in order to establish the optimal treatment strategy for severe haemophilia, further information is needed on the long-term effects of different strategies on HRQoL. In addition, haemophilia-specific HRQoL instruments should be developed in order to provide detailed information for adjustment and evaluation of treatment in individual patients.

Puerto Rican understandings of child disability: methods for the cultural validation of standardized measures of child health

Validating the cultural context of health is important for obtaining accurate and useful information from standardized measures of child health adapted for cross-cultural applications. This paper describes the application of ethnographic triangulation for cultural validation of a measure of childhood disability, the Pediatric Evaluation of Disability Inventory (PEDI) for use with children living in Puerto Rico. The key concepts include macro-level forces such as geography, demography, and economics, specific activities children performed and their key social interactions, beliefs, attitudes, emotions, and patterns of behavior surrounding independence in children and childhood disability, as well as the definition of childhood disability. Methods utilize principal components analysis to establish the validity of cultural concepts and multiple regression analysis to identify intracultural variation. Findings suggest culturally specific modifications to the PEDI, provide contextual information for informed interpretation of test scores, and point to the need to re-standardize normative values for use with Puerto Rican children. Without this type of information, Puerto Rican children may appear more disabled than expected for their level of impairment or not to be making improvements in functional status. The methods also allow for cultural boundaries to be quantitatively established, rather than presupposed.

The value of patient-reported health status in predicting short-term outcomes after coronary artery bypass graft surgery

BACKGROUND

Risk stratification for comparison of outcomes after coronary artery bypass grafting (CABG) typically includes only clinical measures of risk. Patient-reported health status may be an important independent predictor of short-term health outcomes.

OBJECTIVE

To determine whether patient-reported health status, as measured by the Physical and Mental Component Summary scores of the SF-36, predicts in-hospital mortality and prolonged length of stay after CABG, after controlling for other clinical predictors of those outcomes.

RESEARCH DESIGN

Prospective cohort study conducted from September 1993 to November 1995.

SUBJECTS

One thousand seven hundred seventy-eight adults who underwent isolated CABG for myocardial ischemia.

MEASURES

In-hospital mortality and prolonged length of stay (> 14 days).

RESULTS

There were 27 deaths and 223 patients with prolonged length of stay in the study sample. A 10-point decrease in the Physical Component Summary (PCS) score increased the odds of in-hospital mortality by 61% (OR, 1.61; 95% CI, 1.04-2.49), independent of established clinical risk factors. Similarly, a 10-point decrease in the PCS score increased the odds of prolonged length of stay by 33% (OR, 1.33; 95% CI, 1.13-1.57). A 10-point decrease in the Mental Component Summary score (MCS) decreased the odds of mortality by 36% (OR, 0.64; 95% CI, 0.43-0.95).

CONCLUSIONS

The PCS score is independently and significantly associated with in-hospital mortality and prolonged length of stay, after controlling for clinical risk factors. The MCS score is independently and significantly associated only with mortality, though the direction of the effect is unexpected. The result likely reflects a property of the scoring of the MCS and not a finding of clinical substance. Although caution must be taken when interpreting the summary scores, the SF-36 yields information not otherwise captured by clinical data and may be useful in risk stratification for in-hospital mortality and prolonged length of stay after CABG.

Quantifying the harmful effect of psoriasis on health-related quality of life

BACKGROUND

Psoriasis affects 7 million people in the United States, causing substantial cost, social stigma, and disability.

OBJECTIVE

The purpose of this study was to evaluate the health effects of skin disease by comparing psoriasis to other primary medical disorders using 3 different scales of health-related quality of life.

METHODS

A self-administered questionnaire consisting of 3 health-related quality of life measures was given sequentially to 35 eligible patients with psoriasis presenting to the Dermatology Branch of the National Cancer Institute (NCI) for an investigational therapeutic protocol.

RESULTS

All patients (100%) agreed to participate. The median Psoriasis Area and Severity Index (PASI) score was 13.0. Overall, 82.9% at least often felt the need to hide their psoriasis, and 74.3% claimed their self-confidence was at least often affected by their psoriasis. The median EQ-5D health state utility score was 13.0% less than healthy individuals (P <.001). On the SF-36, the mean general health score was 13.2% less (P =.005) and the median social functioning score 18.7% less (P =.005) than that of patients with no chronic conditions.

