The PedsQL in pediatric cancer: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales, Multidimensional Fatigue Scale, and Cancer Module

The PedsQL Present Functioning Visual Analogue Scales: preliminary reliability and validity

Background

The PedsQL™ Present Functioning Visual Analogue Scales (PedsQL™ VAS) were designed as an ecological momentary assessment (EMA) instrument to rapidly measure present or at-the-moment functioning in children and adolescents. The PedsQL™ VAS assess child self-report and parent-proxy report of anxiety, sadness, anger, worry, fatigue, and pain utilizing six developmentally appropriate visual analogue scales based on the well-established Varni/Thompson Pediatric Pain Questionnaire (PPQ) Pain Intensity VAS format.

Methods

The six-item PedsQL™ VAS was administered to 70 pediatric patients ages 5–17 and their parents upon admittance to the hospital environment (Time 1: T1) and again two hours later (Time 2: T2). It was hypothesized that the PedsQL™ VAS Emotional Distress Summary Score (anxiety, sadness, anger, worry) and the fatigue VAS would demonstrate moderate to large effect size correlations with the PPQ Pain Intensity VAS, and that patient" parent concordance would increase over time.

Results

Test-retest reliability was demonstrated from T1 to T2 in the large effect size range. Internal consistency reliability was demonstrated for the PedsQL™ VAS Total Symptom Score (patient self-report: T1 alpha = .72, T2 alpha = .80; parent proxy-report: T1 alpha = .80, T2 alpha = .84) and Emotional Distress Summary Score (patient self-report: T1 alpha = .74, T2 alpha = .73; parent proxy-report: T1 alpha = .76, T2 alpha = .81). As hypothesized, the Emotional Distress Summary Score and Fatigue VAS were significantly correlated with the PPQ Pain VAS in the medium to large effect size range, and patient and parent concordance increased from T1 to T2.

Conclusion

The results demonstrate preliminary test-retest and internal consistency reliability and construct validity of the PedsQL™ Present Functioning VAS instrument for both pediatric patient self-report and parent proxy-report. Further field testing is required to extend these initial findings to other ecologically relevant pediatric environments.

The impact of realized access to care on health-related quality of life: a two-year prospective cohort study of children in the California State Children's Health Insurance Program

OBJECTIVE

To examine the effect of realized access to care (problems getting care, access to needed care) on health-related quality of life (HRQOL) in the California State Children's Health Insurance Program.

STUDY DESIGN

This was a prospective cohort study (n = 4,925; 70.5% [3438] had complete data). Surveys were taken at enrollment and after 1 and 2 years in the program. Parents and children reported HRQOL (PedsQL 4.0 Generic Core Scales). Repeated-measures analysis accounted for within-person correlation and adjusted for baseline PedsQL, baseline realized access, race/ethnicity, language, chronic health condition, and having a regular physician.

RESULTS

Realized access to care during the prior year was related to HRQOL for each subsequent year. Foregone care and problems getting care were associated with decrements of 3.5 (P < .001) and 4.5 (P < .001) points for parent proxy-report PedsQL and with decrements of 3.2 (P < .001) and 4.4 (P < .001) points for child self-report PedsQL. Improved realized access resulted in higher PedsQL scores, continued realized access resulted in sustained PedsQL scores, and foregone care resulted in cumulative declines in PedsQL scores.

CONCLUSIONS

Realized access to care is associated with statistically significant and clinically meaningful changes in HRQOL in children enrolled in the California State Children's Health Insurance Program.

Health-related quality of life of pediatric patients receiving allogeneic stem cell or bone marrow transplantation: results of a longitudinal, multi-center study

The results of a 5-year longitudinal prospective study about the health-related quality of life (HRQL) of pediatric patients receiving allogeneic bone marrow or stem cell transplantation (BMT) are described. The patients' HRQL was assessed twice before, and five times after BMT, the end point being 1 year after BMT. For the measurement of HRQL, standardized questionnaires were completed by patients, parents and physicians. The final sample consisted of 68 patients aged 4-18 years, of which 19 were lost in the course of the study owing to relapse, transplant rejection and/or death. The worst HRQL was seen shortly after transplant and HRQL thereafter improved steadily, although the improvement was not always linear and not all patients drew benefit from this average positive evolution. Compromised emotional functioning, a high level of worry and reduced communication during the acute phase of treatment had a negative impact on HRQL 1 year after BMT. Nausea and pain during the acute phase of treatment did not have an effect on later HRQL. The interobserver agreement of HRQL reports between parents and their children was moderate to good, and generally better than child-physician and parent-physician agreement.

Double-Blind, Placebo-Controlled Study of Quality of Life, Hematologic End Points, and Safety of Weekly Epoetin Alfa in Children With Cancer Receiving Myelosuppressive Chemotherapy

Purpose

To evaluate the effects of once-weekly epoetin alfa (EPO) on health-related quality of life (HRQOL), hemoglobin (Hb), transfusions, and tolerability in children with cancer.

Methods

Anemic patients 5 years to 18 years of age receiving myelosuppressive chemotherapy for nonmyeloid malignancies, excluding brain tumors, received intravenous EPO 600 units/kg to 900 units/kg or placebo once-weekly for 16 weeks. Patients and parents completed the pediatric health-related quality-of-life generic scales (GS) and cancer-specific scales (CS).

Results

One hundred eleven patients received EPO and 111 patients received placebo. Mean final values for GS total score (P = .763 among patients; P = .219 among parents) and CS domain scores (P ≥ .238; P ≥ .081, respectively) were not significantly different between treatment groups. EPO-treated patients had greater increases in Hb overall (P = .002) and were more likely to be transfusion free after 4 weeks (38.7% v 22.5%; P = .010). Change in Hb was correlated with change in PedsQL-GCS total score in the EPO group (r = 0.242; P = .018), but was not in the placebo group (r = 0.086; P = .430). Adverse events were comparable between treatment groups.

Conclusion

This study confirmed the tolerability and hematologic benefits of once-weekly EPO in children with cancer. No significant difference in HRQOL was detected between treatment groups, but a significant positive correlation was observed between Hb changes and HRQOL changes in the EPO group. Additional studies are warranted to assess HRQOL when anemia is managed optimally in children with cancer.

Online Psychological Treatment for Pediatric Recurrent Pain: A Randomized Evaluation

OBJECTIVE

To evaluate the efficacy of a distance treatment delivered through Internet and telephone for pediatric recurrent pain.

METHODS

Forty-seven participants (9-16 years of age) were randomly assigned to either an Internet-based treatment or a standard medical care waitlist. Treatment employed a Web-based manual for children and parents with weekly therapist contact by telephone or e-mail. At 1- and 3-month follow-ups, participants were assessed on the outcome variables of pain and quality of life. A 50% reduction in diary pain scores was considered clinically significant.

RESULTS

Significant between-group differences were found: 71 and 72% of the treatment group achieved clinically significant improvement at the 1- and 3-month follow-ups, respectively, whereas only 19 and 14% of the control group achieved the criterion. No significant differences were found on the quality of life variable.

CONCLUSIONS

Distance methods have considerable potential for making effective treatments more accessible with lower associated costs.

Health Related Quality of Life in Malaysian children with thalassaemia

Background

Health Related Quality of Life (HRQoL) studies on children with chronic illness such as thalassaemia are limited. We conducted the first study to investigate if children with thalassaemia have a lower quality of life in the four dimensions as measured using the PedsQL 4.0 generic Scale Score: physical, emotional, social and role (school) functioning compared to the healthy controls allowing for age, gender, ethnicity and household income.

Methods

The PedsQL 4.0 was administered to children receiving blood transfusions and treatments at Hospital Kuala Lumpur, Malaysia using PedsQL 4.0 generic Scale Score. Accordingly, the questionnaire was also administered to a control group of healthy school children. Socio-demographic data were also collected from patients and controls using an interview schedule designed for the study.

