Response shift recalibration and reprioritization in health-related quality of life was identified prospectively in older men with and without stroke

Motor neurone disease: A point-prevalence study of patient reported symptom prevalence, severity and palliative care needs

BACKGROUND

Motor neurone disease is a rare but debilitating illness with incomplete evidence regarding patients' symptom burden. Palliative care and generalist clinicians are often in-experienced in caring for these patients and assessing their needs.

AIM

To identify the symptom prevalence and severity experienced by patients with motor neurone disease. Secondary objectives were to examine differences in symptom burden and clusters according to phenotype, functional status, palliative care provision and those in their last months of life.

DESIGN

A point prevalence study assessing patient-reported symptoms using a modified IPOS-Neuro assessment tool, incorporating 41 symptom items.

SETTING/PARTICIPANTS

Patients with motor neurone disease attending the State-wide Progressive Neurological Disease Service or inpatient unit at Calvary Health Care Bethlehem, Melbourne Australia, from March to December 2021.

RESULTS

A total of 102 patients participated, the majority diagnosed with lumber-onset (30.4%), bulbar-onset (28.4%) and cervical-onset (25.5%) phenotypes. Patients experienced a median of 17 symptoms (range 2-32) with a median of 3 symptoms rated as severe/overwhelming (range 0-13). Motor and functional symptoms predominated, with differences in symptom clusters present according to phenotype. Patients had a higher number of severe/overwhelming symptoms if they were accessing palliative care services (p = 0.005), in their last 6 months of life (p = 0.003) and experiencing moderate or severe functional impairment (p < 0.001).

CONCLUSIONS

Patients with motor neurone disease report high symptom burden. A validated motor neurone disease-specific symptom assessment tool is needed to accurately assess patients, including important variations in symptom clusters according to phenotype. Further research must focus on evidence-based treatment guidelines for symptoms experienced commonly and severely.

IMPACT-ALS: summary of results from a European survey of people living with ALS

OBJECTIVE

The IMPACT-ALS survey collected the experiences of people living with ALS (plwALS) across nine European countries. We aimed to better understand the functional burden of ALS to ensure the experiences of plwALS inform the development of person-centered therapies.

METHODS

The content was informed by the US IMPACT-ALS survey, with adjustments relevant to the European population. Questionnaires consisted of four modules, each of which was pilot tested in advance of distribution. Data were captured using the Qualtrics software and were analyzed in SPSS.

RESULTS

857 respondents completed the survey, with a participation rate ranging from 0.2% to 6.3% across the nine participating countries. The majority were male and aged 55-74 years old. In the previous 2 weeks, symptoms experienced included weakness (81%), fatigue (61%), speech impairment (38%), pain (27%), and depression and other mood changes (23%). Eighty-two percent of respondents reported fears, of which the most common were leaving family too soon (68%) and death from respiratory failure (50%). Lifestyle changes since diagnosis were reported by 89% of respondents, with less time spent doing most daily activities but more time on the internet (81%), reading (56%) and communicating with family and friends (55%). Stopping progression of ALS was the most desired impact for a new therapy for 68% respondents.

CONCLUSIONS

The European IMPACT-ALS survey has generated insights into the complex experiences of plwALS. The data provide unique patient perspectives on common symptoms, fears, functional limitations, lifestyle changes, and wishes for future therapies that will enhance patient-centric care in ALS.

EQ-5D-3L Norms for the European Older Population: Country-Specific Norms for 15 European Countires Based on the Survey of Health, Ageing, and Retirement in Europe

OBJECTIVES

This study presents a country-specific 3-level version of EQ-5D population norms for the European older population.

METHODS

Norm data were obtained from the fourth wave of the Survey of Health, Ageing and Retirement in Europe, and determined, for each EQ-5D dimension, the EQ-visual analog scale (EQ-VAS) and EQ-5D index values by 7 age groups and sex for 15 European countries. The EQ-5D index values were calculated using the European VAS value set for all countries.

