Measurement of functional status, quality of life, and utility in rheumatoid arthritis

Health-Related Quality of Life According to Sociodemographic Characteristics in the South Korean Population

Health-related quality of life (HRQoL) concerns satisfaction with life and happiness with regard to physical, mental, and social factors. RAND-36 is a publicly available, self-administered questionnaire that examines eight health dimensions. This study evaluated the HRQoL of the South Korean population using the RAND-36 questionnaire and compared HRQoL across sociodemographic characteristics. From May 2015 to May 2019, South Koreans who visited public places aged 19−80 years were recruited and the RAND-36 questionnaire was administered. Overall, 1002 participants were recruited (mean age 45.34 years, 52% men). Men scored better than women in both physical and mental health (p < 0.05). There were significant differences in bodily pain (p < 0.05), general health perception (p < 0.05), and energy/fatigue (p < 0.05) dimensions according to the participants’ health condition. The HRQoL of South Koreans was lower than average in most dimensions compared with other countries. As the first study to assess this, its data can be used in future studies that apply RAND-36 to evaluate the HRQoL of diseased individuals, as they can compare their findings with those of our study population.

Translation and validation of the new version of the Knee Society Score - The 2011 KS Score - into Brazilian Portuguese

Objective

Translation, cultural adaptation, and validation of the new version of the Knee Society Score – The 2011 KS Score – into Brazilian Portuguese and verification of its measurement properties, reproducibility, and validity. In 2012, the new version of the Knee Society Score was developed and validated. This scale comprises four separate subscales: (a) objective knee score (seven items: 100 points); (b) patient satisfaction score (five items: 40 points); (c) patient expectations score (three items: 15 points); and (d) functional activity score (19 items: 100 points).

Method

A total of 90 patients aged 55–85 years were evaluated in a clinical cross-sectional study. The pre-operative translated version was applied to patients with TKA referral, and the post-operative translated version was applied to patients who underwent TKA. Each patient answered the same questionnaire twice and was evaluated by two experts in orthopedic knee surgery. Evaluations were performed pre-operatively and three, six, or 12 months post-operatively. The reliability of the questionnaire was evaluated using the intraclass correlation coefficient (ICC) between the two applications. Internal consistency was evaluated using Cronbach's alpha.

Results

The ICC found no difference between the means of the pre-operative, three-month, and six-month post-operative evaluations between sub-scale items.

Conclusion

The Brazilian Portuguese version of The 2011 KS Score is a valid and reliable instrument for objective and subjective evaluation of the functionality of Brazilian patients who undergo TKA and revision TKA.

A study of quality of life in Internet health chat room users

Maintenance of quality of life (QoL) is central to healthcare and an increasingly important outcome of care provision reflecting enhanced awareness of the need to consider the effects of a disease or treatment on a patient's life. However, while its assessment has intuitive appeal it is predicated on the belief that QoL can be effectively defined, assessed and quantified. Achieving this is, however, difficult as individuals value different things and, it is claimed, often define QoL differently; there are no ‘generally agreed referents' and no ‘gold standard’ through which it can be measured. This may significantly affect the value and the uses to which such data can be put.

The study described here represents the first stage of a programme of work focusing upon defining QoL as it is currently perceived in the UK; it relied upon a qualitative, descriptive survey involving a sample of Internet health chat room users. It attempts to define QoL and to identify the factors contributing to life quality in these respondents. A subsidiary aim was to evaluate the use of email as a recruitment tool in such research.

A common definition was difficult to find but, in general terms, is taken to represent ‘what you think of your life’. Within this a range of factors are seen to contribute to individual perceptions and it was possible to identify those appearing to determine perceptions of QoL in this study population. Email was an effective route for recruiting subjects in this work.

Mediation analysis of relationships between chronic inflammation and quality of life in older adults

Background

This article summarizes exploratory analyses of relationships between chronic inflammation, its physical consequences, and quality of life (QoL). It summarizes key findings from preliminary analyses, and contextualizes these results with extant sociomedical literature to recommend directions for future research.

Methods

Cross-sectional data from the National Social Life, Health, and Aging Project (NSHAP) were used to explore these relationships. Inflammation was assessed via the biomarker C-reactive protein (CRP). We examined associations between CRP levels and two different domains of QoL: happiness with life in general and happiness with intimate relationships. We used ordinal logistic regression with companion OLS models and Sobel-Goodman tests to assess potential mediation, and also conducted a variety of sensitivity analyses.

Results

Findings suggest that mediation pathways for the overall association between chronic inflammation and QoL may differ markedly across particular outcome constructs. Specifically, it shows mediation potential for the clinical sequelae of chronic inflammation in frameworks using happiness as an outcome measure, but not in those using relationship satisfaction. Disability appears to mediate the effect of inflammation by 27 %; chronic pain appears to exert a similar mediation effect of 21 %.

Conclusions

Pain and disability linked to chronic inflammation appear to play a small but significant mediating role in the overall reduction in QoL observed among older adults with biomarker evidence of chronic inflammation. We note that these patterns are best framed as dynamic elements of a complex causal fabric, rather than powerful determinants that override other factors contributing to QoL. Hypotheses for further exploration using longitudinal data from the NSHAP are thus offered, pending availability of Wave III data in future years.

The Impact of Fatigue on Patients with Multiple Sclerosis

Although fatigue is recognized as a symptom of MS, there have been insufficient methods for evaluating this symptom. We administered the Fatigue Impact Scale to 85 MS patients and 20 hypertensive patients. Neurologic impairment, mental health, and general health status were also assessed. MS patients reported significantly higher fatigue impact than hypertensive patients. Most MS patients reported fatigue as either their worst (14%), or one of their worst (55%) symptoms. Disease classification and neurologic impairment had little bearing on Fatigue Impact Scale scores in the MS sample. The best predictive models for mental health and general health status in the MS sample both included the Fatigue Impact Scale as a significant factor. This study demonstrates that: 1) fatigue is a very prevalent and severe problem in MS, 2) fatigue impact cannot be predicted by clinical measures of neurologic impairment, 3) fatigue has a significant effect on the mental health and general health status of MS patients.

Cultural adaptation of the Michigan Hand Outcomes Questionnaire in patients with Carpal Tunnel Syndrome: A Turkish version study

Objective

Cultural adaptations of the questionnaires are important for easy use. We aimed to assess the reliability and validity of the Turkish Version of the Michigan Hand Outcomes Questionnaire in patients with Carpal Tunnel Syndrome.

Methods

To assess test-retest reliability, the Turkish “Michigan Hand Outcomes Questionnaire” and “Disabilities of Arm, Shoulder and Hand” questionnaires were answered by patients and controls and were repeated a week later. For testing internal consistency, the Cronbach's alpha test was used. For testing validity, correlations between the subscales of the “Michigan Hand Outcomes Questionnaire” and “Disabilities of Arm, Shoulder and Hand” questionnaire were measured in patient groups. One hundred patients with idiopathic Carpal Tunnel Syndrome and 50 healthy participants were included in the study.