Results

Of the 96 thalassaemia patients approached, 78 gave consent to be interviewed giving a response rate of 81.3%. Out of 235 healthy controls approached, all agreed to participate giving a response rate of 100%. The mean age for the patients and schoolchildren is 11.9 and 13.2 years respectively. The age range for the patients and the schoolchildren is between 5 to 18 years and 7 to 18 years respectively. After controlling for age and demographic background, the thalassaemia patients reported having significantly lower quality of life than the healthy controls.

Conclusion

Thalassaemia has a negative impact on perceived physical, emotional, social and school functioning in thalassaemia patients which was also found to be worse than the children's healthy counterparts. Continuing support of free desferal from the Ministry of Health should be given to these patients. More understanding and support especially from health authorities, school authorities and the society is essential to enhance their quality of life.

Fatigue et maladies cardiovasculaires

Fatigue is a frequent complaint during cardiovascular disease and can sometimes constitute the first clinical manifestation of this disease. It is responsible for deterioration of the quality of life and prognosis. Although physical and mental fatigue are often intimately interrelated, these two aspects of fatigue correspond to different pathophysiological mechanisms and different clinical features and the neurobiological links between the two are only just beginning to be studied. Physical fatigue is related to loss of efficacy of the effector muscle, due to multiple causes: mismatch of cardiac output during exercise, muscle and microcirculatory deconditioning, neuroendocrine dysfunction, associated metabolic disorders. Mental fatigue corresponds to predominantly depressive mood disorders with a particular entity, vital exhaustion. The diagnostic approach is designed to eliminate other organic causes of fatigue. Functional tests investigating physical (exercise capacity) and mental dimensions (mood disorders) can be used to analyse their respective roles and to propose personalized management, in which rehabilitation has an essential place due to its global approach. The objective of this reduction of fatigue is threefold: to improve independence, to improve quality of life and to limit morbidity and mortality.

Health-related quality of life in pediatric patients with ESRD

As part of creating a pediatric ESRD-specific Health-Related Quality of Life (HRQOL) assessment instrument, we established pilot data with the PedsQL 4.0 Generic Core Scales in 96 pediatric patients with ESRD receiving hemodialysis (HD), peritoneal dialysis (PD) or with a renal transplant (TX). Patient age ranges were: 2-4 (8; PD n=3, TX n=5), 5-7 (12; HD n=9, TX n=3), 8-12 (25; HD n=5, PD n=6, TX n=14), 13-18 (51; HD n=18, PD n=10, TX n=23). PedsQL ESRD data were compared to healthy children (n=131 child report; n=145 parent report) and across HD/PD/TX. For all domains, ESRD patient HRQOL scores were significantly lower than healthy controls. Transplant patients reported better physical and psychosocial health than dialysis patients. No difference was noted between HD and PD patients for any PedsQL domain. Our data demonstrate that the PedsQL 4.0 Generic Core Scales is a useful measurement instrument to screen for HRQOL impairment in pediatric patients with ESRD. We suggest that the ESRD-specific HRQOL instrument in development is needed to help define condition-specific HRQOL differences between modalities.

Measurement of health-related quality of life in survivors of cancer in childhood in Central America: feasibility, reliability, and validity

Cancer is the commonest cause of disease-related death in children over 5 years of age in various parts of Latin America, but the survival rates are improving. This study assessed the health status and health-related quality of life (HRQL) of more than 200 survivors of cancer in childhood in the countries of a Central American consortium devoted to pediatric hematology-oncology. Patients' self-reports and parental proxy assessments were collected using interviewer-administered Spanish-language questionnaires, and physicians provided assessments using self-complete questionnaires, based on the complementary Health Utilities Index (HUI) Mark 2 (HUI2) and Mark 3 (HUI3) health status classification systems. Inter-rater agreement, measured by intra-class correlation (ICC), was fair to moderate (0.34<ICC<0.55) between patients, parents, and physicians for HRQL scores. There was substantial or almost perfect agreement (ICC>0.60) for all 3 pairs of assessors for readily assessable attributes: HUI2 sensation, HUI3 vision, HUI3 hearing, and HUI3 ambulation. Less than 40% of the patients reported being in perfect health. More than 20% reported being in health states with HRQL scores corresponding to moderate or severe disability, notably in the attributes of emotion and cognition. The results reflect a common profile in survivors of cancer in childhood, including those from industrialized societies. This study illustrates the feasibility of collecting reliable and valid information on HRQL in the developing country context, raising the prospect that such information could be used to influence clinical practice.

Health status and health-related quality of life in adolescent survivors of cancer in childhood

PURPOSE

Adolescent survivors of cancer in childhood face particular challenges due to their maturational trajectory, including psychosocial adjustments, self-help skills, intellectual functioning and socialization. To better understand these, we assessed the health status and health-related quality of life (HRQL) in a 20-year cohort of such survivors in a single institution.

METHODS

Health status and HRQL were measured with a self-complete questionnaire from the Health Utilities Index (HUI) family of multi-attribute, preference-based instruments that provide utility scores for single attributes and overall HRQL.

RESULTS

Eighty-four (42 males, 42 females) of 129 eligible subjects (65%) participated. More than 80% of the respondents reported some form of morbidity. Overall HRQL utility scores were lower for both the males and females than for corresponding members of the Canadian general population. Female survivors self-reported a significantly greater burden of morbidity (mean overall HUI2/HUI3 scores: .83/.73 vs. .90/.84 for males, p < .02), which was most evident in the attributes of emotion and cognition.

CONCLUSIONS

The majority of adolescent survivors of cancer in childhood carry a morbidity burden into their teen and young adult years. These findings may guide the support required by this population.

The PedsQL as a patient-reported outcome in children and adolescents with Attention-Deficit/Hyperactivity Disorder: a population-based study

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common chronic mental health condition in children and adolescents. The application of health-related quality of life (HRQOL) as a pediatric population health measure may facilitate risk assessment and resource allocation, the identification of health disparities, and the determination of health outcomes from interventions and policy decisions for children and adolescents with ADHD at the local community, state, and national health level.

METHODS

An analysis from an existing statewide database to determine the feasibility, reliability, and validity of the 23-item PedsQL 4.0 (Pediatric Quality of Life Inventory) Generic Core Scales as a patient-reported outcome (PRO) measure of pediatric population health for children and adolescents with ADHD. The PedsQL 4.0 Generic Core Scales (Physical, Emotional, Social, School Functioning) were completed by families through a statewide mail survey to evaluate the HRQOL of new enrollees in the State of California State's Children's Health Insurance Program (SCHIP). Seventy-two children ages 5-16 self-reported their HRQOL.

RESULTS

The PedsQL 4.0 evidenced minimal missing responses, achieved excellent reliability for the Total Scale Score (alpha = 0.92 child self-report, 0.92 parent proxy-report), and distinguished between healthy children and children with ADHD. Children with ADHD self-reported severely impaired psychosocial functioning, comparable to children with newly-diagnosed cancer and children with cerebral palsy.

CONCLUSION

The results suggest that population health monitoring may identify children with ADHD at risk for adverse HRQOL. The implications of measuring pediatric HRQOL for evaluating the population health outcomes of children with ADHD internationally are discussed.

Quality of life in children with chronic kidney disease—patient and caregiver assessments

BACKGROUND

Children with chronic kidney disease (CKD) require strict dietary and lifestyle modifications, however, there is little information on their quality of life. Our objective was to compare health-related quality of life (HRQOL) in children with different stages of CKD to each other and to a control population.

METHODS

A cross-sectional assessment of HRQOL for physical, emotional, social and school domains was performed using the PedsQL Generic Core Scale. Data were collected from 20 children with chronic renal insufficiency (CRI; creatinine > 200 micromol/l), 12 on maintenance haemodialysis or peritoneal dialysis (DIAL) and 27 with renal transplants (TX). Caregiver proxy reports were obtained for CRI (n = 20), DIAL (n = 17) and TX (n = 21). Between-group differences were assessed with ANOVA for the CKD groups; t-tests compared our CKD samples with controls.

