Performance of a self-administered mailed version of the Quality of Well-Being (QWB-SA) questionnaire among older adults

Post-Traumatic Osteoarthritis, Psychological Health, and Quality of Life After Lower Limb Injury in U.S. Service Members

INTRODUCTION

The aims of this project were to assess (1) the prevalence and timing of post-traumatic osteoarthritis (PTOA) after a traumatic lower limb injury, (2) the risk of PTOA based on injury type, and (3) the association of PTOA with psychological health and quality of life (QoL).

MATERIALS AND METHODS

The Wounded Warrior Recovery Project (WWRP) database and the Expeditionary Medical Encounters Dataset were queried to identify service members injured during deployment. The Military Health System Data Repository was utilized to extract medical record data to identify individuals with PTOA. Data on PTSD, depression symptoms, and QoL were extracted from the WWRP.

RESULTS

Of the 2,061 WWRP participants with lower limb injuries, 124 (6%) were diagnosed with PTOA, with first PTOA diagnosis occurring 3.8 ± 3.1 years after injury. Of the injury categories identified, only fractures were associated with high odds of lower limb PTOA (adjusted odds ratio [OR] = 3.92, 95% confidence interval [CI]: 2.38, 6.44). Individuals with PTOA diagnoses reported lower QoL scores relative to those without PTOA (F(1,2057) = 14.21, B = -0.05, P < .05). Additionally, rates of PTSD and depression symptoms were high but not different between those with or without PTOA.

CONCLUSIONS

Despite a low prevalence of lower limb PTOA in our study, fractures increased the risk of PTOA after deployment-related injuries. Additionally, those with PTOA reported lower QoL scores relative to those without PTOA. The findings of this study highlight the personalized needs of patients with trauma beyond just the repair of the immediate injury.

Readability analysis and concept mapping of PROMs used for headache disorders

OBJECTIVE

To assess the readability and the comprehensiveness of patient-reported outcome measures (PROMs) utilized in primary headache disorders literature.

BACKGROUND

As the health-care landscape has evolved toward a patient-centric model, numerous PROMs have been developed to capture treatment outcomes in patients with headache disorders. For these PROMs to advance our understanding of headache disorders and their treatment impact, they must be easy to understand (i.e., reading grade level 6 or less) and comprehensively capture what matters to patients with headache. The aim of this study was to (a) assess the readability of PROMs utilized in headache disorders literature, and (b) assess the comprehensiveness of PROMs by mapping their content to a health-related quality of life framework.

METHODS

In this scoping review, recently published systematic reviews were used to identify PROMs used in primary headache disorders literature. Readability analysis was performed at the level of individual items and full PROM using established readability metrics. The content of the PROMs was mapped against a health-related quality-of-life framework by two independent reviewers.

RESULTS

In total, 22 PROMs (15 headache disorders related, 7 generic) were included. The median reading grade level varied between 7.1 (interquartile range [IQR] 6.3-7.8) and 12.7 (IQR 11.8-13.2). None of the PROMs were below the recommended reading grade level for patient-facing material (grade 6). Three PROMs, the Migraine-Treatment Assessment Questionnaire, the Eurolight, and the European Quality of Life 5 Dimensions 3 Level Version, were between reading grade levels 7 and 8; the remaining 19 PROMs were above reading grade level 8. In total, the PROMs included 425 items. Most items (n = 134, 32%) assessed physical function (e.g., work, activities of daily living). The remaining items assessed physical symptoms (n = 127, 30%; e.g., pain, nausea), treatment effects on symptoms (n = 65, 15%; e.g., accompanying symptoms relief, headache relief), treatment impact (n = 56, 13%; e.g., function, side effects), psychological well-being (n = 41, 10%; e.g., anger, frustration), social well-being (n = 29, 7%; e.g., missing out on social activities, relationships), psychological impact (n = 14, 3%; e.g., feeling [not] in control, feeling like a burden), and sexual well-being (n = 3, 1%; e.g., sexual activity, sexual interest). Some of the items pertained to treatment (n = 27, 6%), of which most were about treatment type and use (n = 12, 3%; e.g., medication, botulinum toxin), treatment access (n = 10, 2%; e.g., health-care utilization, cost of medication), and treatment experience (n = 9, 2%; e.g., treatment satisfaction, confidence in treatment).

CONCLUSION

The PROMs used in studies of headache disorders may be challenging for some patients to understand, leading to inaccurate or missing data. Furthermore, no available PROM comprehensively measures the health-related quality-of-life impact of headache disorders or their treatment, resulting in a limited understanding of patient-reported outcomes. The development of an easy-to-understand, comprehensive, and validated headache disorders-specific PROM is warranted.

A group-based exercise and behavioural maintenance intervention for adults over 65 years with mobility limitations: the REACT RCT

Background

Mobility limitation in older age reduces quality of life, generates substantial health- and social-care costs, and increases mortality.

Objective

The REtirement in ACTion (REACT) trial aimed to establish whether or not a community-based active ageing intervention could prevent decline in physical functioning in older adults already at increased risk of mobility limitation.

Design

A multicentre, pragmatic, two-arm, parallel-group randomised controlled trial with parallel process and health economic evaluations.

Setting

Urban and semi-rural locations across three sites in England.

Participants

Physically frail or pre-frail older adults (aged ≥ 65 years; Short Physical Performance Battery score of 4–9). Recruitment was primarily via 35 primary care practices.

Interventions

Participants were randomly assigned to receive brief advice (three healthy ageing education sessions) or a 12-month, group-based, multimodal exercise and behavioural maintenance programme delivered in fitness and community centres. Randomisation was stratified by site and used a minimisation algorithm to balance age, sex and Short Physical Performance Battery score. Data collection and analyses were blinded.

Main outcome measures

The primary outcome was change in lower limb physical function (Short Physical Performance Battery score) at 24 months, analysed using an intention-to-treat analysis. The economic evaluation adopted the NHS and Personal Social Services perspective.

