The adaptations of a quality of life questionnaire for routine use in clinical practice: the Chronic Respiratory Disease Questionnaire in cystic fibrosis

The measurement properties of tests and tools used in cystic fibrosis studies: a systematic review

There is no consensus on how best to measure responses to interventions among children and adults with cystic fibrosis (CF). We have systematically reviewed and summarised the characteristics and measurement properties of tests and tools that have been used to capture outcomes in studies among people with CF, including their reliability, validity and responsiveness. This review is intended to guide researchers when selecting tests or tools for measuring treatment effects in CF trials. A consensus set of these tests and tools could improve consistency in how outcomes are captured and thereby facilitate comparisons and synthesis of evidence across studies.

Health-related quality of life measurement in cystic fibrosis: advances and limitations

Health-related quality of life (HRQoL) measurement in cystic fibrosis (CF) allows the inclusion of the patient's perspective in research and clinical practice. HRQoL scales have been used for many purposes and this review focuses on how HRQoL measurement has been implemented in CF research and care. Specifically, the review considers 1) the instruments used to measure HRQoL, 2) the factors that influence how people report HRQoL, 3) the monitoring of HRQoL in clinical practice, 4) HRQoL as an outcome measure in interventions and clinical trials and 5) whether HRQoL can predict survival. The challenge for the future is to use the available information to develop and evaluate psychological interventions that would be expected to improve HRQoL in children and adults with CF.

Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup

Breathlessness is common in advanced disease and can have a devastating impact on patients and carers. Research on the management of breathlessness is challenging. There are relatively few studies, and many studies are limited by inadequate power or design. This paper represents a consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. The aims of this paper are to facilitate the design of adequately powered multi-centre interventional studies in breathlessness, to suggest a standardised, rational approach to breathlessness research and to aid future 'between study' comparisons. Discussion of the physiology of breathlessness is included.

Validation of the Italian version of the Cystic Fibrosis Quality of Life Questionnaire (CFQoL), a disease specific measure for adults and adolescents with cystic fibrosis

BACKGROUND

Disease specific, health-related quality of life (HRQoL) measurement is important in cystic fibrosis (CF). This work aimed to translate the original English Cystic Fibrosis Quality of Life Questionnaire (CFQoL) into Italian, evaluate the linguistic translation and to psychometrically evaluate the Italian version of the CFQoL.

METHODS

The linguistic translation followed the international guidelines of forward and backward translation. Psychometric evaluation of the Italian CFQoL involved the assessment of construct validity, internal reliability, concurrent validity, known groups validity and test-retest reliability.

RESULTS

The instrument was acceptable to adolescents and adults with CF and demonstrated robust psychometric properties. Principle components analysis indicated that the factorial structure was essentially similar to the original, and the internal reliability of each domain was good (Cronbach alpha coefficients 0.73 to 0.91). Appropriate domains of the CFQoL and SF-36 correlated well indicating good concurrent validity (r=0.68-0.80). Consistent with theoretical expectations some domains were able to discriminate between disease severity groups. Test-retest reliability, assessed by intraclass correlation coefficients, was found to be excellent (ICC 0.83 to 0.98).

CONCLUSIONS

The Italian CFQoL is a valid and reliable measure. Its use in individual patient monitoring and research should complement traditional clinical outcome measures.

Patient-reported outcomes in cystic fibrosis

Over the past 20 years, there has been tremendous progress in the area of patient-reported outcomes (PROs). A PRO instrument is defined as any measure of a patient's health status that is elicited directly from the patient and assesses how the patient "feels or functions with respect to his or her health condition." The advances seen in clinical research regarding PROs has been mirrored in research in cystic fibrosis (CF). A large number of instruments have been used for both therapeutic and nontherapeutic clinical research for many chronic conditions. This review will summarize a history of the development of PROs and how PROs are viewed by the U.S. Food and Drug Administration. We will then review the current state of the art of patient-reported outcomes in CF, specifically addressing the evaluation of different PRO instruments in terms of their reliability and validity. Finally, we will delineate further areas for development of PROs in CF. We believe that the future of CF research will incorporate a more diverse selection of PRO outcome measures; these outcome measures ultimately may be incorporated into clinical care to standardize symptom assessment and provide information regarding the need for specific clinical interventions to improve the quality of care delivered to these patients.

Work disability in adults with cystic fibrosis and its relationship to quality of life

With increasing numbers of cystic fibrosis (CF) patients surviving to adulthood, issues related to vocation inevitably arise and warrant specific attention. We examined the percentage of participants with CF currently working and explored risk factors for work disability among adults with CF.

