Quality of life measures in health care. I: Applications and issues in assessment

Improving quality of life in hypertension management using a fixed-dose combination of olmesartan and amlodipine in primary care

OBJECTIVES

To assess quality of life (QoL) in unselected patients in primary care treated with a fixed-dose combination of olmesartan and amlodipine. Research design and methods. Multicenter, noninterventional, noncontrolled observational study in 8241 patients seen by 2187 physicians over 12 - 18 weeks.

MAIN OUTCOME MEASURES

Changes in QoL were assessed by using the Short Form 12 (SF-12) questionnaire completed by 5434 patients (65.9%) at baseline and 4924 patients (59.8%) at the follow-up visit.

RESULTS

Patients had a mean age of 62.8 ± 11.8 years (48.1% female), mean blood pressure [BP] at baseline was 161.8 ± 16.6/93.6 ± 10.2 mmHg and 74.8% had at least one co-morbid risk factor or condition. All 12 items of the SF-12 improved over the observational period (p < 0.0001) as did the physical (46.8 vs 40.4; p < 0.0001) and mental summary scores (52.4 vs 47.5; p < 0.0001). Correlations of changes in systolic and diastolic BP, pulse pressure and heart rate with scores were significant, although weak (maximum -0.2055 for physical health and changes in systolic blood pressure).

CONCLUSIONS

The fixed-dose combination of olmesartan and amlodipine significantly improves QoL in an unselected population of patients in primary-care practice. This might translate into improved patient compliance and improved long-term antihypertensive efficacy.

Health-related quality of life, and its determinants, among older people in rural Vietnam

Background

The proportion of people in Vietnam aged 60 and above has increased rapidly in recent decades. However, there is a lack of evidence, particularly in rural settings, on their health-related quality of life (HRQoL) within the context of socioeconomic changes and health-sector reform in the country. This study assesses the level and determinants of HRQoL in a rural district in order to provide evidence for designing and implementing appropriate health policies.

Methods

In 2007, 2,873 people aged 60+ living in 2,240 households randomly selected from the FilaBavi demographic surveillance site (DSS) were interviewed using a generic EQ-5D questionnaire to assess their HRQoL. Socioeconomic characteristics of the people and their households were extracted from the DSS's re-census that year, and the EQ-5D index was calculated based on the time trade-off tariff. Multilevel-multivariate linear regression analysis was performed to measure the affect of socioeconomic factors on HRQoL.

Results

The EQ-5D index at old age was found to be 0.876 (95%CI: 0.870-0.882). Age between 60-69 or 70-79 years, position as household head, working until old age, literacy, and belonging to better wealth quintiles are determinants of higher HRQoL. Ageing has a primary influence on the deterioration of HRQoL at older ages, mainly due to reduction in physical rather than mental functions. Educational disparity in HRQoL is low, and exists mostly between basic and higher levels of education. Being a household head and working at old age are advantageous for attaining better quality of life in physical rather than psychological terms. Economic conditions affect HRQoL through sensory rather than physical utilities. Long-term living conditions more likely affect HRQoL than short-term economic conditions.

Conclusions

HRQoL at old age is at a high level, and varies substantially according to socioeconomic factors. Its determinants should be addressed in social and health policies designed to improve health of older people, especially among the most vulnerable groups.

Development and preliminary validation of the Lip Reanimation Outcomes Questionnaire

OBJECTIVE: Lip paralysis is associated with eating, speaking, and appearance impairments. The lip reanimation outcome questionnaire is designed to assess these functional impairments after lip reanimation.

STUDY DESIGN: Cross-sectional validation study.

SETTING: Tertiary care academic center.

SUBJECTS AND METHODS: Patients who underwent lip reanimation and control subjects. A disease-specific instrument was created by systematic literature review and expert opinion. The 15-item patient completed subscale was administered to 20 lip reanimation patients. Photographs of 19 patients and three control subjects were taken in four poses and rated by six raters (2 surgeons, 2 residents, and 2 novices) by the use of a external rater subscale, and reliability was determined by the use of intraclass correlation coefficients (ICC). Content and construct validity were assessed.

RESULTS: Internal consistency (ICC range 0.813-0.915 for each domain), test—retest reliability (ICC range 0.616-0.981 for each item) for the patient completed subscale, and interrater (ICC = 0.852) and interlevel reliability (ICC = 0.929) for the external rater subscale were substantial to excellent. The content validity index was 0.87. Construct validity was demonstrated by poorer scores in patients with transected nerves versus intact nerves for appearance ( P = 0.04) and oral competence ( P = 0.011). Photographs of control patients had lower asymmetry scores ( P < 0.001), and the instrument detected greater asymmetry in patients with progressively more exaggerated smile ( P < 0.001).

CONCLUSION: The lip reanimation outcome questionnaire has promising reliability and validity in this preliminary study, but additional psychometric testing with larger samples is required before the survey can be recommended for clinical use.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Patient perception of outcomes following failed spinal instrumentation with polyetheretherketone rods and titanium rods

STUDY DESIGN

A structured questionnaire.

OBJECTIVE

The purpose of this study was to determine whether material rod composition and its imaging characteristics can determine patient perceptions of pain, outcome, and need for revision surgery in the context of the failure of spinal instrumentation following lumbar arthrodesis.

SUMMARY OF BACKGROUND DATA

Patient perceptions of radiographic images in the context of failed spinal instrumentation may influence clinical outcomes and patient satisfaction. Due to radiolucency, failed polyetheretherketone (PEEK) rods may be perceived differently by patients than more traditional materials.

METHODS

Patients presenting primarily with chief complaints of back pain completed a 2-page, 22-question questionnaire containing 3 alternative radiographic images of failed rod instrumentation following posterolateral lumbar arthrodesis. The images represented failed rods composed of either PEEK, PEEK with a longitudinal radio-opaque marker, or traditional titanium. Statistical analysis with the Cochran Q test was performed to determine whether there were statistical differences in the responses.

RESULTS

The responses suggested a preference for the images representing PEEK instrumentation as being associated with superior clinical outcomes, the least pain, the most comfort, and the least likelihood of required revision surgery.

CONCLUSION

PEEK rods possess radiolucent properties that can alter patient perceptions of clinical outcomes when compared with images of other equally unfavorable scenarios. The significance of these patient perceptions must still be demonstrated. However, they may play an important role in clinical outcomes and patient satisfaction.