CONCLUSION

Individuals with psoriasis are significantly affected in their health state utility, perception of general health, and social functioning when compared with individuals without chronic disease and those with certain primary medical conditions.

Reliability and validity of the COOP/WONCA health status measure in patients with chronic obstructive pulmonary disease

The objective of the study was to assess the reliability and validity of the Dartmouth Primary Care Cooperative Information Project/World Organization of National Colleges, Academies, and Academic Associations of General Practice/Family Physicians (COOP/WONCA) questionnaire in outpatients with chronic obstructive pulmonary disease (COPD). The test-retest reliability of individual items of the COOP/WONCA questionnaire was assessed using a weighted kappa-statistic, and construct validity was assessed by correlating items of the COOP/WONCA with the EQ-5D health status measure. Discriminant validity was assessed by comparing scores for known groups, at the same time comparing the results with those of a lung-specific health status questionnaire. The individual items of the COOP/WONCA had test-retest reliabilities of 0.67-0.78 (weighted kappa). Spearman's rank correlations between COOP/WONCA single-item scores and corresponding EQ-5D ranged 0.45-0.72, which were generally higher than associations between non-corresponding items. Four of the five COOP/WONCA items did not discriminate between patient groups divided according to forced expiratory flow in 1 sec (FEV1) in percent of predicted and 6-min walking distance, while four of five items of the lung-specific questionnaire discriminated well between these groups. The COOP/WONCA chart system was reliable and showed properties supporting the construct validity of the measure. The items, however, did not discriminate well between known groups, indicating that this questionnaire is not very sensitive in patients with COPD. The reliability of the COOP/WONCA items was acceptable for use at group level, but lower than current recommendations for use in individual patients.

A comparison of the SF-36 and Nottingham Health Profile in patients with chronic neuropathic pain

The aim of this study was to evaluate and compare the psychometric properties of two generic health-related quality of life (HRQoL) instruments, the Short Form Health Survey (SF-36) and the Nottingham Health Profile (NHP) in a group of patients with chronic peripheral neuropathic pain (PNP). The sample consisted of 126 adults (56 men and 70 women) with PNP following a lesion of a peripheral nerve, spinal nerve or nerve root or patients with post-herpetic neuralgia. The battery of tests included visual analogue scales (VASs) for pain assessment and global rating of health and verbal rating scales of pain and other symptoms, as well as patient descriptors. The SF-36 had higher internal consistency reliability coefficients (alpha=0.79, range 0.70-0.90) than the NHP (alpha=0.68, range 0.49-0.79). Correlations between comparable dimensions of the two instruments were significant (range from -0.79 for the physical and mental dimensions to -0.29 for the social dimension) indicating a moderate degree of convergent validity. The study population had significantly worse scores on all dimensions of the two instruments when compared with the general population. Subjects with high VAS scores for pain on movement and those with low global health ratings had poorer scores on the both instruments. Overall, the SF-36 performed somewhat better on psychometric testing than did the NHP. However, the NHP contains dimensions such as sleep and more pain items which might be of particular importance in the PNP population. Since the instruments are short, both could be retained for continued testing in outcome studies of this population.

Cross-sectional study of health-related quality of life in African Americans with chronic renal insufficiency: the African American Study of Kidney Disease and Hypertension Trial

We measured health-related quality of life (HRQL) by using the Medical Outcomes Study 36-Item Short-Form (SF-36) in a cross-sectional study of 1,094 African American men and women with mild to moderate chronic renal insufficiency (mean glomerular filtration rate, 45.7 mL/min/1.73 m2) caused by hypertension before randomization onto the African American Study of Kidney Disease and Hypertension (AASK) Trial. Scales contributing to physical health and a summary measure, the Physical Component Summary (PCS) score (mean, 43.4 +/- 10.9 [SD]), were significantly lower than scales relating to mental health and the Mental Component Summary (MCS) score (51.3 +/- 10.3). All scales (except Role-Physical) and the PCS and MCS were significantly higher in men (44.3 +/- 10.9 and 51.8 +/- 10.0, respectively) than women (41.9 +/- 10.8 and 50.5 +/- 10.6, respectively). In multivariate analysis, employment status, education level, household income, body mass index, comorbid medical conditions, years of hypertension, number of antihypertensive drugs prescribed, exercise status, and male sex were significant independent predictors of PCS. Fewer factors predicted MCS and included employment status, marital status, current smoking, age, comorbid medical conditions, and male sex. In the entire AASK cohort, mean scores for individual scales, except Mental Health, and the PCS were lower, but the mean MCS score was slightly higher than values for the US general population. Values for individual scales of the SF-36 and the PCS were substantially higher among AASK participants compared with African-American hemodialysis patients. Six of the eight scales were lower in the AASK cohort compared with groups of racially mixed and exclusively African-American hypertensive subjects. We conclude that physical aspects of quality of life are substantially reduced compared with mental components among AASK participants, and a number of demographic and clinical characteristics significantly impact on HRQL.