Results

In test-retest reliability, intraclass correlations of the subscales of the “Michigan Hand Outcomes Questionnaire” were high. Cronbach's alphas were found to be high in all subscales. There was no significant correlation between asthetics and pain scales. We found significant differences between patients and controls regarding all subscales of the “Michigan Hand Outcomes Questionnaire”. Correlations between subscales of the “Michigan Hand Outcomes Questionnaire” and “Disabilities of Arm, Shoulder and Hand” questionnaire were significant. We found no difference between one-hand effected and two-hand effected patients, in terms of the “Michigan Hand Outcomes Questionnaire”, “Disabilities of Arm, Shoulder and Hand” questionnaire Function/Symptom and Work average scores.

Conclusion

This study showed that the Turkish version of the “Michigan Hand Outcomes Questionnaire” is reliable and valid and can be used in Turkish patients with Carpal Tunnel Syndrome because it is comprehensible and practicable.

Chronic inflammation and quality of life in older adults: a cross-sectional study using biomarkers to predict emotional and relational outcomes

Background

This study explores relationships between chronic inflammation and quality of life, making a case for biopsychosocial modeling of these associations. It builds on research from social and clinical disciplines connecting chronic conditions, and inflammatory conditions specifically, to reduced quality of life.

Methods

Data from Wave I of the National Social Life, Health, and Aging Project are modeled using ordinal logistic and ordinary least-squares regression techniques. Inflammation is measured using C-reactive protein; quality of life is conceptualized as happiness with life overall as well as intimate relationships specifically.

Results

For most NSHAP participants, chronic inflammation significantly predicts lower odds of reporting high QoL on both emotional and relational measures. Social structural factors do not confound these associations. Inconsistent results for participants with very high (over 6 mg/L) CRP measurements suggest additional social influences.

Conclusions

Findings echo strong theoretical justification for investigating relationships between CRP and QoL in greater detail. Further research should explore possible mediation of these associations by sociomedical sequelae of chronic disease as well as social relationship dynamics. Elaboration is also needed on the mechanisms by which social disadvantage may cause chronic inflammation.

Translation and Validation of the Knee Society Score - KSS for Brazilian Portuguese

OBJECTIVE

To translate, culturally adapt and validate the "Knee Society Score"(KSS) for the Portuguese language and determine its measurement properties, reproducibility and validity.

METHODS

We analyzed 70 patients of both sexes, aged between 55 and 85 years, in a cross-sectional clinical trial, with diagnosis of primary osteoarthritis ,undergoing total knee arthroplasty surgery. We assessed the patients with the English version of the KSS questionnaire and after 30 minutes with the Portuguese version of the KSS questionnaire, done by a different evaluator. All the patients were assessed preoperatively, and again at three, and six months postoperatively.

RESULTS

There was no statistical difference, using Cronbach's alpha index and the Bland-Altman graphical analysis, for the knees core during the preoperative period (p =1), and at three months (p =0.991) and six months postoperatively (p =0.985). There was no statistical difference for knee function score for all three periods (p =1.0).

CONCLUSION

The Brazilian version of the Knee Society Score is easy to apply, as well providing as a valid and reliable instrument for measuring the knee score and function of Brazilian patients undergoing TKA.

LEVEL OF EVIDENCE

Level I - Diagnostic Studies- Investigating a Diagnostic Test- Testing of previously developed diagnostic criteria on consecutive patients (with universally applied 'gold' reference standard).

The use of patient-specific measurement instruments in the process of goal-setting: a systematic review of available instruments and their feasibility

OBJECTIVE

The aim of this study was to identify the currently available patient-specific measurement instruments used in the process of goal-setting and to assess their feasibility.

METHODS

After a systematic search in PubMed, EMBASE, CINAHL, PsychINFO and REHABDATA, patient-specific instruments were included, structured in a goal-setting practice framework and subjected to a qualitative thematic analysis of feasibility.

RESULTS

A total of 25 patient-specific instruments were identified and 11 were included. These instruments can be used for goal negotiation, goal-setting and evaluation. Each instrument has its own strengths and weaknesses during the different phases of the goal-setting process. Objective feasibility data were revealed for all instruments such as administration time, instruction, training and availability. Subjective feasibility could only be analysed for the Canadian Occupational Performance Measure, Goal Attainment Scaling, Self-Identified Goal Assessment and Talking Mats. Relevant themes were that Canadian Occupational Performance Measure and Goal Attainment Scaling were time consuming and difficult for patients with cognitive problems, but they facilitated goal-setting in a client-centred approach. Talking Mats was especially feasible for patients with cognitive and communication impairments.

CONCLUSIONS

A total of 11 instruments were identified, and although some had strong points, there is no single good instrument that can be recommended specifically. Applying a combination of the strengths of the available instruments within a goal-setting framework can improve goal setting and tailor it to individual patients.

The effect of a new syringe design on the ability of rheumatoid arthritis patients to inject a biological medication

Self-administration of new biological medications can be difficult for Rheumatoid Arthritis patients with functional impairment and hand and dexterity limitation. Twenty-three Rheumatoid Arthritis (RA) patients participated in this study to compare preferences and injection forces using a conventional syringe and a new ergonomically designed syringe. Injection force measurements were collected in two ways: a) isometric forces, with the syringes' plungers in fixed positions (depressed halfway and fully depressed), and b) forces exerted during injection of the medication. Subjects' grip and pinch strengths were measured. A perception questionnaire gauged subjects' impressions and preferences. Subjects were capable of exerting significantly higher isometric forces using the new syringe with the plunger fixed both halfway and fully depressed. During injection of the medication, peak and mean injection forces were significantly higher, and duration was shorter, when using the new syringe. Subjects rated the new syringe higher on all twenty attributes on preference and performance. Therefore, it is expected that the new syringe will benefit self-administration of medication injection for RA patients.

Translation, cultural adaptation and reproducibility of the Cochin Hand Functional Scale questionnaire for Brazil

OBJECTIVE

To translate, to perform a cultural adaptation of and to test the reproducibility of the Cochin Hand Functional Scale questionnaire for Brazil.

METHODS

First, the Cochin Hand Functional Scale questionnaire was translated into Portuguese and was then back-translated into French. These translations were reviewed by a committee to establish a Brazilian version of the questionnaire to be tested. The validity and reproducibility of the Cochin Hand Functional Scale questionnaire was evaluated. Patients of both sexes, who were aged 18 to 60 years and presented with rheumatoid arthritis affecting their hands, were interviewed. The patients were initially interviewed by two observers and were later interviewed by a single rater. First, the Visual Analogue Scale for hand pain, the Arm, Shoulder and Hand Disability questionnaire and the Health Assessment Questionnaire were administered. The third administration of the Cochin Hand Functional Scale was performed fifteen days after the first administration. Ninety patients were assessed in the present study.

