Development and pilot-testing of a health-related quality of life chronic generic module for children and adolescents with chronic health conditions: a European perspective

Quality of life in paediatric gastrointestinal and liver disease: a systematic review

OBJECTIVES

To identify and appraise all studies relating to and instruments developed to measure quality of life (QOL) in children with gastrointestinal or liver diseases.

METHODS

A literature search was undertaken using MEDLINE, EMBASE, CINAHL, and PsycINFO to identify relevant articles published up to the end of 2005. These were reviewed by both authors and data were extracted using a standardised form. Articles were excluded if no attempt was made to measure QOL, they did not relate to children ages <17 years, they did not relate to gastrointestinal or liver diseases, or they were review articles. Quality of life instruments identified were rated according to proposed criteria.

RESULTS

From a total of 2379 articles identified in the initial search, a total of 2309 were excluded, leaving 70 included studies. These were assigned to the following categories: inflammatory bowel disease, n = 17; cystic fibrosis, n = 20; liver disease, n = 11; surgery, n = 15; and miscellaneous, n = 7. These studies describe the impact that these diseases have on the QOL of affected children. A total of 11 disease-specific QOL instruments and 1 generic instrument with a chronic disease module were identified, but only 5 of these fulfilled the proposed quality criteria and can be recommended for future use.

CONCLUSIONS

Chronic gastrointestinal and liver diseases can have an enormous effect on the QOL of affected individuals and their families. A number of disease-specific paediatric QOL instruments have been developed and validated. Quality of life is an important outcome that should be incorporated into clinical practice and measured when treatments are evaluated. Future research should explore how QOL can best be improved in children in whom it is severely impaired.

Monitoring health related quality of life in adolescents with diabetes: a review of measures

Particularly in chronic conditions, monitoring health related quality of life (HRQoL) of adolescents in clinical practice is increasingly advocated. We set out to identify and review the clinical utility of available generic and diabetes specific HRQoL questionnaires suitable for use in adolescents with type 1 diabetes. Four generic and five diabetes specific questionnaires were identified and evaluated. The responsiveness of most instruments warrants further research and standardisation of HRQoL measurement should be sought to facilitate comparisons across centres and countries. The PedsQL and the KINDL-R appear, at this time, to be the most suitable instruments.

Field testing of a European quality of life instrument for children and adolescents with chronic conditions: the 37-item DISABKIDS Chronic Generic Module

OBJECTIVES

The aim of this study was to shorten the Health-Related Quality of Life (HRQL) DISABKIDS Chronic Generic Measure (DCGM) for children and adolescents and to test its reliability, construct, and external validity.

STUDY DESIGN

1153 children and adolescents (8-16 years) with chronic health conditions (asthma, arthritis, epilepsy, cerebral palsy, diabetes, atopic dermatitis, cystic fibrosis) and their family were recruited from different paediatric clinical settings in seven European countries. A two-time assessment comprised reports on sociodemographics, health status and HRQL of children/adolescents.

RESULTS

The 37-item DCGM describes six dimensions (Independence, Physical Limitation, Emotion, Social Inclusion, Social Exclusion and Treatment) confirmed by Confirmatory Factor Analysis, multi-item scaling and item-goodness of fit to Rasch model. Internal consistency (Cronbach's alpha: 0.70-0.87) and test-retest reliability (ICC: 0.71-0.83) were satisfactory. Correlations between DCGM-37 and other HRQL instruments were the highest between dimensions evaluating similar concepts. Regarding discriminant validity of the DCGM-37, girls and older adolescents reported lower emotional we ll-being. Children belonging to families with low level of affluence and those with severe health conditions were found to have worse HRQL in all domains.

CONCLUSION

Reliability, construct validity as well as convergent and discriminant validity of the DCGM-37 were shown.

Measuring quality of life

Progress in the assessment of quality of life (QoL) measures for children and their value in clinical practice are considered. The most parsimonious approach to assessment includes modular assessment of generic and disease-specific QoL. Differences occur between child and parent proxy ratings, so it is recommended that ratings from multiple observers are made where possible. QoL measures may be of value in clinical practice, but the inadequate availability of the resources necessary to analyse results and provide the required support is a major barrier. Although the assessment of QoL in children remains challenging, its value is increasingly recognised by both researchers and clinicians.

Quality of life among adolescents with cerebral palsy: what does the literature tell us?