Discriminative capacity of the EQ-5D, SF-6D, and SF-12 as measures of health status in population health survey

PURPOSE

To compare the EQ-5D, SF-6D, and SF-12 in terms of their capacity to discriminate between groups defined by relevant socio-demographic and health characteristics in a general population survey.

METHODS

Data were obtained from the 2006 Catalan Health Interview Survey, a representative sample (n = 4,319) of the general population of Catalonia (Spain). Effect sizes (ES) and Receiver Operating Characteristic (ROC) curves were calculated to evaluate the instruments' capacity to distinguish between groups based on socio-demographic variables, recent health problems, perceived health, psychological distress, and selected chronic conditions.

RESULTS

All instruments showed a similar discriminative capacity between groups based on socio-demographic variables, recent medical visit (ES = 0.47-0.55), activity limitations (ES = 0.92-0.98), perceived health (ES = 0.97-1.33), and psychological well-being (ES = 1.17-1.57). Effect sizes between respondents with and without any of fourteen selected chronic conditions were large (0.76-1.04) for 4, moderate (0.55-0.74) for 8, and small (0.17-0.39) for two on the EQ-5D index. A similar pattern was observed for the SF-12 but ES were predominantly moderate (7 conditions) or small (6 conditions) on the SF-6D.

CONCLUSIONS

The EQ-5D and SF-12 were largely comparable in estimating the health burden of chronic conditions, recent health problems, and social inequalities. The SF-6D was less sensitive than the EQ-5D index and SF-12, particularly for physical chronic conditions.

Quality of life following endonasal skull base surgery

The importance of quality of life (QOL) outcomes following treatments for head and neck tumors are now increasingly appreciated and measured to improve medical and surgical care for these patients. An understanding of the definitions in the setting of health care and the use of appropriate QOL instruments and measures are critical to obtain meaningful information that guides decision making in various aspects of patient health care. QOL outcomes following cranial base surgery is only recently being defined. In this article, we describe the current published data on QOL outcomes following cranial base surgery and provide preliminary prospective data on QOL outcomes and sinonasal morbidity in patients who underwent endonasal cranial base surgery for management of various skull base tumors at our institution. We used a disease-specific multidimensional instrument to measure QOL outcomes in these patients. Our results show that although sinonasal morbidity is increased, this is temporary, and the vast majority of patients have a very good QOL by 4 to 6 months after endonasal approach to the cranial base.

Burden of skin diseases

Skin diseases are among the most common health problems worldwide and are associated with a considerable burden. The burden of skin disease is a multidimensional concept that encompasses psychological, social and financial consequences of the skin disease on the patients, their families and on society. Chronic and incurable skin diseases, such as psoriasis and eczema, are associated with significant morbidity in the form of physical discomfort and impairment of patients' quality of life; whereas malignant diseases, such as malignant melanoma, carry substantial mortality. With the availability of a wide range of health status and quality-of-life measures, the effects of most skin diseases on patients' lives can be measured efficiently. The aim of this review is to present some of the published data in order to highlight the magnitude of the burden associated with some common skin diseases and also to suggest ways to quantify this burden of skin disease.

Neuropsychological functions and metabolic aspects in subclinical hypothyroidism: the effects of L-thyroxine

Thyroid hypofunction is a slowly progressing graded phenomenon [Vanderpump MP, Tunbridge WM, French JM, Appleton D, Bates D, Clark F, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995;43(1):55-68]; subclinical forms (SCH) often represent a laboratory diagnosis in apparently asymptomatic patients. In the absence of adequate parameters for thyroid hormone action in tissues, the level of TSH increase corresponding to negative effects remains unsettled. We studied a wide range of physiological processes in a strictly selected population of 38 female patients (56.4+/-12.6 years) with minor forms of SCH (TSH 6.6+/-1.8 mIU/L), after exclusion of neurological, psychiatric and somatic disorders or confounding conditions. The investigations, performed at admission and after 6 months of l-thyroxine (LT4) treatment, included metabolic evaluation, health status perception and an extensive battery of neuropsychological tests and psychological rating scales. Lipid metabolism improved after LT4 (total cholesterol: 231.9+/-49.6 mg/dl pre- vs 221.0+/-40.0 mg/dl post-treatment; LDL cholesterol: 183.1+/-62.9 vs 162.7+/-53.7 mg/dl; apolipoprotein A1: 183.5+/-64.5 vs 160.9+/-50.3 mg/dl; p<0.05 for all comparisons), while glucose metabolism was unchanged. Health status perception was favourably influenced by the treatment (total SF-36 score 97.8+/-18.4 pre- vs 108.5+/-14.8 post-, p<0.0001); in a matched control group with euthyroid goiter, tested to examine the effects of medical care in the absence of treatment, no significant differences were found in the SF-36 scores at admission and after 6 months (109.3+/-15.1 vs 109+/-14.2, p=0.9). Attention performance improved after LT4; HRSD and HRSA scores did not significantly change, but negative correlations were found between FT3 levels and affective scores at admission, and between the post-treatment changes of affective scores and of FT3. In our study subtle disturbances of health status perception, attention and lipid metabolism associated to SCH of mildest degrees were reverted by LT4 replacement, reinforcing reports of unfavourable consequences of marginal thyroid disease.

Analysis of evidence-based medicine for shoulder instability

Clinical research has become a major influencing factor in the determination of treatment choice in our society. Outcome data have been requested by third-party payers, patients, and administrators alike. Currently, there are over 10 different scoring systems that have been used to evaluate the efficacy of treatment for shoulder instability. Some of these scoring systems are based on the specific condition of shoulder instability; however, other systems are broadly based to incorporate a spectrum of shoulder conditions. This review summarizes the process of proper development and testing of the scoring systems, discusses their role in clinical research with respect to shoulder instability, and explains the dichotomy of postoperative recurrence of instability and high shoulder scores. The Shoulder Rating Questionnaire (SRQ), Melbourne Instability Shoulder Score (MISS), Western Ontario Shoulder Instability Index (WOSI), Oxford Instability Score (OIS), and Simple Shoulder Test were shown to be reliable for patients with instability. The SRQ, MISS, WOSI, OIS, and American Shoulder and Elbow Surgeons score have all been shown to be largely responsive. There are 2 shoulder scoring systems, the WOSI and the MISS, that we recommend be used to evaluate shoulder instability. The SRQ and OIS were found to be less responsive for patients with instability compared with patients with other shoulder dysfunctions. Other scoring systems lack inter-rater reliability, validity, and/or responsiveness for patients in the instability population. The optimal scoring system for patients with upper extremity problems other than those with shoulder instability has yet to be determined; however, the American Shoulder and Elbow Surgeons score may be considered, because this instrument has been proven to be valid, reliable, and responsive.