RESULTS

Two questions were modified as a result of the assessment of cultural equivalence. The Cronbach's alpha value for this assessment was 0.93. The intraclass intraobserver and interobserver correlation coefficients were 0.76 and 0.96, respectively. The Spearman's coefficient indicated that there was a low level of correlation between the Cochin Hand Functional Scale and the Visual Analogue Scale for pain (0.46) and that there was a moderate level of correlation of the Cochin Scale with the Health Assessment Questionnaire (0.66) and with the Disability of the Arm, Shoulder and Hand questionnaire (0.63). The average administration time for the Cochin Scale was three minutes.

CONCLUSION

The Brazilian version of the Cochin Hand Functional Scale was successfully translated and adapted, and this version exhibited good internal consistency, reliability and construct validity.

Collaboration with patients in the design of patient-reported outcome measures: capturing the experience of fatigue in rheumatoid arthritis

OBJECTIVE

Patient-reported outcome measures (PROMs) need to include concepts and language relevant to patients and be easily understood. These studies aimed to develop draft PROMs to measure rheumatoid arthritis (RA) fatigue and its impact by collaborating with patients to identify language and experiences, create draft PROM items, and test them for comprehension, with decisions supported throughout by a patient research partner.

METHODS

In study 1, interview transcripts of RA patients describing their fatigue (n = 15) were subjected to content and inductive thematic analysis to identify fatigue language and experiences. In study 2, 3 focus groups of RA patients (n = 17) explored these and developed the wording for visual analog scales (VAS) and identical numerical rating scales (NRS), then a draft multi-item questionnaire was developed with the patient research partner. Study 3 comprised 15 RA patients who completed the PROMs during cognitive interviewing to explore understanding.

RESULTS

Studies 1 and 2 identified key patient terminology (fatigue, exhaustion) and 12 potential fatigue concepts (Cognition, Coping, Duration, Emotion, Energy, Frequency, Impact, Planning, Quality of Life, Relationships, Sleep, and Social Life). Patients' proposals were clarified into draft screening VAS/NRS for fatigue severity, effect, and coping, plus a draft 45-item questionnaire. Study 3 showed that 14 questions required clarification or revision of response options.

CONCLUSION

Collaboration with patients enabled development of draft RA fatigue PROMs grounded in the patient data, strengthening face and content validity and ensuring comprehension. The draft conceptual framework that emerged has resulted in draft PROMS ready for item reduction, and testing of construct and criterion validity and reliability.

Measure of function in rheumatoid arthritis: individualised or classical scales?

BACKGROUND

The Health Assessment Questionnaire Disability Index (HAQ-DI) is the most widely used measure of function in rheumatoid arthritis (RA).

OBJECTIVE

To evaluate individualised forms of the HAQ-DI and thus enhance the incorporation of patients' views in outcome assessment.

PATIENTS AND METHODS

HAQ-DI data were prospectively obtained from 370 outpatients with RA treated with leflunomide over a 6-month period. At baseline and final visits, patients had to rate the importance they attached to each activity addressed by the 20 HAQ-DI items, and to select the five activities they considered the most important. Different individualised scales were evaluated: scales preserving all domains, in which the score for each item is multiplied by or added to its importance; and scales involving, for each patient, only the five most important items. The psychometric properties of these scales were compared with those of the HAQ-DI.

RESULTS

For each HAQ-DI item, severity and importance scores were weakly correlated. Scores for all individualised scales were highly correlated with the HAQ-DI score (r(s)>0.75). All scales had a good internal consistency (Cronbach's alpha 0.87-0.88). Compared with the HAQ-DI, individualised scales did not have better sensitivity to change (standardised response mean 0.64-0.69 vs 0.74).

CONCLUSION

Individualised scales have similar properties to the HAQ-DI. However, individualised questionnaires measuring importance gave complementary information to the measure of disability. Individualisation is probably not needed for group assessment in all randomised controlled trials but, the use of individualised questionnaires may be clinically relevant for individual patients with RA.

Individualising the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) function subscale: incorporating patient priorities for improvement to measure functional impairment in hip or knee osteoarthritis

OBJECTIVE

Recommended outcome measures in osteoarthritis are standardised scales identical for each patient. As patient-specific scales are of increasing interest when considering patient priorities in outcome assessment, this study aims to validate individualised forms of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) function subscale.

PATIENTS AND METHODS

WOMAC function subscale data were prospectively obtained from 1218 outpatients with hip or knee osteoarthritis requiring non-steroidal anti-inflammatory drugs. Patients also rated the importance to remove disability in each activity of the WOMAC function subscale, and selected the five activities they considered the most important to be improved upon. After treatment, patients again completed the WOMAC function subscale. Several individualisation methods were evaluated: methods whereby the score of each item is multiplied by, or added to, its importance, and methods based on the five most important activities (WOMAC top 5). Psychometric properties of individualised scales were compared to those of the WOMAC function subscale.

RESULTS

The missing data rate was 11%, 13% and 2% for the WOMAC function, its individualised forms and the WOMAC top 5, respectively. Combining severity and importance of each item did not improve the properties of the scales. The WOMAC top 5 was the most responsive scale (standardised response mean: 0.96 vs 0.80, p<0.001).

CONCLUSION

Because of its better responsiveness, ease of use, low missing data rate and ability to highlight patient priorities, the WOMAC top 5 could be an interesting tool in therapeutic evaluation in hip or knee osteoarthritis.

Applicability of the 12-Item Short-Form Health Survey in patients with progressive systemic sclerosis

OBJECTIVE

To evaluate the applicability of the 12-Item Short-Form Health Survey (SF-12) as an instrument to measure health-related quality of life in a sample of patients with progressive systemic sclerosis (PSS) through the analysis of its reproducibility and its correlation with functional and clinical parameters.

METHODS

A test-retest reproducibility study for the comparative analysis of the intraclass correlation coefficients (ICCs) of the SF-12 and the SF-36. A total of 46 patients diagnosed with PSS were studied, regardless of the presence of respiratory symptoms.

RESULTS

The physical component summary 12 (PCS-12) score had an ICC of 0.47 (95%CI: 0.05-0.71; p < 0.02), whereas the mental component summary (MCS-12) score had an ICC of 0.72 (95%CI: 0.49-0.84; p < 0.001). The PCS-36 score had an ICC of 0.88 (95%CI: 0.78-0.93; p < 0.001), and the MCS-36 score also had an ICC of 0.88 (95%CI: 0.78-0.93; p < 0.001).

CONCLUSION

The SF-12 is a reliable instrument for measuring health-related quality of life in patients with PSS, since it has been proven to be reproducible. However, this version of the SF-12 should only be used in clinical research settings.

Psychometric evaluation of condition-specific instruments used to assess health-related quality of life, attitudes, and related constructs in stuttering

PURPOSE

This study assessed the psychometric properties of instruments used to measure constructs similar to stuttering-specific health-related quality of life. In the stuttering literature, most such instruments were originally intended to measure speakers' attitudes about, or reactions to, their stuttering.

