Development and validation of the Asthma Life Impact Scale (ALIS)

Generating Items for Measuring Needs-Based Quality of Life and Self-Perceived Health Inequity in Patients with Multimorbidity: Development of the MultiMorbidity Questionnaire (MMQ)

Purpose

To describe the processes of developing domains and items for the MultiMorbidity Questionnaire (MMQ), a multimorbidity-specific PROM for the assessment of Needs-based QoL.

Patients and Methods

We developed items and domains for the MMQ through 17 qualitative content validity questionnaire interviews with adults with multimorbidity by testing items from an item bank (covering items with content inspired by existing Needs-based QoL measures for single diseases). The interviews alternated between an explorative part and more focused cognitive interview techniques.

Results

Testing the 47 items from the first draft of the MMQ items showed that the Needs-based approach as a framework did not cover all the QoL aspects our informants stated as being important. Therefore, the conceptual framework was supplemented by Self-perceived health inequity, and new items were generated. MMQ, measuring Needs-based QoL (MMQ1) and Self-perceived health inequity (MMQ2), was assembled. MMQ1 covers the domains: "Physical ability" (10 items), "Limitations in everyday life" (15 items), "Worries" (11 items), "My social life" (11 items), "Self-image" (12 items), and "Personal finances" (2 items). Self-perceived health inequity proved to be a relevant framework for other aspects of QoL not covered by the Needs-based approach to QoL. MMQ2 covers the domains: "Experiences of being stigmatized" (five items), "Experiences of not being seen and heard" (four items), "Insufficient understanding of the burden of disease" (three items) and "Experiences of feeling powerless" (five items).

Conclusion

We have developed the final MMQ draft, a multimorbidity-specific PROM for the assessment of Needs-based QoL (MMQ1) and Self-perceived health inequity (MMQ2) with high content validity (regarding content relevance and comprehensiveness). The final MMQ draft will be assessed for its psychometric properties using Modern Test Theory.

Fundamental Measurement: The Need Fulfilment Quality of Life (N-QOL) Measure

The quality adjusted life year (QALY) has serious problems related to its failure to adhere to measurement theory. If a QALY is to be meaningful, the utility score that translates time spent to an equivalent time spent in so-called perfect health must have ratio properties (i.e., it must support multiplication). Multiattribute utility scores (e.g. those generated by the EQ-5D-5L) fail to meet this standard. The multiattribute instruments produce ordinal scores that lack a true zero and they generate negative values. The manifest deficiencies of multiattribute utility instruments render them unfit, not only as a measure of therapy response but also in generating QALY claims. After 30 years of belief in their use, utilities and QALYs are clearly analytical dead ends.

The purpose of this commentary is to demonstrate a coherent way forward in health technology assessment by focusing, not on clinical attributes as surrogates for quality of life, but on measures that are based on a conceptual model describing patient value in terms of need-fulfilment. Building on an extensive, yet often overlooked literature, need-based measures that fit Rasch Measurement Theory criteria are converted from ordinal scores to interval scores to evaluate response to therapy. These measures meet the requirements of single attribute fundamental measurement which is the standard in the physical sciences. It is proposed that a translation from a Rasch interval scale (defined by logits) can be transformed to a bounded ratio scale. Need based Quality of Life (N-QOL) scales bounded by 0 (where no needs are fulfilled) to 1 (where all needs are fulfilled) form such scales. The N-QOL supports the full range of arithmetic operations. Multiattribute utilities and mathematically invalid QALYs can be put to one side as unfortunate historical curiosities in favor of a disease or target population specific N-QOL scale. Such a scale has the required properties to evaluate disease specific response to therapy This can also support N-QOL adjusted life years with a need- fulfillment life year (NALY) metric with ratio properties.

A structured review evaluating content validity of the Asthma Control Test, and its consistency with U.S. guidelines and patient expectations for asthma control

OBJECTIVE

To assess whether the content of the Asthma Control Test (ACT) served as a valid measure of asthma control (i.e., content validity) by mapping ACT items to the National Heart, Lung and Blood Institute (NHLBI) guideline asthma control definitions, and to language used by patients to describe their asthma.

DATA SOURCES

PubMed and EMBASE databases were used for a structured literature analysis.