Results

Between June 2016 and October 2017, 777 participants (mean age 77.6 years, standard deviation 6.8 years; 66% female; mean Short Physical Performance Battery score 7.37, standard deviation 1.56) were randomised to the intervention arm (n = 410) or the control arm (n = 367). Data collection was completed in October 2019. Primary outcome data at 24 months were provided by 628 (80.8%) participants. At the 24-month follow-up, the Short Physical Performance Battery score was significantly greater in the intervention arm (mean 8.08, standard deviation 2.87) than in the control arm (mean 7.59, standard deviation 2.61), with an adjusted mean difference of 0.49 (95% confidence interval 0.06 to 0.92). The difference in lower limb function between intervention and control participants was clinically meaningful at both 12 and 24 months. Self-reported physical activity significantly increased in the intervention arm compared with the control arm, but this change was not observed in device-based physical activity data collected during the trial. One adverse event was related to the intervention. Attrition rates were low (19% at 24 months) and adherence was high. Engagement with the REACT intervention was associated with positive changes in exercise competence, relatedness and enjoyment and perceived physical, social and mental well-being benefits. The intervention plus usual care was cost-effective compared with care alone over the 2 years of REACT; the price year was 2019. In the base-case scenario, the intervention saved £103 per participant, with a quality-adjusted life-year gain of 0.04 (95% confidence interval 0.006 to 0.074) within the 2-year trial window. Lifetime horizon modelling estimated that further cost savings and quality-adjusted life-year gains were accrued up to 15 years post randomisation.

Conclusion

A relatively low-resource, 1-year multimodal exercise and behavioural maintenance intervention can help older adults to retain physical functioning over a 24-month period. The results indicate that the well-established trajectory of declining physical functioning in older age is modifiable.

Limitations

Participants were not blinded to study arm allocation. However, the primary outcome was independently assessed by blinded data collectors. The secondary outcome analyses were exploratory, with no adjustment for multiple testing, and should be interpreted accordingly.

Future work

Following refinements guided by the process evaluation findings, the REACT intervention is suitable for large-scale implementation. Further research will optimise implementation of REACT at scale.

Trial registration

This trial is registered as ISRCTN45627165.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 14. See the NIHR Journals Library website for further project information.

Do Generic Preference-Based Measures Accurately Capture Areas of Health-Related Quality of Life Important to Individuals with Amyotrophic Lateral Sclerosis: A Content Validation Study

Objective

The objectives of this study were to 1) assess the content validity of generic preference-based measures (GPBMs), and (2) examine the convergent validity of the EuroQol 5 Dimension 5 Level (EQ-5D-5L), against the Patient Generated Index (PGI) in Amyotrophic Lateral Sclerosis (ALS).

Methods

Participants were recruited from 3 clinical sites across Canada. The PGI, EQ-5D-5L and Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) were administered through an online or hardcopy survey and scores compared for convergent validation. Domains nominated by participants as important to their health-related quality of life were generated using the PGI, classified using the International Classification of Functioning, Disability and Health (ICF) and mapped onto GPBMs to determine content coverage.

Results

Fifty-two participants (N=28 female; 61.3 ± 11.6 mean age ± standard deviation (SD); 3.5 ± 2.9 mean ± SD years since diagnosis) completed this study. The top three ICF domains identified by participants were recreation and leisure, lower limb mobility, and interpersonal relationships. The Quality of Well-Being Self-Administered (QWB-SA) scale had the highest content coverage (87%) and the Health Utilities Index 3 (HUI3) had the lowest (33%). Two domains were covered by all GPBMs and no GPBM included all domains identified as important by participants. A moderate correlation coefficient of 0.52 between the PGI and EQ-5D-5L was found.

Conclusion

The majority of GPBMs covered only approximately half of the domains important to individuals with ALS suggesting the need for an ALS specific preference-based measure to better reflect the health-related quality of life of this population.

Content validity of preference-based measures for economic evaluation in chronic obstructive pulmonary disease

BACKGROUND

Generic preference-based measures (GPBMs) are health-related quality of life (HRQoL) measures commonly used to evaluate the cost-utility of interventions in healthcare. However, the degree to which the content of GPBMs reflect the HRQoL of individuals with chronic obstructive pulmonary disease (COPD) has not yet been assessed. The purpose of this study was to examine the content and convergent validity of GPBMs in people with COPD.

METHODS

COPD patients were recruited from healthcare centers in Ontario, Canada. The Patient-Generated Index (PGI) (an individualized HRQoL measure) and the RAND-36 (to obtain SF-6D scores; a GPBM) were administered. Life areas nominated with the PGI were coded using the International Classification of Functioning Disability and Health and mapped onto GPBMs.

RESULTS

We included 60 participants with a mean age of 70 and FEV1% predicted of 43. The mean PGI score was 34.55/100 and the top three overarching areas that emerged were: 'mobility' (25.93%), 'recreation and leisure' (25.19%) and 'domestic life' (19.26%). Mapping of the nominated areas revealed that the Quality of Well-Being scale covered the highest number of areas (84.62%), Health Utilities Indices covered the least (15.38% and 30.77%) and other GPBMs covered between 46 and 62%. A correlation of 0.32 was calculated between the SF-6D and the PGI.

CONCLUSIONS

The majority of GPBMs covered approximately half of the areas reported as being important to individuals with COPD. When areas relevant to COPD are not captured, HRQoL scores generated by these measures may inaccurately reflect patients' values and affect cost-effectiveness decisions.

The Relationships Between Self-reported Pain Intensity, Pain Interference, and Quality of Life Among Injured U.S. Service Members With and Without Low Back Pain

Low back pain is a prevalent military and veteran health problem and individuals injured on deployment may be at particularly high risk of pain conditions. Given that increasing numbers of active duty and veteran military personnel are seeking care in community settings, it is critical that health care providers are aware of military health issues. The current study examined the prevalence of low back pain among individuals with deployment-related injuries, compared their self-reported pain intensity and interference ratings, and assessed the relationship between low back pain, self-reported pain ratings, and quality of life. Almost half of participants had low back pain diagnoses, and individuals with low back pain reported significantly higher intensity and interference due to their pain than individuals without low back pain. Finally, the relationship between low back pain and quality of life was explained by self-reported pain indices, underscoring the importance of patient-centered metrics in pain treatment.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation

PURPOSE

Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes.

MATERIALS AND METHODS

Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status.

RESULTS

Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning.

CONCLUSIONS

Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

Prevalence of Low Back Pain and Relationship to Mental Health Symptoms and Quality of Life After a Deployment-related Lower Limb Amputation

STUDY DESIGN

Retrospective, cross-sectional study.

OBJECTIVE

To assess the prevalence and association of low back pain (LBP) with psychosocial factors in Service members with amputations.

SUMMARY OF BACKGROUND DATA

LBP is a common secondary health condition after amputation with important implications related to function and quality of life. A growing body of evidence suggests that psychosocial factors influence LBP in patients without amputation. However, there is a dearth of information regarding the association of psychosocial factors and LBP after amputation.

METHODS

Seventy-nine individuals with lower limb amputations who were a part of the Wounded Warrior Recovery Project were included in the analysis. Data on posttraumatic stress disorder (PTSD), depression, and quality of life (QOL) were collected from the Wounded Warrior Recovery Project, while data on LBP and LBP chronicity were extracted from the Military Health System Data Repository. General linear models were utilized to analyze associations between LBP and psychosocial factors, while controlling for injury severity and time since amputation.