METHOD

Seventeen instruments were identified through a comprehensive literature search. Based on specific criteria from previous publications, 10 were selected for complete review and evaluated using 15 measurement standards related to conceptual model, reliability, validity, responsiveness, interpretability (norms), burden (respondent and administrative), depth, and versatility.

RESULTS

None of the available instruments met more than 8 of the 15 measurement standards assessed.

CONCLUSIONS

Available instruments do not satisfy psychometric criteria for use in individual or group-level decision making, either as measures of their originally intended constructs or as measures of health-related quality of life. Problems with the conceptual model, reliability, validity, and responsiveness of available instruments, as well as the lack of comprehensive normative data, combine to suggest the need for development and validation of a stuttering-specific health-related quality of life measure.

Functional outcomes after nonrecurrent dislocation of primary total hip arthroplasty

The influence of dislocation on functional outcomes of primary total hip arthroplasty is unclear. The purpose of this study was to assess the effect of nonrecurrent dislocations treated with closed reduction after primary total hip arthroplasty on postoperative outcome in the short to medium term. Ninety-six patients were enrolled in this retrospective case-control study. There were 32 patients who had a postoperative dislocation. The control group consisted of 64 matched patients who did not dislocate. All patients had a minimum of 1-year follow-up. The 2 groups were compared using the SF-12, reduced WOMAC, and satisfaction questionnaire. There was no statistical difference between the 2 groups in subjective functional outcomes using the WOMAC or SF-12. However, there was a trend toward better quality of life scores in the control group, and they were more satisfied with their surgery compared with the dislocation group.

Tradução, validação e adaptação cultural da escala de atividade de vida diária

OBJETIVO: Realizar a tradução, adaptação cultural e validação do "Knee Outcome Survey- Activities of Daily Living Scale" (ADLS) para a língua portuguesa, bem como verificar suas propriedades de medida, reprodutibilidade e validade, para que o mesmo possa ser usado como um instrumento específico para avaliação de sintomas em pacientes brasileiros portadores de afecções no joelho durante as atividades de vida diária. MÉTODOS: Foram realizadas 2 entrevistas,na primeira o questionário foi aplicado em conjunto ao Lysholm, SF-36 e EAV (examinador 1). Após aproximadamente 30 minutos da primeira entrevista, os mesmos pacientes responderam apenas ao ADLS (examinador 2). Após um intervalo entre 7 a 10 dias, foi realizada a terceira entrevista constituída de nova aplicação do ADLS (examinador 2). RESULTADOS: A amostra consistiu de 53 entrevistados, sendo a média de idade de 33.0566 anos e patologia mais freqüente a lesão ligamentar (56,6%). O índice de Sperman obteve um valor de 0,986 (alfa=0,05, ro<0,01) na reprodutibilidade inter-examinador e de 0,980 (alfa=0,05, ro<0,01). CONCLUSÃO: O questionário ADLS em português é um instrumento útil para avaliação de atividades de vida diária de pacientes brasileiros com afecções no joelho.

Quality of Life in Indian Patients with Rheumatoid Arthritis

PURPOSE OF STUDY

Rheumatoid arthritis (RA) is a multisystem disease with various extra-articular manifestations (EAMs). Health-related quality of life (HRQOL) issues are assuming increasing importance in chronic rheumatic diseases like RA. No data on QOL in RA is available from the Indian subcontinent. There is also a paucity of literature on the impact of EAMs on HRQOL in RA. The objective of this study was to address these lacunae.

METHODS

The study group comprised 81 patients with RA from a rheumatology clinic in India. Quality of life was estimated by the generic HRQOL measure: World Health Organization quality of life instrument (WHOQOL-Bref). Disease activity in RA was measured by calculating Disease Activity Score-28 (DAS28).

RESULTS

The mean HRQOL scores of the patients were 12.0+/-2.8, 13.2+/-2.7, 14.4+/-2.9 and 13.3+/-2.6 in the physical, psychological, social, and environmental domains of the WHOQOL-Bref respectively. Age, gender, disease duration, educational status, constitutional symptoms, rheumatoid factor positivity, erosions and deformities did not influence HRQOL. Disease activity had a negative influence on the physical and psychological domains. Patients with EAMs had significantly higher DAS28 scores compared to patients without EAMs. Even after adjustment for disease activity, patients with EAMs had lower HRQOL scores than patients without these features (statistically significant for physical domain).

CONCLUSIONS

The physical domain of HRQOL is most affected in Indian patients with RA. Increasing disease activity and presence of EAMs worsens the quality of life.

A study compared nine patient-specific indices for musculoskeletal disorders

BACKGROUND AND OBJECTIVE

Patient-specific quality of life indices show great potential, but certain conceptual and methodological concerns have yet to be fully addressed. The present study reviewed nine patient-specific instruments used in musculoskeletal disorders: the Canadian Occupational Performance Measure (COPM), Juvenile Arthritis Quality of life Questionnaire (JAQQ), McMaster-Toronto Arthritis questionnaire (MACTAR), Measure Yourself Medical Outcome Profile (MYMOP), Patient-Specific Index (PASI) for total hip arthroplasty, Problem Elicitation Technique (PET), Patient Generated Index (PGI) of quality of life, Patient-Specific Functional Scale (PSFS), and Schedule for the Evaluation of Individual Quality of Life (SEIQoL).

STUDY DESIGN AND SETTING

Each tool was evaluated for purpose, content validity, face validity, feasibility, psychometric properties, and responsiveness.

RESULTS

This critical appraisal revealed important differences in terms of the concept underlying these indices, the domains covered, the item-generation techniques and the scoring (response scale, methods) in each scale. The nine indices would generate different responses and likely scores for the same patient, despite the fact that they all include patient-generated items.

CONCLUSION

Although the value of these indices in treatment planning and monitoring at an individual level is strong, more studies are needed to improve our understanding of how to interpret the numeric scores of patient-specific indices at both an individual and a group level.

Assessing the quality of life—reality or impossible dream?

Many now claim that maintaining or improving the quality of life is the essence of healthcare (i.e. care and/or treatment that improves the patients' quality of life). Interest in QL, however, stems from increasing recognition that individuals are an integrated whole rather than a series of disconnected parts or disease states. Though this represents a significant change from the past--when the emphasis lay solely on physical or medical condition--it is not, in itself, meaningful unless reliable and valid ways of evaluating the human aspects of the experience can be identified (i.e. quality of life). As quality of life (QL) is seen as a positive state, a desirable outcome of healthcare interventions, it has gained credence as an appropriate outcome measure and has intuitive appeal. Indeed, it is suggested that, because of its close relationship to mortality, self-perceived QL may be the most important outcome of both acute and, particularly, chronic disease. Lack of consensus about its meaning has, however, resulted in ambiguity and, therefore, difficulties in its measurement reflecting, in turn, the difficulty in identifying the components of this multifaceted concept. This paper explores these issues and questions whether we are, in fact, attempting to measure something that cannot truly be measured.