This review describes trends in quality of life (QOL) and health-related quality of life (HRQOL) among adolescents with cerebral palsy (CP). Twenty original articles were identified by a structured search of multiple databases and grouped by design. Categories included descriptive cross-sectional studies (n=8), measurement validation studies (n=9), and exploratory qualitative studies (n=3). Several trends were apparent. First, individuals with CP are reported to have decreased QOL and HRQOL compared with a normative population in some but not all areas of well-being. Second, functional status measures such as the Gross Motor Function Classification System are reliable indicators of variations in physical function, but do not correlate consistently with psychosocial well-being. Third, although adolescents with CP have different life issues than adults or children, limited research on factors associated with QOL and HRQOL has been described for this age range. We recommend that clinicians and researchers interested in assessing well-being among adolescents with CP include participants from across the spectrum of motor impairment, allow adolescents to self-report whenever possible, and assess adolescents independently, rather than including them with individuals from other age groups or clinical populations.

Development of an Internet-based real-time system for monitoring pharmacological interventions in children with neurodevelopmental and neuropsychiatric disorders

Few children have a 'pure' diagnosis of neuropsychiatric disorders such as attention deficit hyperactivity disorder or autism. Most have complex, overlapping symptoms, and it is often these associated and common comorbidities that cause as much, if not more impairments, than the core symptoms. Prescribing decisions are therefore complex and made on the basis of eliciting a range of agreed 'target symptoms'. At present, however, there are no agreed systems that allow monitoring of all areas of potential change, and few services are able to monitor symptoms, side effects, impact on family life and individual children's quality of life systematically. At best many clinics use a plethora of paper-based standardized questionnaires, based on individual diagnoses. This article describes the development of a novel biomedical informatics system that has been designed to allow parents, professionals and children to use a web-based, real-time symptom monitoring system to enable more effective treatments, better pathways of shared care, and more equitable and efficient service delivery for this group of vulnerable children.

Pediatric health-related quality of life questionnaires in clinical trials

PURPOSE OF REVIEW

This review summarizes recent studies on the feasibility, reliability and validity of pediatric health-related quality of life questionnaires and gives an overview of recent applications of these measures in pediatrics.

RECENT FINDINGS

The often-applied short form of the Child Health Questionnaire (CHQ-PF28) provides reliable physical and psychosocial summary measures, but reliable estimates for each scale require the longer version (CHQ-PF50). In addition to this questionnaire, the Pediatric Quality of Life Inventory is another reliable and valid measure. The TNO-AZL Preschool Children Quality of Life questionnaire is a feasible and reliable measure for preschool children. Generally, generic questionnaires are less sensitive to the impact of specific diseases than are disease-specific questionnaires. Parent and self-reports provide different outlooks on quality of life, which complement each other.

SUMMARY

There are several feasible, reliable and validated pediatric quality of life questionnaires that can be used in clinical trials. These include generic and disease-specific questionnaires and health profile measures, as well as preference-based measures in pediatric settings. Generally, a combination of these types of questionnaires would be the most appropriate approach. Moreover, a combination of parent and self-reports should be applied. Appropriate selection of outcome measures will enhance the quality of pediatric studies and the ability to assess treatment effects in clinical trials.

The DISABKIDS generic quality of life instrument showed cross-cultural validity

OBJECTIVE

The aim was to test the performance of a cross-culturally developed disease-generic quality of life (QoL) measure for children with chronic diseases in a multinational clinical study.

STUDY DESIGN AND SETTING

The study was conducted in pediatric hospitals across seven European countries in a sample of 1,153 children with seven chronic conditions, aged 8-16. The design included test and retest on child, parent, and clinical measures concerning health status, functioning, and quality of life.

RESULTS

The condition-generic QoL measure showed satisfactory item and scale performance, as well as structural validity across the seven countries. There was a high agreement between the child and proxy assessment across the different countries in all subscales of the condition-generic instrument, except for socioemotional dimensions in some countries. Gender, age, and severity-adjusted covariance analyses showed significant country differences in QoL. The discriminative potential of the condition-generic measure to distinguish between clinical characteristics was higher than that of a generic measures.

CONCLUSION

The psychometric performance of both items and scales of the DISABKIDS condition oriented measure was good across cultures, despite a range of cross-cultural differences. The condition-generic measure performs better in discriminating with respect to clinical characteristics than the generic measures; however, results need replication in representative studies.

Generic health-related quality-of-life assessment in children and adolescents: methodological considerations

