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

Comparison of clinical and patient-based measures to assess medium-term outcomes following shoulder surgery for disorders of the rotator cuff

OBJECTIVE

To compare different assessments following shoulder surgery for impingement syndrome with or without rotator cuff tear or repair.

METHODS

A prospective study of 93 patients was conducted. Standard assessments were performed before, at 6 months, and at 4 years following shoulder surgery using the patient-based Oxford Shoulder Score (OSS), the Medical Outcomes Study Short Form-36 (SF-36) questionnaire, and a surgeon-assessed Constant Shoulder Score. Patients were categorized according to the surgery received in relation to the presence of cuff tears: full repair, partial repair, cuff tear/no repair, no tear/no repair.

RESULTS

Most patients (57%) received subacromial decompression for impingement with no cuff tear. This group had the fewest pre- and postoperative symptoms. The category of patients who received only partial repair of a cuff tear had worse scores on all outcome assessments compared with other groups. Patient-based measures were more stable over time than the Constant.

CONCLUSION

The shoulder-specific measures had greater sensitivity than the SF-36 in registering significant differences in outcomes between comparison groups at 6 months and 4 years.

Comparison of patient and doctor responses to a total hip arthroplasty clinical evaluation questionnaire

BACKGROUND

Surgeons traditionally undertake a prospective evaluation of patients undergoing total hip arthroplasty in order to determine outcomes. The validity of doctor-derived data is questionable because of the potential for interobserver error, reporting bias, and differences between the perceptions of doctors and patients. Also, the use of doctor-derived data necessitates the use of costly outpatient services. Consequently, there are likely to be benefits associated with the use of patient-derived clinical evaluation data. However, few studies have focused on whether data obtained from the patient and doctor differ.

METHODS

The agreement between patient and doctor responses on a sixteen-item total hip arthroplasty clinical evaluation questionnaire completed at more than 2900 clinical assessments was determined. Data from repeated assessments performed preoperatively and postoperatively enabled stratified analyses that were used to examine reasons for disagreement and factors influencing agreement. Agreement was measured with use of the kappa coefficient.

RESULTS

For twelve of the sixteen items, the patient responses had acceptable agreement with the doctor responses. Some important differences between patient-derived and doctor-derived data were found. If the patient had other joint or health problems, had a revision total hip arthroplasty, or reported mild or moderate pain, there was a greater chance of reduced agreement on the pain items. Younger patients demonstrated better agreement with doctors than older patients did.

CONCLUSIONS

Patients' perceptions of symptoms and outcomes after total hip arthroplasty are relatively similar to those of their doctor. There is minimum risk of misinterpreting outcomes data by replacing doctor-completed questionnaires with patient-completed questionnaires in uncomplicated total hip arthroplasty cases. For patients with comorbid joint problems or other health problems, and for those reporting substantial pain, direct physician involvement in the evaluation of pain is recommended. The selective use of patient-completed questionnaires has the potential to substantially reduce the costs of outcomes evaluation programs by minimizing doctor input. Pending revision of some of the items, the use of this patient-completed questionnaire is advocated.

HRQL and severity of brain ultrasound findings in a cohort of adolescents who were born preterm

PURPOSE

To determine whether health-related quality of life (HRQL) in a cohort of adolescents who were born prematurely is related to the severity of brain ultrasound examination findings during the newborn period.

METHODS

This study uses a historical, prospective methodology to investigate the 84 members of a cohort of infants born prematurely (<33 weeks gestation) at Thomas Jefferson University Hospital during a 25-month period, from 1979 to 1981. We extracted the following information from their neonatal intensive care unit (NICU) records: ultrasound examination findings (graded for intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL); and records of medical illness (respiratory, gastrointestinal, and other) during the NICU stay. We followed-up the members of this cohort 18-19 years later, obtaining data on 53 (63%). We correlated the NICU data with the following self-report outcome measures: HRQL, Disabilities Questionnaire [parental report indicating the severity of complications of prematurity (DISAB)] and psychological assessment tests [Beck Depression Inventory (BDI), Coopersmith Self-Esteem Inventory (CSEI), and Body Shape Questionnaire (BSQ)]. We used the method of multiple discriminant function analysis to determine statistical significance of differences between the two ultrasound groups, grades 0-2 IVH, no PVL vs. grades 3-4 IVH and/or PVL.

RESULTS

A statistically significant difference was obtained between the two ultrasound groups (grades 0-2 IVH, no PVL vs. grades 3-4 IVH and/or PVL) among the HRQL variables (Wilks' lambda =.764, df = 5, p <.470). The relative contribution of dependent variables (HRQL1, HRQL2, HRQL3, HRQL4, DISAB) to the group separation was assessed through the interpretation of discriminant function-variable correlation. HRQL1 and DISAB made the largest discriminant between groups, which is supported by results from univariate Student's t-tests. Study subjects with grades 3-4 IVH and/or PVL ultrasound findings obtained much lower HRQL1 scores (better overall estimation of HRQL) and much higher DISAB scores than subjects with grades 0-2 IVH, no PVL ultrasound findings.

CONCLUSIONS

It appears that the lower an adolescent's score on overall HRQL (HRQL1), (i.e., the better the self-perceived overall quality of life), the more likely he or she displayed the higher severity of brain ultrasound examination findings during the NICU hospitalization. A larger study of premature infants who are followed into adolescence is required to better understand the factors that determine the association of IVH and PVL with HRQL.

The community-acquired pneumonia symptom questionnaire: a new, patient-based outcome measure to evaluate symptoms in patients with community-acquired pneumonia

STUDY OBJECTIVE

s: To develop and validate a patient-based outcome measure to evaluate symptoms in patients with community-acquired pneumonia (CAP).

DESIGN

A psychometric study within an international, prospective, randomized, double-blind study. The CAP-symptom questionnaire (CAP-Sym) is a new, 18-item, patient-reported outcome measure that evaluates the bothersomeness of CAP-related symptoms during the past 24 h using a 6-point Likert scale. We used "gold standard" psychometric methods to comprehensively evaluate the acceptability, reliability, validity, and responsiveness of the CAP-Sym.

SETTING

Sixty-four centers in 13 countries (France, Germany, Hungary, Israel, Italy, Norway, Poland, Portugal, South Africa, Spain, Sweden, Switzerland, United Kingdom).

PATIENTS

Five hundred fifty-six patients with CAP, recruited from outpatient clinics, general practice, and hospital centers.

INTERVENTIONS

Randomization 1:1 to moxifloxacin (400 mg once daily), oral or standard oral treatment (amoxicillin, 1 g tid, or clarithromycin, 500 mg bid), alone or in combination, for up to 14 days.

RESULTS

Standard psychometric tests confirmed the acceptability (item nonresponse, item-endorsement frequencies, item/scale floor and ceiling effects), reliability (internal consistency, item-total and inter-item correlations, test-retest reliability), validity (content, construct, convergent, discriminant, known groups), and responsiveness of the CAP-Sym.