Role of health-related quality of life in palliative chemotherapy treatment decisions

PURPOSE

To determine the frequency with which health-related quality-of-life (HRQL) considerations lead to modification or discontinuation of palliative chemotherapy, and the association between physicians' ratings of patients' HRQL and such treatment decisions.

METHODS

Four consecutive medical consultations of 203 patients receiving outpatient palliative chemotherapy were tape-recorded and the content was analyzed to determine the frequency of and reasons for treatment alterations. Physicians rated their patients' HRQL by using the COOP/WONCA health assessment charts. Data on tumor response and treatment toxicity were obtained from the audiotapes and, when necessary, were confirmed by medical chart audits.

RESULTS

Treatment was modified in 54 cases (26%) and discontinued in 40 (20%). The primary reasons for modifying treatment were toxicity (n = 22), HRQL considerations (n = 18), and tumor progression (n = 14). The primary reasons for discontinuation of treatment were tumor progression (n = 23), HRQL considerations (n = 6), and toxicity (n = 3). For eight patients, a combination of tumor progression and HRQL issues resulted in discontinuation of treatment. Treatment decisions were associated significantly with physicians' global ratings of patients' HRQL but not with more specific HRQL domains. In the presence of tumor progression or serious toxicity, HRQL considerations played little or no role in treatment decisions. Furthermore, approximately 70% of patients without evidence of tumor progression or toxicity, but with seriously impaired HRQL, continued to receive their treatment as planned.

CONCLUSION

Contrary to previous findings based on physicians' self-report data, HRQL considerations seem to play a relatively minor role in decisions regarding modification or discontinuation of palliative chemotherapy.

Health-related quality of life and gastrointestinal disease

Society is changing rapidly, and new aspects need to be considered when evaluating treatment of disease. Health-related quality of life (HRQL) is a relatively new addition to the tools clinicians use to gain a better understanding of the impact of disease and its treatment. The questions 'What is it?', 'How it is measured?' and 'How can the information be used?' are now better understood than a few years ago. Generic instruments to capture HRQL enable a broad assessment of a range of aspects and can be used to make comparisons between different patient populations. Irrespective of the choice of instrument, they can classify the influence of different factors, such as gender, age, general health status and disease severity. Health-related quality of life assessments have been made in many areas of gastroenterology, such as reflux disease, inflammatory bowel disease and irritable bowel syndrome, to describe the burden of illness and the impact of treatment. Health-related quality of life as a prediction of treatment response is another interesting option. Its ability in the context of surgical intervention and outcomes is also emerging even though more work must be done in this area. Health-related quality of life evaluations, as an additional tool in the management of patients, are here to stay.

Quality-of-life assessment in osteoporosis: health-status and preference-based measures

Health-status and preference-based approaches to assessing health-related quality of life (HR-QOL) in osteoporosis are reviewed. Osteoporosis-targeted health-status instruments [i.e. Osteoporosis Quality-of-Life Questionnaire (OQLQ), Osteoporosis Assessment Questionnaire (OPAQ), Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO), Osteoporosis-Targeted Quality-of-Life Questionnaire (OPTQoL), Osteoporosis Functional Disability Questionnaire (OFDQ), Quality-of-Life Questionnaire in Osteoporosis (QUALIOST)], which have been utilised to document the adverse impact of osteoporosis on HR-QOL in diverse clinical and epidemiological studies, are described first. Preference-based approaches to osteoporosis health-outcome measurement are then considered in both clinical and health policy settings. In the clinical setting, direct preference assessments [i.e. visual analogue scale (VAS), time tradeoff (TTO), standard gamble (SG)] using either experienced or described health outcomes have consistently shown significantly lower values for osteoporosis-related health states relative to usual or ideal health. In the health-policy context, preference-classification systems [i.e. EuroQoL (EQ-5D), Health Utilities Index (HUI)] for valuing health in economic studies are reviewed. At present, there is little evidence to guide the choice of one system over another for assessing the cost effectiveness of osteoporosis interventions; however, use of a consistent set of health-state values is essential. Further research is needed to characterise associations between osteoporosis-targeted health-status instruments and preference-based health-outcome measures. In addition, the longitudinal impact of osteoporosis and related fractures on HR-QOL must be documented.

