Quality of life bibliography and indexes: 1993 update

Discriminant and convergent validity of a subjective quality-of-life instrument aimed at high content validity for schizophrenic persons

OBJECTIVE

To analyse whether a subjective quality-of-life (QoL) instrument (QLiS-Quality-of-Life in Schizophrenia), developed on the basis of a large number of open-ended interviews with schizophrenic patients, has sufficient discriminant and convergent validity to justify its application as a schizophrenia-specific QoL instrument.

METHOD

The discriminant and convergent validity of the QLiS (comprising 12 subscales) was analysed in a cross-sectional study. Schizophrenic persons (n = 135) from different care settings were surveyed using the QLiS, the WHOQOL-Bref, the SWN and 7-point satisfaction items. Partial correlational analyses and regression analyses controlling for general life satisfaction were conducted comparing the QLiS subscales with those of the other instruments.

RESULTS

Positive correlation coefficients were found among all subscales of the QLiS and the other QoL instruments (WHOQOL-BREF from r = 0.29 to r = 0.72; SWN, r = 0.14 to r = 0.83; satisfaction scales, r = 0.18 to r = 0.69). One QLiS subscale (cognitive functioning) was shown to be empirically redundant (r>0.80) to the mental functioning subscale of the SWN. All other subscales proved to have unique variance. The non-QLiS QoL instruments only accounted for substantial amounts of variance (>20% after controlling for global life satisfaction) in the QLiS subscales leading a normal life, appreciation by others, appraisal of accommodation/housing and social contacts.

DISCUSSION

Most of the QLiS subscales can be regarded as sufficiently distinct from other QoL instruments, and thus show evidence of discriminant and convergent validity.

CONCLUSION

A subjective QoL questionnaire with high content validity can provide additional empirical information about schizophrenics' QoL not accounted for by other common QoL instruments.

Measuring Quality of Life in Children with Adenotonsillar Disease with the Child Health Questionnaire: A First U.K. Study

OBJECTIVE

To validate the Child Health Questionnaire (CHQ) and assess the quality of life of inner-city British children with adenotonsillar disease.

METHODS

The primary caregiver of a consecutive series of 43 patients referred for adenotonsillar disease to a pediatric otolaryngology clinic completed the Child Health Questionnaire. Questionnaires were analyzed for data quality and completeness, items/scale correlation, internal consistency and discriminant validity, interscale correlation, reliability estimates and external validity.

RESULTS

CHQ demonstrated excellent measuring characteristics in our population. In a comparison with healthy children, 11 out of 15 measures of quality of life were significantly depressed in our sample. Compared with children with rheumatoid arthritis, scores were equivalent in most areas, with the exception of the global health subscale and overall physical score, where our sample scored significantly lower.

CONCLUSION

The CHQ (PF 28 version) is an accurate and reliable way of assessing the impact of adenotonsillar disease on the quality of life in children in Britain. This appears to be quite significant in most aspects of a child's life.

Validation of a voice prosthesis questionnaire to assess valved speech and its related issues in patients following total laryngectomy

OBJECTIVES

To establish the reliability and validity of a new self-administered questionnaire to assess valved speech and its related issues in patients who have undergone a total laryngectomy operation.

DESIGN

Cross-sectional psychometric validation study.

SETTING

Tertiary cancer care centre.

PATIENTS

We identified sixty-one total laryngectomy patients with no sign of recurrent disease and using voice prosthesis from the speech and language therapy database of the Royal Marsden Hospital. The patients were assessed using a postal self-administered voice prosthesis questionnaire concerning the voice valve and it's related issues. Patients were also asked to complete the University of Michigan voice related quality of life and University of Washington head and neck quality of life (version 4) questionnaires.

MAIN OUTCOME MEASURES

Test-retest and internal consistency reliability; content; criterion and construct validity.

RESULTS

We received completed questionnaires from fifty-one of the sixty-one total laryngectomy patients identified for the study providing a response rate of 84%. The median age of the group was 65 years (range: 40-85) with thirty-seven males and fourteen females. The internal consistency reliability using the Cronbach's alpha coefficient was 0.87 (range: 0.85 to 0.89). Test-retest reliability showed that more than 75% of patients had a score on re-test that was within 1 point of their original score. Content validity was ensured during the design process. The median Spearman correlation coefficient was 0.25 for convergent construct validity with the University of Washington head and neck quality of life questionnaire and 0.64 for criterion validity on comparison with the University of Michigan voice related quality of life scale.