CONCLUSIONS

The CAP-Sym is a practical and scientifically sound patient-based outcome measure of CAP-related symptoms that has been developed using "gold standard" methods. As the only fully validated measure of symptoms in patients with CAP, which is quick and easy to administer and is more responsive than the generic Medical Outcomes Study 36-Item Short-Form Health Survey, the CAP-Sym provides a practical and rigorous method for improving the evaluation of outcomes in clinical trials and audit.

The quality of life in patients with Crohn's disease

BACKGROUND

Health-related quality of life studies provide insight into the influence of Crohn's disease on patients' lives, and the potential impact on professional and personal productivity.

AIM

To compare health-related quality of life in Crohn's disease patients with that in other patients and healthy controls, and between medically and surgically treated Crohn's disease patients, and to correlate health-related quality of life with Crohn's disease activity.

METHODS

An expanded MEDLINE search of full length, English language, adult Crohn's disease studies from January 1966 to September 2000 was performed. The key words utilized were: 'Quality of Life', 'Health Status' or 'Health Related Quality of Life' and 'Crohn's' or 'Inflammatory Bowel Disease'.

RESULTS

A total of 258 articles were identified; 236 subsequently were excluded, leaving 22 for analysis. Compared with Crohn's disease patients, the health-related quality of life was better in healthy controls and in ulcerative colitis patients (except pre-colectomy), but similar to or worse than that in many other medical conditions. The health-related quality of life was directly correlated with Crohn's disease activity, and was worse in active disease than in remission. The health-related quality of life was improved only in the short term in surgically vs. medically treated Crohn's disease patients.

CONCLUSIONS

Health-related quality of life analysis provides important insights into the impact of Crohn's disease, and should be included in clinical trials. Researchers, clinicians and other health care providers need to be cognizant of the impact of the health-related quality of life upon patients' lives.

A theoretical approach to measuring quality of life

The purpose of this article is to discuss conceptual issues surrounding health-related quality of life (HRQOL) and to provide an example of how structural equation modeling can address some of these conceptual issues. This article reports the development of the measurement model for overall quality of life, a dimension of HRQOL as conceptualized by Wilson and Cleary (1995). The sample (N = 1410) is from the AIDS Time-Oriented Health Outcome Study (ATHOS) databank, a longitudinal observational database of persons with HIV-associated illness. The hypothesized second-order factor model consists of 5 latent variables and 17 measured items. The fit indicators (RMSEA = .0717; SRMR = .0450; CFI = .951) suggest that the model provides an adequate description of the pattern of relationships in the data. A theoretical approach to HRQOL will expand its clinical use as an outcome measure and increase its relevance.

Activity, participation, and quality of life 6 months poststroke

OBJECTIVES

To estimate the extent of activity and participation of individuals 6 months poststroke and their influence on health-related quality of life (QOL) and overall QOL, information that would be useful in identifying services that stroke patients would need in the community.

DESIGN

Inception cohort study.

SETTING

Ten acute care hospitals in metropolitan areas of the province of Quebec.

PARTICIPANTS

Persons with first-ever stroke, either ischemic or hemorrhagic. In parallel, a population-based sample of community-dwelling individuals without stroke, frequency matched in age and city district, were also recruited.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Stroke subjects were interviewed by telephone at 6-month intervals for 2 years of follow-up. The community-dwelling individuals without stroke were also followed.

RESULTS

A total of 434 persons were interviewed approximately 6 months poststroke. Their average age +/- standard deviation was 68.4+/-12.5 years; the average age of the 486 controls was 61.7+/-12.4 years. The stroke group scored on average 90.6/100 on the Barthel Index; 39% reported a limitation in functional activities, 54% reported limitations with higher-level activities of daily living such as housework and shopping, and 65% reported restrictions in reintegration into community activities. By using the Medical Outcomes 36-Item Short-Form Health Survey (SF-36), persons with stroke rated their physical health 7 points lower than healthy peers; also, 7 of the 8 subscales of the SF-36 were affected by stroke.

CONCLUSION

Almost 50% of the community-dwelling stroke population lived with sequelae of stroke such that, unless there was a full-time and able-bodied caregiver at home, they needed some form of home help. A large proportion also reported lack of meaningful activity, indicating a need for organized support groups for people with stroke; otherwise, boredom will lead to depression and worsening of function, affect, health status, and QOL.

Case control study on health-related quality of life in adult coeliac disease

AIMS

To evaluate whether health-related quality of life in adult coeliac disease is related to: 1) adhesion to gluten-free diet; 2) manifestation of clinical features; and 3) associated diseases.

PATIENTS AND METHODS

A total of 68 coeliac patients (54 female and 14 male) aged between 18 and 74 years, on gluten-free diet for at least two years were studied. The subjective health status was measured by means of the Short Form 36 Health Survey. A series of 136 subjects, matched according to sex, age and ethnic group, were evaluated as control group.

RESULTS

Patients obtained worse scores with respect to healthy controls at all domains of Short Form 36 Health Survey (p<0.05); compliers showed better results than non-compliers. The lowest scores were obtained in patients with more than six symptoms, mostly in non-compliers, the highest in compliers with less than six symptoms. Patients with two or more associated diseases presented significantly worse scores than patients with only one associated disease.

CONCLUSIONS

The importance of gluten-free diet in clinical management of coeliac disease is confirmed by results of the present study; moreover, the results seem to indicate that a complex interplay of factors should be taken into account in evaluating health-related quality of life in adult coeliac disease. Accordingly, our data show that health-related quality of life of coeliac patients is impaired not only by poor compliance but also by different negative factors such as severity of illness (in terms of number of symptoms) at diagnosis and comorbidity.

Helicobacter pylori eradication ameliorates symptoms and improves quality of life in patients on long-term acid suppression. A large prospective study in primary care