RESULTS

Children with CKD scored lower than the controls in all subscales, however, only TX compared with controls was significant (P < 0.02). DIAL children scored equal to or higher than the TX group in all domains. Analysis of covariance with number of medications as covariate yielded a significant result for the physical subscale (F = 8.95, df = 3, 53, P = 0.004). Proxy caregiver scores were lower than patient scores in all four domains.

CONCLUSIONS

Children with CKD rate their HRQOL lower than the healthy controls do. It may be reassuring to caregivers that children on dialysis rate their HRQOL higher than would be expected. However, it is of some concern that caregiver perception of improved HRQOL following transplantation was not shared by their children in the present study.

Siblings of pediatric cancer patients: the quantitative and qualitative nature of quality of life

This study used both quantitative and qualitative methodologies to assess the pediatric health-related quality of life (HRQOL) in siblings (n = 77) of cancer patients attending summer camp. On quantitative measures (Pediatric Quality of Life Inventory (PedsQL) parent and child versions), siblings reported statistically significant improvements in HRQOL from pre-to post camp. The parent sample, as a whole, did not report a statistically significant improvement in the siblings' HRQOL; however, statistically significant improvements were found when the analysis controlled for the responses of bereaved parents. On the qualitative measures (Sibling Qualitative Interview and Camp Okizu Satisfaction Surveys), both children and parents described the positive impact of camp. Using grounded theory, we identified the major themes and found that the positive emotional and social experiences captured by the quotes were paralleled in the quantitative findings of improved HRQOL in psychosocial domains on the PedsQL. These findings suggest the beneficial effects of camp as a psychological intervention and illustrate the value of integrating quantitative and qualitative methodological approaches in research.

Health care utilization and needs after pediatric traumatic brain injury

OBJECTIVE

Children with moderate to severe traumatic brain injury (TBI) show early neurobehavioral deficits that can persist several years after injury. Despite the negative impact that TBI can have on a child's physical, cognitive, and psychosocial well-being, only 1 study to date has documented the receipt of health care services after acute care and the needs of children after TBI. The purpose of this study was to document the health care use and needs of children after a TBI and to identify factors that are associated with unmet or unrecognized health care needs during the first year after injury.

METHODS

The health care use and needs of children who sustained a TBI were obtained via telephone interview with a primary caregiver at 2 and 12 months after injury. Of the 330 who enrolled in the study, 302 (92%) completed the 3-month and 288 (87%) completed the 12-month follow-up interviews. The health care needs of each child were categorized as no need, met need, unmet need, or unrecognized need on the basis of the child's use of post-acute services, the caregiver's report of unmet need, and the caregiver's report of the child's functioning as measured by the Pediatric Quality of Life Inventory (PedsQL). Regardless of the use of services or level of function, children of caregivers who reported an unmet need for a health care service were defined as having unmet need. Children who were categorized as having no needs were defined as those who did not receive services; whose caregiver did not report unmet need for a service; and the whose physical, socioemotional, and cognitive functioning was reported to be normal by the caregiver. Children with met needs were those who used services in a particular domain and whose caregivers did not report need for additional services. Finally, children with unrecognized needs were those whose caregiver reported cognitive, physical, or socioemotional dysfunction; who were not receiving services to address the dysfunction; and whose caregiver did not report unmet need for services. Polytomous logistic regression was used to model unmet and unrecognized need at 3 and 12 months after injury as a function of child, family, and injury characteristics.

RESULTS

At 3 months after injury, 62% of the study sample reported receiving at least 1 outpatient health care service. Most frequently, children visited a doctor (56%) or a physical therapist (27%); however, 37% of caregivers reported that their child did not see a physician at all during the first year after injury. At 3 and 12 months after injury, 26% and 31% of children, respectively, had unmet/unrecognized health care needs. The most frequent type of unmet or unrecognized need was for cognitive services. The top 3 reasons for unmet need at 3 and 12 months were (1) not recommended by doctor (34% and 31%); (2) not recommended/provided by school (16% and 17%); and (3) cost too much (16% and 16%). Factors that were associated with unmet or unrecognized need changed over time. At 3 months after injury, the caregivers of children with a preexisting psychosocial condition were 3 times more likely to report unmet need compared with children who did not have one. Also, female caregivers were significantly more likely to report unmet need compared with male caregivers. Finally, the caregivers of children with Medicaid were almost 2 times more likely to report unmet need compared with children who were covered by commercial insurance. The only factor that was associated with unrecognized need at 3 months after injury was abnormal family functioning. At 12 months after injury, although TBI severity was not significant, children who sustained a major associated injury were 2 times more likely to report unmet need compared with children who did not. Consistent with the 3-month results, the caregivers of children with Medicaid were significantly more likely to report unmet needs at 1 year after injury. In addition to poor family functioning's being associated with unrecognized need, nonwhite children were significantly more likely to have unrecognized needs at 1 year compared with white children.

CONCLUSIONS

A substantial proportion of children with TBI had unmet or unrecognized health care needs during the first year after injury. It is recommended that pediatricians be involved in the post-acute care follow-up of children with TBI to ensure that the injured child's needs are being addressed in a timely and appropriate manner. One of the recommendations that trauma center providers should make on hospital discharge is that the parent/primary caregiver schedule a visit with the child's pediatrician regardless of the post-acute services that the child may be receiving. Because unmet and unrecognized need was highest for cognitive services, it is important to screen for cognitive dysfunction in the primary care setting. Finally, because the health care needs of children with TBI change over time, it is important for pediatricians to monitor their recovery to ensure that children with TBI receive the services that they need to restore their health after injury.

Quality-of-life in children and adolescents with cystic fibrosis managed in both regional outreach and cystic fibrosis center settings in Queensland

OBJECTIVES

To assess the health-related quality-of-life (HRQOL) of children/adolescents with cystic fibrosis (CF) and compare HRQOL in children managed by cystic fibrosis outreach service (CFOS) with those treated in a cystic fibrosis center (CFC). To compare HRQOL of children with CF in Queensland with previously published HRQOL data from the United States and examine the relationship between HRQOL scores and pulmonary function.

STUDY DESIGN

Participants were children/adolescents with CF and their parents managed by the Royal Children's Hospital Queensland at a CFC or CFOS. Two HRQOL surveys were used: PedsQL and Cystic Fibrosis Questionnaire (CFQ).

RESULTS

There were 91 CFC and 71 CFOS participants with similar demographics. PedsQL total summary score was statistically higher in CFOS, P=.05. There was no significant difference in CFQ scores between groups. Queensland parents reported lower HRQOL for their children compared with US parents (P<.01) despite similar pulmonary function. Declining pulmonary function correlated with worse CFQ scores in adolescents, P<.05.

CONCLUSIONS

Children living in regional Queensland reported as good as or slightly better HRQOL compared with children attending a CFC. Parent proxy HRQOL scores were generally low suggesting a reduced perception of HRQOL by parents for their children.

Feasibility and safety of a pilot randomized trial of infection rate: neutropenic diet versus standard food safety guidelines

The neutropenic diet is an intervention that excludes certain foods, especially fresh fruits and vegetables, from the diets of pediatric oncology patients to reduce infection rate. The purpose of this study was to demonstrate a safe and feasible methodology to evaluate the infection rate in pediatric cancer patients randomized to the neutropenic diet or to Food and Drug Administration (FDA)-approved food safety guidelines. Pediatric oncology patients receiving myelosuppressive chemotherapy were randomized to the neutropenic diet or to FDA food safety guidelines and followed through one chemotherapy cycle. The primary outcome was febrile neutropenia. Secondary outcomes were adherence and diet tolerability. Nineteen patients were enrolled. Four patients on each diet arm developed febrile neutropenia. The adherence rate was 94% for the neutropenic diet and 100% for the food safety guidelines. Although patients were able to tolerate both diets, there was more reported difficulty adhering to the neutropenic diet. Infection rates for children with cancer on the neutropenic diet were similar to those for patients following food safety guidelines. The results of this study suggest that a larger randomized trial to determine the effectiveness of food safety guidelines in minimizing the risk of food borne infection is safe and feasible in children with cancer.