CONCLUSIONS

The voice prosthesis questionnaire is the first validated and reliable self-administered questionnaire designed specifically for evaluating valved speech and its related issues in patients who have undergone total laryngectomy. The voice prosthesis questionnaire has significant utility for audit, outcomes research and monitoring in this unique group of patients.

Positive and Negative Religious Coping in German Breast Cancer Patients

A growing interest has been focusing on the relationship between religious coping and psychosocial adjustment among cancer patients. However, previous research mostly has not differentiated between positive and negative components of religious coping. The current cross-sectional study investigated the role of both positive religious coping, i.e., a confident and constructive turning to religion, and negative religious coping, i.e., religious struggle and doubt, in a sample of 156 German breast cancer patients. Participants were assessed upon admission to an inpatient rehabilitation program. In addition to religious coping, two basic nonreligious coping styles (depressive coping and active problem-focused coping) and psychosocial adjustment (anxiety and depression) were measured. Major research questions concerning the mediating role of nonreligious coping and the relative predictive power of positive and negative religious coping were primarily addressed using structural equation modeling. Results indicated that the relationship between religious coping and psychosocial outcomes was completely mediated by nonreligious coping, whereby only depressive coping and not active problem-focused coping proved to be a mediating variable. Positive and negative religious coping were somewhat positively related to each other; their (indirect) predictive power on psychosocial adjustment was identical though in an opposite direction. All in all, the results correspond to previous Anglo-American research. There are, however, some discrepancies which may be due to the specific religious-cultural background in Germany.

Quality of life in young Italian patients with primary headache

OBJECTIVE

To compare the quality of life of young Italian patients with headache with that of the juvenile Italian population free of chronic disease.

METHODS

The Quality of Life Headache in Youth (QLH-Y) Questionnaire developed by Dutch investigators was translated into Italian and validated in a young Italian population. The forward/backward translation and, for psychometric testing, the factor analysis and Cronbach coefficient alpha were used. A new instrument (Questionnaire for Young Subjects Affected by Primary Headache) was developed to assess psychological, physical, and social functioning and functional status and was used to compare the quality of life of the patients with headache with that of headache-free controls. For psychometric testing (via the questionnaire), we selected a sample of 394 subjects (178 males and 216 females, aged 10 to 18 years): 320 subjects from three schools of North Italy and 74 patients with headache from the Paediatric Headache Center of Padua. In the latter group, 48 patients had tension-type headache and 26 had migraine without aura, according to the International Headache Society diagnostic criteria.

RESULTS

The data derived from the comparison of 84 headache-free subjects (control group) and the 74 young patients with headache confirmed that primary headache negatively influenced the latter's quality of life: patients scored significantly (P<.05) lower on psychological, physical, and social functioning than the headache-free controls.

CONCLUSIONS

Quality of life is compromised significantly in young patients with primary headache disorders. The questionnaire used in this study is a valid and reliable self-administered instrument that may facilitate clinical research in headache.

Outcomes and patient-based hearing status in conductive hearing loss

OBJECTIVES/HYPOTHESIS

To study hearing status and quality of life outcomes in patients with conductive hearing loss (CHL), and to develop a prognostic disease severity staging system for use in future clinical outcomes studies in CHL.

STUDY DESIGN

Clinical outcomes research study in three stages: 1) Prospective development and psychometric validation of a disease-specific hearing status outcomes instrument for CHL. 2) Prospective observational outcomes study of patient-based hearing status and quality of life (QOL) outcomes after treatment of CHL. 3) Development of a prognostic disease-severity staging system to stratify patients into groups of similar treatment outcome.

METHODS

Psychometric instrument validation: assessment of test-retest reliability, internal consistency reliability, content, construct and criterion validity, and responsiveness to change. Statistical assessment of the impact of CHL on patient-based hearing status and QOL, and the change in hearing status and QOL after treatment. Using data from the prospective study and multivariate regression, identification of pretreatment independent variables, which predict good outcome after treatment, and development of a severity staging system.