METHOD

We recruited 50 consecutive patients from an adult cystic fibrosis service. Demographic, employment history, illness severity indicators and CF-attributed work disability factors were evaluated. Demographic risk factors for work disability using the illness severity measures of FEV(1), S-K score, CRDQ, and recent hospitalisation as independent variables were determined.

RESULTS

Factorial analysis of a disability index (DI) indicated no dependency on FEV(1) or S-K score, but dependency on quality of life indices (p<0.05), age (p<0.05) and hospital admission rate (p<0.05). Hours worked per week were dependent on quality of life (p<0.01) (mastery of disease domain), fewer hospital admissions (p<0.01) and age (p<0.05). Sixty-eight percent of the sample reported that CF resulted in significant impediments to employment. However, few had sought vocational guidance (6%).

CONCLUSION

Determinants of workforce participation shows that hours worked and perceived disability are more dependent on mastery of disease, age, and time in hospital, than on clinical severity scores. Health professionals may assist productivity through career counselling or tailored programs.

Which measurement scales should we use to measure breathlessness in palliative care? A systematic review

INTRODUCTION

There is no universally accepted measurement scale to assess breathlessness in adult palliative care patients. This significantly hampers clinical practice and research into effective interventions. The aim is to systematically identify and appraise breathlessness measurement scales, which are validated for use in palliative care or which show potential for use.

METHODS

We undertook systematic searches of electronic databases (Cochrane databases 2005, MEDLINE 1966-2005, OLDMEDLINE 1950-1965, EMBASE 1980-2005, PsycINFO 1872-2005, AMED 1985-2005, CINAHL 1982-2005, SIGLE 1980-2005) with follow-up searches (reference lists of included papers, hand-searches of relevant journals). The basic search strategy was 'breathlessness (etc.) AND measurement (scales, validation etc.) AND palliative care/cardiac failure/respiratory disease/ neoplasm etc.', modified for each database, without language restriction. Patient-based scales with evaluations of at least two psychometric characteristics were included. Exercise-based tests were excluded. Scales were appraised with particular emphasis on construct validity and responsiveness.

RESULTS

We identified 29 scales: six to measure breathlessness severity, four to assess breathlessness descriptions, and 19 to measure functional impact of breathlessness.

SEVERITY

The Numeric Rating Scale (NRS) and modified Borg Scale have been evaluated in COPD (the NRS has also been evaluated in cancer). Both require further assessment of responsiveness and test-retest reliability over time intervals relevant to palliative care. Visual Analogue Scales have also been evaluated, but require larger sample sizes than NRS for evidence of intervention effectiveness.

DESCRIPTIONS

The Japanese Cancer Dyspnoea Scale (CDS) has been evaluated in patients with cancer, but requires further assessment of construct validity and responsiveness. FUNCTIONAL IMPACT: The Chronic Respiratory Questionnaire dyspnoea subscale (CRQ-D) has been evaluated in chronic lung diseases and heart failure; the MND Respiratory Scale is similar. CRQ-D has face and construct validity, test-retest reliability and responsiveness, and shows promise for palliative care.

CONCLUSION

The NRS, modified Borg, CRQ-D and CDS appear most suitable for use in palliative care, but further evaluation is required before adopting any scale as standard. This review has been registered with the Cochrane collaboration and will be published and updated as a Cochrane review.

Clinical and economic choices in the treatment of respiratory infections in cystic fibrosis: Comparing hospital and home care

BACKGROUND

A cost-effectiveness evaluation comparing home-based and hospital-based treatment with intravenous antibiotics for respiratory exacerbations in adults with cystic fibrosis (CF) has not been previously undertaken.

METHODS

The study was conducted in a UK adult CF centre from a health service perspective. Clinical outcome and resource use data were obtained from a retrospective one-year study and combined with unit cost data in an incremental economic analysis. The primary outcome measure was percentage change in FEV(1); "effectiveness" was defined as maintenance of baseline average FEV(1) over the one-year study period.

RESULTS

116 patients received 454 courses of intravenous antibiotics. At the end of 1 year, there had been a mean percentage decline in FEV(1) compared with baseline average for home-treated patients but an improvement for hospital-treated patients (Tukey's HSD mean difference 10.1%, 95% CI 2.9 to 17.2, p = 0.003). Treatment was deemed "effective" in more hospital (58.8%) than home (42.6%) patients. The cost of hospital treatment was higher than home treatment (mean difference 9,005 pounds, 95% CI 3,507 to 14,700, p<0.001). The mean ICER was 46,098 pounds (2.5th and 97.5th percentiles -374,044 and 362,472).