RESULTS

In individuals with amputations, 19.0% had acute LBP and 49.4% had recurrent LBP. Individuals with amputations and recurrent LBP reported higher PTSD symptom severity compared with those without LBP (B = 9.213, P < 0.05). More severe depression symptoms were observed in those with amputations and recurrent LBP compared with those without LBP (B = 5.626, P < 0.05). Among individuals with amputations, those with recurrent LBP reported lower QOL compared with those without LBP (B = -0.058, P < 0.05). There were no differences in PTSD, depression or QOL in those with amputations with and without acute LBP.

CONCLUSIONS

Presence of recurrent LBP after amputation appears to be associated with more severe PTSD and depression symptoms as well as lower QOL. Further research is needed to assess the efficacy of addressing psychosocial factors for improving pain and function in service members with amputations and LBP.

LEVEL OF EVIDENCE

3.

Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data

Background

Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL).

Methods

A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward’s minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan’s multiple range test was used to group clusters into domains by QOL.

Results

Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain.

Conclusions

The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.

Translation, cultural adaptation, and validation of the quality of well being self-administered questionnaire in general population in Indonesia

Background The quality of well being self-administered (QWB-SA) questionnaire is one of the generic instruments which can be used to measure the utility score to assess the quality-adjusted life years (QALYs) as an outcome parameter in pharmacoeconomics study. This research aimed to study the translation, cultural adaptation, and validation of the QWB-SA questionnaire in Indonesian language. Methods This research was conducted among the general population of 459 people in Yogyakarta city. The translation was done using the forward-backward method by independent linguists, and then reviewed by a team consisting of linguists, methodologists, and pharmacists. The psychometric evaluations included face validity, internal-construct validity, convergent validity, and known-group validity tests, while the reliability test was the test-retest of reliability with the Spearman's rank correlation and Pearson test. Results The translation results and cultural adaptations were modified from the aspect of idiomatic, semantic and conceptual equivalence of the items on the QWB-SA questionnaire. The internal-construct validity showed a very strong and moderate correlation among dimensions and the QWB utility index. The convergent validity showed moderate-to-weak correlation compared to the Euro-quality of life-5 dimension questionnaire. The reliability test showed the Cronbach alpha coefficient of 0.626, and the test-retest of reliability showed a strong and moderate correlation. Conclusions The QWB-SA questionnaire is valid and reliable, and can be used as an alternative to measure utility as a QALY's parameter in the health-economic evaluation.

Physical Activity and Performance Impact Long-term Quality of Life in Older Adults at Risk for Major Mobility Disability

INTRODUCTION

Older adults are a rapidly growing segment of the U.S.

POPULATION

Mobility problems that lead to further disability can be addressed through physical activity interventions. Quality of life outcome results are reported from a large trial of physical activity for sedentary older adults at risk for mobility disability.

METHODS

Data were from the Lifestyle Interventions and Independence for Elders study. This multisite RCT compared physical activity to health education among 1,635 randomly assigned sedentary older adults at risk for mobility disability in 2010-2011. Measures included demographics; comorbidity; a timed 400-meter walk; the Short Physical Performance Battery; and the Quality of Well-Being Scale (0-1.0 scale). Baseline and long-term follow-up (2.6 years) health-related quality of life data were collected as a secondary outcome. Multivariate linear regression modeling was used to examine covariates of health-related quality of life over time in 2017.

RESULTS

The sample had an overall mean Quality of Well-Being score of 0.613. Both groups declined in quality of life over time, but assignment to the physical activity intervention resulted in a slower decline in health-related quality of life scores (p=0.03). Intervention attendance was associated with higher health-related quality of life for both groups. Baseline characteristics including younger age, fewer comorbid conditions, non-white ethnicity, and faster 400-meter walk times were also associated with higher health-related quality of life over time.

CONCLUSIONS

Declining mobility measured by physical performance is associated with lower quality of life in sedentary older adults. Physical activity interventions can slow the decline in quality of life, and targeting specific subgroups may enhance the effects of such interventions.

Assessing the impact of headaches and the outcomes of treatment: A systematic review of patient-reported outcome measures (PROMs)

Aims To critically appraise, compare and synthesise the quality and acceptability of multi-item patient reported outcome measures for adults with chronic or episodic headache. Methods Systematic literature searches of major databases (1980-2016) to identify published evidence of PROM measurement and practical properties. Data on study quality (COSMIN), measurement and practical properties per measure were extracted and assessed against accepted standards to inform an evidence synthesis. Results From 10,903 reviewed abstracts, 103 articles were assessed in full; 46 provided evidence for 23 PROMs: Eleven specific to the health-related impact of migraine (n = 5) or headache (n = 6); six assessed migraine-specific treatment response/satisfaction; six were generic measures. Evidence for measurement validity and score interpretation was strongest for two measures of impact, Migraine-Specific Quality of Life Questionnaire (MSQ v2.1) and Headache Impact Test 6-item (HIT-6), and one of treatment response, the Patient Perception of Migraine Questionnaire (PPMQ-R). Evidence of reliability was limited, but acceptable for the HIT-6. Responsiveness was rarely evaluated. Evidence for the remaining measures was limited. Patient involvement was limited and poorly reported. Conclusion While evidence is limited, three measures have acceptable evidence of reliability and validity: HIT-6, MSQ v2.1 and PPMQ-R. Only the HIT-6 has acceptable evidence supporting its completion by all "headache" populations.

Are Quality-Adjusted Life Years a Good Proxy Measure of Individual Capabilities?

BACKGROUND

There is a debate in the health economics literature concerning the most appropriate way of applying Amartya Sen's capability approach in economic evaluation studies. Some suggest that quality-adjusted life years (QALYs) alone are adequate while others argue that this approach is too narrow and that direct measures of capability wellbeing provide a more extensive application of Sen's paradigm.

OBJECTIVE

This paper empirically explores whether QALYs provide a good proxy for individual capabilities.

METHODS

Data is taken from a multinational cross-sectional survey of individuals with seven health conditions (asthma, arthritis, cancer, depression, diabetes, hearing loss, heart disease) and a healthy population. Each individual completed the ICECAP-A measure of capability wellbeing for adults and six health utility instruments that are used to generate QALYs, including EQ-5D and SF-6D. Primary analysis examines how well health utility instruments can explain variation in the ICECAP-A using ordinary least squares regression.