How do common chronic conditions affect health-related quality of life?

BACKGROUND

Comorbidity is common. National Institute for Health and Clinical Excellence (NICE) guidelines have been created to make best use of resources to improve patients' quality of life but do not currently take account of comorbidity. The effect of multiple chronic conditions with regard to health-related quality of life (HRQoL) is poorly researched. Criticisms of previous research have been due to patient-defined chronic conditions, lack of quantification of the effects of confounding factors, selection of affected patients only, small sample sizes, and upper age limits.

AIM

This study aims to address these issues, looking into the impact of combinations of chronic conditions on HRQoL.

DESIGN OF THE STUDY

Participants filled in a questionnaire containing general health information, specific respiratory questions, and the EQ-5D measure of HRQoL. The questionnaires were then matched up to their GP records to obtain their disease status for six common chronic diseases (asthma, chronic obstructive pulmonary disease, ischaemic heart disease, hypertension, diabetes, and cerebrovascular disease).

METHOD

Data from a mailed questionnaire were analysed from 5169 patients aged >16 years from two general practices in Wythenshawe, Manchester in 2004. Completion of the questionnaire was taken to indicate consent to participate.

RESULTS

Significant correlations were found between a lower HRQoL and increasing numbers of chronic conditions (P<0.001), increasing age, possible obstructive airway disease, lack of higher education, smoking, and female sex. These all remained significant following regression, except for sex, with number of chronic conditions being a strong predictor of the weighted health state index score, EQ-5D(index) (coefficient = -0.079, P<0.001).

CONCLUSION

Increasing numbers of chronic conditions have a strong negative effect on HRQoL.

[Linguistic adaptation of the endometriosis health profile 5: EHP 5]

OBJECTIVES

The aim of this work was to develop a French version of an English quality of life questionnaire specific of endometriosis: endometriosis health profile 5.

MATERIALS AND METHODS

After many translations and reverse translations, we got a first French version of EHP 5. This scale was then distributed in two centres: Poissy and Versailles. This questionnaire was completed by women with endometriosis proven and chronic pain. We studied acceptability and feasibility.

RESULTS

Eighteen patients were included. All items have been completed satisfactorily. Our version was described as understandable and easy to complete.

CONCLUSION

Our work consisted in developing a French version of EHP 5 which was very well received by the patient. However, the psychometric and clinical validation remains to be done.

The value of adding the Quality of Life Enjoyment and Satisfaction Questionnaire to outcome assessments of psychiatric inpatients with mood and affective disorders

PURPOSE

In the domain of mental health outcomes, increasing interest has been shown in complementing traditional symptom measures with measures of a patient's quality of life. The objective of this study was to evaluate the value of including the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) in the routine assessment battery used at a psychiatric hospital.

METHODS

The sample consisted of 1,276 consecutive inpatients treated at a private psychiatric hospital over a two-year period. Admission and discharge data were collected for the Q-LES-Q, the mental health subscales of the Medical Outcomes Short Form Questionnaire (SF-36), the Depression Anxiety Stress Scales, and the Health of the Nation Outcome Scale.

RESULTS

Large patient improvements from admission to discharge were seen across all instruments (effect sizes from 0.8 to 1.5), including the Q-LES-Q (effect size 1.3). The Q-LES-Q correlated with existing symptom measures, and regression analyses revealed that quality of life predicted length of hospital stay even after symptoms of depression and anxiety were taken into account.

CONCLUSIONS

Although the Q-LES-Q was correlated with symptom measures already in use, it added to the ability to predict patient length of stay, and showed some divergence from measures of clinical outcomes. This pattern was seen despite intentionally restricting the sample to patients with mood and affective disorder diagnoses. The value of considering quality of life in a comprehensive assessment of mental health outcomes is discussed.

Quality of life of persons with lower-limb amputation during rehabilitation and at 3-month follow-up

OBJECTIVE

To describe and compare the quality of life (QOL) of persons with lower-limb amputation (LLA) at admission (T1), discharge (T2), and 3 months after rehabilitation discharge (T3) and to explore the relationships between QOL and demographic and clinical variables including body image.

DESIGN

Longitudinal case series.

SETTING

Inpatient rehabilitation facility.

PARTICIPANTS

Consecutive sample of 19 unilateral persons with LLA (14 men, mean age, 53.4+/-14.6y).

INTERVENTION

Interdisciplinary rehabilitation.

MAIN OUTCOME MEASURES

Generic and specific QOL measures and perception of body image at T1, T2, and T3.

RESULTS

Subjective QOL was relatively high at T1, T2, and T3 (0.87/2, 1.1/2, and 1.0/2, respectively) except for items related to physical functioning. There was no significant change over time for all but 1 QOL satisfaction measure (ability to go outside, P=.024). Prosthesis-related QOL was high at discharge and follow-up. Body-image disturbances were absent over the study period. QOL satisfaction and prosthesis satisfaction were strongly related to lower-limb pain and psychosocial factors (eg, body image).

CONCLUSIONS

QOL of persons with LLA was high and remained relatively stable during inpatient rehabilitation and 3 months after discharge.

Validation of interactive voice response system administration of the Short Inflammatory Bowel Disease Questionnaire

BACKGROUND

The Short Inflammatory Bowel Disease Questionnaire (SIBDQ) is a written, self-administered instrument measuring quality of life in IBD. We assessed the validity of an interactive voice response system (IVRS) as a new mode of administering the SIBDQ.

METHODS

An IVRS was designed using prerecorded questions to collect data via touchtone telephone. Subjects with Crohn's disease (CD) or ulcerative colitis (UC) were randomized into 2 groups with different orders of administration: written, self-administered followed by IVRS (S-I) or IVRS followed by written, self-administered (I-S). Half of the S-I group was also randomized to receive a second IVRS. Sixty-four subjects were studied: 30 in S-I, 34 in I-S.