Our objective was to determine prescribing patterns for H2 receptor antagonists (H2RA) in primary care and to establish the prevalence and impact of Helicobacter pylori (Hp) eradication in this population of patients. Patients on long-term (6 months or longer) H2RA were identified through a computerized database at the six primary care practices in North England. Hp status was identified by serology, and those positive received standard proton pump-based triple therapy followed by a urea breath test to confirm Hp eradication. The main outcome measures were the indications for prescribing long-term H2RA in primary care, the prevalence of patients with a positive Hp serology, and the impact of Hp eradication on the subsequent need for acid suppression, severity of dyspepsia, gastrointestinal symptom rating score (GSRS), quality of life (QOL), and overall feeling of well-being. One thousand seven (1.5%) patients were on long-term H2RA. Peptic ulcer disease (PUD) was the most common indication for prescribing (42%), followed by nonulcer dyspepsia (28%) and gastroesophageal reflux disease (23%). In 81% of the patients treatment with H2RA therapy followed a previous endoscopic or radiological investigation. Only 27 (2.5%) patients had had their Hp status checked within the last 6 months. Of the 471 patients who eventually had their Hp serology tested, 297 (63%) were Hp positive. Fifty-eight percent of the Hp-positive patients had PUD. Successful Hp eradication was achieved in 250 (84%) of the patients, of whom 247 (83%) finished the 1-year follow-up. This was associated with a significant reduction in the amount of H2RA being consumed (P < 0.00001). There was also a significant improvement in the symptom scores and the GSRS after successful Hp eradication (P < 0.00001). Overall 67% of the patients reported an improvement in the QOL and 77% noted a feeling of well-being 1 year after Hp eradication. A significant proportion of patients in primary care is still being maintained on long-term H2RA, imposing a considerable financial drain on the NHS resources. Approximately two-thirds of these patients will be Hp positive, and among them the largest group will comprise patients with PUD. Hp eradication in such patients results in a significant reduction in usage of acid suppression and an improvement in overall QOL and severity of dyspeptic symptoms.

The quality of life in the post-menopausal woman

Health-related quality of life is a subjective parameter which refers to the effects of an individual's physical state on all aspects of psychosocial functioning. Measures of quality of life attempt to gauge the effects of ill health across a number of physical, psychological and social parameters. Standardized menopause-specific instruments which measure symptoms of the climacteric need to satisfy the criteria of factor analysis, of subscales measuring different aspects of symptomatology, and sound psychometric properties and to be standardized among populations of women. Five scales fulfil these four criteria; they are the Greene Climacteric Scale, the Women's Health Questionnaire, the Menopausal Symptom List, the Menopause Rating Scale and the Utian Menopause Quality of Life Score. Experience utilizing the Menopause Rating Scale in a Berlin study established different types of menopause coping styles. The most important factors analysed were attractiveness, self-confidence, re-orientation in life and partner relationship. Comparing the sum-score of the Short-Form 36 with the score of the somatic and psychological dimensions of the Menopause Rating Scale allows the conclusion that the severity of menopausal symptoms is what reflects best the profile of quality-of-life dimensions.

Health-related quality of life among persons with irritable bowel syndrome: a systematic review

AIM

To perform a systematic review of the literature with three objectives: (1) to compare the health related quality of life (HRQoL) of patients with irritable bowel syndrome with that of healthy controls; (2) to compare the HRQoL of irritable bowel syndrome patients to those with other diseases; and (3) to examine therapy-associated changes in HRQoL of irritable bowel syndrome patients.

METHODS

Searches of all English and non-English articles from 1980 to 2001 were performed in Medline and Embase, and two investigators performed independent data abstraction.

RESULTS

Seventeen articles met our selection criteria. 13 studies addressed objective no. 1; 11 showed a significant reduction in HRQoL among irritable bowel syndrome patients. Of these, only one study was considered of high quality. Four studies addressed objective no. 2, none of which was considered to be high quality in addressing this objective. Four trials (three of high quality) addressed objective no. 3. One showed that symptomatic improvement with Leupron compared to placebo was accompanied an improvement only in the comparative health domain of the HRQoL. The second study reported significant positive changes in HRQoL after 12 weeks of cognitive behavioural therapy. The third report of two placebo-controlled studies indicated significant improvement with alosetron on most domains of Irritable Bowel Syndrome Quality of Life Questionnaire.

CONCLUSIONS

(i) There is reasonable evidence for a decrease in HRQoL in patients with moderate to severe irritable bowel syndrome; however, the data are conflicting regarding the impact of irritable bowel syndrome on HRQoL in population-based studies of nonconsulters. (ii) HRQoL in irritable bowel syndrome patients is impaired to a degree comparable to other chronic disorders such as GERD and depression. (iii) A therapeutic response in irritable bowel syndrome-related pain has a corresponding improvement in HRQoL. (iv) Limitations of the literature include focusing on moderate-severe irritable bowel syndrome in referral centres, and lack of appropriate controls

Health outcomes assessment in community pharmacy practices: a feasibility project

OBJECTIVES

To evaluate the feasibility and benefit of capturing outcomes data in community pharmacy settings, and to characterize the health status, resource use, and medication use of patients with musculoskeletal disorders.

METHODS

Patients (n = 460) with musculoskeletal disorders including osteoarthritis (OA), rheumatoid arthritis (RA), and low back pain from 12 community pharmacy sites responded to disease-specific questions, the Medical Outcomes Study Short Form-36 (SF-36) health survey, demographics, and resource use using touch screen computer technology. Patients provided information and met with a community pharmacist for scheduled visits at baseline, 3, 6, 9, and 12 months. Pharmacists, with the aid of the patient-reported information, documented medication use and identified and addressed drug therapy problems of the patients at each visit. Baseline results, based on descriptive statistics are reported.

RESULTS

OA was reported by 71% of the patients, 55% reported low back pain, and 19% reported RA. Despite receiving a variety of analgesic medications, a majority of the patients reported experiencing moderate to severe pain. SF-36 scores of the study population were significantly lower than age-adjusted population norms, with arthritis patients reporting worse physical health than patients with low back pain. Drug therapy problems were identified in 58% of the population, with need for additional drug therapy (31%) and adverse drug reactions (18%) being the most common problems identified.

CONCLUSIONS

Results indicate that routine capture of patient-reported health outcomes data is feasible in community pharmacy settings using touch screen technology.

Health-related quality of life and gastrointestinal disease

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

Computer-based quality of life questionnaires may contribute to doctor-patient interactions in oncology

It is well recognized that oncologists should consider patients' quality of life and functioning when planning and delivering anticancer treatment, but a comprehensive assessment of how a patient feels requires a thorough inquiry. A standardized measurement of patients' quality of life may support clinicians in identifying important problems for discussion during the limited time of the medical consultations. The aim of this study was to assess the feasibility of computer-administered individual quality of life measurements in oncology clinics with immediate feedback of results to clinicians and to examine the impact of the information on consultations. The study employed a prospective non-randomized design with pre-test post-test within subjects comparisons and involved three medical oncologists and 28 cancer patients receiving chemotherapy. The intervention consisted of completion of quality of life questionnaires before the consultations and informing clinicians of the results. The main outcome measures were patients' perceptions of the content of baseline and intervention consultations and satisfaction with communication. A qualitative analysis of clinicians' interviews was performed. When clinicians had the quality of life results they enquired more often about daily activities (Z= -2.71, P=0.007), emotional problems (Z= -2.11, P=0.035) and work related issues (Z= -1.89, P=0.058). There was an increase in the number of issues discussed during the intervention consultation (Z= -1.89, P=0.059). Patients were highly satisfied with both consultations. The computer measurement was well accepted by patients who felt that the questionnaires were a useful tool to tell the doctors about their problems. The clinicians perceived that the quality of life data broadened the range of the clinical inquiry and helped them identify issues for discussion. Having symptoms and functional problems expressed quantitatively on a scale was useful for detection of change over time.