The PedsQLTM 4.0 as a School Population Health Measure: Feasibility, Reliability, and Validity

BACKGROUND

The application of health-related quality of life (HRQOL) as a school population health measure may facilitate risk assessment and resource allocation, the tracking of student health at the school and district level, the identification of health disparities among schoolchildren, and the determination of health outcomes from interventions and policy decisions at the school, district, and county level.

OBJECTIVE

To determine the feasibility, reliability, and validity of the 23-item PedsQL 4.0 (Pediatric Quality of Life Inventory) Generic Core Scales as a school population health measure for children and adolescents.

DESIGN

Survey conducted in 304 classes at 18 elementary schools, 4 middle schools, and 3 high schools within a large metropolitan school district.

METHODS

The PedsQL 4.0 Generic Core Scales (Physical, Emotional, Social, School Functioning) were completed by 2437 children ages 8-18 and 4227 parents of children ages 5-18.

RESULTS

The PedsQL 4.0 evidenced minimal missing responses, achieved excellent reliability for the Total Scale Score (alpha = 0.89 child, 0.92, parent report), and distinguished between healthy children and children with chronic health conditions. The PedsQL 4.0 was related to indicators of socioeconomic status (SES) at the school and district level. The PedsQL School Functioning Scale was significantly correlated with standardized achievement scores based on the Stanford 9.

CONCLUSION

The results demonstrate the feasibility, reliability and validity of the PedsQL 4.0 Generic Core Scales as a school population health measure. The implications of measuring HRQOL in schoolchildren at the school, district, and county level for identifying and ameliorating health disparities are discussed.

Assessment of health-related quality of life in children with cancer

BACKGROUND

In pediatric settings, measures of health-related quality of life (HRQL) are often obtained by proxy, especially from parents, but the correlation between parental report and patient report has not been clearly established. In the current study, the authors examined the agreement between child and parent reports of HRQL in children with cancer (both those receiving treatment and those off treatment) and healthy controls.

METHODS

Two groups of children with cancer who differed with regard to treatment status (n = 199) and a group of healthy control children (n = 108) were assessed using a standardized measure of HRQL. Both children and parents reported on the child's HRQL using parallel forms of the Children's Health Questionnaire.

RESULTS

Significant parent-child correlations were found for all 10 HRQL scales, and these correlations were higher in the cancer groups compared with controls. Parents in the cancer groups tended to underestimate the HRQL of their children compared with the child report, although there were no significant parent-child mean differences in the group of patients who were off treatment and only 2 significant differences in the group of children receiving treatment. In contrast, parents in the control group tended to overestimate the HRQL of their children, and the parent-child differences were found to be larger, achieving statistical significance on 8 of 10 scales.

CONCLUSIONS

Parents and children tend to report comparable child HRQL outcomes, and this is particularly true in oncology populations. In cases in which the child is either too young or too ill to provide a self-report, parent-reported HRQL can be viewed as a reliable substitute.

Anorexia/cachexia-related quality of life for children with cancer

BACKGROUND

Anorexia is a common symptom in patients with cancer, which can lead to poor tolerance of treatment and can contribute to cachexia in extreme cases. Children with advanced-stage cancer are especially vulnerable to malnutrition resulting from anorexia and cachexia. Currently, there are no instruments that measure common concerns specifically associated with anorexia and cachexia in children with cancer. The purpose of the current article was to test the psychometric properties of a newly developed pediatric Functional Assessment of Anorexia and Cachexia Therapy (peds-FAACT) for children with cancer.

METHODS

Ninety-six patients (ages 7-17 yrs) receiving cancer treatment and their parents were asked to complete the 12-item peds-FAACT. The authors implemented both classical test theory and item response theory to evaluate the agreement between parents and patients, internal consistency and unidimensionality of the scale, and stability of items across subgroups.

RESULTS

As a result, a patient-reported six-item scale was recommended as the core measure for all pediatric patients with cancer and four additional peripheral items were recommended for adolescent patients.

CONCLUSIONS

The peds-FAACT demonstrated good psychometric properties, differentiated patients with different functional performance status, and was determined to be a useful tool for future clinical trials.

The Pediatric Quality of Life Inventory: An Evaluation of Its Reliability and Validity for Children With Traumatic Brain Injury

OBJECTIVES

To assess the reliability and validity of the Pediatric Quality of Life Inventory, version 4.0 (PedsQL), and to compare it with that of the Behavior Rating Inventory of Executive Function (BRIEF) among children with traumatic brain injury (TBI).

DESIGN

Prospective cohort study that documented the health-related quality of life of 391 children at 3 and 12 months postinjury.

SETTING

Four level I pediatric trauma centers.

PARTICIPANTS

Children (age range, 5-15 y) hospitalized with a TBI or an extremity fracture.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Parent-reported PedsQL and BRIEF scale scores.

RESULTS

Both the PedsQL and BRIEF scales showed good internal consistency (PedsQL alpha range, .74-.93; BRIEF alpha range, .82-.98) and test-retest reliability (PedsQL r range, .75-.90; BRIEF r range, .82-.92), respectively. Factor analysis revealed that most PedsQL items loaded most highly on their conceptually derived scale. The PedsQL cognitive function scale detected the largest differences among groups of children with varying severities of TBI as well as parents' assessment of change in cognition postinjury.

CONCLUSIONS

Although the reliability of the 2 instruments is comparable, the PedsQL discriminates better among children with TBI. The PedsQL is a promising instrument for measuring the health of children after TBI.

Quality of life of children following bone marrow transplantation: critical review of the research literature

Children's quality of life (QOL) following bone marrow transplant (BMT) is an important but poorly understood concept. The aim of this paper is to critically review all research study designs to determine the QOL of childhood BMT recipients and to identify implications for research, practice and theory. The studies' methodological quality was evaluated separately by two investigators according to a set of formal criteria modified from Hoodin and Weber (Psychosomatics 44 (2003) 181). The review yielded one retrospective, one cross-sectional, six descriptive surveys and two prospective longitudinal study designs. The studies included 568 childhood BMT recipients ranging from 0.8 to 33 years. Only one study used a generic and disease-specific, psychometrically sound, QOL measure. Timing of assessments ranged from pre-BMT to 21 years following BMT. Due to the poor methodological quality, rendering conclusions across the studies was challenging. While the available evidence seems to suggest children experience good QOL following BMT, several studies found BMT to have a negative impact on various aspects of QOL. These results appear to be influenced by timing and type of measurements undertaken. Ultimately, there is a need for larger, more methodologically rigorous trials using prospective longitudinal study designs with pre- and post-measures to examine all QOL domains in children.

Profile of Daily Life in Children With Brain Tumors: An Assessment of Health-Related Quality of Life

Purpose

The survival of children with CNS tumors approaches 70%, yet health-related quality of life (HRQOL) has not been investigated rigorously in this population. We aimed to show that universal assessment of HRQOL could be obtained easily by using the PedsQL 4.0 and to provide a composite profile of their daily lives.

Patients and Methods

The PedsQL was administered to all patients seen in the neuro-oncology clinic at Lucile Packard Children's Hospital (Palo Alto, CA) from December 2001, to September 2002. Patients were compared with healthy controls by using two-sided t tests to evaluate statistically significant differences.

Results

One hundred thirty-four patients (73 male; mean age ± standard deviation, 11.8 ± 5.4 years; 55 had low-grade glioma, 32 had medulloblastoma/primitive neuroectodermal tumor/embryonal tumor, 17 had malignant astrocytoma, nine had germ-cell tumor, and 21 had other types of tumors) were assessed, each in less than 20 minutes. Scores on both child and parent-proxy reports for the total HRQOL, psychosocial, physical, emotional, social, and school-functioning scales were all significantly lower than controls (P < .01). Patients with low-grade glioma were reported to have the highest total HRQOL. Children receiving radiation therapy (XRT) but no chemotherapy had significantly lower total, psychosocial, emotional, and social functioning than those receiving other treatments, including XRT plus chemotherapy.