RESULTS

The mean SIBDQ scores were not different between written and IVRS modes (P = 0.26) with r = 0.93. IVRS scores were lower in active than inactive CD (36.1 +/- 9.6 versus 54.7 +/- 8.6, P < 0.001) and lower in active than inactive UC (40.8 +/- 9.6 versus 59.8 +/- 10.0, P < 0.001). Mean scores correlated highly with disease activity indices, and were not different between first and second IVRS administrations (P = 0.85) with r = 0.92. IVRS had excellent internal consistency (Cronbach alpha = 0.90).

CONCLUSIONS

IVRS administration of the SIBDQ yields results similar to written self-administration, with excellent procedural validity, test-retest reliability, and internal consistency.

Quality of life of patients with irritable bowel syndrome in Korea

OBJECTIVE

The impact of irritable bowel syndrome (IBS) on HRQOL has been widely studied in the West. However, there are few data from Asian countries. The aim of this study was to assess the health-related quality of life (HRQOL) of patients suffering from IBS in Korea.

METHODS

Consecutive patients from six secondary and six tertiary medical centers in Korea were enrolled and completed self-administered questionnaires on sociodemographics and IBS-associated symptoms. HRQOL was assessed using the generic Short Form 36 (SF-36) and the disease-specific IBS-QOL questionnaires.

RESULTS

Of the 932 patients with abdominal pain and bowel symptoms, 664 IBS patients who fulfilled the Rome II criteria were analyzed. On all eight SF-36 scales, IBS patients had a significantly worse HRQOL than the general population (P < 0.01). The overall score for the IBS-QOL was 74.2. The health concern domain was most affected (mean score 64.2), and the sexual domain (mean score 86.7) was least affected in the IBS-QOL. Significant impairment of HRQOL was only observed in patients with severe symptoms both in the generic and specific HRQOL measurement, whereas patients with mild and moderate symptoms showed only mild impairment (P < 0.01). Female patients reported a significantly lower HRQOL than male patients (P < 0.05), but the difference was minimal. The IBS-QOL was significantly associated with female gender, total symptom score, self-reported symptom severity, and level of education in the multivariate analysis.

CONCLUSIONS

IBS-related symptoms had a great effect on the HRQOL of Korean patients. These results and the considerable prevalence of IBS in Korea indicate that IBS has a substantial social impact in this country.

Measuring the Impact of Headache in Children: A Critical Review of the Literature

Headache is the most frequent neurological symptom and commonest manifestation of pain in childhood. Measuring the impact of headache in terms of health status, functioning and quality of life can inform the prioritization of competing resource claims, screen for unmet need, improve communication between patient and physician and monitor response to treatment. We undertook a critical review of the literature measuring the impact of headache in children and identified 33 papers that contained relevant information. Findings reflected a wide range of settings, age groups, methodologies and outcome measures. Considerable methodological limitations affected all studies, including inadequate description of study design, methodology and data analysis. Nevertheless, although we found the existing literature to be of inconsistent quality, the impact of headache in children and adolescents is substantial. Rigorous studies are required to quantify this burden using measures that are valid and reliable and whose development has been informed by both theoretical and practical perspectives.

[Health-related quality of life in women operated on by surgical anti-incontinence procedures: comparison of three techniques]

OBJECTIVES

To assess the health-related quality of life (Contilife) after three surgical anti-incontinence procedures (Tension-Free Vaginal Tape [TVT], Transobturator Vaginal Tape [TOT], and Transobturator Vaginal Tape [TVT-O]).

PATIENTS AND METHODS

We performed a prospective analysis of 90 women (30 TVT, 30 TOT, 30 TVT-0) with genuine stress incontinence pre- and postoperatively at 18 months. The objective cure rate was determined by clinical and urodynamic examination and the subjective cure rate by the Contilife questionnaire.

RESULTS

Prior to surgery, patients complained more of effort activities, followed by global well-being. Postoperatively, all domains improved significantly without statistical difference between the three groups and 90% of the patients would advise the intervention to one of their friends.

DISCUSSION AND CONCLUSION

Surgical outcomes vary greatly depending on the methodology of the study. Health-related quality of life seems paramount to decide time of surgery and to evaluate postoperatory results. We have chosen the Contilife questionnaire because of its scientific and clinical validity, reliability, responsiveness and linguistic validation. These results confirm that TVT/TOT/TVT-O procedures are a safe and effective surgical method and that they significantly improved health-related quality of life.

Modified rush pin technique for two- or three-part proximal humeral fractures

PURPOSE

To report the outcomes of modified Rush pin fixation for proximal humeral fractures.

METHODS

42 men and 20 women aged 19 to 94 (mean, 64) years with 2- or 3-part proximal humeral fractures underwent reduction and fixation using the modified Rush pin technique. 11 patients died from reasons unrelated to the surgery.

RESULTS

Of 40 (out of 51) patients completing a subjective functional assessment using an Oxford Shoulder Questionnaire, 28 (70%) had 2-part and 10 (25%) had 3-part displaced fractures, and the remaining 2 (5%) had fracture-dislocations (one being 2-part and one 3-part). 25 (63%) patients were very satisfied (including one with a 3-part fracture after 6 months of rehabilitation), 7 (17%) were moderately satisfied, and 8 (20%) were not satisfied. There were 8 complications, including pin cut-out from the proximal fragment (n=2), proximal pin migration (n=2), distal pin migration (n=1), cortical perforation during surgery (n=1), mild ulnar nerve symptoms (n=1). No patients had non-union, myositis ossificans, avascular necrosis of the humeral head, or axillary nerve injury.

CONCLUSION

The modified Rush pin fixation minimises tissue dissection; the implants are cheap and readily available; and the technical expertise is easily learnt. This technique is a suitable alternative of fixing proximal humeral fractures, especially in the elderly.

A pre- and post-treatment evaluation of vision-related quality of life in uveitis

Aim:

To study the effect of treatment on vision-related quality of life (VR-QOL) in uveitis patients.

Materials and Methods:

Interviewer-administered questionnaire-based evaluation of visual function and VR-QOL in Tamil-speaking adult patients with active uveitis at presentation and follow-up by the same interviewer.

Results:

Ninety-eight patients participated in this study. There was a statistically significant improvement in VR-QOL in all the scales following treatment (P < 0.001). Patients with chronic uveitis showed better improvement upon treatment than patients with acute uveitis. The visual symptoms scale showed moderate gains following treatment (effect size 0.56). Persons with bilateral disease had poorer mean scores compared to those with unilateral disease. Visual acuity was closely correlated with VR-QOL scores.