Changes in functional outcome and quality of life in patients and caregivers after aneurysmal subarachnoid hemorrhage

OBJECT

Although the case-fatality rate after subarachnoid hemorrhage (SAH) does not change considerably after the first 4 weeks, functional outcome and the quality of life (QOL) may. To assess the extent of changes in functional outcome and QOL after SAH, the authors conducted a follow-up study at 18 months in patients and caregivers who had participated in a previous study of QOL 4 months after SAH.

METHODS

In a consecutive series of 98 patients admitted with SAH, 68 had survived until 4 months postbleed, at which time an initial outcome assessment had been performed in 64 of them. This series of 64 patients was contacted again at a median of 18 months after SAH. In all patients, functional outcome was assessed by means of the modified Rankin Scale (mRS). In 48 patients and 35 caregivers QOL was assessed using the SF-36, the Sickness Impact Profile (SIP), and a visual analog scale. The results were compared with the scores that had been obtained at 4 months after SAH. Thirty-two patients (50%) had improved at least one point on the mRS, in 23 patients functional outcome had remained unchanged, six patients had deteriorated one point on the mRS, and three had died. No major changes in the QOL of patients and caregivers could be found on the SIP, but on the SF-36 an improved QOL was detected in patients with better Rankin grades. On both instruments, the QOL at 18 months was still reduced compared with the reference population in all patients.

CONCLUSIONS

Functional outcome improves significantly between 4 months and 18 months post-SAH; studies on functional outcome after SAH can be compared only if outcome is assessed at the same time interval. The improved functional outcome seems to be accompanied by an improved QOL.

The spanish version of the paediatric asthma quality of life questionnaire (PAQLQ): metric characteristics and equivalence with the original version

The Paediatric Asthma Quality of Life Questionnaire (PAQLQ), developed by Juniper et al., assesses the impact of asthma on children's daily life. It contains 23 items, covering three dimensions: symptoms, activities limitation and emotional function.

AIMS

To develop an equivalent Spanish version of the PAQLQ, and to assess its measurement characteristics.

METHODS

The forward and back-translation method was used for the adaptation. A longitudinal study (assessments at the 1st and 5th weeks), with patients from the emergency and outpatient departments of three Spanish hospitals, was designed to test the properties of the new adapted version. At each visit, a trained interviewer administered the PAQLQ, a Global Index of Change and a General Health Perception scale. The Peak Expiratory Flow Rate (PEFR) was also recorded daily, together with symptoms, during the prior week.

RESULTS

Ninety-nine patients (66.7% males, 42.4% suffering an exacerbation, mean age of 11.3 years) with the following types of asthma were evaluated: mild intermittent (31.3%), mild persistent (36.4%), moderate persistent (29.3%) and severe persistent (3%). At the 1st visit, the mean pre-bronchodilator %PEFR was 87.3%. The Cronbach's alpha ranged from 0.86 to 0.95. As expected, correlations between the PAQLQ scores, and the Asthma Control Score (0.53-0.67), the General Health Perception (0.34-0.55), and the %PEFR (0.44-0.55) were moderate. The PAQLQ scores remained unchanged in stable patients while increased significantly in those showing improvements.

CONCLUSIONS

After a standard cross-cultural adaptation process, the Spanish version of the PAQLQ has shown to be equivalent to the original, with similar internal consistency reliability, validity and sensitivity to clinical changes.

Anxiety, depression and functional capacity in older women with mitral valve stenosis

Mitral valve stenosis can lead to a range of symptoms that affect daily life. As many of the people with this problem are elderly, the difficulties resulting from age can be exacerbated by illness. A pilot descriptive study was designed to examine the differences in anxiety, depression and functional capacity in women with mitral valve stenosis who were aged over 60 years when compared to a similar group of volunteers who did not have any cardiac disease. Measurement was undertaken using the Hospital Anxiety and Depression scale, the SF-36 Health Status questionnaire and the Functional Limitations Profile. Forty women were recruited to the study: 20 women with mitral valve stenosis and 20 volunteers. Each person was asked to complete the three questionnaires on one occasion only. Non-parametric statistics were used for analysis. Patients fared worse than volunteers with significant differences between groups in respect of anxiety (P = 0.03), depression (P = 0.02) and overall function (P < 0.001), but not in physical (P = 0.52) or mental health (P = 0.32). Future research could focus on strategies that would help alleviate anxiety and depression and improve functional capacity in older women with mitral valve stenosis.

Do varicose veins affect quality of life? Results of an international population-based study

PURPOSE

This study assessed the impact of varicose veins (VV) on quality of life (QOL) and patient-reported symptoms.

METHODS

A cross-sectional population-based study was held in 166 general practices and 116 specialist clinics for venous disorders of the leg in Belgium, Canada (Quebec), France, and Italy. Study subjects included a sample of 259 reference patients without VV (CEAP class 0 or 1) and 1054 patients with VV who were classified as having VV alone (367; 34.8%), VV with edema (125; 11.9%), VV with skin changes (431; 40.9%), VV with healed ulcer (100; 9.5%), and VV with active ulcer (31; 2.9%). The main outcome measure was generic and disease-specific QOL, as measured by means of the Short-Form Health Survey-36 (SF-36) and the VEINES-QOL scale, and patient-reported symptoms as measured by the VEINES-SYM scale.

RESULTS

In patients with VV, age-standardized mean SF-36 physical (PCS) and mental (MCS) scores were 45.6 and 46.1 in men and 44.2 and 43.2 in women, respectively, compared with population norms of 50. PCS scores decreased according to increasing severity of concomitant venous disease, with the lowest mean scores of 37.3 and 35.5 found in patients with VV and active ulcer. However, adjusted analyses showed no statistically significant differences between patients with VV alone and patients without VV for PCS (0.0), MCS (1.0), VEINES-QOL (-0.1), or VEINES-SYM (0.0) scores. In comparison with patients without VV, the largest differences were seen in patients with VV and edema (PCS, VEINES-QOL, and VEINES-SYM score differences of -1.8, -2.5, and -2.9, respectively) and in patients with VV and ulceration (differences of -3.3, -3.4, and -2.7, respectively). The high prevalence of major symptoms of venous disorders in patients in CEAP class 0 or 1 being treated for venous disorders (76.1% of patients had heaviness, aching legs, or swelling) might have contributed to the impairment of QOL in the reference group.

CONCLUSION

Results indicate that impairment in physical QOL in patients with VV is associated with concomitant venous disease, rather than the presence of VV per se. Findings concerning QOL in patients with VV can only be reliably interpreted when concomitant venous disease is taken into account. In patients with VV alone, the objectives of cosmetic improvement and the improvement of QOL should be considered separately.