RESULTS

Data resulting from 50 013 older respondents (mean age 65.9 years, range 50-111 years, 55.6% women) revealed an increasing number of self-reported health problems on EQ-5D dimensions and decreasing EQ-VAS scores with increasing age and for women compared with men. There are notable differences between countries in terms of the age gradient, the proportion of respondents in full health, and sex. Across all age groups, problems with pain & discomfort are the most frequent (36%-73% any problems), whereas problems with self-care are the least frequent (3%-31% any problems). The mean EQ-VAS score is 71.2 and the mean European VAS score is 0.79.

CONCLUSIONS

Given the growing number of older adults and elderly people in Europe, these population norms provide a valuable source of reference data that can be used to compare older adults or patient subgroups to the average of the general elderly population in a similar age or sex group in 15 European countries. The index value results may be further used to assess the burden of disease across older European populations and to identify the unmet needs of targeted older patient populations.

Subjective health perception prioritizes psychological well-being over physical function in advanced ALS: A multigroup structural equation modeling analysis

BACKGROUND

Despite declining physical function, individuals with ALS report relative preservation of overall health perception, or health-related quality of life (HRQoL). This paradoxical finding is attributed to psychological adaptation to deficits.

OBJECTIVE

The aim of this cross-sectional study was to examine reprioritization of factors that determine HRQoL with disease progression.

METHODS

As standard care, patients with ALS self-reported ALSFRS-R (measure of bulbar, motor, and respiratory function), PHQ-9 (measure of depression), and EQ-5D-3L (utility index that includes a visual analog scale asking about health perception [EQ-VAS]). ALS was staged by the FT9 method and classified into early (stages 0-2) and late (stages 3-4) disease. Multigroup structural equation modeling was used to evaluate weights of physical (PHY) and psychological well-being (PSY) for early and late disease, on EQ-VAS (as a measure of overall HRQoL).

RESULTS

There were 578 patients (mean age 61.5 ± 11.9, 59% male) with ALS: 423 (73%) early and 155 (27%) late disease. A measurement model was established with good model fit (RMSEA = 0.076, CFI = 0.943, SRMR = 0.045). In adjusted models, standardized weights of PHY and PSY on HRQoL in early disease were 0.34 (standard error = 0.06) and 0.24 (0.06) respectively, whereas for late disease they were 0.39 (0.07) and 0.42 (0.07). Importantly, PHY and PSY were significantly correlated in early but not in late disease.

CONCLUSIONS

Our study found health perception is more representative of psychological well-being and less representative of physical function across the disease progression. Greater allocation for psychological health would be the most effective strategy to maximize subjective health status as ALS advances.

Consent Issues in the Management of Acute Ischemic Stroke

This position statement briefly reviews the principle of informed consent, the elements of decisional capacity, and how acute stroke may affect this capacity. It further reviews the role of surrogate decision-making, including advance directives, next of kin, physician orders for life-sustaining treatment, and guardianship. In some cases of acute stroke in which the patient lacks decisional capacity and no advance directives or surrogates are available, consent to treatment may be presumed. The document describes the rationale for this position and various considerations regarding its application to IV thrombolysis, neuroendovascular intervention, decompressive craniectomy, and pediatric stroke. The document also reviews consent issues in acute stroke research.

Changes in PHQ-9 depression scores in acute stroke patients shortly after returning home

Introduction

Post-stroke depression is a disabling condition that occurs in approximately one-third of stroke survivors. There is limited information on changes in depressive symptoms shortly after stroke survivors return home. To identify factors associated with changes in post-stroke depressive symptoms during the early recovery period, we conducted a secondary analysis of patients enrolled in a clinical trial conducted during the transition period shortly after patients returned home (MISTT).

Methods

The Michigan Stroke Transitions Trial (MISTT) tested the efficacy of social worker case management and access to online information to improve patient-reported outcomes following an acute stroke. Patient Health Questionnaire-9 (PHQ-9) scores were collected via telephone interviews conducted at 7 and 90 days post-discharge; higher scores indicate more depressive symptoms. Generalized estimating equations were used to identify independent predictors of baseline PHQ-9 score at 7 days and of changes over time to 90 days.