Conclusion:

The VR-QOL measurement has shown that it is sensitive to demonstrate the problems of patients with uveitis irrespective of their demographic profile. The scores improved significantly in patients with uveitis following treatment and have shown close correlation to visual acuity thus demonstrating that VR-QOL is effective in assessing the response to treatment.

"It's hard to tell": the challenges of scoring patients on standardised outcome measures by multidisciplinary teams: a case study of neurorehabilitation

Background

Interest is increasing in the application of standardised outcome measures in clinical practice. Measures designed for use in research may not be sufficiently precise to be used in monitoring individual patients. However, little is known about how clinicians and in particular, multidisciplinary teams, score patients using these measures. This paper explores the challenges faced by multidisciplinary teams in allocating scores on standardised outcome measures in clinical practice.

Methods

Qualitative case study of an inpatient neurorehabilitation team who routinely collected standardised outcome measures on their patients. Data were collected using non participant observation, fieldnotes and tape recordings of 16 multidisciplinary team meetings during which the measures were recited and scored. Eleven clinicians from a range of different professions were also interviewed. Data were analysed used grounded theory techniques.

Results

We identified a number of instances where scoring the patient was 'problematic'. In 'problematic' scoring, the scores were uncertain and subject to revision and adjustment. They sometimes required negotiation to agree on a shared understanding of concepts to be measured and the guidelines for scoring. Several factors gave rise to this problematic scoring. Team members' knowledge about patients' problems changed over time so that initial scores had to be revised or dismissed, creating an impression of deterioration when none had occurred. Patients had complex problems which could not easily be distinguished from each other and patients themselves varied in their ability to perform tasks over time and across different settings. Team members from different professions worked with patients in different ways and had different perspectives on patients' problems. This was particularly an issue in the scoring of concepts such as anxiety, depression, orientation, social integration and cognitive problems.

Conclusion

From a psychometric perspective these problems would raise questions about the validity, reliability and responsiveness of the scores. However, from a clinical perspective, such characteristics are an inherent part of clinical judgement and reasoning. It is important to highlight the challenges faced by multidisciplinary teams in scoring patients on standardised outcome measures but it would be unwarranted to conclude that such challenges imply that these measures should not be used in clinical practice for decision making about individual patients. However, our findings do raise some concerns about the use of such measures for performance management.

[Principles of quality of life measurement and its application in childhood]

BACKGROUND

The evaluative and critical analysis of articles on the quality of life which appear in growing number in the medical literature, and the adaptation of the measures to clinical practice can be realised only through knowledge of the professional standards of the measuring methods.

OBJECTIVE

To outline the most widely accepted definitions of life- and health-related quality of life, to define the application possibilities as well as the parameters of the measuring methods. To demonstrate the most common problems as well as the possibilities of implementing pediatric measures. To give concrete guidance on evaluating previous measures and designing new ones.

METHOD

Through a review of literature on methodology, cultural equivalence and paediatric measures, the authors outline the most frequent problems and give examples of some methods corresponding to the current professional standards.

CONCLUSION

The quality of health care can be improved by using patient-reported outcome measures such as health-related quality of life measures. To assess different patient groups, modular approaches with general and disease-specific modules are advisable. The linguistic and cultural equivalence and the international comparability of the results can be achieved by adhering to professional guidelines and by performing psychometric tests to control the parameters of the methodology. In paediatric measures efforts should be made to conduct the simultaneous questioning of children and their parents as early as possible.

Quality of life in hypertension management using olmesartan in primary care

OBJECTIVE

Differences in quality of life (QoL) using antihypertensive drugs may account for differences in compliance, persistence and blood pressure control. As this is the prerequisite for cardiovascular risk reduction, QoL was investigated using highly tolerable drugs (such as olmesartan).

RESEARCH DESIGN/METHODS

The non-interventional study was carried out in 4252 primary care patients with 6 weeks of follow up. Documentation of patient characteristics included concomitant diseases and antihypertensive medication, blood pressure, pulse pressure, pulse rate and evaluation of QoL using the SF-12 questionnaire. Comparison of data at 6 weeks after adding or switching to olmesartan treatment (median dose: 20 mg) with baseline values.

MAIN OUTCOME MEASURES

Patients had mild-to-moderate hypertension, 52.6% of whom were male and the mean age was 60.5 +/- 11.9 years. Dyslipidaemia (38.3%), diabetes (20.9%) and coronary heart disease (16.4%) were the most frequent concomitant diseases. After 6 weeks, blood pressure was reduced by -22.8 +/- 14.1/-11.5 +/- 8.3 mmHg (p < 0.001 versus baseline). All items of the SF-12 questionnaire and both sum scores improved over the course of treatment (p < 0.001 versus baseline), and were well compatible with non-hypertensive controls. Improvements were higher when switching from alpha-blockers, calcium channel blockers, beta-blockers, diuretics and angiotensin-converting enzyme inhibitors as compared with angiotensin II type 1 receptors blockers (ARBs), in particular on the mental health scale (p < 0.001). Adverse events were rare (0.66%), with dizziness (n = 8; 0.19%) being the most frequent.

CONCLUSIONS

As was shown in the current study, patients on olmesartan treatment not only achieve adequate blood pressure control but also experienced a substantial improvement of QoL. This may contribute to long-term blood pressure control using ARBs.

The use of a patient-based questionnaire (the Oxford Shoulder Score) to assess outcome after rotator cuff repair

INTRODUCTION

It is increasingly important for surgeons to monitor the outcome of their practice for the purpose of audit. The main difficulty has been the lack of appropriate methods of assessing outcome. Outcome has traditionally been assessed by clinical means which can be inaccurate, irreproducible and subject to surgeon bias. In addition, the perspective of the patient and surgeon may differ with respect to outcome and interest has grown in patient-based scoring systems. The Oxford Shoulder Score (OSS) is one such patient-based scoring system. The main aim of this study was to assess whether a patient-based questionnaire, in this case the OSS, could be effectively used to audit outcome from shoulder surgery. A secondary aim was to assess the value of gathering outcome information by post.

PATIENTS AND METHODS

A total of 24 patients (14 male; median age 59 years; age range, 43-73 years) who had completed a pre-operative OSS questionnaire and had undergone rotator cuff repair were included in the study. Participants were assessed postoperatively at regular intervals using the OSS at hospital visits and by postal questionnaire.