Onychomycosis: health-related quality of life considerations

The symptoms of onychomycosis and their impact on personal appearance are important determinants of patients' perceptions of their own health. The effect of onychomycosis is greater on psychosocial than physical functioning and is directly related to the extent of nail involvement. This review identified a number of disease-targeted questionnaires that have been developed to assess the impact of onychomycosis and its treatment on health-related quality of life (HR-QOL). The instruments differ considerably in the extent to which they have been psychometrically tested. Most have been shown to provide both valid and reliable measurement of HR-QOL in patients with onychomycosis of the toes. However, not all have been tested in patients with fingernail disease. The generic and disease-targeted scales of most of the available questionnaires exhibit poor variability, which may limit their responsiveness to clinically important change. Only one instrument, the Onychomycosis Disease-Specific Questionnaire, has been incorporated into a clinical trial. Thus, information relating to the impact of onychomycosis treatment on HR-QOL is limited. Future efforts should focus on the systematic evaluation of existing questionnaires in all populations for which they were developed. In addition, it is important that disease-targeted measures be included in future clinical trials so that a better understanding of the impact of onychomycosis treatment on patient HR-QOL may be gained.

Pancreas after kidney transplants

BACKGROUND

For certain uremic diabetic patients, a sequential transplant of a kidney (usually from a living donor) followed by a cadaver pancreas has become an attractive alternative to a simultaneous transplant of both organs. The purpose of this study was to compare outcomes with simultaneous pancreas-kidney (SPK) versus pancreas after kidney (PAK) transplants to determine advantages and disadvantages of the two procedures.

METHODS

Between January 1, 1994, and June 30, 2000, we performed 398 cadaver pancreas transplants at our center. Of these, 193 were SPK transplants and 205 were PAK transplants. We compared these two groups with regard to several endpoints, including patient and graft survival rates, surgical complications, acute rejection rates, waiting times, length of hospital stay, and quality of life.

RESULTS

Overall, surgical complications were more common for SPK recipients. The total relaparotomy rate was 25.9% for SPK recipients versus 15.1% for PAK recipients (P = 0.006). Leaks, intraabdominal infections, and wound infections were all significantly more common in SPK recipients (P = 0.009, P = 0.05, and P = 0.01, respectively, versus PAK recipients). Short-term pancreas graft survival rates were similar between the two groups: at 1 year posttransplant, 78.0% for SPK recipients and 77.9% for PAK recipients (P = not significant). By 3 years, however, pancreas graft survival differed between the two groups (74.1% for SPK and 61.7% for PAK recipients), although this did not quite reach statistical significance (P = 0.15). This difference in graft survival seemed to be due to increased immunologic losses for PAK recipients: at 3 years posttransplant, the incidence of immunologic graft loss was 16.2% for PAK versus 5.2% for SPK recipients (P = 0.01). Kidney graft survival rates were, however, better for PAK recipients. At 3 years after their kidney transplant, kidney graft survival rates were 83.6% for SPK and 94.6% for PAK recipients (P = 0.001). The mean waiting time to receive the pancreas transplant was 244 days for SPK and 167 days for PAK recipients (P = 0.001).

CONCLUSIONS

PAK transplants are a viable option for uremic diabetics. While long-term pancreas graft results are slightly inferior to SPK transplants, the advantages of PAK transplants include the possibility of a preemptive living donor kidney transplant, better long-term kidney graft survival, significantly decreased waiting times, and decreased surgical complication rates. Use of a living donor for the kidney transplant expands the donor pool. Improvements in immunosuppressive regimens will hopefully eliminate some of the difference in long-term pancreas graft survival between SPK and PAK transplants.