RESULTS

Test-retest reliability (r >0.70) and internal consistency reliability (alpha >0.70) were adequate for both subscales of the hearing status instrument. Construct validity was demonstrated by adequate convergent/divergent validity with other health status instruments on multi-item multitrait correlation matrixes. Criterion validity was demonstrated using audiometric threshold data. Responsiveness to change was demonstrated using the standardized response mean after treatment (SRM = 0.40 and 0.61 for the two subscales). Emotional hearing status and social/situational hearing status improved significantly after treatment of CHL: emotional score, 31.1 to 56.6 (P < .001); social/situational score, 56.7 to 63.7 (P = .01). Mean QOL subscale scores for patients with CHL were not significantly different from healthy populations, and global QOL scores did not change significantly after treatment of CHL. Using proportional improvement in emotional hearing status as an outcome, we identified several pretreatment factors that predicted good outcome (i.e., larger proportional improvement): level of pretreatment emotional hearing status, presence of sensorineural component of HL, and etiology of CHL (otosclerosis vs. all other causes). Some hypothesized predictive independent factors, such as bilateral HL, audiometric threshold level, pretreatment functional status, employment status, age, and duration of HL, were not identified as significant predictors of outcome in the multivariate analysis. We constructed a prognostic disease severity staging system in which the three predictor variables were each given a score of 0 or 1, and these three scores were added to obtain the disease stage (stage 0, 1, 2, or 3). Higher disease stage indicated more severe disease or a lower proportional improvement in emotional hearing status after treatment. This staging system appropriately stratified patients into groups of similar outcome after treatment (P = .02) and has significant potential use for future outcomes research on CHL.

CONCLUSIONS

We have developed and validated a patient-based hearing status outcomes instrument for use in CHL. We have measured hearing status and quality of life outcomes after treatment of CHL, and we have developed a prognostic disease severity staging system that predicts the improvement in emotional hearing status after treatment of CHL.

Quality of life in survivors of prolonged mechanical ventilatory support

OBJECTIVE

To examine the long-term quality of life (QOL) in a group of patients after prolonged mechanical ventilatory support.

DESIGN

Prospective cohort study.

SETTING

Outpatient follow-up.

PATIENTS

Survivors of prolonged mechanical ventilatory support who were discharged from a ventilator rehabilitation unit (VRU).

INTERVENTIONS

Measurement of health-related QOL using the Sickness Impact Profile (SIP).

MEASUREMENTS AND MAIN RESULTS

Forty-six patients were contacted approximately 2 yrs after their discharge from the VRU and asked to complete the SIP. Twenty-five patients (age, 59 +/- 17 yrs; duration of mechanical ventilatory support, 45 +/- 36 days [mean +/- sd]) agreed to participate in this study and completed the SIP questionnaire 23 +/- 18 months after their discharge from the VRU. Patients' VRU stay was 29 +/- 21 days. Two patients were discharged with nocturnal ventilatory support, and the rest were completely weaned of mechanical ventilatory support before discharge. Fifteen patients (60%) were discharged to home, eight patients (32%) were discharged to a rehabilitation facility, and two patients (8%) were discharged to a skilled-care facility. Most patients had mild dysfunction, and the global SIP score was 12 +/- 10, the physical dimension score was 12 +/- 12, and the psychosocial dimension score was 9 +/- 11 (SIP scores range from 0 to 100, with higher scores indicating worse QOL). Subgroup analysis showed that postoperative patients had lower SIP scores compared with patients with chronic respiratory diseases (global SIP, 7 +/- 6 vs. 19 +/- 8; p <.05). Moreover, the patients in the postoperative group were older, but had similar SIP scores as patients who had acute lung injury (17 +/- 15). Global SIP scores correlated with age (r = -.40; p =.046), but not with duration of mechanical ventilatory support (r = -.23) or VRU admission Acute Physiology and Chronic Health Evaluation II scores (r = -.39; p =.06).

CONCLUSIONS

In survivors of prolonged mechanical ventilatory support, using specific selection criteria shows that there is minimal impairment in the QOL at long-term follow-up. Although some patients continue to have moderate to severe limitations, it is the cause of respiratory failure and the underlying disease, rather than duration of ventilatory support, that have a significant impact on 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.

Spiritual conflicts associated with praying about cancer

A secondary analysis of data from a study designed to describe how persons use prayer to cope with cancer is presented in this paper to illuminate the spiritual conflicts that can be experienced among persons with cancer. Employing phenomenological methods, 30 persons from various phases of the cancer experience and religious backgrounds, were interviewed in depth about why, when, and how they prayed, as well as what they prayed about and the outcomes they expected. The secondary analysis revealed that many of these informants had hesitancies about petitionary prayers for particular things, a cure, or for themselves. They also indicated questions about theodicy and the meaning of having cancer, the nature of God, and acknowledged 'unanswered' prayer. Several described an inner conflict about releasing control to God. A few referred to bargaining with God, and a few doubted their personal spirituality and worth, if they were praying correctly, and if prayer was efficacious.

Searching for information on outcomes: do you need to be comprehensive?