STUDY SELECTIONS

Full-text, English-language articles that reported findings from qualitative studies conducted in adults, focusing on patient descriptors of asthma symptoms, impacts, or severity, were included. Pediatric studies, studies conducted in patients without asthma, and studies that did not contain qualitative data were excluded.

RESULTS

ACT items reflected all domains of asthma impairment described in the NHLBI guidelines, except pulmonary function. Following the literature review, 28 full-text publications were identified that included patient descriptors that could be mapped to ACT items. For example, per ACT Item 1, patients described having trouble at work, school, and completing household chores; and, per ACT Item 2, patients used the phrase "short of breath" to describe asthma-associated symptoms.

CONCLUSION

ACT item content corresponded well with the NHLBI guideline definitions of the impairment domain of asthma control (focused on asthma symptoms and impact), and we identified numerous examples in the literature indicating that ACT concepts and item content mirror the language patients use when discussing asthma symptoms and impact, and their degree of asthma control. This provides further evidence to support content validity of the ACT as a measure of asthma control.

The Patient Needs in Asthma Treatment (NEAT) questionnaire: Further evidence on its psychometric properties

BACKGROUND

Building on previous psychometric work, we sought to assess the Patient Needs in Asthma Treatment (NEAT) questionnaire's validity, responsiveness to change, and the minimal important change (MIC) over a 3-year period (Study 1) and its reliability and the smallest detectable change (SDC) in a test-retest study (Study 2) among patients self-reporting physician-diagnosed asthma.

METHODS

In Study 1, a total of 207 patients completed a survey which included the NEAT, the Asthma Control Test (ACT), the Asthma Quality of Life Questionnaire-Sydney (AQLQ-S), and a question on treatment satisfaction in 2014 and 2017. In Study 2, a total of 78 patients completed NEAT twice on average four weeks apart in 2018.

RESULTS

Concurrent validity: In linear regressions, unmet patient needs were cross-sectionally associated with poorer asthma control (β = -0.21; P = 0.01), asthma-related quality of life (QoL) (β = 0.31; P < 0.01), and treatment satisfaction (β = -0.59; P < 0.01). Predictive Validity: Higher unmet needs at baseline predicted worse treatment satisfaction at follow-up (β = -0.28; P < 0.01), but neither asthma control nor asthma-related QoL. Responsiveness to change was demonstrated by linear regressions of changes in the total NEAT score and changes in AQLQ-S (β = 0.21; P < 0.01) and treatment satisfaction (β = -0.36; P < 0.01). MIC: Patients whose NEAT score increased between baseline and follow-up by the identified MIC (0.301) reported lower treatment satisfaction at follow-up (β = -0.17; P = 0.01). Test-retest reliability was demonstrated by correlations between NEAT baseline and follow-up scores (eg, intra-class correlation coefficients for total score = 0.78). The SDC (0.384) was slightly larger than MIC.

CONCLUSION

NEAT is a promising tool for assessing asthma treatment needs.

Measurement of patient-reported outcomes. 2: Are current measures failing us?

All instruments designed to measure latent (unobservable) variables, such as patient-reported outcomes (PROs), have three major requirements; a coherent construct theory, a specification equation, and the application of an appropriate response model. The theory guides the selection of content for the questionnaire and the specification equation links the construct theory to scores produced with the instrument. For the specification equation to perform this role, the patient-reported outcome measure (PROM) must employ a response model that generates values for its individual items. The most commonly applied response model in PROM development is the Rasch model. To date this level of measurement sophistication has not been achieved in PRO measurement. Consequently, it is not possible to establish a PROM's true construct validity. However, the development of the Lexile Framework for Reading has demonstrated that such objective measurement is possible for latent variables. This article argues that higher quality PROM development is needed if meaningful and valid PRO measurement is to be achieved. It describes the current state of PROM development, shows that published reviews of PROMs adopt inappropriate criteria for judging their quality, and illustrates how the use of traditional PROMs can lead to incorrect (and possibly dangerous) conclusions being drawn about the efficacy of interventions.