EQ-5D in patients with dementia: an investigation of inter-rater agreement

BACKGROUND

There are difficulties in obtaining health-related quality of life (HRQL) data from patients with dementia due to variation in their cognitive ability, degree of insight and capacity to make judgments. The use of proxies is one solution.

OBJECTIVES

To examine the inter-rater agreement of patient and proxy completion of the EuroQol EQ-5D instrument (EQ-5D).

RESEARCH DESIGN

The EQ-5D instrument was completed separately by patients, their caregivers and a physician. Assessment of inter-rater agreement involved comparison of self-completed (patient) and proxy-completed (caregiver and physician) responses for each dimension of EQ-5D, using a weighted kappa score. Three key hypotheses were tested. (1) Interrater agreement would be stronger between patient and caregiver than between patient and physician. (2) Interrater agreement would be stronger on the 'observable' and objective dimensions of EQ-5D. (3) Interrater agreement between patient and proxies would be stronger for patients with earlier dementia.

SUBJECTS

The sample comprised 64 patients with a range of dementia severity.

MEASURES

The EQ-5D health state classification system and visual analogue scale were used to assess HRQL. Global severity of dementia was determined using the Clinical Dementia Rating Scale.

RESULTS

The principal finding of this study was that responses to EQ-5D questions were highly variable across the three raters such that none of the three hypotheses were strongly supported.

CONCLUSIONS

The data provide some support for the use of EQ-5D when interviewer administered. However, there are serious concerns regarding the validity of patient self-rated HRQL data obtained in this study and uncertainty exists regarding who the appropriate proxy should be, as different groups of proxies provide different results. It was not clear whether caregivers or physicians represent better proxies. Further research should focus on the comparison of caregivers and physicians as proxies.

Assessing health-related quality of life in cataract patients: the relationship between utility and health-related quality of life measurement

The relationship between health-related quality of life (HQL) measures and patient preference for their health status was studied. Study subjects consisted of 132 patients at four hospitals who were scheduled for cataract surgery. Generic and disease-specific health status measures were determined in study subjects. The Medical Outcomes Study Short-form 36 (SF-36) item health status instrument was used to measure generic health status and the Visual Function 14 (VF-14) item visual health status instrument was used as the disease-specific health measure. Preference for general health and visual health was measured by assessing utilities assigned by patients to certain health states. Utilities assigned for general health were correlated with all categories of the SF-36 and VF-14 scores. Utilities assigned for visual health were correlated with four categories of the SF-36 (role limitation due to emotional health, general health, physical functioning, and vitality) and VF-14 scores. Utilities assigned for visual health were more strongly correlated with VF-14 scores than generic measures of health. Verbal ratings for visual health were correlated with Snellen visual acuity (SVA) (r = 0.20), utilities assigned for visual health (r = 0.58), VF-14 scores (r = 0.74), all categories of the SF-36 (r values ranging from 0.21 to 0.28), utilities assigned for general health (r = 0.19), and verbal ratings for general health (r = 0.29). Utility measures and verbal ratings for general and visual health were shown to be appropriate HQL measures. These measures were strongly correlated with other established generic and disease-specific health measures and should be included in the array of health status measures.

The Health Utilities Index (HUI) system for assessing health-related quality of life in clinical studies

This paper reviews the Health Utilities Index (HUI) systems as means to describe health status and obtain utility scores reflecting health-related quality of life (HRQoL). The HUI Mark 2 (HUI2) and Mark 3 (HUI3) classification and scoring systems are described. The methods used to estimate multiattribute utility functions for HUI2 and HUI3 are reviewed. The use of HUI in clinical studies for a wide variety of conditions in a large number of countries is illustrated. HUI provides a comprehensive description of the health status of subjects in clinical studies. HUI has been shown to be a reliable, responsive and valid measure in a wide variety of clinical studies. Utility scores provide an overall assessment of the HRQoL of patients. Utility scores are also useful in cost-utility analyses and related studies. General population norm data are available. The widespread use of HUI facilitates the interpretation of results and permits comparisons. HUI is a useful tool for assessing health status and HRQoL in clinical studies.