RESULTS

The completion level for the OSS was 97% and the response rate to the postal questionnaire was 96%. At 3 months' post-surgery, 21 of 24 patients had improved; at final review (16-37 months), 23 patients had improved following surgery. The OSS was observed to be a robust tool for the quantitative assessment and tracking of patient outcomes after surgery.

CONCLUSIONS

This study shows the value of using a postal questionnaire to follow-up patients after surgery and demonstrates the successful use of a patient-based questionnaire to audit the outcome from shoulder surgery.

Knee arthroplasty: disabilities in comparison to the general population and to hip arthroplasty using a French national longitudinal survey

Background

Knee arthroplasty is increasing exponentially due to the aging of the population and to the broadening of indications. We aimed to compare physical disability and its evolution over two years in people with knee arthroplasty to that in the general population. A secondary objective was to compare the level of disabilities of people with knee to people with hip arthroplasty.

Methodology/Principal Findings

16,945 people representative of the French population were selected in 1999 from the French census and interviewed about their level of disability. This sample included 815 people with lower limb arthroplasty. In 2001, 608 of them were re-interviewed, among whom 134 had knee arthroplasty. Among the other participants re-interviewed, we identified 68 who had undergone knee arthroplasty and 145 hip arthroplasty within the last two years (recent arthroplasty). People with knee arthroplasty reported significantly greater difficulties than the general population with bending forward (odds ratio [OR] = 4.7; 95% confidence interval [CI]: 1.7, 12.6), walking more than 500 meters (OR = 6.0; 95% CI: 1.5, 24.7) and carrying 5 kg kilograms for 10 meters (OR = 4.6; 95% CI: 1.3, 16.4). However, the two years evolution in disability was similar to that in the general population for most activities. The level of mobility was similar between people with recent knee arthroplasty and those with recent hip arthroplasty. Nevertheless, people with recent knee arthroplasty reported a lower level of disability than the other group for washing and bending forward (OR = 0.3; 95% CI: 0.1, 0.6 and OR = 0.4; 95% CI: 0.1, 0.9, respectively).

Conclusions/Significance

People with knee arthroplasty reported a higher risk of disability than the general population for common activities of daily living but a similar evolution. There was no relevant difference between recent knee and hip arthroplasties for mobility.

Disease severity, quality of life and health care in plaque-type psoriasis: a multicenter cross-sectional study in Germany

BACKGROUND

Plaque-type psoriasis produces significant morbidity, has negative effects on patients' health-related quality of life (HRQoL), and represents an economic burden.

OBJECTIVES

The assessment of disease severity, HRQoL and health care in plaque-type psoriasis in everyday German medical practice.

METHODS

Details of patients with plaque-type psoriasis were recorded by 48 dermatologists in Germany. During the visit, demographic data, medical history, previous and current treatments, occupational impairment, the current state of the disease (measured by the Psoriasis Area and Severity Index; PASI), overall lesion severity, and HRQoL were evaluated.

RESULTS

In total, 1,511 plaque-type psoriasis patients were included. The average PASI score was 12.0. The average Dermatology Life Quality Index score was 8.6. Among the patients with the severest psoriasis (PASI >20), only 45.4% had ever been prescribed systemic treatments.

CONCLUSIONS

Psoriasis patients have a reduced HRQoL and are not sufficiently treated in practice. A more widespread use of systemic treatment and the definition of treatment goals are essential to improve the standard of care for psoriasis patients.

The suitability of the WHOQOL-BREF for Canadian and Norwegian older adults

The aim of this study was to examine the validity and reliability of the WHOQOL-BREF, a generic quality of life scale, among older people in Canada and Norway. Very similar data from the Canadian and Norwegian Field Trial data (Canada n = 192; Norway, n = 469) were analyzed and compared. Higher negatively skewed mean scores were found for all WHOQOL-BREF domains in Canada. For both study samples, missing values were highest for the sex item from the social domain. Ceiling effects were found (Canada n = 21; Norway n = 11) primarily among items in the physical and environmental domains. In both study samples, a multitrait multimethod procedure indicated items correlated most strongly with their parent domains; however, equally appreciable correlations were observed between physical, psychological, and environmental items (r = 0.33-0.64; p < 0.01). The social domain had the lowest internal consistency (α = 0.67 Canada, α = 0.55 Norway). Confirmatory factor analyses (CFA) yielded marginal goodness-of-fit between the hypothesized WHOQOL-BREF measurement model and the sample data as well as differing patterns of domain misspecification. Patterns of correlations (p < 0.01) of WHOQOL-BREF domains with WHOQOL-OLD facets, a global QOL item, the SF-12, and the geriatric depression scale provided evidence of convergent and divergent validity. Domain scores also significantly discriminated between health and unhealthy populations and presence of morbidity. Empirical support was found, in part, for the construct validity of the WHOQOL-BREF in older adults. Despite some different patterns found in the CFA, possibly due to cultural or sampling differences, it appears that the instrument is reliable, valid, and facilitates cross-cultural comparisons.

The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature

OBJECTIVE

The purpose of this paper is to summarize the best evidence regarding the impact of providing patient-reported outcomes (PRO) information to health care professionals in daily clinical practice.

METHODS

Systematic review of randomized clinical trials (Medline, Cochrane Library; reference lists of previous systematic reviews; and requests to authors and experts in the field).

RESULTS

Out of 1,861 identified references published between 1978 and 2007, 34 articles corresponding to 28 original studies proved eligible. Most trials (19) were conducted in primary care settings performed in the USA (21) and assessed adult patients (25). Information provided to professionals included generic health status (10), mental health (14), and other (6). Most studies suffered from methodologic limitations, including analysis that did not correspond with the unit of allocation. In most trials, the impact of PRO was limited. Fifteen of 23 studies (65%) measuring process of care observed at least one significant result favoring the intervention, as did eight of 17 (47%) that measured outcomes of care.

CONCLUSIONS

Methodological concerns limit the strength of inference regarding the impact of providing PRO information to clinicians. Results suggest great heterogeneity of impact; contexts and interventions that will yield important benefits remain to be clearly defined.

Effect of gluten-free diet and co-morbidity of irritable bowel syndrome-type symptoms on health-related quality of life in adult coeliac patients

BACKGROUND

Both coeliac disease and irritable bowel syndrome show impaired health-related quality of life, however, the impact of irritable bowel syndrome-type symptoms on health-related quality of life in coeliac disease is unclear.