Conclusion

The PedsQL can be used to assess HRQOL rapidly and easily in children with CNS tumors, who have significantly worse HRQOL than healthy children. Children receiving XRT fare worse overall; chemotherapy added to XRT does not seem to worsen HRQOL. Assessment of HRQOL should be included as an outcome in future clinical trials.

Preliminary psychometric evaluation of the Child Health Ratings Inventory (CHRIs) and Disease-Specific Impairment Inventory-Hematopoietic Stem Cell Transplantation (DSII-HSCT) in parents and children

PURPOSE

To describe the initial results of the Child Health Ratings Inventory (CHRIs), 20-item generic health-related quality of life (HRQL) instrument and the 10-item disease-specific (DS) module, the Disease Specific Impairment Inventory-Hematopoietic Stem Cell Transplantation (DSII-HSCT), for children and adolescents, ages 5-18 years and their parents following HSCT.

STUDY DESIGN

Using cross sectional design, 122 children with a median age of 11 years (range 5.0-18 years) completed the questionnaire (CHRIs + DSII-HSCT) with research assistance. Seventy-four parents independently completed a parallel version of the questionnaire; health care providers assigned a global clinical severity rating.

RESULTS

The generic core includes four domains: physical, role, and emotional functioning, and energy. The DS module has three domains: worry, hassles, and body image. The Cronbach's alpha for parents and for older children (8 years and over) exceeded 0.70 for all generic and DS domains. While the range of alpha coefficients was lower for younger children, ages 5-7 year, only the alpha coefficient for one domain (energy) was less than 0.70. The instrument satisfactorily discriminated between clinically important groups: those early in the transplant process (< 6 months) versus those later (> 12 months) and by provider-assigned clinical severity ratings.

CONCLUSION

results suggest that the CHRIs generic core and its DSII-HSCT module is a promising measure of HRQL after pediatric HSCT. Although parent and child reports were moderately correlated and revealed complementary results, the unique perspectives of both raters provide a more complete picture of HRQL. Longitudinal application is underway to further characterize the measurement properties of the CHRIs and to determine the instrument's responsiveness and sensitivity to change over time in this vulnerable population.

Relationship of quality of life and physical function measures with disease activity in children with systemic lupus erythematosus

The objective of this study is to assess relationship of systemic lupus erythematosus (SLE) activity with quality of life (QOL) and physical function and determine which is more closely correlated with SLE activity in children; and identify factors critical to children's QOL. In this cross-sectional study, children with SLE and parents completed corresponding versions of physical function (Childhood Health Assessment Questionnaire CHAQ), and QOL (Pediatric Quality of Life Inventory-PedsQL Generic/Rheumatology modules) questionnaires. SLE Disease Activity Index (SLEDAI), Systemic Lupus International Collaborating Clinics/ACR Damage Index (SDI), severity, self-concept and socioeconomic status (SES) were measured. For 24 children, CHAQ scores significantly correlated with SLEDAI (rho = 0.4, p = 0.04), SDI (rho = 0.6, p = 0.004), and associated with severity (p = 0.03). PedsQL scores did not significantly correlate with above parameters. Higher self-concept/SES correlated (p < 0.05) with better physical function and QOL. For 19 parents, the only significant correlation was between SLEDAI and Worry domain-Rheumatology module (rho = 0.5, p = 0.01). Lack of strong correlation of disease activity with QOL and physical function suggests that they are different constructs with partial overlap, and should be considered collectively while evaluating the impact of SLE on children/families. Self-concept and SES should be assessed while measuring QOL in children. Larger sample is required to confirm results.

Health-related quality of life measurement in pediatric clinical practice: an appraisal and precept for future research and application

Health-related quality of life (HRQOL) measurement has emerged as an important health outcome in clinical trials, clinical practice improvement strategies, and healthcare services research and evaluation. HRQOL measures are also increasingly proposed for use in clinical practice settings to inform treatment decisions. In settings where HRQOL measures have been utilized with adults, physicians report such measures as useful, some physicians alter their treatment based on patient reports on such instruments, and patients themselves generally feel the instruments to be helpful. However, there is a dearth of studies evaluating the clinical utility of HRQOL measurement in pediatric clinical practice. This paper provides an updated review of the literature and proposes a precept governing the application of pediatric HRQOL measurement in pediatric clinical practice. Utilizing HRQOL measurement in pediatric healthcare settings can facilitate patient-physician communication, improve patient/parent satisfaction, identify hidden morbidities, and assist in clinical decision-making. Demonstrating the utility of pediatric HRQOL measurement in identifying children with the greatest needs, while simultaneously demonstrating the cost advantages of providing timely, targeted interventions to address those needs, may ultimately provide the driving force for incorporating HRQOL measurement in pediatric clinical practice.

Alternative outcome measures for pediatric clinical sepsis trials

OBJECTIVE

To review nonmortality outcome measures in clinical trials of therapies to treat sepsis in children.

DATA SOURCE

Literature review using the search word terms "sepsis" + "surrogate markers," "sepsis" + "biomarkers," or "sepsis" + "outcomes."

STUDY SELECTION

Articles were generally categorized as those dealing with review of patient-centered outcomes, characteristics of good surrogate markers, resolution of organ dysfunction, morbidity and functional status, quality-of-life measures, intensive care unit costs, and biomarkers.

DATA EXTRACTION AND SYNTHESIS

Information potentially relevant for development of surrogate markers for pediatric sepsis trials was extracted and organized as noted above.

CONCLUSIONS

Multiple potential surrogate markers are being actively investigated for their potential validity and utility in pediatric clinical trials of sepsis and increasingly for adult sepsis trials. This is important because as mortality decreases, it becomes an impractical primary end point. Surrogate end points that address patient-related morbidity and intensive care unit costs may also be quantified. Treatment of sepsis and corresponding end points for clinical trials should be aimed at both the duration and the quality of survival.

The PedsQL: reliability and validity of the short-form generic core scales and Asthma Module

OBJECTIVE

We sought to assess the reliability and validity of the PedsQL 4.0 SF15, a shortened version of the 23-item PedsQL 4.0 Generic Core Scales, which is a pediatric health-related quality of life (HRQoL) instrument, and the PedsQL 3.0 SF22 Asthma Module, a short-form of the PedsQL 3.0 Asthma Module.

METHODS

The PedsQL 4.0 SF15 and the PedsQL 3.0 SF22 Asthma Module were administered by telephone to 125 adolescents (aged 12-18) and 338 parents of children with asthma (aged 2-11). Healthy (n = 451) and chronically ill (n = 422) children, matched by age, respondent status, and ethnicity to the asthma sample, provided data for selected validity tests.

RESULTS

The Total Score from the PedsQL 4.0 SF15 and the Asthma Symptoms scale and Treatment Problems scale from the PedsQL 3.0 SF22 Asthma Module were sufficiently reliable for group comparisons (alpha > or = 0.70 across all age groups) in the asthma sample. The PedsQL 4.0 SF15 and the PedsQL 3.0 SF22 Asthma Module were able to distinguish between children of different clinical status and correlated as expected with measures of productivity and family functioning in the asthma sample. The psychometric properties of the PedsQL 4.0 SF15 were generally comparable to those of the original instrument.

CONCLUSION

The Total Score of the PedsQL 4.0 SF15 and the Asthma Symptoms scale of the PedsQL 3.0 SF22 Asthma Module demonstrated the best reliability and validity and should be suitable for group-level comparisons of generic and asthma-specific HRQoL in clinical research studies of children with asthma.

The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity

BACKGROUND

The application of health-related quality of life (HRQOL) as a pediatric population health measure may facilitate risk assessment and resource allocation, the tracking of community health, the identification of health disparities, and the determination of health outcomes from interventions and policy decisions.