Results

Of 265 patients, 193 and 185 completed the PHQ-9 survey at 7 and 90 days, respectively. The mean PHQ-9 score was 5.9 at 7 days and 5.1 at 90 days. Older age, being unmarried, and having moderate stroke severity (versus mild) were significantly associated with lower 7-day PHQ-9 scores (indicating fewer depressive symptoms). However, at 90 days, both unmarried patients and those with moderate or high stroke severity had significant increases in depressive symptoms over time.

Conclusions

In stroke patients who recently returned home, both marital status and stroke severity were associated with depressive symptom scores; however, the relationships were complex. Being unmarried and having higher stroke severity was associated with fewer depressive symptoms at baseline, but both factors were associated with worsening depressive symptoms over time. Identifying risk factors for changes in depressive symptoms may help guide effective management strategies during the early recovery period.

Longitudinal validity of self-rated health: the presence and impact of response shift

Objective: This paper aimed to examine the longitudinal validity of self-rated health (SRH) and whether it would be affected by possible changes in evaluation standards (i.e., response shift) over time.Design: Data are from a longitudinal survey of a nationally representative sample in China. Analytical sample was restricted to respondents aged 45 and above (n = 15,893). Individual fixed effects models were used to analyze changes in ratings on health anchoring vignettes and self-rated health over time.Main outcome measures: SRH at two time points with a -two-year span.Results: Both SRH and anchoring vignettes ratings displayed changes over a two-year span for all the studied age groups. Compared with the self-assessed change in health ("How would you rate your health as compared to that of last year?"), changes in SRH reported over time displayed a more stable and optimistic pattern. SRH responded to doctor diagnosed chronic disease and changes in functional limitation, before and after adjusting for evaluation standards.Conclusion: SRH is responsive to the newly diagnosed chronic disease and functional limitation, regardless of whether we consider response shift within the same respondents over time.

Implications of response shift for micro-, meso-, and macro-level healthcare decision-making using results of patient-reported outcome measures

PURPOSE

Results of patient-reported outcome measures (PROMs) are increasingly used to inform healthcare decision-making. Research has shown that response shift can impact PROM results. As part of an international collaboration, our goal is to provide a framework regarding the implications of response shift at the level of patient care (micro), healthcare institute (meso), and healthcare policy (macro).

METHODS

Empirical evidence of response shift that can influence patients' self-reported health and preferences provided the foundation for development of the framework. Measurement validity theory, hermeneutic philosophy, and micro-, meso-, and macro-level healthcare decision-making informed our theoretical analysis.

RESULTS

At the micro-level, patients' self-reported health needs to be interpreted via dialogue with the clinician to avoid misinterpretation of PROM data due to response shift. It is also important to consider the potential impact of response shift on study results, when these are used to support decisions. At the meso-level, individual-level data should be examined for response shift before aggregating PROM data for decision-making related to quality improvement, performance monitoring, and accreditation. At the macro-level, critical reflection on the conceptualization of health is required to know whether response shift needs to be controlled for when PROM data are used to inform healthcare coverage.

CONCLUSION

Given empirical evidence of response shift, there is a critical need for guidelines and knowledge translation to avoid potential misinterpretations of PROM results and consequential biases in decision-making. Our framework with guiding questions provides a structure for developing strategies to address potential impacts of response shift at micro-, meso-, and macro-levels.

Evaluation of the effectiveness of Persian diabetes self-management education in older adults with type 2 diabetes at a diabetes outpatient clinic in Tehran: a pilot randomized control trial

Purpose

The effectiveness of diabetes self-management interventions has been more generally demonstrated in adults, but there is little evidence of diabetes self-management specific to older adults situated in Iran. The purpose of this study was to evaluate the effectiveness of Persian Diabetes Self-Management Education on self-efficacy, quality of life, self-care activity, depression and loneliness in older adults with type 2 diabetes.

Methods

In pilot randomized controlled trial, a total of 34 participants ≥60 years with type 2 diabetes were randomly assigned into intervention (n = 17) and control (n = 17) group in an outpatient diabetes clinic in Tehran. To assess the primary outcome of participant experiences, the Diabetes Management Self-efficacy Scale (DMSES) was the method of measurement. The Diabetes Quality of Life-Basic Clinical Inventory (DQoL-BCI), Patient Health Questionnaire-9 (PHQ-9), Diabetes Self-Management Education Scale (DSMES), and adult Social-Emotional Loneliness Scale Short form (SELSA-S) were used as secondary outcomes. Participants' evaluations were completed at baseline, while measurements were conducted two and four weeks after allocation, using repeated measurements of Univariate and multivariate ANOVA (adjusted for baseline values) to analyze the data.