Integrating baseline health status data collection into the process of care

BACKGROUND

Health status data are an increasingly important component of outcomes assessment and can be used to facilitate quality assessment and improvement efforts. An enormous challenge to the use of health status data among hospitalized patients, however, is collecting baseline data at the time of treatment, an essential component for risk-adjusting subsequent outcomes. The Mid America Heart Institute of Saint Luke's Hospital (Kansas City, Mo), attempted to integrate the collection of health status assessments within the process of performing coronary revascularization.

THE DATA COLLECTION STRATEGY

The data collection strategy was developed for each admission portalelective outpatients (admissions for same-day procedures), inpatients, and emergent cases. Health status data were collected on all patients with coronary artery disease who were receiving a percutaneous coronary intervention or coronary artery bypass graft with no disruption to physician scheduling or nursing staff.

RESULTS

In general, patients were agreeable to completing the health status survey. Despite initial efforts to educate the hospital staff about the goal and purpose of health status assessment, staff members who were unaware of the uses of these data seemed to minimize their value. Providing examples of how to use these data relative to the staff member's specific occupational role facilitated buy-in for this project.

EPILOGUE

After the pilot study, which lasted until June 1999, data were continually collected for 18 months, through August 2000, even with the cessation of external grant funding for this project. Baseline data collection finally stopped, primarily because of a failure to accommodate data collection into the routine flow of patient care by existing nursing staff.

The RAND-36 measure of health-related quality of life

The RAND-36 is perhaps the most widely used health-related quality of life (HRQoL) survey instrument in the world today. It is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. Physical and mental health summary scores are also derived from the eight RAND-36 scales. This paper provides example applications of the RAND-36 cross-sectionally and longitudinally, provides information on what a clinically important difference is for the RAND-36 scales, and provides guidance for summarizing the RAND-36 in a single number. The paper also discusses the availability of the RAND-36 in multiple languages and summarizes changes that are incorporated in the latest version of the survey.

The use of 2 health-related quality-of-life measures in a sample of persons infected with human immunodeficiency virus

The purpose of this analysis was to examine the ability of the MOS-HIV (Medical Outcomes Study-Human Immunodeficiency Virus) Health Survey and the EuroQol Group's EQ-5D questionnaire to discriminate between subjects in predefined disease-severity groups on the basis of clinical-indicator status (i.e., CD4 cell counts, HIV type 1 [HIV-1] RNA copies). This study used medical records of and instruments completed by 242 HIV-infected patients. The ability of the health-related quality-of-life instruments to discriminate between subjects stratified by disease severity was assessed by means of receiver-operating characteristic (ROC) curve analysis. The EQ-5D (P<.05) and MOS-HIV physical health summary (PHS) scores (P<.01) were able to discriminate between groups of subjects stratified by disease severity on the basis of either CD4 cell counts or HIV-1 RNA copies. These findings provide further evidence of the validity of the use of EQ-5D and the MOS-HIV questionnaire and suggest that they may be practical tools for the monitoring of health status from the HIV-infected patient's perspective.

Impact of transrectal ultrasound guided prostate biopsy on quality of life: a prospective randomized trial comparing 6 versus 12 cores

PURPOSE

Recent studies advocating an increase in the number of cores of sextant transrectal ultrasound guided biopsy of the prostate to improve the cancer detection rate often have not addressed the impact on quality of life. We performed a prospective randomized trial comparing 6 to 12 prostate biopsy cores to determine the impact on the cancer detection rate, pain and morbidity, and quality of life. We report the impact on health related and screening specific quality of life in men undergoing 6 versus 12 core transrectal ultrasound guided prostate biopsy.

MATERIALS AND METHODS

We prospectively randomized 244 men with a mean age plus or minus standard deviation of 65 +/- 8 years, serum total prostate specific antigen between 2.5 and 20.0 ng./ml., and/or digital rectal examination findings suspicious of cancer to undergo 6 or 12 core peripheral zone tissue biopsy. Of the men 71 (29%) were black. All patients completed a self-administered questionnaire before, and 2 questionnaires 2 and 4 weeks after the procedure. Health related quality of life was measured using 2 subscales (emotional well-being and role limitation due to physical health) of the short form 36-Item Health Survey. Screening specific quality of life was addressed by questions on the functional consequences of the procedure (return to daily activity, work-employment and sports-exercise). Health related and screening specific quality of life responses were compared in the groups.