Patient-assessed health in ankylosing spondylitis: a structured review

OBJECTIVE

To review evidence relating to the measurement properties for all disease-specific, multi-item, patient-assessed health instruments in patients with ankylosing spondylitis (AS).

METHODS

Systematic literature searches were made to identify instruments, using predefined criteria relating to reliability, validity, responsiveness and precision.

RESULTS

Twelve AS-specific and three arthritis-specific instruments met the inclusion criteria. Three AS-specific instruments that measure health-related quality of life (HRQL) were reviewed. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Dougados Functional Index (DFI) had the greatest amount of evidence for reliability, validity and responsiveness across a range of settings. Four instruments lacked evidence for test-retest or internal consistency reliability. Most were assessed for validity through comparisons with other instruments, global judgements of health, mobility or clinical and sociodemographic variables. Most were assessed for responsiveness through mean score changes. Three instruments lacked evidence of responsiveness.

CONCLUSION

This review provides a contribution to AS assessment. AS-specific multi-item measures specific to the assessment of pain, stiffness, fatigue and global health were not identified; where assessed, these domains were largely measured with single-item visual analogue scales. Single items may provide a limited reflection of these important domains. The BASFI and DFI remain the instruments of choice for functional assessment. HRQL is recommended as a core assessment domain. Further concurrent evaluation is recommended.

Avaliação da qualidade de vida na incontinência anal: validação do questionário FIQL (Fecal Incontinence Quality of Life)

RACIONAL: A incontinência anal acarreta incapacitação física e psicológica, determinando impacto na qualidade de vida. Para quantificar esse impacto em nosso meio, não existem instrumentos específicos validados. OBJETIVOS: Avaliar a qualidade de vida na incontinência anal, através da validação do questionário "Fecal Incontinence Quality of Life" (FIQL), que é composto por 29 questões distribuídas em 4 domínios: estilo de vida, comportamento, depressão e constrangimento, sua escala de pontuação varia de 1 a 4 com exceção das questões 1 e 4 que variam de 1 a 5 e 1 a 6, respectivamente. MATERIAL E MÉTODO: Após tradução e adaptação cultural, estudou-se a validação do instrumento através das propriedades de medida de reprodutibilidade e validade. Para a avaliação da reprodutibilidade aplicou-se o questionário em 50 pacientes com incontinência anal por dois examinadores, sendo reaplicado por um dos examinadores após período de 7 a 10 dias. A validade construtiva foi testada através da comparação do FIQL e o SF-36, questionário genérico de qualidade de vida e entre o FIQL e um índice de incontinência anal. O índice de incontinência anal utilizado foi o de Jorge-Wexner, que varia de 0 (continência perfeita) a 20 (incontinência total). A validade discriminativa foi avaliada através da aplicação do FIQL em dois grupos controle: indivíduos voluntários hígidos e portadores de constipação intestinal. RESULTADOS: Verificou-se que o FIQL apresentou correlação significativa com outros instrumentos (SF-36 e índice de incontinência) e que a qualidade de vida no portador de incontinência anal está comprometida em todos os domínios: estilo de vida: 2,4 comportamento: 2,0, depressão: 2,5 e constrangimento: 1,9, quando comparado com os indivíduos voluntários hígidos (3,9, 3,9, 4,1 e 4,0), e pacientes com constipação intestinal (3,7, 3,8, 3,6 e 3,8), respectivamente. CONCLUSÃO: O FIQL é útil para a avaliação da qualidade de vida na incontinência anal em nossa população.

[Translation and validation of an instrument for evaluation of severity of symptoms and the functional status in carpal tunnel syndrome]

The objective of the present study was to translate, to do cultural equivalence and validation of the Levine et al. (1993) or Boston Carpal Tunnel Questionnaire (BCTQ) to Portuguese. The BCTQ application to patients, selected by the question "What was the reason that brought you to look for a physician and that led him to ask this examination?" showed very good reproducibility. The validity was measured through the comparison of the severity symptoms scores (SSS) and the functional status scores (FSS) with the results of grip forces, Minnesota, two point discrimination, Semmes-Weinstein filaments perception and sensory conduction at the median nerve. The internal consistency was evaluated through Chronbach's alpha coefficient comparing the SSS and the FSS. The measuring properties were evaluated through paired t-test between pre and pos-surgical scores. Reproducibility, internal consistency, validation and measuring properties of the translated BCTQ were similar to those found by Levine et al. with the original version.

Measuring the meaning of disability in rheumatoid arthritis: the Personal Impact Health Assessment Questionnaire (PI HAQ)

BACKGROUND

Measurement of disability in rheumatoid arthritis is often used to support treatment decisions and outcome assessments, but is used without reference to the impact of disability on individual patients.

OBJECTIVE

To develop and validate a scale to measure individual values for functions, which is used to weight the level of an individual patient's functional loss and thus calculate the personal impact of disability.

METHODS

In four linked studies, first the phraseology for values was explored to develop a stem question for the value scale couched in terms patients understand (face validity). Then short and long versions of the value scale were compared (content validity) and tests of internal consistency and short term reliability undertaken (criterion validity). Finally, the value scale was examined for long term reliability and agreement with expected variables (criterion and construct validity), after which personal impact scores were calculated and their construct validity examined.

RESULTS

Patients understand the concept of values, and a positively phrased stem question was developed for the value scale, for which a short version was reasonably equivalent to a long version. The value scale was reliable over one week (96% changed by <1 point) with positive interitem correlation. Reasonable six and 12 month reliability was shown (52% changed by <0.5 points), and the value scale was independent of disability and clinical, psychological, personality, and social support variables. Personal impact scores were then calculated by using the value scores to weight disability scores. Impact scores varied widely between patients of similar disability. Personal impact for disability showed convergent validity with dissatisfaction with disability, perceived increase in disability, increased disease activity, worse psychological status, low social support, and time trade off for disability. It discriminated between patients with low and high dissatisfaction with disability, life satisfaction, depression, pain, and helplessness.

CONCLUSION

This individualised personal impact scale should lend meaning to disability scores, improving the interpretation of clinical and research data.