[Evaluation of permanent disability levels in occupational pulmonary diseases]

Compensation for occupational pulmonary diseases requires the establishment of guidelines based on standardized and objective criteria, in order to provide compensation that is as fair as possible to patients who suffer from them. A review of the elements necessary for the examination of an individual file was carried out by a working group. It is accepted that respiratory functional exploration is the key element in assessing the level of permanent disability in all of these conditions, with the exception of thoracic malignancies. Guiding scales have been developed for the respiratory impairment of three types of conditions: occupational asthma, thoracic malignancy, and other respiratory diseases. Additional criteria for increasing the permanent disability level are also proposed in order to take into account professional prejudice, in particular the possibility or not of continuing the occupational activity, in the same job or after changing to another. For certain respiratory diseases, a periodic reassessment of the initially attributed permanent disability level is recommended as well as the initial one at the time of definitive cessation of occupational activity.

CHF-PROM: validation of a patient-reported outcome measure for patients with chronic heart failure

BACKGROUND

Due to a lack of an appropriate disease-specific patient-reported outcome (PRO) instrument for chronic heart failure including its social support and treatment aspects in China, this study was performed to develop a patient-reported outcome measure (PROM) for patients with chronic heart failure and evaluate its reliability, validity, and feasibility.

METHODS

According to the standard PROM guidelines established by the Food and Drug Administration, an item pool was formed by reviewing a large amount of relevant literature and interviewing patients with chronic heart failure about their main symptoms. Thus, the primary scale was created after adjusting the items and language with the help of patients and experts in the field. Next, 155 patients from 8 hospitals in different districts were recruited for a pilot survey using questionnaires containing these items. The patients' responses were analyzed using the classical test theory and item response theory to select high-quality items and determine the subdomains of the scale. This was followed by a formal investigation in the same eight hospitals. In total, 360 patients and 100 healthy subjects were included to evaluate the reliability, validity, and feasibility of the items. Through this process, the final scale was established.

RESULTS

The final scale comprised 12 subdomains with 57 items related to physical, psychological, social, and therapeutic areas. The data analysis results of the formal investigation showed that the PROM for chronic heart failure had good reliability, validity, and feasibility. Reliability was verified by Cronbach's alpha coefficient, which was 0.913 for the total scale, 0.903 for the physical domain, 0.941 for the psychological domain, 0.827 for the social domain, and 0.839 for the therapeutic domain. The construct validity results met the relative criteria of confirmatory factor analysis. Discriminant validity was represented by score comparisons of nine subdomains. The response rate and the effective rate of return of the CHF-PROM were 98.94% and 98.92%, respectively.

CONCLUSIONS

The final scale coincides with the theoretical framework and better reflects the overall quality of life of patients with chronic heart failure. This scale can be used as a valid instrument to evaluate clinical treatment and clinical trials of chronic heart failure.

BC-PROM: validation of a patient-reported outcomes measure for patients with breast cancer

Key issues of treatment for patients with breast cancer such as patient satisfaction with treatments, compliance, and some side effects are essential for evaluating quality of life by patient-reported outcomes in clinical trials. The study aimed to develop and evaluate a specific patient-reported measure which included physical, psychological, social, and therapeutic domain for assessing the survival of patients with breast cancer.The pool of items was drafted after a theoretical revision and cognitive interviews with women with breast cancer. The draft scale was formed after the adjustment of the items and dimensions, and the selected items were submitted to expert's judgments. Five statistical methods were used to select these items by 2 validation samples. The final scale was administered to a sample of 417 patients from 8 hospitals and 135 controls for reliability, validity, and responsive analyses.The final BC-PROM consisted of 52 items, 13 subdomains, and 4 domains, being developed after preexamination and formal examination. Cronbach alpha coefficient was 0.902 and 0.712 for the full scale and therapeutic domain. The structural validity results showed that the multidimensional measurement of the scale fulfilled expectations. Differences in the BC-PROM mean scores were significant between cancer patients and healthy participants in 13 subdomains (P < .05), indicating good responsiveness. Among the sample survey of patients, the scale copy acceptance rate was 98.2%, completion rate 94.6%, and average filling time 10 minutes.The new and reliable BC-PROM was developed in patients with breast cancer and applied to clinical treatment evaluation and clinical trials for such patients.