OBJECTIVE

To determine the feasibility, reliability, and validity of the 23-item PedsQL 4.0 (Pediatric Quality of Life Inventory) Generic Core Scales as a measure of pediatric population health for children and adolescents.

DESIGN

Mail survey in February and March 2001 to 20 031 families with children ages 2-16 years throughout the State of California encompassing all new enrollees in the State's Children's Health Insurance Program (SCHIP) for those months and targeted language groups.

METHODS

The PedsQL 4.0 Generic Core Scales (Physical, Emotional, Social, School Functioning) were completed by 10 241 families through a statewide mail survey to evaluate the HRQOL of new enrollees in SCHIP.

RESULTS

The PedsQL 4.0 evidenced minimal missing responses, achieved excellent reliability for the Total Scale Score (alpha =.89 child;.92 parent report), and distinguished between healthy children and children with chronic health conditions. The PedsQL 4.0 was also related to indicators of health care access, days missed from school, days sick in bed or too ill to play, and days needing care.

CONCLUSION

The results demonstrate the feasibility, reliability, and validity of the PedsQL 4.0 as a pediatric population health outcome. Measuring pediatric HRQOL may be a way to evaluate the health outcomes of SCHIP.

Health-related quality of life assessment in hematologic disease

Evaluating health-related quality of life (HRQL) for children who have benign hematologic disorders can: (1) aid in the evaluation of different therapies and emerging new technologies; (2) serve as an invaluable source of anticipatory guidance, for current and future patients; and (3) serve an important evaluative function of clinical services or programs to identify potential areas in which additional services, supports, or interventions are needed. The past 20 years have been marked by the dramatic growth in the field of HRQL research, although much of the progress in conceptualization, instrument development, and refinement has occurred in adults. Pediatric health services researchers and their clinical colleagues have had to grapple with the methodologic challenges in evaluating HRQL in children. This article includes a discussion of instrumentation, respondent selection, and study design consideration in the evaluation of HRQL in children who have benign hematologic disorders.

Psychological research in childhood cancer: the Children's Oncology Group perspective

OBJECTIVE

To review benefits and barriers to psychological research on childhood cancer in multidisciplinary, multicenter clinical-trial cooperative groups and identify opportunities for research activities in the coming decade.

METHODS

Review of progress of cooperative-group research in the Children's Oncology Group and legacy groups and the contribution of psychological research to this effort.

RESULTS

Multidisciplinary, multicenter clinical-trial cooperative groups offer opportunities for psychological research that may be impossible at local institutions. Benefits include collaboration with other disciplines, access to adequate numbers of participants, shared research infrastructure, and access to longitudinal cohorts. Barriers include cost, standardization and quality control, competition for limited resources, and authorship and publication challenges.

CONCLUSIONS

The inclusion of psychological research as a task of the multidisciplinary cooperative group contributes to a transdisciplinary science focused on cure of childhood cancer followed by optimal quality of survivorship. The focus of this research for the next decade should be on the development of intervention studies that address acute problems, lessen the impact of late effects of treatment, and ultimately prevent these effects by better diagnostic classification and targeted treatment. This focus should ultimately lead to translation of intervention research findings to standard of care in the larger childhood cancer community.

Psychosocial Functioning in Pediatric Cancer

OBJECTIVE

To describe the emergence of pediatric psycho-oncology and to summarize research on psychosocial aspects of childhood cancer and survivorship.

METHODS

To review research into illness communication and informed consent, procedural pain, late effects, psychological distress, coping and adjustment, and special risk populations. Methodological challenges, appropriate methodology, and directions for future research are discussed.

RESULTS

The past 30 years have seen change from avoidance of communication about cancer to an emphasis on straightforward discussion of diagnosis and prognosis. Behavioral research has led to interventions to reduce procedural distress. Late effects have been observed in social functioning. Although average levels of distress in survivors of pediatric cancer are typical, subsets of more vulnerable patients and family members exist. Factors predicting positive and negative coping have been identified.

CONCLUSIONS

As the numbers of pediatric cancer survivors increase, psychosocial researchers will be better able to conduct longitudinal studies not only of adjustment and its predictors but also of the impact of the emerging medical treatments and interventions to ameliorate late effects of treatment. Additional funding, improving methodology, and multi-institutional cooperation will aid future pediatric psycho-oncology investigators.

Measuring Physical Symptoms in Children and Adolescents With Cancer

The purpose of this review of the literature was to evaluate measures of physical symptoms in children and adolescents with cancer or those having completed treatment for cancer. Objectives included identification of instruments measuring physical symptoms, a description of how symptoms were conceptualized, description of reliability and validity measures, and assessment of developmental appropriateness for the intended age groups. The electronic databases Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsychLit were searched. Reports of cancer symptoms published in the English language between January 1988 and October 2003 were selected. Inclusion criteria were study samples consisting of children or adolescents with cancer and use of a tool developed for use in children or adolescents with cancer in which physical symptoms comprised a portion of the total measure. Nineteen studies met criteria for review and 23 instruments were identified. Five studies reported measures of the single symptoms of nausea and vomiting and fatigue; 9 studies reported measures of multiple symptoms. An additional 5 studies reported physical symptoms as a component of quality of life measures. Initial psychometric evaluation of these instruments demonstrates acceptable reliability and validity. Areas for future research include application of these measures in specific populations, intervention-based studies, and outcome-focused studies.

Survivors of childhood cancer and their guardians

BACKGROUND

Survivors of childhood cancer are at increased risk for osteoporosis, cardiovascular disease, and second malignancies-conditions for which modifiable risk factors are recognized and lifestyle interventions have shown benefit. Although some data regarding health behaviors of this population exist, receptivity to health promotion is largely unknown.

METHODS

A survey was mailed to 380 survivors (age range, 11-33 years) of childhood leukemia, lymphoma, or central nervous system carcinomas (and guardians of survivors < 18 years old) to elicit data on exercise, dietary intake of calcium, fat, and fruits and vegetables, smoking status, readiness to pursue lifestyle change, quality of life, and interest in various health interventions.

RESULTS

Responses from 209 survivors (a 55% response rate) suggested that most did not meet guidelines for fruit and vegetable consumption (79%), calcium intake (68%), or exercise (52%), 42% were overweight/obese, and 84% consumed > 30% of calories from fat. Older (> 18 years) compared with younger (< 18 years) survivors were more likely to smoke (17% vs. 1%), to be obese (21.6% vs. 14.6%), and to have suboptimal calcium intakes (75.6% vs. 57.6%). No differences in lifestyle behaviors were observed between cancer groups. Compared with interventions aimed at weight control, improving self-esteem, or smoking cessation, the highest levels of interest were found consistently for interventions aimed at getting in shape and eating healthy. Survivors preferred mailed interventions to those delivered in-person, by telephone counselors, or via computers.

CONCLUSIONS

Survivors of childhood cancer practiced several suboptimal health behaviors. Health promotion interventions aimed at areas of interest and delivered through acceptable channels have the potential to improve long-term health and function of this vulnerable population.

Parent proxy-reported health-related quality of life and fatigue in pediatric patients diagnosed with brain tumors and acute lymphoblastic leukemia

BACKGROUND

Pediatric patients with brain tumors (BT) are often excluded from health-related quality of life (HRQOL) studies even though they experience more severe disease and treatment-related sequelae than children with other types of cancer. Parent proxy assessments of HRQOL allow for greater inclusion of children who are developmentally immature, physically ill, or cognitively impaired.

METHODS

Parents of children ages 2-18 years who were diagnosed at Childrens Hospital Los Angeles and Children's Hospital San Diego with BT (n = 86) or acute lymphoblastic leukemia (ALL; n = 170) evaluated their children's HRQOL over the previous week using the parent-proxy versions of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core scales, the PedsQL 3.0 Acute Cancer Module, and the PedsQL Multidimensional Fatigue scales. Multiple regression analyses were used to determine the independent effect of the child's diagnosis on HRQOL. Separate analyses were conducted for patients receiving treatment, patients who had not received treatment for < 12 months, and patients who had not received treatment for > or = 12 months.