RESULTS

After controlling for cancer diagnosis, patient age, race, education, report of pain and baseline emotional well-being there was no significant difference in the mean change in emotional well-being scores at 2 and 4 weeks in the 6 and 12 core groups (p = 0.7 and 0.3, respectively). Similarly after controlling for these factors and baseline role limitation due to physical health there was no significant difference in the mean change in role limitation due to physical health scores at 2 and 4 weeks in the 2 groups (p = 0.3 and 0.5, respectively). There was no difference in the percent of men returning to routine daily activity (p = 0.6), work-employment (p = 0.5) or sports-exercise (p = 0.3) at 0 to 1, 2 to 3 and 4 to 7 days or longer than 1 week after the procedure in the groups.

CONCLUSIONS

Doubling the sextant biopsy does not affect the quality of life in regard to emotional well-being, role limitation due to physical health, or return to routine daily activity, work-employment or sports-exercise.

Quality of life and utility in patients with non-small cell lung cancer. Quality-of-life Study Group of the Master 2 Project in Pharmacoeconomics

BACKGROUND

Although several studies have determined quality of life in patients with lung cancer, there is still little information about the use of generic questionnaires [e.g. the 36-item Short Form health survey (SF-36)] and utility questionnaires [e.g. the EuroQOL instrument (EQ-5D)] in this disease.

OBJECTIVES

To (i) measure quality of life and utility in patients with non-small cell lung cancer (NSCLC) using the SF-36 and the EuroQOL questionnaires; (ii) to evaluate the impact of some clinical variables on quality of life and utility; (iii) to assess the correlation between the measurements produced by the 2 questionnaires.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS

95 patients from 15 Italian hospitals with NSCLC (93% male, mean age 62 years) completed both questionnaires.

RESULTS

The mean scores for the 8 domains of the SF-36 ranged from 20.8 (physical role) to 63.0 (social functioning). The mean physical and mental summed scores of the SF-36 were 36.8 [standard deviation (SD) 9.8] and 43.0 (SD 11.5), respectively. The EuroQOL mean score was 0.58 (SD 0.32) in the self-classifier (SC) version and 0.58 (SD 0.20) in the visual analogue scale (VAS) version. Among the clinical variables that affected quality of life and utility, the presence of metastasis had the greatest impact: patients with metastasis had statistically significantly lower scores for 2 domains of the SF-36 (physical functioning, p = 0.009; bodily pain, p = 0.016), for the physical component summed score of the SF-36 (p = 0.015) and for both utility estimates (EuroQOL-SC, p = 0.027; EuroQOL-VAS, p = 0.038) than patients without metastasis. Both the SC and VAS EuroQOL scores showed a statistically significant correlation with each of the 8 domains of the SF-36. The scores for both the SF-36 and the EuroQOL in patients with NSCLC were considerably worse (relative differences ranging from -8 to -73%) than the corresponding values (normative data) previously reported for healthy individuals.

CONCLUSIONS

Our study quantified the degree to which quality of life is impaired in patients with NSCLC, showed that the presence of metastasis had an important role, and indicated a strong correlation between the measurements produced by the 2 questionnaires. The EuroQOL measurements obtained from these patients will aid evaluation of the cost-utility ratio for NSCLC therapies.

A review of health-related quality-of-life measures in stroke

The objective of this review was to evaluate health-related quality of life (HR-QOL) measures for use with patients with stroke. HR-QOL measures are increasingly used for assessment in many health conditions; these measures may serve an important role in evaluating the impact of stroke and of stroke interventions. HR-QOL measures used in patients with stroke should: (i) cover the domains of HR-QOL that may be affected by stroke; (ii) have administration characteristics suitable for use in patients with stroke; and (iii) have undergone reliability and validity assessment in patients with stroke. The present study evaluates HR-QOL measures with reference to these requirements. A systematic literature review was conducted to identify and evaluate HR-QOL measures of potential use in studies of patients with stroke. Identified measures were assessed with regard to stroke-relevant domains covered, measure characteristics (e.g. self-administration versus administration by an interviewer, interviewer time to complete) and psychometric properties of reliability and validity. The measures evaluated vary widely on domains covered, and limited assessment of the performance of HR-QOL measures has been conducted in patients with stroke. No existing measure comprehensively covers all relevant domains or addresses fully the issues of obtaining and combining HR-QOL assessments in patients and proxies in many stroke populations. Additional psychometric testing in stroke populations is needed for existing HR-QOL measures. In addition, stroke-targeted HR-QOL measures need to be developed and evaluated with patients with stroke.