Exploring health-related quality of life in patients with diseases of the ear, nose, and throat: a multicenter observational study

OBJECTIVES

This study was undertaken to explore which diseases of the ear, nose, and throat impact daily functioning of patients in an outpatient setting and to observe how specific demographic variables affect health-related quality of life (HRQOL) in these patients.

METHODS

This multicenter observational study was conducted anonymously during a 6-week period at outpatient clinics in adults > or = 18 years of age. The Short Form-12 (SF-12) was used to assess HRQOL. Demographic and clinical variables were recorded for each patient.

RESULTS

In data from 5806 patients, the SF-12 physical component score was 43.8, and the mental component score was 49.4. SF-12 physical and emotional functioning scores for ENT patients were poorer than established standards (50 +/- 10) for the U.S. population (P < 0.001).

CONCLUSIONS

ENT diseases adversely affect the HRQOL in patients visiting their otolaryngologist. Clinical and demographic variables are important considerations in the measurement of HRQOL.

The quality of quality of life studies in general surgical journals

BACKGROUND

There has been a tremendous increase in interest on quality of life in surgical research. An increase in interest does not necessarily translate into better research. This study evaluates surgical articles that claim to measure or make some conclusion on quality of life.

STUDY DESIGN

All articles published in the calendar years 1996 and 1999 that purported to assess quality of life as end points or make some conclusion about quality of life were chosen for review from eight general surgical journals. Articles were assessed for use of a quality of life instrument, type of instrument, validation of the instrument, appropriateness of the instrument for the hypothesis, quality of statistical analysis, and adherence to the Gill and Feinstein criteria.

RESULTS

Of the 18 articles published in 1996, 72% used a quality of life instrument. Eighteen instruments were used in 13 studies: 7 generic, 10 disease-specific, and 1 ad hoc. Forty-three percent were validated, 39% were appropriate for the study hypothesis, 39% had correct statistical analysis. The majority did not meet the Gill and Feinstein criteria. Of the 24 studies published in 1999, 63% used a quality of life instrument. Twenty-two instruments were used in 15 studies: 11 generic, 5 disease-specific, and 6 ad hoc. Fifty-five percent were validated, 45% were appropriate, 45% had correct statistical analysis. Once again, the majority did not meet the Gill and Feinstein criteria.

CONCLUSIONS

Despite the emphasis on quality of life outcomes, a substantial number of studies made errors in conceptually defining quality of life and in use of quality of life instruments. Researchers and journal reviewers need to be better versed on the techniques of quality of life research.

Patient satisfaction after total knee arthroplasty: a comparison between subjective and objective outcome assessments

We used a visual analog scale (VAS) to assess the satisfaction after total knee arthroplasty (TKA) in a group of 108 patients (126 TKAs) with short-term to medium-term follow-up. We also used the Knee Society scoring system, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), pain VAS, and survival analysis. A comparison between the subjective and objective outcome systems revealed only poor correlations. This comparison suggests that the concerns and priorities of patients and surgeons differ. The outcome assessed with the satisfaction VAS revealed a significantly better subjective outcome in rheumatoid arthritis patients compared with osteoarthritis patients, whereas Knee Society scores were not different. The satisfaction VAS provides additional information about subjective outcome after TKA.

Perceived symptoms and health-related quality of life reported by uncomplicated hypertensive patients compared to normal controls

OBJECTIVES

This study compared the prevalence and intensity of symptoms and the health-related quality of life (HQL) of patients taking antihypertensive medications and patients without disease.

METHODS

This cross-sectional study used surveys mailed to patient's homes. All consecutive patients over age 30 years attending either a general medicine or hypertension clinic during 3 months were eligible (n = 437). Hypertension group (HTN-G) patients were diagnosed with primary hypertension, prescribed antihypertensive medications, and had no other symptomatic conditions or drug therapies. Control group (CNTL-G) patients were seen in the general medicine clinic and had no chronic symptomatic conditions or drug therapies. Measures included the Symptom Distress Checklist (SDC, list of 51 symptoms, frequency, and level of distress), the Medical Outcomes Study Short Form-36 (SF-36), medications, blood pressures, and other data obtained from medical records and patient self-report.

RESULTS

A total of 222 patients responded (46% CNTL-G, 55% HTN-G). HTN-G patients were somewhat older (59.0 +/- 11.2 vs 48.5 +/- 11.7 years, P = 0.001) and had a higher percent of minorities (24.8% vs 13.5%, P = 0.02), but otherwise similar. After adjusting for age and race differences, HTN-G patients reported significantly more symptoms (8.8 +/- 7.8 vs 4.7 +/- 4.8, P = 0.001) and related distress (32.2 +/- 4.2 vs 12.0 +/- 18.2, P = 0.001) as well as lower scores (reduced HQL) for most of the SF-36 domains. In general, hypertensive patients had more physical, but not mental symptoms than control patients.

CONCLUSIONS

Hypertensive patients receiving antihypertensive medications have more symptoms and lower HQL. Differences were detected by both a brief, general HQL instrument and a detailed, disease-specific instrument. Routine screening of treated hypertensive patients using a brief HQL questionnaire to detect physical symptoms may prove feasible and useful.

Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders

STUDY OBJECTIVE

To determine whether community pharmacists can use point-of-service health status assessments to identify and resolve drug-related problems (DRPs) in ambulatory patients with selected musculoskeletal (MSK) disorders.

DESIGN

Twelve-month, prospective, multicenter demonstration project.

SETTING

Twelve independent community pharmacies in eastern Iowa.

PATIENTS

Ambulatory patients with self-reported diagnosis of osteoarthritis, rheumatoid arthritis, or low back pain.

MEASUREMENTS

During quarterly pharmacy visits for 1 year, patients used touch-screen computers to report their health status. Patients answered questions on the Short Form-36 (SF-36) general health survey, as well as questions assessing limitations associated with their MSK condition. Pharmacists used this data in interviewing patients to assess for DRPs.

MAIN RESULTS

The study enrolled 461 patients, of whom 388 returned for the 12-month visit. During this 1-year period, community pharmacists identified 926 cumulative DRPs. Patients with no DRPs had significantly higher physical component summary scores on the SF-36 (p<0.05) than patients with more than one DRP at baseline (36.2 vs 31.6), 6 months (39.2 vs 33.3), and 12 months (40.1 vs 35.4). At 12 months, actions performed by pharmacists led to resolution or improvement of 70.7% of DRPs.

CONCLUSION

Drug-related problems are numerous in community-dwelling patients with MSK disorders and correspond to decreased physical health status. Community pharmacists can use patient-reported measures of health status to identify DRPs and initiate processes to resolve them.

Treatment efficacy of intermittent claudication by surgical intervention, supervised physical exercise training compared to no treatment in unselected randomised patients I: one year results of functional and physiological improvements

OBJECTIVES

to compare the effect of surgery, exercise and simple observation on maximum exercise power in claudicants.