CONCLUSIONS

Hospital treatment was more effective but more expensive than home treatment. Potential methods to improve outcome at home should be considered but these may have resource implications.

Measuring and reporting quality of life outcomes in clinical trials in cystic fibrosis: a critical review

Good quality clinical trials are essential to inform the best cystic fibrosis (CF) management and care, by determining and comparing the effectiveness of new and existing therapies and drug delivery systems. The formal inclusion of quality of life (QoL) as an outcome measure in CF clinical trials is becoming more common. Both an appropriate QoL measure and sound methodology are required in order to draw valid inferences about treatments and QoL. A review was undertaken of randomised controlled trials in cystic fibrosis where QoL was measured. EMBASE, MEDLINE and ISI Web of Science were searched to locate all full papers in the English language reporting randomised controlled trials in cystic fibrosis, published between January 1991 and December 2004. All Cochrane reviews published before December 2004 were hand searched. Papers were included if the authors had reported that they had measured QoL or well being in the trial. 16 trials were identified. The interventions investigated were: antibiotics (4); home versus hospital administration of antibiotics (1); steroids (1); mucolytic therapies (6); exercise (3) and pancreatic enzymes (1). Not one trial evaluated in this review provided conclusive results concerning QoL. This review highlights many of the pitfalls of QoL measurement in CF clinical trials and provides constructive information concerning the design and reporting of trials measuring QoL.

Validation of the Dutch cystic fibrosis questionnaire (CFQ) in adolescents and adults

BACKGROUND

This study assesses the reliability and validity of the Dutch version of a disease-specific measure of health-related quality of life (HRQOL) for adolescents and adults with CF (CFQ-14+). The 47-item CFQ-14+ covers nine domains, three symptom scales and one health perception scale.

METHODS

To assess psychometric characteristics of the CFQ-14+, cross-sectional (homogeneity, discriminative and construct validity) and test-retest designs were used. Eighty-four adolescents and adults with CF (mean age: 21.4 years, range 14.0-46.5 years) and a wide range of lung function (mean FEV1: 59.9% predicted, range 15-121%) completed the questionnaire during a routine visit.

RESULTS

Internal consistency was acceptable for most domains of the CFQ-14+ (alpha = 0.43-0.92) and test-retest reliability was high for all domain scores (0.72-0.98). Several domains of the CFQ-14+ were able to differentiate between individuals with varying disease severity and between nourished and malnourished patients. Construct validity of the questionnaire was fair, with moderate to strong correlation between physically orientated domains and pulmonary function (rs = 0.36-0.62).

CONCLUSION

The results demonstrate that the CFQ-14+ questionnaire is a well-validated measure of HRQOL assessment in adolescents and adults with CF.

Quality of life in children and adolescents with cystic fibrosis: implications for optimizing treatments and clinical trial design

Health related quality of life (QOL) as an outcome measure in clinical trials is becoming increasingly important. Trials should not only be able to demonstrate the pharmacologic activity of a therapy, but of equal importance, they should demonstrate clinical effectiveness that is of significant benefit to the patient. QOL measurement provides a way of incorporating the child/parent's perspective of how cystic fibrosis (CF) and its therapies impact on their lives. Several validated generic instruments have been employed to measure QOL in adolescents and adults. QOL assessment is more difficult in children and, therefore, has been employed less often in children with CF. Difficulties arise with the issue of whether children can report their own experiences directly, or whether a parent or clinician should report on behalf of the child. A child-centered approach is imperative since the literature indicates that children are able to report on their own QOL. An additional complication has been the use of adult measures with children. These are often inappropriate in their complexity, use of language, response scales, and time frame. The evaluation of pharmacologic therapies can profit from QOL measurement. The effectiveness of a drug and any adverse effects that impact on daily life can be assessed from the child/parent's viewpoint. Home therapy versus hospital therapy and drug delivery systems, are additional areas where QOL as an outcome measure is valuable. There have been relatively few appropriately powered trials in CF, and only a minority of these have evaluated QOL as an outcome measure. This review highlights areas where QOL measurement is appropriate. It focuses on the pharmacologic trials that have employed QOL assessment for antibiotic, mucociliary clearance, anti-inflammatory, and nutritional therapies. Methodological issues of incorporating QOL assessment into trials center on cross-cultural and data interpretation issues. QOL measurement in CF has been patchy and largely unreliable. The notion that improved symptoms equate with improved QOL is erroneous. Measurement of how symptoms impact on QOL is essential. Currently, the development and validation of CF specific measures (across the CF age range) provides optimism for appropriate QOL measurement in clinical trials, and for future meta-analysis and systematic reviews.