Co-calibrating quality-of-life scores from three pulmonary disorders: implications for comparative-effectiveness research

Background Efficient use of health resources requires accurate outcome assessment. Disease-specific patient-reported outcome (PRO) measures are designed to be highly relevant to patients with a specific disease. They have advantages over generic PROs that lack relevance to patient groups and miss crucial impacts of illness. It is thought that disease-specific measurement cannot be used in comparative effectiveness research (CER). The present study provides further evidence of the value of disease-specific measures in making valid comparisons across diseases. Methods The Asthma Life Impact Scale (ALIS, 22 items), Living with Chronic Obstructive Pulmonary Disease (LCOPD, 22 items) scale, and Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR, 25 items) were completed by 140, 162, and 91 patients, respectively. The three samples were analyzed for fit to the Rasch model, then combined into a scale consisting of 58 unique items and re-analyzed. Raw scores on the three measures were co-calibrated and a transformation table produced. Results The scales fit the Rasch model individually (ALIS Chi(2) probability value (p-Chi(2)) = 0.05; LCOPD p-Chi(2 )=( )0.38; CAMPHOR p-Chi(2 )=( )0.92). The combined data also fit the Rasch model (p-Chi(2 )=( )0.22). There was no differential item functioning related to age, gender, or disease. The co-calibrated scales successfully distinguished between perceived severity groups (p < 0.001). Limitations The samples were drawn from different sources. For scales to be co-calibrated using a common item design, they must be based on the same theoretical construct, be unidimensional, and have overlapping items. Conclusions The results showed that it is possible to co-calibrate scores from disease-specific PRO measures. This will permit more accurate and sensitive outcome measurement to be incorporated into CER. The co-calibration of needs-based disease-specific measures allows the calculation of γ scores that can be used to compare directly the impact of any type of interventions on any diseases included in the co-calibration.

Patients' needs in asthma treatment: development and initial validation of the NEAT questionnaire

OBJECTIVE

We aimed to develop and tentatively validate an instrument assessing patients' needs related to asthma treatment.

METHODS

Patients were recruited through various approaches (e.g. physicians, pharmacies and patient organizations). Utilizing a mixed methods design, we first conducted five focus groups to explore needs among patients. Next, we devised an item pool which was revised, reduced and evaluated by patients. Finally, data from a survey (n = 362) were used to further reduce the item pool and to examine the questionnaire's psychometric properties and validity.

RESULTS

Four broad needs categories emerged from the focus groups: (1) information needs; (2) consideration of patient views in diagnosis; (3) consideration of patient views in treatment planning; and (4) addressing patients' fears. We devised 45 items, which were reduced to 22 items based on patient feedback. The survey data suggested a 13-item scale with four subscales ("patient expertise", "drug effects", "handling drugs" and "exacerbations"). Cronbach's alpha was acceptable for those subscales (>0.7) and for the total score (0.9). Increasing scores on subscales and the total score (implying more unmet needs) showed close and consistent associations with poor asthma control, reduced quality of life and low treatment satisfaction.

CONCLUSIONS

The development process of the Needs in Asthma Treatment (NEAT) questionnaire ensured that needs of asthma patient are captured with high validity. The NEAT questionnaire has been shown to be valid, thereby representing a promising tool for research and delivery of patient-centered care.

Residential hazards, high asthma prevalence and multimorbidity among children in Saginaw, Michigan

OBJECTIVES

Comorbidities complicate our understanding of childhood asthma and its risk factors. This study examined the relationships between asthma, self-reported burden of disease symptoms and residential hazards in a representative sample of households in Saginaw, Michigan.

STUDY DESIGN

A population-based cross-sectional survey.

METHOD

The study involved 643 households randomly selected from the City of Saginaw (Michigan) with children 12 years of age or younger or pregnant woman. The survey was completed using random digit dialing, Computer-Assisted Telephone Interviewing (CATI) method. The audit instrument for residential hazards developed for the study was used to gather information on 71 household hazards organized in eight scales (dimensions): structural scale, moisture/mold scale, electrical scale, ventilation and combustion appliances scale, pest scale, pets scale, fire scale, and lifestyle-associated factors scale. The data were used to calculate an aggregate score of the household hazard index (HHI) for each housing unit. We also collected information on 43 symptoms of diseases likely to be associated with exposure to residential hazards as well as the demographic characteristics for each household.