Clinimetric instruments to assess functional health status in patients with haemophilia: a literature review

The World Federation of Hemophilia scoring system (WFH-1) evaluates primarily body functions and structures, whereas assessment of the whole area of functional health status is considered nowadays to be a better measure. In addition, the WFH-1 lacks psychometric properties (reliability, validity and sensitivity to change). This study aimed to gain insight into the clinimetric assessment of functional health status in patients with haemophilia by way of a systematic literature search. A standardized literature search and selection was performed on the databases of CINAHL (1982-2001), Medline (1966-2001), and PubMed (January-July 2001). Clinimetric instruments applied in the selected articles were classified based on the international classification of functioning, disability, and health (ICF) and analysed for their psychometric properties. In 19 articles published between 1979 and 2001, 34 clinimetric instruments were used to assess functional health status. Instruments were classified as measuring the ICF components body structure and function (n = 17), activities (12) and participation (4). Reliability was measured in four articles on three different instruments, the validity (construct) of the instruments for patients with haemophilia was reported in six articles on five instruments, and sensitivity to change in three articles on three instruments. The populations under study varied in number (7-9 35), mean age (21.6-50.8 years), and in the distribution of haemophilia severity. Reports on the evaluation of functional health status in patients with haemophilia are increasing. Further research on the psychometric properties of the instruments is warranted in more groups of patients with haemophilia. Development of the new core set of clinimetric instruments, the WFH-2, might benefit from this strategy.

Health-related quality-of-life treatments for severe haemophilia: utility measurements using the Standard Gamble technique

Prophylaxis for haemophilia improves outcomes, but at a substantial cost. Cost-utility analysis balances improvements seen in health-related quality of life (HRQoL) against costs, with the purpose of aiding healthcare decision-making. This analysis uses a measure of HRQoL known as utility. The objective of this study was to measure HRQoL (utility) values for states of health that result from on-demand therapy or prophylaxis. The HRQoL for different health states (including target joint bleeding, different intensities of prophylaxis, and indwelling intravenous catheters [ports]) was measured for healthy adults (n=30), parents of haemophilic children (n=30), and adults with haemophilia (n=28). Parents and patients rated health states similarly. Healthy adults gave the lowest ratings. The following rank, in order of HRQoL, was obtained: prophylaxis (low > medium > high) > on-demand therapy > prophylaxis with port> prophylaxis with infected port > on-demand therapy with development of a target joint. We conclude that: (1) haemophilia and its treatment reduce HRQoL; (2) prophylaxis is preferred to on-demand therapy; (3) intravenous ports substantially reduce HRQoL; (4) and an intravenous port to provide prophylaxis is preferable to on-demand therapy if a target joint develops.

Long-term disability assessment after surgical treatment of low grade spondylolisthesis

The aim of this study was to determine whether assessment of back surgery with disability scores is relevant. We also attempted to answer the question of whether this evaluation should be conducted by a surgeon or a medical doctor. This retrospective study analyzes the long-term outcome (average follow-up 7 years, range: 3-12) of 40 patients (mean age: 46.2 years) treated by posterior surgical decompression, posterolateral arthrodesis, with or without instrumentation, for symptomatic low-grade spondylolisthesis. All patients were interviewed postoperatively and examined the same day by an orthopedic surgeon, who was not involved in the patients' treatment, as well as by a medical doctor rehabilitation specialist. Impairment was assessed by a standardized clinical examination and by visual analog scales (VAS) of pain. Disability was assessed using two scales: the Quebec disability scale and the Beaujon scale. Anxiety and depression were assessed with a validated specific questionnaire (HAD). Patient's perceived handicap was assessed on a 100-mm VAS. Our results show that the scores of the two disability scales were highly correlated with the patient's overall satisfaction ( r = 0.73 and 0.77 for the Quebec scale and the Beaujon scale, respectively). The intraclass correlation coefficient showed very good or excellent correlation between the data collected by the surgeon and the rehabilitation specialist, ranging from 0.8 to 0.97. This finding clearly demonstrates that interview by a surgeon who is not involved in the patient's treatment does not influence the patient's assessment in terms of impairment, disability, or handicap. Moreover, our results suggest that disability scales are the most relevant outcome measures in the assessment of spine surgery.

Values for function in rheumatoid arthritis: patients, professionals, and public

BACKGROUND

Although many disability questionnaires measure fact very efficiently, they do not allow for consideration of the relevance of that disability to the patient. Data suggest that professionals misinterpret the relevance of disability for the patient and thus, also, the outcome of treatment.

OBJECTIVES

Firstly, to examine agreement on levels of importance for the items on a validated disability scale (Health Assessment Questionnaire (HAQ) and Modified HAQ (MHAQ)), within groups of patients with rheumatoid arthritis, health professionals, and controls. Secondly, to see if functional items important to patients are included in the HAQ, and whether the HAQ items are important to patients.

METHODS

25 patients with RA, 25 rheumatology health professionals, and 25 healthy controls were asked to rate the importance of the HAQ (20 items) and MHAQ (eight domains). Before seeing the HAQ, patients were asked to generate items of function important to them.

RESULTS

Only a slight-fair agreement within each group was found for the level of importance of the HAQ and MHAQ, and also within any combination of the groups (kappa values <0.38). Most of the functional items valued by patients were contained on the HAQ (70%), and no HAQ items were consistently rated as unimportant.

CONCLUSION

Patients, professionals, and healthy controls do not agree on the importance of disabilities. These data support the need to assess the personal impact of disability, as well as disability itself. Individual importance of disability weighted by level of disability is proposed as a model for calculating the personal impact of disability. A new tool to assess the personal impact of disability is being developed.

Pain in the nursing home

The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher "normal" from "abnormal" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.

Reliability, validity, and sensitivity to change of the Cochin hand functional disability scale in hand osteoarthritis

OBJECTIVE

To assess the reliability, validity and sensitivity to change of the Cochin hand functional scale in hand osteoarthritis (OA).

BACKGROUND

The Cochin hand functional disability scale has been validated in rheumatoid arthritis.

DESIGN

Patients with hand OA according to Altman's criteria were included. Impairment outcome measures (VAS of pain, hand score of tenderness, clinical hand score of impairment, Kallman's radiographic scale), functional disability measures [Cochin scale, Revel's functional index (RFI), Dreiser's functional index (DFI)] and patients' perceived handicap (VAS) were recorded twice, at baseline and at a 6-month follow-up visit. Interobserver reliability was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct (convergent and divergent) validity was investigated using the Spearman rank correlation coefficient and a factor analysis was performed. Sensitivity to change was assessed using the effect size (ES) and the standardized response mean (SRM), and the non-parametric Spearman rank correlation coefficient (r) was used to assess the correlation between quantitative variable changes and patient's overall opinion.

RESULTS

89 patients (8 males, mean age 63 years) were included. Interobserver reliability was excellent (ICC=0.96). The Bland and Altman method showed no systematic trend. Correlations of the Cochin scale score with RFI (r=0.86), DFI (r=0.87), VAS of handicap (r=0.67), VAS of pain (r=0.54), tenderness (r=0.51), clinical impairment (r=0.32), and Kallman's radiographic scale (r=0.13) indicated a good construct validity. Factor analysis extracted four main factors, accounting for 65% of the total variance. 51 patients were evaluated at the 6-month visit. The Cochin scale score had worsened with SRM and ES values of -0.26 and -0.17 respectively. Changes in the score had one of the highest correlation (r=0.47) with the patient's overall opinion.