The concepts of evidence-based practice and clinical effectiveness are reliant on up to date, accurate, high quality, and relevant information. Although this information can be obtained from a range of sources, computerised databases such as MEDLINE offer a fast, effective means of bringing up to date information to clinicians, as well as health service and information professionals. Common problems when searching for information from databases include missing important relevant papers or retrieving too much information. Effective search strategies are therefore necessary to retrieve a manageable amount of relevant information. This paper presents a range of strategies which can be used to locate information on MEDLINE efficiently and effectively.

Assessment scales for the evaluation of stroke patients

The approval of tissue plasminogen activator to treat acute ischemic stroke and the continuing need to evaluate new neuroprotective drugs and thrombolytic agents in clinical trials have focused interest on the quantitative evaluation of stroke patients. Emphasizing outcomes management in clinical practice has also heightened the importance of quantitative evaluation using assessment scales. Investigators who evaluate, revise, and use assessment scales for the measurement of stroke impairment, disabilites, and handicaps face many challenges. These problems include the heterogeneity of stroke and the need to determine appropriate outcome measures, to use neurological deficit scales that can accurately predict disability, to ensure adequate follow-up, and to use scales that can be used outside of clinical trials by all health care professionals. Such scales should be easily and quickly administered, responsive, valid, and reliable. The most important categories of stroke scales are neurological deficit scales (e.g., Canadian Neurological Scale, European Stroke Scale, and National Institutes of Health [NIH] Stroke Scale), functional outcome scales (e.g., Barthel Index), and global outcome scales (e.g., Modified Rankin Scale). Although stroke-specific, health-related quality-of-life (HRQL) scales have yet to be developed and validated, general HRQL scales such as the Nottingham Health Profile, the Medical Outcomes Study Short Form-36, the Sickness Impact Profile, and the Health Utilities Index may be used to assess stroke patients. Lacking the ideal single stroke outcome scale, we continue to recomend a combination of scales: the NIH Stroke Scale (or similar deficit scale), the Barthel Index, and the Rankin Scale.

On the generalizability of statistical expressions of health related quality of life instrument responsiveness: a data synthesis

Responsiveness statistics have been suggested as criteria for selecting health-related quality of life (HRQoL) instruments or for calculating the required sample size. This paper raises questions about the stability of estimates of instrument responsiveness. The questions are examined by use of data synthesis. A literature search identified instances where two HRQoL instruments were used concurrently on two or more occasions. An effect size difference between the instruments was calculated. The distribution of the differences in the effect size between pairs of instruments used conjointly in different applications was used as an indicator of variation in responsiveness. The effect size for all possible published uses of generic and disease-specific HRQoL instruments was also examined. Responsiveness was found to be subject to considerable variation. Disease-specific instruments were found to be consistently more responsive than generic instruments. The authors suggest use of responsiveness data should be restricted to expanding pilot study results.

Construct validities of the Quality of Well-Being Scale and the MOS-HIV-34 Health Survey for HIV-infected patients

This research assessed the construct validities of two health-related quality-of-life instruments: the Quality of Well-Being Scale (QWB) and the Medical Outcomes Study 34-item HIV Health Survey (MOS-HIV-34). A sample of 100 adult male, HIV-infected patients, across six HIV disease classifications, was used as subjects. Four convergent validity measures of health-related quality of life were used: CD4 cell counts, beta-2 microglobulin levels, disease classification, and age. All convergent validity measures were significant for the QWB. Forty percent of the convergent validity comparisons with the MOS-HIV-34 were statistically significant. Because the two measures provide different perspectives on health-related quality of life, both instruments appear to be useful in measuring health-related quality of life in this patient population.

Construct validity of the Impact of Weight on Quality of Life Questionnaire

The Impact of Weight on Quality of Life questionnaire (IWQOL) is a 74-item self-report, condition-specific instrument that (1) assesses the effect of weight on quality of life in eight key areas, and (2) may be used as a treatment outcome measure and/or an evaluation tool for healthcare policy makers and third-party payers. This study explores IWQOL construct validity and provides new information on internal consistency, treatment effects, and differences between men and women. IWQOL total scores correlated highly with other measures of overall quality of life, and subscale scores correlated well with counterparts in the assessment battery. Internal consistency estimates for the IWQOL scales generally were high. For the women, 4-week participants, and the total sample, pretreatment-posttreatment differences were significant for all IWQOL scales and total score. For men, treatment differences were significant for the total score and all subscales except for Work and Mobility. Treatment differences for 2-week participants were significant for all scales except for Work. Consistent with previous IWQOL study results, the Comfort With Food scale scores reflected more discomfort at posttreatment as compared with pretreatment. The IWQOL, already translated into French and Italian, currently is demonstrating clinical and research utility as a quality-of-life outcome measure for clinical trials of antiobesity drugs and surgical treatments for patients with obesity.