Preference-based health outcome measures in low back pain

Preference-based health outcome measures were considered in two settings. In the clinical context, utility assessment using the VAS, TTO or SG was described. It is recognized that formal utility assessment is generally not needed in day-to-day clinical practice. When the need to explicitly value alternative health outcomes arises, the VAS is recommended because of its ease of implementation. In the health policy context, preference classification systems are recommended for valuing health when a cost-effectiveness analysis of alternative health care interventions is planned. At present, there is little evidence to base choice of one system over another for assessing the cost-effectiveness of low back pain interventions.

Health-related quality-of-life measurement in hypertension. A review of randomised controlled drug trials

In hypertension, tolerability of drug treatment is important because individuals may see the use of antihypertensive medications as more troubling than their seemingly symptomless disease. This may result in noncompliance and ineffectual long term treatment. In the past 15 years, new antihypertensive medications have been marketed on the basis of the advantages they offer with regard to adverse effects and the unavoidable impact of such adverse effects on a person's quality of life. When related to health, quality of life refers to the physical, psychological and social dimensions of health that are influenced by a person's experiences, beliefs, expectations and perceptions. To measure this concept, many instruments, either generic or specific, may be used. The purpose of this study is to describe, by way of a critical review of the literature, the instruments that are most often used in the measurement of health-related quality of life (HR-QOL) in people using antihypertensive drug treatments. We carried out a search of the literature published in English in the period January 1966 to July 2000, looking for randomised controlled trials of antihypertensive drugs. Using the Medline database, we included 77 papers in our review. Our main finding suggests that HR-QOL changes associated with antihypertensive treatment are measured with many different instruments. In almost all studies, at least 1 instrument specific to a health dimension was used, whereas not many used a generic instrument only. The most commonly measured HR-QOL dimensions were cognitive function, symptomatic well-being, sexual function, psychological well-being, sleep dysfunction, social participation and general health perception. Since the choice of dimensions to measure depends not only on the disease but also on the drug, this review adds further evidence that a generic instrument as well as a preference measurement should be added to a specific instrument.

Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study

PURPOSE

To measure health-related quality of life among adult patients with human immunodeficiency virus (HIV) disease; to compare the health-related quality of life of adults with HIV with that of the general population and with patients with other chronic conditions; and to determine the associations of demographic variables and disease severity with health-related quality of life.

SUBJECTS AND METHODS

We studied 2,864 HIV-infected adults participating in the HIV Cost and Services Utilization Study, a probability sample of adults with HIV receiving health care in the contiguous United States (excluding military hospitals, prisons, or emergency rooms). A battery of 28 items covering eight domains of health (physical functioning, emotional well-being, role functioning, pain, general health perceptions, social functioning, energy, disability days) was administered. The eight domains were combined into physical and mental health summary scores. SF-36 physical functioning and emotional well-being scales were compared with the US general population and patients with other chronic diseases on a 0 to 100 scale.

RESULTS

Physical functioning was about the same for adults with asymptomatic HIV disease as for the US population [mean (+/- SD) of 92+/-16 versus 90+/-17) but was much worse for those with symptomatic HIV disease (76+/-28) or who met criteria for the acquired immunodeficiency syndrome (AIDS; 58+/-31). Patients with AIDS had worse physical functioning than those with other chronic diseases (epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes) for which comparable data were available. Emotional well-being was comparable among patients with various stages of HIV disease (asymptomatic, 62+/-9; symptomatic, 59+/-11; AIDS, 59+/-11), but was significantly worse than the general population and patients with other chronic diseases except depression. In multivariate analyses, HIV-related symptoms were strongly associated with physical and mental health, whereas race, sex, health insurance status, disease stage, and CD4 count were at most weakly associated with physical and mental health.

CONCLUSIONS

There is substantial morbidity associated with HIV disease in adults. The variability in health-related quality of life according to disease progression is relevant for health policy and allocation of resources, and merits the attention of clinicians who treat patients with HIV disease.