CONCLUSION

The Cochin hand functional disability scale which was first developed to assess the rheumatoid hand can be used to evaluate functional disability in hand OA.

Clinical severity of disease, functional disability and health-related quality of life. Three-year follow-up study of 150 Finnish patients with coagulation disorders

A questionnaire-based follow-up study of 150 Finnish patients with coagulation disorders was conducted to evaluate the changes in clinical manifestation of the disease, pain intensity, functional disability and patient's health-related quality of life, occurring during a 3-year period. Health-related quality of life was assessed using the MOS-36 health survey. The clinical severity of the disease manifestation was estimated using the frequency of bleeding episodes into joints and soft tissue during the previous 12 months. Severity of musculoskeletal morbidity, which reflects simultaneous presence of pain and disability, was estimated using intensity of pain and level of disability. Results showed that clinical severity of the disease remained unchanged during the 3-year period for the majority of patients. Nonetheless, the annual number of bleeds in patients with severe or moderately severe haemophilia was still disconcertingly high and the number of bleeding episodes into soft tissue had increased. The clinical severity of the disease manifestation, rather than the severity of the disease based on molecular classification, was a factor that negatively influenced the intensity of pain (both acute and chronic), as well as level of disability. Severity of musculoskeletal morbidity at time 1 and changes in severity of musculoskeletal morbidity over time were found to be significant predictors of physical role, bodily pain, vitality and social functioning. In conclusion, the disease can be relatively well controlled by the availability of coagulation products, thus stabilizing the clinical severity of the disease manifestation during the 3-year period studied. The findings stress the importance of preventing haemorrhages to avoid resulting permanent joint impairment and disability.

Health-related quality of life and functional status of patients with rheumatoid arthritis randomly assigned to receive etanercept or placebo

OBJECTIVE

To compare the functional status and well-being of patients with rheumatoid arthritis (RA) who were randomly assigned to receive placebo, etanercept 10 mg, or etanercept 25 mg during a 26-week, phase III, double-blind clinical trial.

BACKGROUND

No single indicator of disease activity, severity, or therapeutic efficacy has been established for RA. During the past decade, health-related quality of life, a multidimensional way to assess physical, emotional, and social aspects of a disease or its treatment, has become an important outcome in RA studies and in assessments of RA drug therapies.

METHODS

A total of 234 patients completed the Health Assessment Questionnaire (HAQ), the Short-Form 36 (SF-36) (n = 48 patients), items assessing energy and mental health from the Medical Outcomes Study (MOS), and a single-item rating scale assessing current health (feeling thermometer) at baseline and several times during 6 months.

RESULTS

Significant improvements from baseline to last assessment were reported with etanercept versus placebo and in the HAQ Disability Index score (ie, the total HAQ score) and all 8 HAQ categories (P < 0.05), with the exception of grip. Significant improvements with etanercept in the MOS energy and mental health subscales, current health (from the feeling thermometer), and mental and physical function components of the SF-36 were reported (P < 0.05).

CONCLUSIONS

Patients receiving 10- or 25-mg doses of etanercept reported significantly better functional status and well-being than did patients receiving placebo.

The SF-36 Arthritis-Specific Health Index (ASHI): II. Tests of validity in four clinical trials

OBJECTIVE

The SF-36 Arthritis-Specific Health Index (ASHI) was constructed to improve the responsiveness of the SF-36 Health Survey to changes in the severity of arthritis through the use of arthritis-specific scoring algorithms. This study compared the responsiveness of the ASHI and other generic scales and summary measures scored from the SF-36 in clinical trials of health outcomes for patients with arthritis.

METHODS

Longitudinal data for patients (n = 835) participating in four placebo-controlled trials were analyzed. Study participants had at least a 6-month history of moderate to severe osteoarthritis or rheumatoid arthritis of the knee or hip. All had undergone a washout period of 3 to 14 days before baseline assessment to bring about a flare state in osteoarthritis or rheumatoid arthritis symptoms. Their average age was 60 years, and 72% were female. Responders and nonresponders were classified on the basis of physician assessments of changes in arthritis severity, with blinding as to treatment group; treated and untreated (placebo) groups were also compared. For the SF-36 ASHI, generic physical (PCS) and mental (MCS) component summary measures and each of eight subscales scored from the SF-36 (acute version) change scores were computed by subtracting scores before treatment from scores at 2-week follow-up. To evaluate empirical validity, analyses of variance were performed. For each measure, an F-ratio was computed for the comparison between clinically defined groups of responders and nonresponders and between groups of patients assigned to placebo versus drug therapy. Relative validity (RV) coefficients were computed for the ASHI in comparison with PCS, MCS, and the best SF-36 scale to determine which was more responsive.

RESULTS

In analyses of each of the four trials and all trials combined, RV coefficients for the ASHI were higher than those for both of the generic SF-36 summary measures and for the most valid SF-36 scale (Bodily Pain), with only one exception. Across 40 tests of validity in distinguishing treated from untreated patients, the ASHI was 5% to 19% more valid than the best SF-36 scale (RV = 1.05-1.19; RV = 1.10 in all trials combined). The generic summary measures (PCS and MCS) were much less valid in these tests (RV = 0.67 and 0.27, respectively). In analyses of responders and nonresponders, RV coefficients for the ASHI ranged from 0.70 to 1.22 (RV = 1.04 in all trials combined), in comparison with the best SF-36 subscale, which was always Bodily Pain. RV coefficients were lower for PCS (RV = 0.75) and much lower than the MCS (RV = 0.18) in comparisons of treatment outcomes based on all trials combined.

CONCLUSION

The ASHI appears to be more valid than the eight SF-36 scales and PCS and MCS summary measures for purposes of distinguishing between treated and untreated patients and between clinical responders and nonresponders. This study demonstrates the feasibility of improving the validity of the SF-36 through the use of arthritis-specific scoring while retaining the option of generic scoring, which makes it possible to also compare results across diseases and treatments.

The SF-36 Health Survey as a generic outcome measure in clinical trials of patients with osteoarthritis and rheumatoid arthritis: relative validity of scales in relation to clinical measures of arthritis severity

OBJECTIVE

To evaluate the validity of SF-36 Health Survey (SF-36) scale scores and summary measure scores to describe the health burden of arthritis and to be responsive to clinical indicators of arthritis severity used in four clinical trials.

METHODS

Adults participating in four double-blinded, placebo-controlled clinical trials of therapy for osteoarthritis or rheumatoid arthritis were administered the SF-36 concurrent with clinical measures of disease severity (n = 1,016). Data were collected before treatment and 2 weeks after treatment. Mean SF-36 scores for all patients with arthritis at baseline were compared to a sociodemographically equivalent national norm to test the ability of the SF-36 to describe the burden of arthritis. To test the responsiveness of SF-36 scores to clinical measures of arthritis severity, mean SF-36 scale scores were compared across patients differing in arthritis severity before treatment. Two-week mean SF-36 change scores were compared across patients who improved in arthritis severity (responders) versus patients who did not improve (nonresponders). F-statistics and relative validity coefficients were computed to determine how well each SF-36 scale and summary measure discriminated among arthritis severity levels and distinguished treatment responders from nonresponders, relative to the best scale.