RESULTS

The findings show that all seven health conditions have a negative association on overall capability as measured by the ICECAP-A index. Inclusion of health utility instruments into separate regressions improves the predictive power of capability but on average, explains less than half of the variation in capability wellbeing. Individuals with arthritis appear to be less inhibited in terms of capability losses when accounting for health utility, yet those who have depression record significant reductions in capability relative to the healthy population even after accounting for the most commonly used health utility instruments.

CONCLUSION

The study therefore casts doubt on the ability of QALYs to act as a reliable proxy measure of individuals' capability.

Critical Illness in the Elderly: Review of Pathophysiology of Aging and Outcome of Intensive Care

The goal of this article is to review the literature on age and its influence on the pathophysiology of critical illness, outcome after critical illness, and end of life decision making in critically ill elderly patients. Sources for this review included the MEDLINE database and bibliographies of original articles, reviews, and book chapters. The population is aging and the need for medical care and its costs increase with increasing age. A majority of the elderly lead independent lives, although some need help with various functional activities related to daily living. It is difficult to separate the effects of aging from the effects of the comorbidities that develop with increasing age. The physiologic reserve decreases in the elderly and they may not be able to tolerate a critical injury or illness as well as a younger individual. As the elderlyare usually on multiple medications, they are prone to have more drug interactions and side effects, and need close monitoring of the drugs and adjustment of the dosage. Mortality after a critical illness in the elderly is higher compared to younger patients, and it is more related to the acuity of physiologic disturbance than age alone. The effect of age alone on long-term outcome is not well studied, but individuals with poor functional status and/or increased comorbidities have a poor short-term outcome. Functional status usually deteriorates after critical illness, but the long-term survivors usually recover functional abilities, and they are satisfied with their quality of life. Decision making at the end of life is difficult because of the paucity of data on long-term mortality and quality of life, lack of information about patient wishes, and the uncertainty of the prognosis. Because many elderly patients survive critical illness and may return to their previous lifestyle, age alone should not weigh heavily in end of life decisions. As with other age groups, end of life decisions in the elderly should be made after considering long-term outcomes, patient goals, and the benefits and burdens of life-sustaining technology.

Cost-effectiveness of the LIFE Physical Activity Intervention for Older Adults at Increased Risk for Mobility Disability

BACKGROUND

Losing the ability to walk safely and independently is a major concern for many older adults. The Lifestyle Interventions and Independence for Elders study recently demonstrated that a physical activity (PA) intervention can delay the onset of major mobility disability. Our objective is to examine the resources required to deliver the PA intervention and calculate the incremental cost-effectiveness compared with a health education intervention.

METHODS

The Lifestyle Interventions and Independence for Elders study enrolled 1,635 older adults at risk for mobility disability. They were recruited at eight field centers and randomly assigned to either PA or health education. The PA program consisted of 50-minute center-based exercise 2× weekly, augmented with home-based activity to achieve a goal of 150 min/wk of PA. Health education consisted of weekly workshops for 26 weeks, and monthly sessions thereafter. Analyses were conducted from a health system perspective, with a 2.6-year time horizon.

RESULTS

The average cost per participant over 2.6 years was US$3,302 and US$1,001 for the PA and health education interventions, respectively. PA participants accrued 0.047 per person more Quality-Adjusted Life-Years (QALYs) than health education participants. PA interventions costs were slightly higher than other recent PA interventions. The incremental cost-effectiveness ratios were US$42,376/major mobility disability prevented and US$49,167/QALY. Sensitivity analyses indicated that results were relatively robust to varied assumptions.

CONCLUSIONS

The PA intervention costs and QALYs gained are comparable to those found in other studies. The ICERS are less than many commonly recommended medical treatments. Implementing the intervention in non-research settings may reduce costs further.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.

A single question about a respondent's perceived financial ability to pay monthly bills explains more variance in health utility scores than absolute income and assets questions

PURPOSE

To evaluate a general question about ability to meet monthly bills as an alternative to direct questions about income and assets in health utility studies.

METHODS

We used data from the National Health Measurement Study-a US nationally representative telephone survey collected in 2005-2006. It included health utility measures (EuroQol-5D-3L, Health Utilities Index Mark 3, Short Form-6D, and Quality of Well-being Index) and household income, assets, and financial ability to meet monthly bills questions. Each utility score was regressed on: income and assets (Model 1); difficulty paying bills (DPB) (Model 2); income, assets, and DPB (Model 3). All models used survey weights and adjusted for demographics and education.

RESULTS

Among 3666 respondents, as income and assets increased, DPB decreased. The DPB question had fewer missing values (n = 30) than income (n = 311) or assets (n = 373). Model 2 (DPB only) explained more variance in health utility than Model 1 (income and assets only). Including all measures (Model 3) had very modest improvement in R (2), e.g., values were 0.112 (Model 1), 0.166 (Model 2), and 0.175 (Model 3) for EuroQol-5D-3L.

CONCLUSIONS

The single question on DPB yields more information and has less missing values than the traditionally used income and assets questions.

Examining the Value of Menopausal Symptom Relief Among US Women

BACKGROUND

Menopausal symptoms can cause significant distress to women, yet little is known about the value women place on these symptoms.

METHODS

In April 2013, 3397 US women, aged 40 to 69 years, completed an online survey that included 30 paired comparisons. Specifically, respondents were shown two menopausal symptoms described using the Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events and asked, "Which do you prefer?" From their choices, we estimated a generalized linear model to assess the values women place on symptom relief in terms of quality-adjusted life-years (QALYs).

RESULTS

Approximately half the respondents (1753 of 3397 [52%]) always preferred a reduced lifespan (up to 90 days) instead of experiencing menopausal symptoms at their worst for 30 days. For most of the symptoms (248 of 263 [94%]), including low-grade events, QALYs were significantly reduced (P < 0.05). The value women placed on relief ranged widely by symptom domain: the relief from depression, problems with memory, headache, pain in abdomen, problems with anger, and vomiting were the most valuable.

CONCLUSIONS

Overall, the value women place on menopausal symptom relief is surprisingly high. As the first national study to directly ask women about their preferences and to estimate the value of menopausal symptom relief on a QALY scale, this work provides critical evidence for health outcomes research in midlife women and can be applied in the evaluation of treatments that reduce or eliminate menopausal symptoms. This work also provides proof-of-concept for an approach to value Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events responses on a QALY scale.