AIM

To evaluate the effect of gluten-free diet adherence and irritable bowel syndrome-type symptoms co-morbidity on health-related quality of life in adult coeliac disease patients.

PATIENTS AND METHODS

A total of 1130 adults were enrolled in the study comprising 1001 controls from the general population and 129 diagnosed coeliac disease patients from the University Clinic in Cagliari. Irritable bowel syndrome-type symptoms and health-related quality of life were assessed using the Rome II and the SF-36 questionnaires, respectively.

RESULTS

Irritable bowel syndrome-type symptoms prevalence in controls was 10.1% (102/1001) and 55% (71/129) in the coeliac disease patients. Irritable bowel syndrome-type symptom controls and coeliac disease patients both presented significantly lower health-related quality of life (p<or=0.05) compared to healthy controls. Strict diet coeliac disease patients, compared to partial diet patients, showed significantly (p<or=0.05) better scores in all domains, except physical functioning, physical-role and bodily pain. The lowest scores were found in partial diet coeliac disease patients with irritable bowel syndrome-type symptoms.

CONCLUSIONS

The present results confirm the burden of irritable bowel syndrome-type symptoms and coeliac disease on health-related quality of life. Moreover, these data show that health-related quality of life in coeliac disease is impaired by poor compliance and by co-morbidity with irritable bowel syndrome-type symptoms.

Does patient perception of alignment affect total knee arthroplasty outcome?

OBJECTIVE

This study was designed to address a recurring observation in our centre that, despite a satisfactory postoperative radiographic limb alignment, some patients are dissatisfied with the alignment and appearance of their operated leg. We carried out a prospective survey to determine patient perception of limb alignment after total knee arthroplasty (TKA) and whether level of satisfaction with alignment affects clinical outcome.

METHODS

Patients self-rated their alignment, their satisfaction with alignment and their level of knee pain on a visual analogue scale (VAS). Additional outcome measures included pre- and postoperative Knee Society Score (KSS), Oxford Knee Score (OKS) and the Health Survey Short Form (SF-12).

RESULTS

Twenty of 87 (23%) patients were dissatisfied with their new leg alignment and had a poorer perception of pain and range of motion after TKA. Despite this finding, KSS and OKS were no different between patients who were satisfied and those who were dissatisfied with their limb alignment. The SF-12 showed a trend toward lower scores in patients who were dissatisfied with their limb alignment.

CONCLUSIONS

Satisfaction with perceived limb alignment appears to influence outcome after TKA and is not reflected in current outcome scales. Perhaps patients should be counselled on how alignment is restored and on what to expect of their limb alignment and appearance after TKA.

Quality of life in the elderly patients on dialysis

The pattern of end-stage renal disease (ESRD) has changed significantly with the emerging predominance of elderly patients. Age is no longer seen as a contraindication to dialysis. Based on 2004 data, in the USA, patients aged 45-64 years old comprise the largest portion of the incident population, while patients aged 75 and older have the highest incident rates of ESRD. Mortality is higher among the elderly dialysis patients for whom cardiovascular diseases and infections are the most common causes of death. The quality of life (QoL) of these patients has been found to vary in different investigations, dependent on such factors as the investigator(s), the composition of the study group and the criteria used, among others; however, age was always found one of the major determinants of their QoL. Quality-of-life data suggest that older dialysis patients have similar levels of social functioning and mental health as younger dialysis patients but that their level of physical functioning is poorer. As such, the survival and QoL of elderly patients depends mainly on the severity of the comorbid conditions. The rationing of dialysis on the basis of age alone is not justified as dialysis can provide elderly patients with the means to gain the health status that permits them to enjoy life, but in their own way.

Quality of life in CAPD, transplant, and chronic renal failure patients with diabetes

Although quality of life (QoL) is an important outcome measure, there are few studies of QoL in diabetic patients. We performed a cross-sectional study to assess QoL in such patients comparable for age, sex, and co-morbidity.

PATIENTS

Group CAPD: DM (n = 19, 12 males), diabetic CAPD patients; group CAPD: no DM (n = 26, 15 males) CAPD patients without diabetes; group TXP (n = 20, 10 males), diabetic transplant patients; and group CKD: DM (n = 20, 11 males), diabetics with chronic kidney disease. Two valid QoL instruments were used: a generic one (SF-36) and one that is disease-specific (RQLP).

RESULTS

As a whole, CAPD patients scored badly as far as concerned the physical domain, but with a good mental adaptation. Diabetic CAPD patients exhibited worse QoL for physical functioning, energy, vitality, leisure activity, and eating/drinking limitations. Diabetic transplant patients exhibited the best QoL. The RQLP instrument had better discriminative power for domains such as eating/drinking, treatment effects, and psychosocial aspects. Using analysis of co-variance and adjusting for age, sex, and co-morbidity, QoL differences disappeared. In conclusion, diabetic CAPD patients exhibited the worst QoL though with a satisfactory mental adaptation, a renal-specific instrument had better discriminative power, and the prevention of co-morbidity is likely to improve QoL in such patients.

Evolution of disability in adults with hip arthroplasty: a national longitudinal study

OBJECTIVE

To describe disability in individuals with hip arthroplasty and its evolution over 2 years compared with that in the general population, and to compare the degree of disability between subjects with recent and older hip arthroplasty.

METHODS

We selected a national representative sample of 16,945 subjects from the 1999 French population census. This sample, interviewed in 1999 and 2001 about their level of disability, included 527 subjects with hip arthroplasty (i.e., representing 424,000 individuals in the French noninstitutionalized population): 145 who underwent the procedure between 1999 and 2001 (recent hip arthroplasty) and 382 with an older hip arthroplasty.

RESULTS

Subjects with hip arthroplasty reported more difficulty in bending forward (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.1-6.6), climbing stairs (OR 2.2, 95% CI 1.5-3.1), walking >300 meters (OR 1.6, 95% CI 1.03-2.6), dressing (OR 2.9, 95% CI 2.1-4.2), and getting in and out of a chair (OR 2.5, 95% CI 1.7-3.6) than the general population. However, the evolution in disability was similar to that of the general population. Compared with subjects with older hip arthroplasty, those with recent hip arthroplasty reported more difficulty walking >300 meters (OR 2.7, 95% CI 1.3-5.6), washing (OR 2.9, 95% CI 1.6-5.4), dressing (OR 2.2, 95% CI 1.2-4.2), and getting in and out of a chair (OR 2.1, 95% CI 1.1-3.9).