RESULTS

Asthma prevalence rate among the 1206 children was 18.9% with 27.7% of households reporting at least one asthmatic child. The prevalence of health hazards in households of Saginaw was pervasively high with the rate for each of 29 hazards being over 30%. The HHI was found to be a good predictor of health outcomes in homes; the following linear regression equation describes the relationship between childhood asthma and the scores for individual scales of HHI: Number of Asthmatic Children=0.009(Structural)+0.004(Mold) +0 .019(Pests)-0.023(Pets)-0.029(Fire); (r(2)=0.054; p-value<0.001). Children who were living in housing units classified as high risk (top 25% of the HHI score) were found to be disproportionately afflicted with asthma, allergic reaction and burden of symptoms compared to children who lived in low-risk homes. Average number of symptoms in the households was 14±10 and the top 25% of the households had over 26 symptoms. Asthma was associated (comorbid) with each of the 40 symptoms (out of the 43) in the inventory scale, and the HHI was found to be a good predictor of the symptom burden (total count of symptoms) in participating households.

CONCLUSIONS

Recognition of the large extent of comorbidity in asthmatic children has implications for the way in which this disease should be treated or managed. In addition, the study of comorbidity between asthma and related risk factors may be important in understanding complex exposure-disease relationships which could lead to more effective interventions.

Asthma outcome measures

Asthma is a common chronic disease with underlying inflammation of the airway. Advances in science have led to increased understanding of the heterogeneous nature of asthma and its complex mechanisms. Traditionally, asthma-practice guidelines have focused on optimizing lung function and the US FDA has required increases in lung function and reduction of exacerbation as primary outcomes in clinical trials of new asthma therapeutics. Improved lung function is a critical indicator of bronchodilator therapy, but the importance of long-term asthma control while maintained on controller medication is increasingly emphasized. The NIH asthma guidelines suggest the use of patient-reported outcomes, including health-related quality-of-life measures, to assess asthma control. Clinical practices and research studies concerning asthma can benefit from harmonizing the major outcome measures so that comparisons across studies can be made. In this article, we review common asthma outcome measures with a focus on recent efforts to harmonize outcomes for therapeutic clinical trials in asthma.

Adapting the Asthma Life Impact Scale (ALIS) for use in Southern European (Italian) and Eastern European (Russian) cultures

BACKGROUND

The Asthma Life Impact Scale (ALIS) is a disease-specific measure used to assess the quality-of-life of people with asthma. It was developed in the UK and US and has proven to be acceptable to patients, to have good psychometric properties, and to be unidimensional.

OBJECTIVE

This paper reports on the adaptation and validation of the ALIS for use in representative Southern European (Italian) and Eastern European (Russian) languages.

METHODS

The ALIS was translated for both cultures using the dual-panel process. The newly translated versions were then tested with asthma patients to ensure face and content validity. Psychometric properties of the new language versions were assessed via a test?re-test postal survey conducted in both countries.

LIMITATIONS

It is possible that some cultural or language differences still exist between the different language versions. Further research should be undertaken to determine responsiveness. Further studies designed to determine the clinical validity of the Italian ALIS would be valuable.

RESULTS

Linguistic nuances were easily resolved during the translation process for both language adaptations. Cognitive debriefing interviews (Russia n=9, male=11.1%, age mean (SD)=55.4 (13.2); Italy n=15, male=66.7%, age mean (SD)=63.5 (11.2)) indicated that the ALIS was easy to read and acceptable to patients. Psychometric testing was conducted on the data (Russia n=61, age mean (SD)=40.7 (15.4); Italy n=71, male=42.6%, age mean (SD)=49.5 (14.1)). The results showed that the new versions of the ALIS were consistent (Russian and Italian Cronbach's alpha=0.92) and reproducible (Russian test-re-test=0.86; Italian test-re-test=0.94). The Italian adaptation showed the expected correlations with the NHP and the Russian adaptation showed strong correlations with the CASIS and CAFS and weak-to-moderate correlations with %FEV1 and %PEF. In both adaptations the ALIS was able to distinguish between participants based on self-reported general health, self-reported severity, and whether or not they were hospitalized in the previous week.