DESIGN

prospective, randomised study.

METHODS

a total of 264 unselected claudicants were randomised to supervised exercise training, invasive treatment (open surgical or endovascular procedures) or observation. One year treatment outcomes were analysed on an intention to-treat basis.

RESULTS

invasively treated patients showed a significant improvement in maximum walking power, stopping distance, post-ischaemic blood flow and big toe pressure at one year. Patients randomised to physical exercise training or to the control group did not improve in any outcome measure.

CONCLUSION

invasive treatment increased walking capacity, leg blood pressure and flow. Supervised physical exercise training offered no therapeutic advantage compared to untreated controls.

Quality of life in patients with endoscopy-negative heartburn: reliability and sensitivity of disease-specific instruments

OBJECTIVES

Endoscopy-negative gastroesophageal reflux disease (GERD) lacks objective markers of disease severity. Evaluation of therapies for GERD must therefore rely on subjective measures, including patient self-report questionnaires, to measure the clinical effectiveness of therapeutic interventions. We aimed to evaluate the previously validated Gastrointestinal Symptoms Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires for reliability and responsiveness to change over time.

METHODS

Patients (n = 1143) with heartburn, but no esophagitis included in a randomized clinical trial assessing the effectiveness of active treatment with proton pump inhibitors over 4 wk were evaluated.

RESULTS

The test-retest reliability of both questionnaires over time was good to excellent (GSRS 0.53-0.69; QOLRAD 0.65-0.76), as was the responsiveness estimated by standardized response means (GSRS reflux dimension, -1.43; QOLRAD 0.81-1.43) and effect sizes (GRSR reflux dimension, -1.74; QOLRAD 0.82-1.56). The relationship between improvement in the GSRS reflux dimension score and the amount of clinical benefit as estimated by the patients themselves (based on the Overall Treatment Evaluation) suggested a minimally clinical relevant change is 0.5 on the seven graded scales applied. The importance rating indicated that an important change in the GSRS reflux dimension and the QOLRAD dimensions is equivalent to 1.0, and a very important change to 1.5.

CONCLUSIONS

The GSRS and QOLRAD are valid questionnaires that are reliable and sensitive to change. Both questionnaires should be suitable for use in clinical trials of therapeutic interventions for patients with heartburn.

Changes in the quality of life: a major goal of cardiac rehabilitation

BACKGROUND

Quality of life (QOL) is a major goal in the context of preventive and therapeutic cardiology. In this article, quality of life concepts are reviewed, factors limiting QOL in cardiac disease are identified, methods of measurement are explored, and clinically significant changes are defined. The changes effected by cardiac rehabilitation are considered, together with their physiological and psychological correlates. A final section suggests avenues for future research.

METHODS

Relevant articles were identified by computer literature searches and review of extensive personal files.

FINDINGS

In the past, there has been an excessive focus on extending the length rather than the quality of the cardiac patient's life. The overall QOL is a broad concept, influenced by personal perceptions, coping mechanisms, and environmental constraints. The ideal test instrument would be reliable, valid, and responsive to clinical change. Potential options include a Gestalt-type instrument, a disease-specific instrument, a function-specific instrument, or a detailed generic questionnaire. There have been relatively few comparisons between these potential approaches. Currently, the Standard Gamble (Gestalt-type), and Living With Heart Failure Questionnaire (disease-specific type), and the Medical Outcomes Study Short-Form 36 (SF-36) Health Survey (generic-type) are among the most popular approaches. Problems arise in distinguishing a clinically important from a statistically significant change; commonly a score change of 1 standard error of the mean is regarded as clinically important. Correlations of scores with clinical, physiological, and psychological change are sometimes weak, in part because of floor and ceiling effects. Nevertheless, potential gains in QOL provide a stronger argument for preventive and therapeutic programs than do increases in longevity.

CONCLUSIONS

The current literature supports the value of QOL measurements in the management of patients with cardiac disease. However, further research is needed to determine the optimum test instrument, and the best method of interpreting resultant scores.

Assessment of health status and quality of life outcomes for children with asthma

Increasing interest has been directed to understanding health outcomes associated with pediatric disease processes, including asthma. Salient areas of interest to health outcomes research include the child's and parent's subjective experience with the disease, a concept most often identified as quality of life. Quality of life reports fit within a broader scope of outcome measures embodied in the concept of children's health status. This article provides a description for how a child's health status can be understood theoretically, from a research perspective and in clinical practice. Emphasis is directed to how information obtained from both the child and parent is critical to outcomes research and clinical practice. Unique methodologic problems in assessing child health outcomes such as the challenge of understanding how the child's changing cognitive development may have an impact on responses to outcome measures and the role of contextual variables such as family characteristics are discussed. A variety of subjective and objective outcome measures currently exist that may be used in research on children with asthma. Practical guidelines for implementing outcomes research for children with asthma are presented. Clinical researchers must use multiple outcome measures for assessing asthma characteristics, including psychosocial characteristics, which have an impact on adherence and treatment regimens.

Influence of inflammatory bowel disease on different dimensions of quality of life

OBJECTIVE

To establish the impairment of different dimensions of quality of life in inflammatory bowel disease (IBD).

DESIGN

Prospective observational study.

PARTICIPANTS

289 patients [160 with ulcerative colitis (UC) and 129 with Crohn's disease (CD)].

MEASURES

Health-related quality of life was assessed by means of the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Psychological General Well Being Index (PGWBI).

RESULTS

In active IBD, all dimensions of the quality of life scored significantly lower than in inactive IBD, indicating a poor quality of life. Social impairment was the least impaired dimension of the IBDQ in active UC and CD, compared with digestive and systemic symptoms. In inactive IBD, the systemic symptoms domain received the lowest score (P < 0.01). In a subgroup of 22 patients studied before and after remission, emotional function was the most impaired dimension after achieving remission. The Psychological General Well Being Index was significantly impaired in active UC [78.5 (range 64-89)] and CD [76.5 (range 69-97)] relative inactive IBD [104 (range 93-111)] vs 106 (95-113), respectively; P < 0.05].

CONCLUSIONS

Quality of life is impaired in IBD. During relapse, clinicians should pay attention to digestive symptoms and psychological distress. In remission, they should be sensitive to systemic symptoms.