RESULTS

Patients with BT exhibited more problems than patients with ALL in the physical, social, psychosocial, school, cognitive, and fatigue domains of HRQOL. The Core Physical Health, Core Psychosocial Health, and Fatigue Total scores for patients with BT demonstrated peak improvements for children who had not received treatment for < 12 months and sharp declines for children who had not received treatment for > or = 12 months. The Core Physical Health and Fatigue Total scores for patients with ALL were highest (better HRQOL) for those who had not received treatment for > or = 12 months.

CONCLUSIONS

Pediatric patients and survivors of BT experienced more fatigue and HRQOL problems than patients with ALL, and HRQOL differed by treatment status.

The PedsQL Family Impact Module: preliminary reliability and validity

BACKGROUND

The PedsQL Measurement Model was designed to measure health-related quality of life (HRQOL) in children and adolescents. The PedsQL 4.0 Generic Core Scales were developed to be integrated with the PedsQL Disease-Specific Modules. The newly developed PedsQL Family Impact Module was designed to measure the impact of pediatric chronic health conditions on parents and the family. The PedsQL Family Impact Module measures parent self-reported physical, emotional, social, and cognitive functioning, communication, and worry. The Module also measures parent-reported family daily activities and family relationships.

METHODS

The 36-item PedsQL Family Impact Module was administered to 23 families of medically fragile children with complex chronic health conditions who either resided in a long-term care convalescent hospital or resided at home with their families.

RESULTS

Internal consistency reliability was demonstrated for the PedsQL Family Impact Module Total Scale Score (alpha = 0.97), Parent HRQOL Summary Score (alpha = 0.96), Family Functioning Summary Score (alpha = 0.90), and Module Scales (average alpha = 0.90, range = 0.82 - 0.97). The PedsQL Family Impact Module distinguished between families with children in a long-term care facility and families whose children resided at home.

CONCLUSIONS

The results demonstrate the preliminary reliability and validity of the PedsQL Family Impact Module in families with children with complex chronic health conditions. The PedsQL Family Impact Module will be further field tested to determine the measurement properties of this new instrument with other pediatric chronic health conditions.

Health-related quality of life as a predictor of pediatric healthcare costs: a two-year prospective cohort analysis

Background

The objective of this study was to test the primary hypothesis that parent proxy-report of pediatric health-related quality of life (HRQL) would prospectively predict pediatric healthcare costs over a two-year period. The exploratory hypothesis tested anticipated that a relatively small group of children would account for a disproportionately large percent of healthcare costs.

Methods

317 children (157 girls) ages 2 to 18 years, members of a managed care health plan with prospective payment participated in a two-year prospective longitudinal study. At Time 1, parents reported child HRQL using the Pediatric Quality of Life Inventory™ (PedsQL™ 4.0) Generic Core Scales, and chronic health condition status. Costs, based on health plan utilization claims and encounters, were derived for 6, 12, and 24 months.

Results

In multiple linear regression equations, Time 1 parent proxy-reported HRQL prospectively accounted for significant variance in healthcare costs at 6, 12, and 24 months. Adjusted regression models that included both HRQL scores and chronic health condition status accounted for 10.1%, 14.4%, and 21.2% of the variance in healthcare costs at 6, 12, and 24 months. Parent proxy-reported HRQL and chronic health condition status together defined a 'high risk' group, constituting 8.7% of the sample and accounting for 37.4%, 59.2%, and 62% of healthcare costs at 6, 12, and 24 months. The high risk group's per member per month healthcare costs were, on average, 12 times that of other enrollees' at 24 months.

Conclusions

While these findings should be further tested in a larger sample, our data suggest that parent proxy-reported HRQL can be used to prospectively predict healthcare costs. When combined with chronic health condition status, parent proxy-reported HRQL can identify an at risk group of children as candidates for proactive care coordination.

Adventure therapy for adolescents with cancer

The objective of this study was to describe adolescents' with cancer experience in an adventure therapy program from a health related quality of life (HRQL) perspective. A qualitative descriptive research method was used. Eleven adolescents and five health professionals participated in a guided group adventure therapy expedition in a remote area of Canada. The expedition was videotaped and data were collected using an unstructured interview format with both adolescents and health professionals. Emerging themes were identified using a qualitative descriptive exploratory analysis. Four major themes and related sub-themes were generated. The major themes were: developing connections, togetherness, rebuilding self-esteem, and creating memories. Adventure therapy was viewed by the adolescents and health care professionals as a positive experience with multiple benefits. This preliminary research will contribute to an understanding of adolescents' experiences with cancer and provide a basis for future studies evaluating the impact of adventure therapy on HRQL.

Challenges to the measurement of health-related quality of life in children receiving cancer therapy

Measures of health-related quality of life (HRQL) assess those areas of a patient's functioning that are affected by their cancer and its therapy. Although HRQL measures are integrated frequently into studies of survivors of childhood cancer, their use in the assessment of children receiving therapy has been limited by several methodological challenges. These arise from issues specific to measuring HRQL in young children, who comprise a large proportion of the pediatric oncology population, and from issues associated with assessing HRQL during therapy, when the patient's health status is in constant flux. This study summarizes the commonly used HRQL measures, and examines factors that impact their broad application. These include the influence of developmental changes on the content and format of HRQL measures, the role of proxy assessors, the important characteristics of measurement tools used to assess patients receiving active therapy, and the issues related to the ideal timing of serial HRQL assessments in prospective trials.

Validity of the child health questionnaire for use in children with sickle cell disease

OBJECTIVE

To provide accurate data on health-related quality of life (HRQL), there must be a valid tool to measure this outcome. The objective of this study was to determine the validity of the Child Health Questionnaire (CHQ) as a measure of HRQL in sickle cell disease (SCD) by examining the relationship between HRQL and disease severity.

METHODS

This was a cross-sectional study of children conducted at two urban, hospital-based clinics. The study participants were children with SCD ages 5 to 18 years who presented for a routine visit to the comprehensive SCD clinic. The main outcome was HRQL, as measured by the CHQ-Parent Form 28 (PF28). A t test was used to compare HRQL between those with mild and severe disease.

RESULTS

Parents/caretakers of 95 children completed the CHQ-PF28. Children with mild SCD had a significantly better HRQL, as evidenced by a higher mean physical summary score (39.1), than those with severe disease (28.0) (difference=11.1, 95% confidence interval 5.03-18.11). There was no significant difference in psychosocial summary scores between groups.

CONCLUSIONS

The CHQ is a valid tool to assess HRQL in children with SCD and could serve as an important adjunct to determine the effect of SCD on the lives of children.

The PedsQL in pediatric cancer pain: a prospective longitudinal analysis of pain and emotional distress

The objective of this prospective study was to investigate the cross-sectional and longitudinal associations between pain and emotional distress in children and adolescents with cancer as measured by the Pediatric Quality of Life Inventory (PedsQL) Emotional Functioning and Pain Scales. The PedsQL 1.0 Generic Core Scales are multidimensional scales developed as the generic core measure to be integrated with the PedsQL Disease-Specific Modules. The PedsQL 1.0 Cancer Module was designed to measure pediatric cancer-specific health-related quality of life. The PedsQL Generic Core Scales, Emotional Functioning Scale and Cancer Module Pain Scale, were administered to 69 children and 59 adolescents and their parents at Time 1 and Time 2, which was 6 months on average after Time 1. Prospective hierarchical multiple regression analyses supported a longitudinal predictive model with Time 1 pain predicting Time 2 pain and Time 1 emotional distress predicting Time 2 emotional distress, respectively. Time 1 emotional distress did not predict Time 2 pain, and Time 1 pain did not predict Time 2 emotional distress. The results demonstrate that pediatric cancer pain and emotional distress, although associated cross-sectionally, are differentially predictive in prospective longitudinal analyses. These results suggest that both pain and emotional distress should be targeted for treatment interventions concurrently to enhance long-term health-related quality of life of the pediatric patient with cancer.