Human health benefits and burdens of a pharmaceutical treatment: Discussion of a conceptual integrated approach

The effects of a pharmaceutical treatment have until now been evaluated by the field of Health Economics on the patient health benefits, expressed in Quality-Adjusted Life Years (QALYs) versus the monetary costs. However, there is also a Human Health burden associated with this process, resulting from emissions that originate from the pharmaceutical production processes, Use Phase and End of Life (EoL) disposal of the medicine. This Human Health burden is evaluated by the research field of Life Cycle Assessment (LCA) and expressed in Disability-Adjusted Life Years (DALYs), a metric similar to the QALY. The need for a new framework presents itself in which both the positive and negative health effects of a pharmaceutical treatment are integrated into a net Human Health effect. To do so, this article reviews the methodologies of both Health Economics and the area of protection Human Health of the LCA methodology and proposes a conceptual framework on which to base an integration of both health effects. Methodological issues such as the inclusion of future costs and benefits, discounting and age weighting are discussed. It is suggested to use the structure of an LCA as a backbone to cover all methodological challenges involved in the integration. The possibility of monetizing both Human Health benefits and burdens is explored. The suggested approach covers the main methodological aspects that should be considered in an integrated assessment of the health effects of a pharmaceutical treatment.

Health Condition Impacts in a Nationally Representative Cross-Sectional Survey Vary Substantially by Preference-Based Health Index

IMPORTANCE

Many cost-utility analyses rely on generic utility measures for estimates of disease impact. Commonly used generic preference-based indexes may generate different absolute estimates of disease burden despite sharing anchors of dead at 0 and full health at 1.0.

OBJECTIVE

We compare the impact of 16 prevalent chronic health conditions using 6 utility-based indexes of health and a visual analog scale.

DESIGN

Data were from the National Health Measurement Study (NHMS), a cross-sectional telephone survey of 3844 adults aged 35 to 89 years in the United States.

MAIN OUTCOME MEASURES

The NHMS included the EuroQol-5D-3L, Health and Activities Limitation Index (HALex), Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), preference-based scoring for the SF-36v2 (SF-6D), Quality of Well-Being Scale, and visual analog scale. Respondents self-reported 16 chronic conditions. Survey-weighted regression analyses for each index with all health conditions, age, and sex were used to estimate health condition impact estimates in terms of quality-adjusted life years (QALYs) lost over 10 years. All analyses were stratified by ages 35 to 69 and 70 to 89 years.

RESULTS

There were significant differences between the indexes for estimates of the absolute impact of most conditions. On average, condition impacts were the smallest with the SF-6D and EQ-5D-3L and the largest with the HALex and HUI3. Likewise, the estimated loss of QALYs varied across indexes. Condition impact estimates for EQ-5D-3L, HUI2, HUI3, and SF-6D generally had strong Spearman correlations across conditions (i.e., >0.69).

LIMITATIONS

This analysis uses cross-sectional data and lacks health condition severity information.

CONCLUSIONS

Health condition impact estimates vary substantially across the indexes. These results imply that it is difficult to standardize results across cost-utility analyses that use different utility measures.

Patient-Reported Outcome Instruments for Physical Symptoms Among Patients Receiving Maintenance Dialysis: A Systematic Review

BACKGROUND

Patients with end-stage renal disease (ESRD) receiving dialysis have poor health-related quality of life. Physical symptoms are highly prevalent among dialysis-dependent patients and play important roles in health-related quality of life. A range of symptom assessment tools have been used in dialysis-dependent patients, but there has been no previous systematic assessment of the existing symptom measures' content, validity, and reliability.

STUDY DESIGN

Systematic review of the literature.

SETTINGS & POPULATION

Patients with ESRD on maintenance dialysis therapy.

SELECTION CRITERIA FOR STUDIES

Instruments with 3 or more physical symptoms previously used in dialysis-dependent patients and evidence of validity or reliability testing.

INTERVENTION

Patient-reported physical symptom assessment instrument.

OUTCOMES

Instrument symptom-related content, validity, and reliability.

RESULTS

From 3,148 screened abstracts, 89 full-text articles were eligible for review. After article exclusion and further article identification by reference reviews, 58 articles on 23 symptom assessment instruments with documented reliability or validity testing were identified. Of the assessment instruments, 43.5% were generic and 56.5% were ESRD specific. Symptoms most frequently assessed were fatigue, shortness of breath, insomnia, nausea and vomiting, and appetite. Instruments varied widely in respondent time burden, recall period, and symptom attributes. Few instruments considered recall periods less than 2 weeks and few assessed a range of symptom attributes. Psychometric testing was completed for congruent validity (70%), known-group validity (25%), responsiveness (30%), internal consistency (78%), and test-retest reliability (65%). Content validity was assessed in dialysis populations in 57% of the 23 instruments.

LIMITATIONS

Consideration of physical symptoms only and exclusion of single symptom-focused instruments.

CONCLUSIONS

The number of available instruments focused exclusively on physical symptoms in dialysis patients is limited. Few symptom-containing instruments have short recall periods, assess diverse symptom attributes, and have undergone comprehensive psychometric testing. Improved symptom-focused assessment tools are needed to improve symptom evaluation and symptom responsiveness to intervention among dialysis-dependent patients.

US valuation of health outcomes measured using the PROMIS-29

OBJECTIVES

Health valuation studies enhance economic evaluations of treatments by estimating the value of health-related quality of life (HRQOL). The Patient-Reported Outcomes Measurement Information System (PROMIS) includes a 29-item short-form HRQOL measure, the PROMIS-29.

METHODS

To value PROMIS-29 responses on a quality-adjusted life-year scale, we conducted a national survey (N = 7557) using quota sampling based on the US 2010 Census. Based on 541 paired comparisons with over 350 responses each, pair-specific probabilities were incorporated into a weighted least-squared estimator.

RESULTS

All losses in HRQOL influenced choice; however, respondents valued losses in physical function, anxiety, depression, sleep, and pain more than those in fatigue and social functioning.

CONCLUSIONS

This article introduces a novel approach to valuing HRQOL for economic evaluations using paired comparisons and provides a tool to translate PROMIS-29 responses into quality-adjusted life-years.

A review of the psychometric properties of generic utility measures in multiple sclerosis

OBJECTIVE

The reliability and validity of generic utility measures have not yet been summarized in people with multiple sclerosis (MS). It is important to assess the psychometric properties of these measures, to ensure that the values obtained by the scoring system are valid for interpretation and utilization by clinicians, researchers and policy makers. Therefore, the objective of this review was to summarize the evidence from published literature on the psychometric properties of generic utility measures in MS.

METHODS

A structured literature search was conducted by using multiple electronic databases. All potentially relevant abstracts and full-text articles were read to identify publications that may be eligible for inclusion in the review. A meta-analysis was conducted to combine correlation coefficient values for convergent validity. The Schmidt-Hunter method, a weighted mean of the correlation coefficient values, was used. Heterogeneity, the percentage of total variation across studies that is due to between-study differences rather than chance, was assessed using the I (2) statistic.