Results

In the multivariate model, there was a significant difference between the control and intervention groups regarding reported quality of life (p = 0.04) and the medical-domain's reported self-efficacy (p = 0.02). However, there were no significant differences in the reported self-management, depression, loneliness, as well as the other domain of self-efficacy; as compared between the two groups before and after intervention.

Conclusion

The study depicts a promising impact on older adults, imparted by the pertinent program. The finding showed PDSME has a positive effect on quality of life and medical control domain of self-efficacy. This pilot study showed that the program is feasible and duly beneficial if delivered to older adults. This pilot proves appealing to begin further testing within a larger sample population.

Determinants of Health Status After Stroke: A Cohort Study with Repeated Measurements

Background

Knowledge about the long-term course of health following stroke is sparse and relies mainly on studies with short follow-up or few measurements per patient. We aimed to describe the course and analyze the determinants of the course of physical and mental health status after stroke with repeated measurements in a large population-based cohort of first time Danish stroke patients.

Methods

We followed 2,414 first time stroke patients admitted to any hospital in the Central Denmark Region, Denmark, between October 1, 2008 and January 1, 2012, with five questionnaires over a 2 years period. Self-rated health was assessed by the SF-12 instrument. Information on possible clinical and patient-related determinants of self-rated health was obtained from questionnaires and national registers. The scores were analyzed at five selected fixed time-points and as well as longitudinally with mixed models.

Results

The SF-12 mental component summary score (MCS) increased with 0.89 points/year (95% CI=0.6–1.2), while the increase in the physically component summary score (PCS) did not reach statistical significance (0.13/year; 95% CI=−0.2–0.5). The most pronounced changes were seen in the Vitality and Role Physical SF-12 subscales, which both increased by 2.1 points/year. No statistically significant changes over time were found in the Physical Functioning and Bodily Pain subscales. Variables associated with increasing self-rated mental health (MCS) were no comorbidity, older age, male gender, and mild stroke severity. Variables associated with increasing ratings of physical health (PCS) were mild stroke severity, no comorbidity, higher educational level, and younger age. The negative impact of age increased significantly with time during the follow-up period for physical as well as mental health, while the effects of the other variables were stable over time. The results were similar in the two analytical approaches.

Conclusion

In a large, geographically well-defined population of first time stroke patients, the majority of SF-12 sub-scales and the mental component score improved slightly over time. Small improvements in self-rated mental health may be observed during the first 2 years after the stroke. Stroke is a disease with long-term consequences on a wide range of health aspects. Level as well as course differ between sub-groups, and treatment of comorbidity may be an important target with respect to rehabilitation.

US population norms for the EQ-5D-5L and comparison of norms from face-to-face and online samples

Purpose

Normative scores (norms) allow for comparisons between population(s) of interest and the general population, which is useful for burden of disease studies and cost-effectiveness analysis. The primary aim of this study was to estimate US visual analogue scale (EQ VAS) and utility-based norms for the EQ-5D-5L using the face-to-face sample. The secondary aim was to compare norms estimated in the face-to-face and online populations.

Methods

This study estimated population norms from two general population surveys: (a) face-to-face and (b) online. In these surveys, respondents provided their health state using the EQ-5D-5L health classifier and the EQ VAS. Descriptive statistics, including mean, standard deviation (SD), 95% confidence interval, and median for the 5L utility and EQ VAS were estimated for each sample and across relevant respondent characteristics to serve as the basis for US EQ-5D-5L norms

Results

Face-to-face sample respondents (n = 1134) were representative of the US adult general population. In this sample, mean (SD) utility decreased with increasing age until age 45 or greater (age 45–54: 0.816 (0.249) age 55–64: 0.815 (0.243) age 65–74: 0.824 (0.217) age 75 + : 0.811 (0.218)). With increasing age, more problems were reported on all dimensions except anxiety/depression; a smaller proportion of respondents age 65 and older reported problems with anxiety/depression (23.8%) as compared to the youngest respondents (42.1%). Online (n = 2018) mean utility and EQ VAS values were consistently lower than the face-to-face sample.