Questions on life satisfaction for adolescents and adults with cystic fibrosis: development of a disease-specific questionnaire

STUDY OBJECTIVES

The development and psychometric properties of an additional disease-specific module of the Questions on Life Satisfaction for adolescents and adults with cystic fibrosis (FLZ(M)-CF) are described. The Questions on Life Satisfaction (FLZ(M)) instrument allows the respondent to rate the subjective importance and her/his satisfaction with different domains of life.

METHODS

A preliminary 16-item version of the scale was employed in a study with 243 German patients with cystic fibrosis (CF) [16 to 58 years of age; FEV(1), 15 to 121% of predicted], together with the "general life satisfaction" module and the "satisfaction with health" module of the FLZ(M). Item elimination according to the principle of least common variance resulted in the final nine-item version.

RESULTS

Cronbach alpha for the FLZ(M)-CF was 0.80; the split-half reliability was 0.72. Convergent validity of the scale was indicated by Pearson correlations of r = 0.75 with the generic satisfaction with health scale of the FLZ(M), r = 0.30 with FEV(1)%, and r = - 0.26 with daily time for home therapy. The scale discriminated significantly between patients with and without need for assistance in daily life and between patients with and without a partner.

CONCLUSIONS

The FLZ(M)-CF is a reliable and valid instrument, and it is short enough to be used as screening instrument. The combination of generic and disease-specific scales within the FLZ(M) allows comprehensive measurement of life satisfaction for patients with CF who are > 15 years old.

Effect of long term treatment with azithromycin on disease parameters in cystic fibrosis: a randomised trial

BACKGROUND

Relentless chronic pulmonary inflammation is the major contributor to morbidity and mortality in patients with cystic fibrosis (CF). While immunomodulating therapies such as prednisolone and ibuprofen may be beneficial, their use is limited by side effects. Macrolides have immunomodulatory properties and long term use dramatically improves prognosis in diffuse panbronchiolitis, a condition with features in common with the lung disease of CF.

METHODS

To determine if azithromycin (AZM) improves clinical parameters and reduces inflammation in patients with CF, a 3 month prospective randomised double blind, placebo controlled study of AZM (250 mg/day) was undertaken in adults with CF. Monthly assessment included lung function, weight, and quality of life (QOL). Blood and sputum collection assessed systemic inflammation and changes in bacterial flora. Respiratory exacerbations were treated according to the policy of the CF Unit.

RESULTS

Sixty patients were recruited (29 men) of mean (SD) age 27.9 (6.5) years and initial forced expiratory volume in 1 second (FEV1) 56.6 (22.3)% predicted. FEV1% and forced vital capacity (FVC)% predicted were maintained in the AZM group while in the placebo group there was a mean (SE) decline of -3.62 (1.78)% (p=0.047) and -5.73 (1.66)% (p=0.001), respectively. Fewer courses of intravenous antibiotics were used in patients on AZM (0.37 v 1.13, p=0.016). Median C reactive protein (CRP) levels declined in the AZM group from 10 to 5.4 mg/ml but remained constant in the placebo group (p<0.001). QOL improved over time in patients on AZM and remained unchanged in those on placebo (p=0.035).

CONCLUSION

AZM in adults with CF significantly improved QOL, reduced CRP levels and the number of respiratory exacerbations, and reduced the rate of decline in lung function. Long term AZM may have a significant impact on morbidity and mortality in patients with CF. Further studies are required to define frequency of dosing and duration of benefit.

Distinct patient groups in oral cancer: a prospective study of perceived health status following primary surgery

Health-related quality of life (HRQOL) is an important consideration in the management of patients with cancer. Pre-treatment data can give an indication of the anticipated response following cancer treatment. However, in order to use HRQOL data meaningfully it is essential to have an appreciation of how different patient groups respond. The aim of the study was to identify distinct patient groups at baseline using the University of Washington head and neck cancer questionnaire (UW-QOL). It was also the intention to see how these groups differed in their: (1) clinical and demographic attributes; (2) European Organisation for Research and Treatment of Cancer (EORTC) C30 and SF 36 scores; and (3) longitudinal trends over 6 and 12 months. One-hundred and thirty consecutive patients with previously untreated oral and oro-pharyngeal cancer were recruited. All were treated by primary surgery. Attrition was evident in the study but care was taken to allow for this. There were two distinct groups of patients identified by the cumulative UW-QOL score at presentation. These groups discriminated throughout the EORTC C30 and SF 36, at baseline and longitudinally, with the exception of mental health. This study demonstrates that HRQOL items are interrelated. There are difficulties in using baseline scores for treatment selection, and scores need to be interpreted in the light of clinical and demographic factors.