Does better disease-related education improve quality of life? A survey of IBD patients

The importance of health-related quality of life (HRQOL) assessment in patients with chronic disorders such as inflammatory bowel disease (IBD) is now acknowledged by researchers. Of the many factors that may influence HRQOL, patient knowledge of the condition and disease-related information provision have hitherto not been studied. In all, 250 patients with inactive IBD (UC = 128, CD = 122) were randomly chosen from our IBD clinic. Two sets of questionnaires [initially a standard questionnaire to assess level of disease-related information by a patient information score (PIS), followed by a HRQOL questionnaire] were sent to each patient. In the PIS, a score of 7 or more indicated satisfactory disease-related knowledge and in the HRQOL, a score less than 51 suggested a normal QOL, and a score above 60 significantly impaired QOL. A total of 168 patients (66%) returned both the questionnaires (UC = 91, CD = 77). The mean QOL in patients with UC and CD was 62.2+/-8.3 and 63.9+/-9.5 respectively, (P = NS). 99 patients (59%) had significantly impaired QOL (mean score 65+/-7.6) with only 12 patients (8%), 6 in each group, having a normal QOL. Mean PIS score for the patients was 7.04+/-0.1; 53% of the UC patients and 75% of the CD patients (P = 0.006) were considered well informed (ie, PIS scores of 7 or more). The mean PIS for UC patients was 6.5+/-0.4 vs 7.5+/-0.2 for the CD group (P = 0.001). There was, however, no correlation seen between the QOL and PIS scores, both for UC and CD patients (R = 0.3). In conclusion, most patients with IBD have impaired QOL, despite of having inactive disease. The level of disease-related knowledge appears to be better in patients with CD, although that does not seem to affect QOL.

Health-related quality of life (HR-QOL) and regulatory issues. An assessment of the European Agency for the Evaluation of Medicinal Products (EMEA) recommendations on the use of HR-QOL measures in drug approval

Interest in measuring qualitative aspects of life that are most closely related to health and healthcare has increased in recent years. Methods of describing patients' subjective health status now incorporate standardised measures, and several psychometric measures are available. Despite the thousands of empirical and conceptual papers in the medical and pharmacological literature on health-related quality of life (HR-QOL), the value of such measures in the regulatory process is still being debated. We conducted an assessment to understand and document the position of the European Agency for the Evaluation of Medicinal Products (EMEA) on the use of HR-QOL measures in studies conducted for regulatory purposes. Official documents produced and circulated by the EMEA containing recommendations on trial design, conduct and analysis for sponsors and scientific experts were independently reviewed by authors to document the position of the Agency on the specific topic of HR-QOL. All documents found in the Agency website on 30 September 1999 were identified and then assessed to: (i) identify diseases or drugs for which formal HR-QOL assessment is recommended; (ii) identify measures and methods recommended; and (iii) evaluate the reliability of recommendations across documents. Of the 189 documents retrieved, none focused directly on health-related quality of life. A few explicit recommendations were identified for 13 specific drugs or conditions. These recommendations were mostly general and vague, and used nonstandard terminology. In addition, terminology and recommendations were not consistent across documents and, in at least one case, were in contrast with the US Food and Drug Administration (FDA) guidelines. EMEA guidelines incorporating quality-of-life outcomes are welcomed but it is obvious that more detailed guidance is required. Closer collaboration between the EMEA and the FDA is also recommended. Experts from different disciplines should be involved in the preparation of such documents to assure the necessary technical expertise and the representativeness of the various counterparts.

Perceptions of outcomes after unicompartmental and total knee replacements

An independent measurement of the quality of outcome of 31 consecutive Oxford medial unicompartmental knee replacements in 28 patients and 130 total knee replacements in 104 patients performed between 1993 and 1997 is reported. The indications for surgery were anteromedial osteoarthritis for unicompartmental replacement and more extensive osteoarthritis for total knee replacement. All patients were treated by one surgeon. As a validated outcome measure of knee function, the Oxford 12-item knee questionnaire showed identical outcome in both groups with a mean score of 36.5 (maximum possible, 48). Neither the pain nor the functional outcomes were significantly different, although patients receiving unicompartmental replacement were better able to descend stairs. Two patients needed revision surgery in the unicompartmental replacement group compared with only one patient in the total knee replacement group. The femoral component of two unicompartmental replacements showed radiologic signs of loosening. The tibial component of one total knee replacement appeared loose, but the patient had no symptoms. In comparison with total knee replacement, implantation of meniscal bearing unicompartmental replacement technically is demanding and unforgiving. However, revision of a failed Oxford unicompartmental replacement is easier than revision of a failed total knee replacement, and the authors recommend this device for younger patients in whom one could expect a total knee replacement to fail within their lifetime.

The persistent impact of breast carcinoma on functional health status: prospective evidence from the Nurses' Health Study

BACKGROUND

Although physical and emotional function after the diagnosis of breast carcinoma have been described in clinic populations, to the authors' knowledge no previous study has measured change from the preillness level of functional health status in community-dwelling women.

METHODS

The authors conducted a 4-year (1992-96) prospective study of functional recovery after breast carcinoma in a large sample of women, aged 54-73 years. They collected multidimensional measures of self-reported functional health status in 1992, before diagnosis of breast carcinoma, and again in 1996, to examine the risk of decline associated with incident breast carcinoma.

RESULTS

After adjustment for age, baseline functional health status, and multiple covariates, women who developed incident breast carcinoma were more likely to have experienced reduced physical function, role function, vitality, and social function and increased bodily pain compared with women who remained free of breast carcinoma. Risk of decline was attenuated with increasing time since diagnosis. Risk of decline in physical function was evident across all stages of breast carcinoma, even after adjustment for women undergoing treatment for persistent or recurrent disease. We found evidence that the risk of decline among breast carcinoma cases compared with healthy women was largest among those who were most socially isolated.

CONCLUSIONS

Breast carcinoma results in persistent declines in multiple dimensions of functional health status. These prospective data suggest that previous studies reporting no difference in physical function among breast carcinoma cases compared with disease free women underestimated the deleterious effect of the disease on function. Socially isolated women are an especially vulnerable group.

The reliability of the American Knee Society Score

We have investigated the reliability of the American Knee Society Score (AKS), a widely used functional outcome score for knee arthroplasty. 29 subjects were assessed in random order by 6 observers, each patient seen twice by each observer. The interobserver reference intervals were 16 points for the Knee Score (0-100 points) and 21 points for the Function Score (0-100 points). The intraobserver reference intervals were smaller, 11 points and 13 points for the Knee Score and the Function Score, respectively. The presence of arthritis in other joints and general debility did not affect the reliability of the scores. The more experienced observers had greater intraobserver reproducibility. Notably, we found moderate agreement between observers in the subjective variables, while the objective variables produced lower levels of agreement. The high inter- and intraobserver variations of the AKS makes estimation of score change questionable. Reliable use of the AKS would necessitate repeated evaluation by an experienced observer.