The health-related quality of life (HR-QOL) of children and adolescents is increasingly considered a relevant topic for research. Instruments to assess quality of life in children and adolescents of a generic as well as disease- or condition-specific nature are being developed and applied in epidemiological surveys, clinical studies, quality assurance and health economics. This paper attempts to give an overview on the state of the art of HR-QOL assessment in children as it relates to methodological and conceptual challenges. Instruments available in international or cross-cultural research to assess HR-QOL in generic terms were identified and described according to psychometric data provided and the width of application. In an initial literature search, several challenges in the assessment of child and adolescent HR-QOL were identified, ranging from conceptual and methodological to practical aspects. Seven specific major issues were considered: (i) What are the dimensions of HR-QOL relevant for children and adolescents, and do suitable instruments for their measurement exist? (ii) Can these dimensions be collected in a cross-culturally comparable way? (iii) What advantages and disadvantages do self-rated versus externally evaluated HR-QOL measurements of children and adolescents have? (iv) How can HR-QOL be assessed in an age-appropriate way? (v) What are the advantages and disadvantages of disease-specific and generic data collection? (vi) What advantages and disadvantages do profile and index instruments have? (vii) How can HR-QOL be connected with utility- preference values? In a second literature search we identified nine generic HR-QOL instruments and four utility health state classification systems that complied with the prespecified inclusion criteria. It was concluded that (i) HR-QOL instruments are available to assess the dimensions of the construct relevant to children and adolescents; (ii) provided that an instrument was constructed in an appropriate way, the dimensions of HR-QOL can be measured in an interculturally comparable manner; (iii) the HR-QOL of children and adolescents can and should be ascertained by self-rating; (iv) the measurement instruments used have to consider maturity and cognitive development; (v) only generic quality-of-life instruments allow for an assessment of HR-QOL in both healthy and chronically ill children and adolescents; (vi) the representation of HR-QOL achieved through a singular index value is connected to strict psychometric conditions: the index instrument has to be tailored to these psychometric conditions; (vii) how far utility measures are employable with children and adolescents has to be investigated in further studies. The problem aspects identified indicate the necessity for further research. Nevertheless, instruments for assessing the HR-QOL of children and adolescents can be identified that meet the requirements mentioned above.

Coping with a Chronic Pediatric Health Condition and Health-Related Quality of Life

Background: Health-related quality of life (HRQOL) is increasingly considered an important outcome variable in pediatric research. Despite the growing interest little is known about the relationship between HRQOL and other significant constructs such as coping with a chronic health condition. Objective: The current paper examined age, gender, and health condition effects on coping and HRQOL scales and explored the relationship between both constructs. Methods: A study with 295 children and adolescents (8-16 years) with three different chronic health conditions (asthma, diabetes mellitus, and arthritis) was conducted in five European countries. Coping was assessed with the CODI questionnaire and HRQOL with the chronic generic module of the DISABKIDS instrument set, which was developed within the European DISABKIDS study. Results: Significant gender differences were found for the Emotional Reaction and Acceptance scale of the CODI and the Physical and Emotion domain of HRQOL. Age differences were noted for the Wishful Thinking and Avoidance scale as well as the Emotion domain of HRQOL. Interaction effects between age and gender were not detected. Significant differences were also found regarding the type of chronic health condition and the coping scales Wishful Thinking and Distance, as well as Avoidance. Moderate significant correlations were found between the coping scales Emotional Reaction and Acceptance and the HRQOL scales. Conclusion: Gender, age, and health condition differences with regard to the use of different coping strategies need to be taken into consideration. Coping and HRQOL are closely related, especially regarding the Emotional domain where a potential overlap was noted. Here, a more precise separation of constructs is needed.

The European DISABKIDS project: development of seven condition-specific modules to measure health related quality of life in children and adolescents

Background

The European DISABKIDS project aims to enhance the Health Related Quality of Life (HRQoL) of children and adolescents with chronic medical conditions and their families. We describe the development of the seven cross-nationally tested condition-specific modules of the European DISABKIDS HRQoL instrument in a population of children and adolescents. The condition-specific modules are intended for use in conjunction with the DISABKIDS chronic generic module.

Methods

Focus groups were used to construct the pilot version of the DISABKIDS condition-specific HRQoL modules for asthma, juvenile idiopathic arthritis, atopic dermatitis, cerebral palsy, cystic fibrosis, diabetes and epilepsy. Analyses were conducted on pilot test data in order to construct field test versions of the modules. A series of factor analyses were run, first, to determine potential structures for each condition-specific module, and, secondly, to select a reduced number of items from the pilot test to be included in the field test. Post-field test analyses were conducted to retest the domain structure for the final DISABKIDS condition-specific modules.

Results

The DISABKIDS condition-specific modules were tested in a pilot study of 360 respondents, and subsequently in a field test of 1152 respondents in 7 European countries. The final condition-specific modules consist of an 'Impact' domain and an additional domain (e.g. worry, stigma, treatment) with between 10 to 12 items in total. The Cronbach's alpha of the final domains was found to vary from 0.71 to 0.90.

Conclusion

The condition-specific modules of the DISABKIDS instrument were developed through a step-by-step process including cognitive interview, clinical expertise, factor analysis, correlations and internal consistency. A cross-national pilot and field test were necessary to collect these data. In general, the internal consistency of the domains was satisfactory to high. In future, the DISABKIDS instrument may serve as a useful tool with which to assess HRQoL in children and adolescents with a chronic condition. The condition-specific modules can be used in conjunction with the DISABKIDS chronic generic module.