Cancer-specific quality of life questionnaires: the state of the art in Europe

Quality of life (QL) assessment is now regarded as desirable, if not mandatory, by agencies supporting cancer clinical trials around the world, yet doubts persist about the relevance of QL data to clinical practice. A plethora of QL measures is available but the quality of published work remains suboptimal. The appropriate choice of instrument is essential if outcome measures are to be valid and clinically meaningful. This paper reviews the considerations which should determine the choice of QL questionnaire and, taking the specific example of the EORTC approach, aims to provide users with an update on the current state of the art in the development of cancer-specific QL questionnaires.

Health outcomes are about choices and values: an economic perspective on the health outcomes movement

The aim of the health outcomes movement is to reorientate health services so that the spotlight shines less on what is done and more on what is achieved. The health outcomes movement, thus far, has been most successful in addressing what appear to be technical questions relating to the measurement and analysis of health outcomes and in placing their routine use on the agenda of clinical practice and health services planning. If there is one lesson to be drawn from an economic perspective, however, it is that health outcomes are about values and not just technicalities. The need to make choices forces one to consider whether what is achieved is also what is most valued. The success of health service delivery, be it at a clinical, planning or systems level, must therefore be measured against agreed objectives. It follows that time must be taken to establish what patients and the community want from their health services and what each is prepared to give up to achieve its ends. Value judgements are unavoidable. The challenge lies not in measuring the outcomes of health interventions but in deciding what the objectives of the health system ought to be.

Severity of a case for outcome assessment in health care--definitions and classification of instruments

Severity of a case is one of the ingredients in management systems. Severity adjustment systems have limitations, and confusion and diversity characterize definitions of severity of a case. These facts may be a consequence of lack of conceptual knowledge. Based on a holistic theory of health, we introduce a definition of severity of a case from a patient perspective. Here severity is characterized as having two basic components: disease severity and illness severity; and five dimensions: suffering, disabilities, risk of suffering, risk of disabilities and risk of death. A classification of instruments as measures of severity dimensions is presented. This classification is based on definition and application criteria. The article's main contribution is to combine theoretical and practical knowledge about severity of a case, which may empower implementations of outcome management systems in health care.

Evidence for the sensitivity of the SF-36 health status measure to inequalities in health: results from the Oxford healthy lifestyles survey

OBJECTIVES

The short form 36 (SF-36) health questionnaire may not be appropriate for population surveys assessing health gain because of the low responsiveness (sensitivity to change) of domains on the measure. An hypothesised health gain of respondents in social class V to that of those in social class I indicated only marginal improvement in self reported health. Subgroup analysis, however, showed that the SF-36 would indicate dramatic changes if the health of social class V could be improved to that of social class I.

DESIGN

Postal survey using a questionnaire booklet containing the SF-36 and a number of other items concerned with lifestyles and illness. A letter outlining the purpose of the study was included.

SETTING

The sample was drawn from family health services authority (FHSA) computerised registers for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire.

SAMPLE

The questionnaire was sent to 13,042 randomly selected subjects between the ages of 17-65. Altogether 9332 (72%) responded.

OUTCOME MEASURES

Scores for the eight dimensions of the SF-36.

STATISTICS

The sensitivity of the SF-36 was tested by hypothesising that the scores of those in the bottom quartile of the SF-36 scores in class V could be improved to the level of the scores from the bottom quartile of SF-36 scores in class I using the effect size statistic.

RESULTS

SF-36 scores for the population at the 25th, 50th, and 75th centiles were provided. Those who reported worse health on each dimension of the SF-36 (ie in the lowest 25% of scores) differ dramatically between social class I and V. Large effect sizes were gained on all but one dimension of the SF-36 when the health of those in the bottom quartile of the SF-36 scores in class V were hypothesised to have improved to the level of the scores from the bottom quartile of SF-36 scores in class I.

CONCLUSIONS

Analysis of SF-36 data at a population level is inappropriate; subgroup analysis is more appropriate. The data suggest that if it were possible to improve the functioning and wellbeing of those in worst health in class V to those reporting the worst health in class I the improvement would be dramatic. Furthermore, differences between the classes detected by the SF-36 are substantial and more dramatic than might previously have been imagined.