Conclusions

The availability of US EQ-5D-5L norms facilitates interpretation and understanding of general population and patient health.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02650-y) contains supplementary material, which is available to authorized users.

Making healthcare decisions in a person's best interests when they lack capacity: clinical guidance based on a review of evidence

OBJECTIVE

To clarify the concept of best interests, setting out how they should be ascertained and used to make healthcare decisions for patients who lack the mental capacity to make decisions.

CONTEXT

The legal framework is the Mental Capacity Act (MCA) 2005, which applies to England and Wales.

THEORY

Unless there is a valid and applicable Advance Decision, an appointed decision-maker needs to decide for those without capacity. This may be someone appointed by the patient through a Lasting Power of Attorney, or a Deputy appointed by the court. Otherwise the decision-maker is usually the responsible clinician. Different approaches exist to surrogate decision-making cross-nationally. In England and Wales, decision-making is governed by the MCA 2005, which uses a person-centred, flexible best interests (substituted interests) approach.

OBSERVATIONS

The MCA is often not followed in healthcare settings, despite widespread mandatory training. The possible reasons include its focus on single decisions, when multiple decisions are made daily, the potential time involved and lack of clarity about who is the responsible decision-maker.

SOLUTION

One solution is to decide a strategic policy to cover more significant (usually health-related) decisions and to separate these from day-to-day relational decisions covering care and activities. Once persistent lack of capacity is confirmed, an early meeting should be arranged with family and friends, to start a process of sharing information about the patient's medical condition and their values, wishes, feelings and beliefs with a view to making timely treatment decisions in the patient's best interests.

Testing for response shift in treatment evaluation of change in self-reported psychopathology amongst secondary psychiatric care outpatients

OBJECTIVES

If patients change their perspective due to treatment, this may alter the way they conceptualize, prioritize, or calibrate questionnaire items. These psychological changes, also called "response shifts," may pose a threat to the measurement of therapeutic change in patients. Therefore, it is important to test the occurrence of response shift in patients across their treatment.

METHODS

This study focused on self-reported psychological distress/psychopathology in a naturalistic sample of 206 psychiatric outpatients. Longitudinal measurement invariance tests were computed across treatment in order to detect response shifts.

RESULTS

Compared with before treatment, post-treatment psychopathology scores showed an increase in model fit and factor loading, suggesting that symptoms became more coherently interrelated within their psychopathology domains. Reconceptualization (depression/mood) and reprioritization (somatic and cognitive problems) response shift types were found in several items. We found no recalibration response shift.

CONCLUSION

This study provides further evidence that response shift can occur in adult psychiatric patients across their mental health treatment. Future research is needed to determine whether response shift implies an unwanted potential bias in treatment evaluation or a desired cognitive change intended by treatment.

Discussing edaravone with the ALS patient: an ethical framework from a U.S. perspective

The recent approval of edaravone by the United States Food and Drug Administration has generated a mix of hope tempered by reality. The costs of the drug, both monetarily and with regard to intensity of treatment, are high. The benefits, while modest, will be viewed through a very different lens by individuals depending on their goals of care. By virtue of our training and experience, physicians are ideally suited to understand and explain new treatments to our patients. As healthcare providers with a fiduciary responsibility to our patients, we must make sure they are fully informed about both the costs and benefits of non-curative therapies such as edaravone, and be prepared to discuss these in the context of their goals of care and potential impact on quality of life. Respect for our patients' autonomy is critical when discussing these issues, but we should always be guided by the ethical principles of beneficence and non-maleficence.

Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is characterized by the degeneration of both upper and lower motor neurons, which leads to muscle weakness and eventual paralysis. Until recently, ALS was classified primarily within the neuromuscular domain, although new imaging and neuropathological data have indicated the involvement of the non-motor neuraxis in disease pathology. In most patients, the mechanisms underlying the development of ALS are poorly understood, although a subset of patients have familial disease and harbour mutations in genes that have various roles in neuronal function. Two possible disease-modifying therapies that can slow disease progression are available for ALS, but patient management is largely mediated by symptomatic therapies, such as the use of muscle relaxants for spasticity and speech therapy for dysarthria.