Parents' Reports of Barriers to Care for Children With Special Health Care Needs: Development and Validation of the Barriers to Care Questionnaire

OBJECTIVE

To describe the development and validation of the Barriers to Care Questionnaire (BCQ).

METHODS

The 39-item BCQ was developed through review of the literature, focus groups, and cognitive interviews of Spanish- and English-speaking parents of children with chronic health conditions. Barriers to care are conceptualized as a multidimensional construct consisting of pragmatics, health knowledge and beliefs, expectations about care, skills, and marginalization. The BCQ was field tested in 3 samples of children with special health care needs (CSHCN).

RESULTS

Response rate for the field test was 77.2%. There were minimal missing data (0.08%), no floor effects, and minimal ceiling effects (3.8%, total scale). Internal consistency reliability (alpha) for the BCQ total scale was.95 and subscale alpha ranged from.75 to.91. The BCQ total scale and subscales correlated in the expected direction with validated measures of primary care characteristics and health-related quality of life. BCQ scores were higher (fewer barriers) for children with a primary care physician and for those who reported no problems getting care or foregone care.

CONCLUSION

The BCQ is a feasible, reliable, and valid instrument for measuring barriers to care for CSHCN. Its use may inform efforts to support consumer choice, enhance provider accountability, and spur quality improvement.

Health-related quality of life and its relationship to neurological outcome in child survivors of stroke

BACKGROUND

Ischemic stroke during infancy and childhood has the potential to result in neurological impairments and affect a child's ability to function at home, school, and play. There are limited data on the effect of ischemic stroke on quality of life (QOL) of child survivors of ischemic stroke.

OBJECTIVE

To examine parent and child perspectives on QOL and examine factors that correlate with reduced QOL for child survivors of stroke.

METHODS

A prospective single-center cohort design was used. Participants included children 2-18 years of age surviving ischemic stroke. The Pediatric Quality of Life 4.0 Generic Inventory Scale (PedsQL) parent proxy-report (2-18 years of age) and child self-report (5-18 years of age) were completed by participants. Scores were compared with standardized normative data of healthy children and those with chronic medical conditions. Neurological deficits were measured with the Pediatric Stroke Outcome Measure, a standardized evaluation for children. The relationships between stroke type, neurological deficit, and health-related quality of life (HRQOL) were examined.

RESULTS

We assessed the QOL in 84 children with arterial ischemic stroke and 16 with cerebral sinovenous thrombosis at a mean age of 8.4 (4.12) years; 4.4 (2.93) years after their stroke. Results showed that both the parent-proxy and child self-report HRQOL scores were significantly reduced (P>.01) compared with normative data of healthy children. Of greatest concern for both parents and children was the effect of stroke on school, followed by its impact on emotional and social functions. In contrast to other studies, scores in physical domain were better than those in the psychosocial domain. Multivariate analysis showed that of neurological deficits after stroke was a significant predictor of poor HRQOL (P>.05). The children with poor neurological recovery had the lowest mean PedsQL scores and their QOL was significantly poorer compared with normative data of children with chronic health conditions (ie, diabetes, cancer).

CONCLUSION

The PedsQL appears to be a promising assessment tool of HRQOL for children following stroke. Both parent and child perspectives should be included because of the potential for there to be significant differences in perspectives. Although severity of neurological outcome is a significant predictor of reduced HRQOL, it accounted for a small proportion of variance in QOL scores. Further research is required to delineate other factors that are significant predictors of outcome.

Measuring the neuro-cognitive side-effects of irradiation in children with brain tumors

BACKGROUND

Reduction of the treatment-related side effects has become one of the main goals of the recent study protocols for brain tumor therapies. When the treatment burden is decreased in patients with good prognostic features, the potential increased risk of relapse has to be counterbalanced by a significantly improved cognitive outcome. This objective is always clearly stated but comprehensive data on the neuropsychological outcomes are seldom reported.

PROCEDURES AND RESULTS

The appropriate means to measure the long-term morbidity need to be clarified. Health Status and Quality of Life (QOL) questionnaires can be easily administered but these questionnaires represent usually a composite evaluation where cognition is analyzed along with other items such as mood or pain. However, none of these questionnaires has ever been used to measure a difference in cognitive outcome when comparing two different therapeutic strategies in children. Complete neuropsychological evaluations are time consuming, need specialized psychologists and most of the tests have not been rigourously validated. In this respect, Wechsler scales are, however, robust and objective methods to evaluate intelligence. Several studies have been able to show meaningful differences in IQ scores between treatments in children with posterior fossa tumors, even with small numbers of patients.

CONCLUSIONS

In order to evaluate any refinement in the treatment of these patients, widely accepted evaluation tools are needed. Ideally, these methods will have to be sensitive, reproducible, and widely applicable. None of the available tools fullfil all of these criteria but their development should be a major endeavour in modern neuro-oncology.

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

BACKGROUND

Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.

METHODS

An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.

RESULTS

Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.

CONCLUSIONS

Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

Validation of the German version of the Pediatric Quality of Life Inventory (PedsQL) in childhood cancer patients off treatment and children with epilepsy

The Pediatric Quality of Life Inventory (PedsQL) is a relatively new instrument developed in the US to assess health-related quality of life (HRQL) in healthy and ill children and adolescents. It is quick and easy to use, suitable for assessment by children and parents and based on a modular approach with a generic measure addressing all general domains of HRQL and disease-specific modules. We report here the results of translating the original US generic core instrument and the cancer module into German and testing the German PedsQL in samples of paediatric patients who have been treated for cancer or epilepsy. Like in studies with the original instrument, score distributions tended to be skewed toward higher HRQL, but a full response range was demonstrated for each item. The German PedsQL is reliable in terms of internal consistency with the majority of scales exceeding a Cronbach's alpha of 0.70. Clinical validity was confirmed by differences between the cancer and epilepsy groups in the expected direction and by the ability of the PedsQL to discriminate between subjects with different degrees of medical and psychosocial sequelae. Comparing our findings to US results, the German PedsQL seems to be equivalent to the original version. Future methodologic research should evaluate construct validity, sensitivity and responsiveness, and test the usefulness of the instrument in other clinical populations and healthy children.

Evaluation of the built environment at a children's convalescent hospital: development of the Pediatric Quality of Life Inventory parent and staff satisfaction measures for pediatric health care facilities

In preparation for the design, construction, and postoccupancy evaluation of a new Children's Convalescent Hospital, focus groups were conducted and measurement instruments were developed to quantify and characterize parent and staff satisfaction with the built environment of the existing pediatric health care facility, a 30-year-old, 59-bed, long-term, skilled nursing facility dedicated to the care of medically fragile children with complex chronic conditions. The measurement instruments were designed in close collaboration with parents, staff, and senior management involved with the existing and planned facility. The objectives of the study were to develop pediatric measurement instruments that measured the following: (1) parent and staff satisfaction with the built environment of the existing pediatric health care facility, (2) parent satisfaction with the health care services provided to their child, and (3) staff satisfaction with their coworker relationships. The newly developed Pediatric Quality of Life Inventory scales demonstrated internal consistency reliability (average alpha = 0.92 parent report, 0.93 staff report) and initial construct validity. As anticipated, parents and staff were not satisfied with the existing facility, providing detailed qualitative and quantitative data input to the design of the planned facility and a baseline for postoccupancy evaluation of the new facility. Consistent with the a priori hypotheses, higher parent satisfaction with the built environment structure and aesthetics was associated with higher parent satisfaction with health care services (r =.54, p <.01; r =.59, p <.01, respectively). Higher staff satisfaction with the built environment structure and aesthetics was associated with higher coworker relationship satisfaction (r =.53; p <.001; r =.51; p <.01, respectively). The implications of the findings for the architectural design and evaluation of pediatric health care facilities are discussed.