RESULTS

The following generic utility measures were identified: the EQ-5D (n = 9)/EQ-5D-5 Level (EQ-5D-5L) (n = 1), followed by the Health Utilities Index Mark 3/2 (HUI2/HUI3) (n = 3), the SF-6D (n = 2), the Assessment of Quality of Life (AQOL) (n = 2), and the Quality of Well-Being (QWB) scale (n = 1). Ceiling and floor effects were present for the EQ-5D and the SF-6D, but not for the HUI3. The EQ-5D, the SF-6D and the HUI3 demonstrated excellent reliability. In terms of discriminative ability, the SF-6D and the QWB scale were not able to differentiate between moderately and severely disabled MS patients, and the EQ-5D was not able to differentiate between those who were mildly and moderately disabled. The AQOL and the HUI3, on the other hand, demonstrated good discriminative ability, as both measures were able to differentiate between all levels of disability. As for convergent validity, the HUI2/HUI3 were highly correlated (r = 0.7) against measurement instruments that evaluated impairments such as disease severity, ambulation and manual dexterity. The EQ-5D, SF-6D and the QWB scale demonstrated small to moderate correlations (r = 0.4) against instruments evaluating impairments, and slightly stronger correlations against measures of activity limitations/participation restrictions and health-related quality of life (HRQL) (r = 0.6).

CONCLUSION

To our knowledge this is the first study to review the validity and reliability of generic utility measures in MS. The HUI3 demonstrated the strongest psychometric properties when compared with other utility measures. However, the HUI3 only measures impairment and excludes important components of HRQL such as participation restrictions. The EQ-5D, the SF-6D and the QWB scale, on the other hand, do include items on participation. However, these measures demonstrated a lack of content validity in MS by missing certain domains that were important to the disease, as well as difficulty in differentiating between different levels of disability. The addition of MS-specific 'bolt-ons' to generic utility measures and the development of an MS specific utility measure are possible areas of exploration for future research.

Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial

IMPORTANCE

In older adults reduced mobility is common and is an independent risk factor for morbidity, hospitalization, disability, and mortality. Limited evidence suggests that physical activity may help prevent mobility disability; however, there are no definitive clinical trials examining whether physical activity prevents or delays mobility disability.

OBJECTIVE

To test the hypothesis that a long-term structured physical activity program is more effective than a health education program (also referred to as a successful aging program) in reducing the risk of major mobility disability.

DESIGN, SETTING, AND PARTICIPANTS

The Lifestyle Interventions and Independence for Elders (LIFE) study was a multicenter, randomized trial that enrolled participants between February 2010 and December 2011, who participated for an average of 2.6 years. Follow-up ended in December 2013. Outcome assessors were blinded to the intervention assignment. Participants were recruited from urban, suburban, and rural communities at 8 centers throughout the United States. We randomized a volunteer sample of 1635 sedentary men and women aged 70 to 89 years who had physical limitations, defined as a score on the Short Physical Performance Battery of 9 or below, but were able to walk 400 m.

INTERVENTIONS

Participants were randomized to a structured, moderate-intensity physical activity program (n = 818) conducted in a center (twice/wk) and at home (3-4 times/wk) that included aerobic, resistance, and flexibility training activities or to a health education program (n = 817) consisting of workshops on topics relevant to older adults and upper extremity stretching exercises.

MAIN OUTCOMES AND MEASURES

The primary outcome was major mobility disability objectively defined by loss of ability to walk 400 m.

RESULTS

Incident major mobility disability occurred in 30.1% (246 participants) of the physical activity group and 35.5% (290 participants) of the health education group (hazard ratio [HR], 0.82 [95% CI, 0.69-0.98], P = .03).Persistent mobility disability was experienced by 120 participants (14.7%) in the physical activity group and 162 participants (19.8%) in the health education group (HR, 0.72 [95% CI, 0.57-0.91]; P = .006). Serious adverse events were reported by 404 participants (49.4%) in the physical activity group and 373 participants (45.7%) in the health education group (risk ratio, 1.08 [95% CI, 0.98-1.20]).

CONCLUSIONS AND RELEVANCE

A structured, moderate-intensity physical activity program compared with a health education program reduced major mobility disability over 2.6 years among older adults at risk for disability. These findings suggest mobility benefit from such a program in vulnerable older adults.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01072500.

Quality of life assessment in interventional radiology

The aim of this review was to describe quality of life (QoL) questionnaires relevant to interventional radiology. Interventional radiologists perform a large number of palliative procedures. The effect of these therapies on QoL is important. This is particularly true for cancer therapies where procedures with marginal survival benefits may result in tremendous QoL benefits. Image-guided minimally invasive procedures should be compared to invasive procedures, with respect to QoL, as part of comparative effectiveness assessment. A large number of questionnaires have been validated for measurement of overall and disease-specific quality of life. Use of applicable QoL assessments can aid in evaluating clinical outcomes and help to further substantiate the need for minimally invasive image-guided procedures.

US trends in quality-adjusted life expectancy from 1987 to 2008: combining national surveys to more broadly track the health of the nation

OBJECTIVES

We used data from multiple national health surveys to systematically track the health of the US adult population.

METHODS

We estimated trends in quality-adjusted life expectancy (QALE) from 1987 to 2008 by using national mortality data combined with data on symptoms and impairments from the National Medical Expenditure Survey (1987), National Health Interview Survey (1987, 1994-1995, 1996), Medical Expenditure Panel Survey (1992, 1996, 2000-2008), National Nursing Home Survey (1985, 1995, and 1999), and Medicare Current Beneficiary Survey (1992, 1994-2008). We decomposed QALE into changes in life expectancy, impairments, symptoms, and smoking and body mass index.

RESULTS

Years of QALE increased overall and for all demographic groups-men, women, Whites, and Blacks-despite being slowed by increases in obesity and a rising prevalence of some symptoms and impairments. Overall QALE gains were large: 2.4 years at age 25 years and 1.7 years at age 65 years.

CONCLUSIONS

Understanding and consistently tracking the drivers of QALE change is central to informed policymaking. Harmonizing data from multiple national surveys is an important step in building this infrastructure.

Construct validity and reliability of the Handover Evaluation Scale

AIMS AND OBJECTIVES

To examine the psychometric properties of the Handover Evaluation Scale using exploratory and confirmatory factor analysis.