The biopsychosocial model of illness: a model whose time has come

The biopsychosocial model outlined in Engel’s classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel’s call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation’s International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.

Health-related quality of life in stroke patients questionnaire, short version (HRQOLISP-40): validation for its use in Colombia

Background

The health-related quality of life in stroke patients (HRQOLISP-40, short version) survey was developed in Nigeria and constitutes a 40-item, multidimensional, self-administrated questionnaire. We assessed the validity and reliability of the HRQOLISP-40 Spanish version for stroke patients in Colombia.

Methods

The analysis included factor analysis, confirmatory factor analysis, Rasch analysis, convergent validity, internal consistency (261 stroke patients), test-retest reliability (73 patients assessed at two different times) and sensitivity to change (46 patients assessed before and after a rehabilitation intervention).

Results

We found an 8-domain structure. None of the items had a significant impact on the global alpha value in order to be removed. Lin’s concordance correlation coefficient indicated test-retest reliability (Rho IC: 0.76 to 0.95), suggesting an adequate stability of the instrument. Regarding sensitivity to change differences, they were only significant in the psychological and eco-social domains (p <0.05). When comparing SF-36 with HRQOLISP-40, all the correlation coefficients values were significantly different from zero, except those related to vitality. The highest scores were found in the physical and physical functioning domains, with a value of 0.722.

Conclusions

The HRQOLISP-40 scale is valid and reliable for assessing patients’ quality of life after a stroke. Validating quality of life assessment instruments is necessary in order to improve the effectiveness of rehabilitation programs for Colombian stroke patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0770-5) contains supplementary material, which is available to authorized users.

Patient-reported problematic symptoms in an ALS treatment trial

This study was undertaken to determine which symptoms are perceived to be most problematic for patients with ALS and how their severity changes over time. A retrospective study was performed of data from a randomized, double-blind, placebo-controlled trial of ceftriaxone in ALS. Participants completed the ALS Specific Quality of Life Instrument (ALSSQoL) at baseline and at intervals up to 96 weeks. Ten ALSSQoL items ask participants to rate how problematic symptoms are (the subjective feeling of burden of these symptoms), ranging from 0 (no problem) to 10 (tremendous problem). Six are non-bulbar (pain, fatigue, breathing, strength and ability to move, sleep, and bowel and bladder) and four are bulbar (eating, speaking, excessive saliva, and mucus). Results revealed that there were 82 subjects (56% males, mean age 53 ± 10.3 years) with ALSSQoL data for weeks 0 and 96. All 10 symptoms became more problematic over time. For non-bulbar symptoms, strength/ability to move and fatigue were the most problematic. Speaking was the most problematic bulbar symptom. In conclusion, although all the symptoms in the ALSSQoL were acknowledged as problematic, some had greater impact than others. All became more problematic over time. This should help prioritize research into symptom management, and assist individual clinicians in their approach to patient care.

Patient-Perceived Outcomes and Quality of Life in ALS

A variety of outcome measures are used in clinical practice and in research to assess patients with amyotrophic lateral sclerosis (ALS). However, there may be discordance between traditional outcome measures such as strength and physical function, and patient-perceived measures of well-being. One such self-perceived measure, reflecting the patient's view, is quality of life (QOL). QOL in patients with severe medical disorder is often underestimated by others. Patients with ALS often have high QOL, and this may persist throughout the disease due to shifting expectations and to reprioritization of factors contributing to QOL. QOL instruments can measure health-related QOL (HRQOL) or global QOL, and can be generic or disease-specific. HRQOL refers primarily to physical and mental health. Global QOL is much broader, and is also determined by non-health-related factors. The choice of a QOL instrument depends on whether the setting is routine patient care or clinical research, whether or not the outcome of a specific intervention is being assessed, and upon the expected efficacy or toxicity of the intervention. Global QOL instruments are best for individual clinical patient care or for comparing groups. HRQOL or a combination of HRQOL and global QOL instruments are most appropriate for assessing specific interventions.