Quality of life measurement in gastrointestinal and liver disorders

Modern medicine has had a considerable impact on mortality rates for serious illness. Many chronic diseases which have previously been associated with an increased mortality now have survival rates approaching those of the background population. However, chronic diseases such as cancer, chronic pain syndromes, and chronic inflammatory conditions impose a considerable burden on families, the health care system, and society. Health related quality of life (HRQOL) is a concept that has developed from the need to estimate the impact of such chronic diseases. HRQOL measurement is a conceptual framework which attempts to predict daily function and well being based on subjective attitudes and experiences of physical, social, and emotional health. It has been evaluated predominantly from the patient's viewpoint as proxy respondents appear to underestimate the full effect of chronic illness on functional status. Measuring HRQOL in clinical research is most frequently undertaken using multi-item questionnaires to estimate daily function. Factors which affect HRQOL can be broadly classed as disease related and disease independent. The use of different assessment techniques permits comparisons between and within disorders. Generic and disease specific instruments used together enhance the ability to direct treatment for individuals and patient populations. Psychometrically sound questionnaires must be used. However, the type of instrument and research methods adopted depend on the question of interest. We have attempted to catalogue and critically assess the disease specific instruments used in the assessment of chronic gastrointestinal disease.

Issues relating to long-term follow-up in hip arthroplasty surgery: a review of 598 cases at 7 years comparing 2 prostheses using revision rates, survival analysis, and patient-based measures

We reviewed 598 cemented Charnley and Hi-nek total hip arthroplasties at 7 years. Data were obtained from general practitioners, hospital medical notes, microfilm, and patient questionnaires. Outcome measures were revision rates, survival analysis, 12-item Oxford Hip Score, and satisfaction ratings. There were 471 Charnley (79%) and 127 Hi-nek (21%) total hip arthroplasties; 139 deaths (23%) occurred, and 5 (<1%) were lost to follow-up. Characteristics of the Charnley and Hi-nek patient groups were similar, with more information missing for Charnley cases. Revision rates were Charnley, 37 (8%), and Hi-nek, 6 (5%) (not significant). Survival analysis revealed no difference between the 2 groups (P = .23). The patients' median Oxford Hip Score was low/good (19), slightly worse for the Hi-nek group (not significant). Taking all evidence together, neither implant was outperforming the other at 7 years.

Laparoscopic hernia repairs. The importance of cost as an outcome measurement at the century's end

At the dawn of this new millennium, surgeons not only must be masters of their craft but also are responsible for identifying and learning new techniques that are being introduced at an ever-increasing rate. Surgeons must overcome the instinctual mistrust of "the new" and, at the same time, avoid over enthusiastic, uncritical adoption of unproven procedures. Today's surgeons must also carefully assess and select the procedures and technologies that they will have time to learn and that will complement their practices and interests. More new things are coming along than any single individual can learn and practice with expertise, which makes general surgery a specialty with relative, as opposed to specifically, defined boundaries. Surgeons also should participate in the process of measuring the outcomes effective and to offer some advantages over open repair, namely less pain and a more rapid recovery period. On the other hand, this surgery has been shown to be difficult to learn and more costly. In a situation such as this, one can delete the procedure from the individual or institutional repertoire or use the modern tools of medical management to attempt to address the "outlier" issues and preserve the good. Laparoscopic hernia repair is a good procedure that can be done in a cost-effective manner if cost-conscious practice guidelines are initiated. It is not yet, however, a technique for all surgeons because of its difficulty to learn and advanced skills needed to perform it well.

Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures

Fractures and subsequent morbidity determine the impact of established postmenopausal osteoporosis. Health-related quality of life (HRQOL) has become an important outcome criterion in the assessment and follow-up of osteoporotic patients. As part of the baseline measurements of the Multiple Outcomes of Raloxifene Evaluation (MORE) study, HRQOL was assessed in 751 osteoporotic (bone mineral density [BMD] T score > or = -2.5) women from Europe with or without vertebral fractures (VFX). This was done using the quality of life questionnaire of the European Foundation for Osteoporosis (QUALEFFO), Nottingham Health Profile (NHP) and the EQ-5D (former EuroQol). QUALEFFO contains questions in five domains: pain, physical function, social function, general health perception, and mental function. Each domain score and QUALEFFO total scores are expressed on a 100-point scale, with 0 corresponding to the best HRQOL. In comparison with patients without VFX, those with VFX were older (66.2 +/- 5.9 years vs. 68.8 +/- 6.3 years; p < 0.001), had higher prevalence of nonvertebral fractures (25% vs. 36%; p = 0.002), and higher QUALEFFO scores (worse HRQOL; total score, 26 +/- 14 vs. 36 +/- 17; p < 0.001). QUALEFFO scores increased progressively with increasing number of VFX, especially lumbar fractures (p < 0.001). Patients with a single VFX already had a significant increase in QUALEFFO scores (p < 0.05). Similar, though weaker, associations were seen for NHP and EQ-5D scores. This study confirms decreased HRQOL for patients with prevalent VFX. In osteoporotic patients, QUALEFFO scores change in relation to the number of VFX. QUALEFFO is suitable for clinical studies in patients with postmenopausal osteoporosis.

The contemporary surgical intensive care unit. Structure, staffing, and issues

Modern ICUs present unique challenges to physician-administrators in the current health care environment. Several models of care (e.g., open versus closed ICUs, physician extenders in the ICU) are used throughout the country, with varying degrees of success. Although all care models may work, the ideal model for a given ICU can be found only through ongoing performance improvement.

Outcome Questionnaire: item sensitivity to change

Although high levels of reliability are emphasized in the construction of many measures of psychological traits, tests that are intended to measure patient change following psychotherapy need to emphasize sensitivity to change as a central and primary property. This study proposes 2 criteria for evaluating the degree to which an item on a test is sensitive to change: (a) that an item changes in the theoretically proposed direction following an intervention and (b) that the change measured on an item is significantly greater in treated than in untreated individuals. Outcome Questionnaire (Lambert et al., 1996) items were subjected to item analysis by examining change rates in 284 untreated control participants and in 1,176 individuals undergoing psychotherapy. Results analyzed through multilevel or hierarchical linear modeling suggest the majority of items on this frequently used measure of psychotherapy outcome meet both criteria. Implications for test development and future research are discussed.

Validation of the Spanish version of the Changes in Sexual Functioning Questionnaire (CSFQ)

The aim of this study is to adapt and validate the Changes in Sexual Functioning Questionnaire (CSFQ) in Spanish. The CSFQ was administered to 206 depressed patients in different Spanish cities, to 326 health sciences students at the University of Oviedo, and to 48 workers undergoing routine health check-ups. The Hamilton Depression Rating Scale (HAM-D) was administered to the depressed patients. The average time spent answering the CSFQ was 15.19 minutes. The CSFQ discriminated the depressed patients from the workers and university students. In the three areas of reliability (internal, test-retest, and inter-rater), the coefficients obtained were greater than 0.80. The factor analysis demonstrated differences in the internal construct of the American CSFQ and its Spanish equivalent. The psychometrc properties of the Spanish version of the CSFQ indicate that it is a valid instrument for clinical use in treating depressed patients.