BACKGROUND

Handover is a fundamental component of clinical practice and is essential to ensure safe patient care. Research indicates a number of problems with this process, with high variability in the type of information provided. Despite the reported deficits with handover practices internationally, guidelines and standardised tools for its conduct and evaluation are scarce. Further work is required to develop an instrument that measures the effectiveness of handover in a valid and reliable way.

DESIGN

Secondary analysis of data collected between 2006-2008 from nurses working on 24 wards across a large Australian healthcare service.

METHODS

A sample of 299 nurses completed the survey that included 20 self-report items which evaluated the effectiveness of handover. Data were analysed using exploratory factor analysis and confirmatory factor analysis supported by structural equation modelling.

RESULTS

Analyses resulted in a 14-item Handover Evaluation Scale with three subscales: (1) quality of information (six items), (2) interaction and support (five items) and (3) efficiency (three items). A fourth subscale, patient involvement (three items), was removed from the scale as it was not a good measure of handover.

CONCLUSIONS

The scale is a self-report, valid and reliable measure of the handover process. It provides a useful tool for monitoring and evaluating handover processes in health organisations, and it is recommended for use and further development.

RELEVANCE TO CLINICAL PRACTICE

Monitoring handover is an important quality assurance process that is required to meet healthcare standards. This reliable and valid scale can be used in practice to monitor the quality of handover and provide information that can form the basis of education and training packages and guidelines to improve handover policies and processes.

Development and validation of a mental health subscale from the Quality of Well-Being Self-Administered

PURPOSE

The purpose of this study was to create and validate a mental health subscale for the Quality of Well-Being Self-Administered (QWB-SA).

METHODS

The QWB-SA and other measures such as the Profile of Mood States (POMS), Medical Outcomes Study 36 Item Short Form (SF-36), EuroQOL 5D (EQ-5D), and Health Utilities Index Mark 2 (HUI) were administered to three samples: a general population (N = 3,844), a non-psychiatric medical population (N = 535), and a psychiatric population (N = 915). Independent expert ratings of which items represented the construct of mental health were used along with psychometric methods to develop and validate a 10-item QWB-SA mental health scale.

RESULTS

The mental health scale demonstrated high internal consistency (Cronbach's alpha = 0.827-0.842) and strong correlations with other measures of mental health, such as the POMS (r = -0.77), mental health scale from the SF-36 (r = 0.72), EQ-5D mood item (r = 0.61), and HUI Emotion Scale (r = 0.59). It was not highly correlated with measures of physical health. Among the psychiatric population, the new mental health scale was moderately correlated with indicators of psychiatric problem severity.

CONCLUSIONS

It is now possible to report outcomes and relationships with mental health in studies that use the QWB-SA. This new mental health subscale can also be used with the large volume of previously collected data using the QWB-SA to examine the impact of illnesses and interventions on mental health-related quality of life.

Quality of life in older people: a structured review of self-assessed health instruments

A range of terms (including quality of life, health-related quality of life and health status) describe a broad set of aspects of self-reported health that can be captured by questionnaires and related instruments. Health in older people particularly requires attention to broader aspects of the impact of health on physical, social and psychological function. A structured review was performed to assess how well such issues are measured by available instruments. A total of 45 instruments were identified that have received some degree of evaluation to establish their use in assessing the health of older individuals. Two types of instruments were included in the review: generic and older-people-specific instruments. The SF-36 has by far the largest evidence base to support its use in older people. The OMFAQ has the best evidence base amongst older-people-specific instruments. Many instruments have only minimal evidence of measurement properties. Concepts such as quality of life are still defined and used in a variety of ways, and major questions must be addressed before uniform practice emerges in this important area of health policy.

Gender differences in multiple underlying dimensions of health-related quality of life are associated with sociodemographic and socioeconomic status

PURPOSE

The purpose of the study was to examine whether gender differences in summary health-related quality of life (HRQoL) are due to differences in specific dimensions of health, and whether they are explained by sociodemographic and socioeconomic (SES) variation.

METHODS

The National Health Measurement Study collected cross-sectional data on a national sample of 3648 black and white noninstitutionalized adults ages 35 to 89 years. Data included the Short Form 36-Item survey, which yielded separate Mental and Physical Component Summary scores (MCS and PCS, respectively), and five HRQoL indexes: Short Form 6 dimension, EuroQol 5 dimension, the Health Utilities Indexes Mark 2 and 3, and the Quality of Well-Being Scale Self-Administered form. Structural equation models were used to explore gender differences in physical, psychosocial, and pain latent dimensions of the 5 indexes, adjusting for sociodemographic and SES indicators. Observed MCS and PCS scores were examined in regression models to judge robustness of latent results.

RESULTS

Men had better estimated physical and psychosocial health and less pain than women with similar trends on the MCS and PCS scores. Adjustments for marital status or income reduced gender differences more than did other indicators. Adjusting results for partial factorial invariance of HRQoL attributes supported the presence of gender differentials, but also indicated that these differences are impacted by dimensions being related to some HRQoL attributes differently by gender.

CONCLUSIONS

Men have better estimated health on 3 latent dimensions of HRQoL-physical, psychosocial, and pain-comparable to gender differences on the observed MCS and PCS scores. Gender differences are partly explained by sociodemographic and SES factors, highlighting the role of socioeconomic inequalities in perpetuating gender differences in health outcomes across multiple domains. These results also emphasize the importance of accounting for measurement invariance for meaningful comparison of group differences in estimated means of self-reported measures of health.

Rasch analysis in the development of a simplified version of the National Eye Institute Visual-Function Questionnaire-25 for utility estimation

PURPOSE

Preference-based health measures value how people feel about the desirability of a health state. Generic measures may not effectively capture the impact of vision loss from ocular diseases. Disease-targeted measures could address this limitation. This study developed a vision-targeted health state classification system based on the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25).

METHODS

Secondary analysis of NEI VFQ-25 data from studies of patients with central (n = 932)- and peripheral-vision loss (n = 2,451) were used to develop a health state classification system. Classical test theory and Rasch analyses were used to identify a smaller set of NEI VFQ-25 items suitable for the central- and peripheral-vision-loss groups.

RESULTS

Rasch analysis of the NEI VFQ-25 items using the peripheral vision-loss data indicated that 11 items fit a unidimensional model, while 14 NEI VFQ-25 items fit using the central-vision-loss data. Combining peripheral-vision-loss data and central-vision-loss data resulted in 9 items fitting a unidimensional model. Six items covering near vision, distance vision, social vision, role difficulties, vision dependency, and vision-related mental health were selected for the health-state classification.

CONCLUSIONS

The derived health-state classification system covers relevant domains of vision-related functioning and well-being.