CONCLUSION

This study describes the potential future disability in the more elderly population, with implications for health-related planning.

Thiopurine treatment in inflammatory bowel disease: clinical pharmacology and implication of pharmacogenetically guided dosing

This review summarises clinical pharmacological aspects of thiopurines in the treatment of chronic inflammatory bowel disease (IBD). Current knowledge of pharmacogenetically guided dosing is discussed for individualisation of thiopurine therapy, particularly to avoid severe adverse effects. Both azathioprine and mercaptopurine are pro-drugs that undergo extensive metabolism. The catabolic enzyme thiopurine S-methyltransferase (TPMT) is polymorphically expressed, and currently 23 genetic variants have been described. On the basis of an excellent phenotype-genotype correlation for TPMT, genotyping has become a safe and reliable tool for determination of a patient's individual phenotype. Thiopurine-related adverse drug reactions are frequent, ranging from 5% up to 40%, in both a dose-dependent and -independent manner. IBD patients with low TPMT activity are at high risk of developing severe haematotoxicity if pharmacogenetically guided dosing is not performed. Based on several cost-benefit analyses, assessment of TPMT activity is recommended prior to thiopurine therapy in patients with IBD. The underlying mechanisms of azathioprine/mercaptopurine-related hepatotoxicity, pancreatitis and azathioprine intolerance are still unknown. Although the therapeutic response appears to be related to 6-thioguanine nucleotide (6-TGN) concentrations above a threshold of 230-260 pmol per 8 x 10(8) red blood cells, at present therapeutic drug monitoring of 6-TGN can be recommended only to estimate patients' compliance.Drug-drug interactions between azathioprine/mercaptopurine and aminosalicylates, diuretics, NSAIDs, warfarin and infliximab are discussed. The concomitant use of allopurinol without dosage adjustment of azathioprine/mercaptopurine leads to clinically relevant severe haematotoxicity due to elevated thiopurine levels. Several studies indicate that thiopurine therapy in IBD during pregnancy is safe. Thus, azathioprine/mercaptopurine should not be withdrawn in strictly indicated cases of pregnant IBD patients. However, breastfeeding is contraindicated during azathioprine/mercaptopurine therapy. Use of azathioprine/mercaptopurine for induction and maintenance of remission in corticosteroid-dependent or corticosteroid-refractory IBD, particularly Crohn's disease, is evidence based. To improve response rates in thiopurine therapy of IBD, comprehensive analyses including metabolic patterns and genome-wide profiling in patients with azathioprine/mercaptopurine treatment are required to identify novel candidate genes.

Critical evaluation of the use of research tools in evaluating quality of life for people with schizophrenia

Schizophrenia may lead to impairments in many aspects of life, including physical, cognitive, and role functioning. The subjective quality of life of people with schizophrenia has been shown to be lower than in the general population and appropriate patient-assessed health outcome measures are necessary to capture the distress and disability experienced by people living with a serious mental illness. Although psychiatry has been slow to become involved in quality of life measurement, the use of quality of life instruments has now been recognized as a means of evaluating the outcome of care interventions, in terms of symptoms and functioning. This paper evaluates the effectiveness of two widely used instruments: The Medical Outcomes Study Short Form Health Survey (SF-36) and The Lancashire Quality of Life Profile (LQoLP) in terms of reliability and validity in measuring the quality of life of people with schizophrenia. The LQoLP appeared to be best suited for evaluation of care programmes, whereas the SF-36 was more appropriate for medical trials, comparisons between patient groups, and assessment of the direct consequences of treatment on health and function. Subjective quality of life should, however, be considered to be distinct from clinical status and quality of life assessment should include the broadest range of indicators, to reflect the holistic ethos of mental health nursing.

Quality of life and continence 1 year after the tension-free vaginal tape operation

OBJECTIVE

The purpose of this study was to evaluate changes in condition-specific and generic quality of life (QOL) and continence rates 1 year after the tension-free vaginal tape (TVT) operation for stress urinary incontinence.

STUDY DESIGN

A total of 99 patients undergoing the TVT operation underwent clinical and urodynamic assessment and completed the German language King's Health Questionnaire (KHQ) and the Short Form 36 (SF-36) before and 3 and 12 months after surgery. Overall, 72 TVTs were performed as isolated procedure and 27 in combination with other operations. Data were analyzed with the Chi-square test, analyses of variance, and the Tukey test.

RESULTS

Overall, the objective continence rate was 80% at 1 year and did not differ significantly between patients with or without concomitant surgery. Significant and clinically relevant (>10 points) improvements were seen in all domains of the KHQ except General Health perception. The SF-36 showed statistically significant but not clinically significant improvement.

CONCLUSION

The TVT operation is associated with improved condition-specific QOL in women with stress urinary incontinence. The condition-specific KHQ is more appropriate than the generic SF-36 for evaluating treatment results in women treated for incontinence.

Percepção de estigma na epilepsia

INTRODUÇÃO: Pessoas com epilepsia frequentemente vivenciam o estigma, muitas vezes mais prejudicial que a própria condição em si. De maneira geral, pode-se dizer que a epilepsia é uma das condições que mais afeta o comportamento e a qualidade de vida, não só da pessoa que tem epilepsia, mas também da família toda, especialmente devido ao estigma existente. Por isso, dizemos que a epilepsia causa um impacto bio-psicosocial na vida das pessoas. Porém, este aspecto do estigma na epilepsia é pouco abordado, especialmente em países em desenvolvimento, como o Brasil, onde superstições, atitudes negativas e falta de informação dificultam a relação da comunidade com a epilepsia. OBJETIVO: Este artigo tem o objetivo de discutir aspectos relevantes do estigma na epilepsia: conceituação e modelos de estigma na área médica e social; estigma e qualidade de vida; fatores operantes; aspectos neurobiológicos e estratégias para se lidar com o estigma na epilepsia. CONCLUSÕES: Este artigo mostrou uma visão geral do estigma englobando seus diferentes aspectos. Pelo fato de ser um conceito multifatorial, o combate ao estigma requer também uma intervenção ampla, envolvendo as áreas médica, psicológica e social. O entendimento do processo do estigma contribui para uma mudança da interpretação social da epilepsia, rumo a construção de uma sociedade mais justa e tolerante, na qual as diferenças sejam respeitadas.