RESULTS

Large and statistically significant differences in mean SF-36 scale scores and summary measures were found such that trial participants scored in worse health than a sociodemographically equivalent US general population norm. In addition, the largest SF-36 scale scores were found to significantly differ across clinically defined levels of arthritis severity. Finally, it was found that the SF-36 scales that best discriminate among arthritis severity groups cross-sectionally were also best at discriminating treatment responders from nonresponders.

CONCLUSION

Results of this study support the validity of the SF-36 to document the health burden of arthritis and as a measure of generic health outcome for clinical trials of alternative treatments for osteoarthritis and rheumatoid arthritis patients.

Monitoring health outcomes among patients with arthritis using the SF-36 Health Survey: overview

As shown here, general health measures cover much of the content included in arthritis-specific measures, but, are they equally sensitive to changes in disease condition? We reviewed the literature on the most widely used general health measure, the SF-36 Health Survey, to see if the empirical evidence supported its validity for use in arthritis patients. As of this writing, there was no documentation of the sensitivity of the SF-36 to short-term changes in arthritic condition over the course of clinical trials and few studies that compared the sensitivity of the SF-36 to arthritis-specific measures. The empirical research reported in this special supplement contributes to the literature on the use of the SF-36 in arthritis patients and demonstrates methods of studying the validity of general health measures to monitor change in specific conditions.

The SF-36 Arthritis-Specific Health Index (ASHI): I. Development and cross-validation of scoring algorithms

An arthritis-specific health index (ASHI) for the SF-36 Health Survey was developed by studying its responsiveness to changes in clinical indicators of arthritis severity. Longitudinal data from 1,076 patients participating in four placebo-controlled trials were analyzed. All had at least a 6-month history of moderate to severe osteoarthritis or rheumatoid arthritis of the knee or hip. All had undergone a washout period of 3 to 14 days before baseline assessment to bring about a flare state in osteoarthritis or rheumatoid arthritis symptoms. Their average age was 60 years and 72% were female. Change scores for the eight-scale SF-36 health profile (acute version) and five arthritis-specific measures of disease severity (knee pain on weight bearing, time to walk 50 feet, physician global evaluation of symptom severity and impact, patient global evaluation of symptom severity and impact, and pain intensity visual analogue scale) were computed by subtracting scores before treatment from scores at two-week follow-up. Canonical correlation methods were used to derive weights for changes in SF-36 scales to score a single index (ASHI) that maximized its correlation with changes in the set of five clinical measures of arthritis severity. The weights used to score the ASHI were cross-validated in a 25% holdout group (N = 144) from the first two osteoarthritis trials and in two additional osteoarthritis and rheumatoid arthritis trials (N = 530). Only one SF-36 canonical variate (ASHI) correlated significantly (F = 4.69, P < 0.0001) with the clinical canonical variate that served as the "criterion" measure of change in the severity of arthritis. Changes in the ASHI and clinical canonical variate were substantially correlated in the developmental sample (r = 0.628, P < 0.0001) and on cross-validation (r = 0.629, P < 0.0001). The clinical canonical variate correlated highly (r = 0.75-0.88) with changes in all but one of the five clinical measures (50-foot walk; r = 0.41). The pattern of correlations between changes in SF-36 scales and the ASHI indicated that ASHI is primarily a measure of bodily pain (r = 0.92) and other aspects of physical and role functioning and well-being (r = 0.69 for Role-Physical, r = 0.68 for Physical Functioning, r = 0.52 for Social Functioning, and r = 0.51 Vitality). The patterns of correlations between SF-36 scales and the ASHI were very similar across developmental and cross-validation samples. This research demonstrates the feasibility and generalizability of a single ASHI scored from changes in responses to the SF-36 Health Survey. The generic SF-36 health profile, which has already been shown to be useful in comparing arthritis with other diseases and treatments, can also be scored specifically to make it more useful in studies of osteoarthritis and rheumatoid arthritis.

Short form 36 (SF-36) health survey: normative data from the general Norwegian population

Anchoring health-related quality of life (HRQOL) measures in population norms makes clinical interpretations more meaningful and is in accordance with practice in other fields of medicine. In this paper norms for the Short Form 36 (SF-36) are presented in a random sample, representative of the general Norwegian population. In addition, sociodemographic variables affecting the scale scores are explored and discussed. The response rate was 67%, being lowest among subjects aged 70 years or over. Data-completeness strongly declined with increasing age. Physical health scales were also strongly affected by age. In all scales, with the exception of general health perceptions, women reported having poorer health than men. Marital status affected the four mental health scales. Educational status affected all the scales, but the effect was smallest in the mental scales. These norms can be employed for comparison in case-control studies, or to interpret HRQOL changes in prospective studies. Differences in social status should be given special attention. Caution should be exercised when assessing subjective health or employing the norms among subjects aged 70 years or over.

Reliability and validity testing of the Michigan Hand Outcomes Questionnaire

In this study, psychometric principles were used to develop an outcomes questionnaire capable of measuring health state domains important to patients with hand disorders. These domains were hypothesized to include (1) overall hand function, (2) activities of daily living (ADL), (3) pain, (4) work performance, (5) aesthetics, and (6) patient satisfaction with hand function. An initial pool of 100 questions was pilot-tested for clarity in 20 patients; following factor analysis, the number of questions was reduced to a 37-item Michigan Hand Outcomes Questionnaire (MHQ). The MHQ, along with the Short Form-12, a generic health status outcomes questionnaire, was then administered to 200 consecutive patients at a university-based hand surgery clinic and was subjected to reliability and validity testing. The mean time required to complete the questionnaire was 10 minutes (range, 7-20 minutes). Factor analysis supported the 6 hypothesized scales. Test-retest reliability using Spearman's correlation demonstrated substantial agreement, ranging from 0.81 for the aesthetics scale to 0.97 for the ADL scale. In testing for internal consistency, Cronbach's alphas ranged from 0.86 for the pain scale to 0.97 for the ADL scale (values >0.7 for Cronbach's alpha are considered a good internal consistency). Correlation between scales gave evidence of construct validity. In comparing similar scales in the MHQ and the Short Form-12, a moderate correlation (range, 0.54-0.79) for the ADL, work performance, and pain scales was found. In evaluating the discriminate validity of the aesthetics scale, a significant difference (p = .0012) was found between the aesthetics scores for patients with carpal tunnel syndrome and patients with rheumatoid arthritis. The MHQ is a reliable and valid instrument for measuring hand outcomes. It can be used in a clinic setting with minimal burden to patients. The questions in the MHQ have undergone rigorous psychometric testing, and the MHQ is a promising instrument for evaluation of outcomes following hand surgery.