Longitudinal association of preference-weighted health-related quality of life measures and substance use disorder outcomes

AIM

To examine the construct validity of generic preference-weighted health-related quality of life measures in a sample of patients with a substance use disorder (SUD).

DESIGN

Longitudinal (baseline and 6-month follow-up) data from a research study that evaluated interventions to improve linkage and engagement with SUD treatment.

SETTING

A central intake unit that referred patients to seven SUD treatment centers in a Midwestern US metropolitan area.

PARTICIPANTS

A total of 495 individuals with a SUD.

MEASUREMENTS

Participants completed two preference-weighted measures: the self-administered Quality of Well-Being scale (QWB-SA) and the standard gamble weighted Medical Outcomes Study SF-12 (SF-6D). They were also administered two clinical assessments: all seven domains of the Addiction Severity Index (ASI) and a symptom checklist based on the DSM-IV. Construct validity was determined via the relationships between disease-specific SUD and generic measures.

FINDINGS

In unadjusted analyses, the QWB-SA and SF-6D change scores were correlated significantly with six ASI subscale change scores, but not with employment status. In adjusted repeated-measures analyses, three of seven ASI subscale scores were significant predictors of QWB-SA and 5/7 ASI subscale scores were significant predictors of SF-6D. Abstinence and problematic use at follow-up were significant predictors of QWB-SA and SF-6D. Effect sizes ranged from 0.352 to 0.400 for abstinence and -0.484 to -0.585 for problematic use.

CONCLUSIONS

Generic preference-weighted health-related quality of life measures show moderate to good associations with substance-use specific measures and in certain circumstances can be used in their stead. This study provides further support for the use of the Quality of Well-Being scale and Medical Outcomes Study SF-12 in clinical and economic evaluations of substance use disorder interventions.

Common generic measures of health related quality of life in injured patients

The measurement of health-related quality of life (HRQOL) through generic outcome instruments is important for comparisons of populations across disease states and interventions. The growing number of questionnaires available has made selection and interpretation more difficult. Profile instruments such as the SF-36 and Sickness Impact Profile provide insight into various domains of health with established population norms. Preference-based measures, including the EQ-5D, Health Utilities Index, SF-6D, and QWB-SA are used to generate utility scores, which can be used for cost-effectiveness analysis and therefore have particular relevance in health policy. Both types of generic measures have been used in clinical trials in injured populations to assess the relative impact of interventions on quality-of-life. Comparisons of internal consistency and test-retest reliability across measures reveal minimal differences between instruments, and reported values are acceptable for group comparisons but insufficient for individual clinical use. There is a dearth of studies evaluating the validity of these measures in the trauma population, but available data suggest most of the available instruments are acceptable. Populations that may require special consideration are patients with head, spinal cord, and upper-extremity injuries. Practical issues to consider in selecting a questionnaire include time for completion, which ranges from less than 2 min for the EQ-5D to 20-30 min for the Sickness Impact Profile. Selection of the appropriate measure ultimately depends largely on the population to be studied and whether utility-estimation is desired.

A preference-based measure of health: the VR-6D derived from the veterans RAND 12-Item Health Survey

PURPOSE

The Veterans RAND 12-Item Health Survey (VR-12) is currently the major endpoint used in the Medicare managed care outcomes measure in the Healthcare Effectiveness Data and Information Set (HEDIS(®)), referred to as the Health Outcomes Survey (HOS). The purpose of this study is to adapt the Brazier SF-6D utility measure to the VR-12 to generate a single utility index.

METHODS

We used the HOS cohorts 2 and 3 for SF-36 data and 9 for VR-12 data. We calculated SF-6D scores from the SF-36 using the algorithms developed by Brazier and colleagues. The values of the Brazier SF-6D were used to estimate utility scores from the VR-12 using a mapping approach based on a 2-stage mapping procedure, named as VR-6D.

RESULTS

The VR-6D derived from the VR-12 has similar distributional properties as the SF-6D. The change in VR-6D showed significant variations across disease groups with different levels of morbidity and mortality.

CONCLUSIONS

This study produced a utility measure for the VR-12 that is comparable to the SF-6D and responsive to change. The VR-6D can be used in evaluations of health care plans and cost-effectiveness analysis to compare the health gains that health care interventions can achieve.

Health of people with intellectual disabilities: A review of factors influencing access to health care

The rights and needs of people with intellectual disabilities are being acknowledged within Department of Health policies. In spite of this, however, it is frequently cited that people with intellectual disabilities are vulnerable to many health problems but have poor access to health-related services. There are many factors that can act as barriers to people with intellectual disabilities enjoying good health and accessing services. These include: (a) a lack of clarity regarding responsibilities for ensuring that health policies are operationalized; (b) social and residential aspects of life being emphasized within the quality of life framework for evaluating services for people with intellectual disabilities, with health as an under-represented domain; (c) a lack of reliable and valid measures that can be used with carers and people with intellectual disabilities to explore health, particularly in comparison to literature on the general population; (d) potential communication difficulties (between the person with intellectual disabilities, their carers and health staff) that can impact on decision-making processes from early identification of health problems through to the stage of gaining appropriate treatment. These areas are discussed giving rise to questions and challenges for policy makers, researchers and clinicians.

Race and preference-based health-related quality of life measures in the United States

BACKGROUND

Health-related quality of life instruments (HRQoL) are widely used to produce measures that summarize population health and to inform decision-making and health policy. Although the literature about the relationship between health and race in the United States is quite extensive, there is a lack of studies that comprehensively examine the relationship between race and preference-based HRQoL. Given the widespread use of these measures, it becomes important to understand the extent of the race differences in HRQoL scores and factors associated with any such differences.

METHODS

We examined the differences in HRQoL, between blacks and whites and associated factors, using the summary scores of the SF-6D, EQ-5D, QWB-SA, HUI2, HUI3, administered by telephone to a nationally representative sample of 3,578 black and white US adults between the ages of 35 and 89 in the National Health Measurement Study (NHMS).

RESULTS

Black women had substantially lower HRQoL than white women. The difference was largely explained by sociodemographic and socioeconomic variables. Black men did not differ significantly from white men, except for the EQ-5D. HRQoL among black men was higher at higher income levels, while the HRQoL of black women was especially low compared to other groups at high income levels.

Standard error of measurement of 5 health utility indexes across the range of health for use in estimating reliability and responsiveness

BACKGROUND

Standard errors of measurement (SEMs) of health-related quality of life (HRQoL) indexes are not well characterized. SEM is needed to estimate responsiveness statistics, and is a component of reliability.

PURPOSE

To estimate the SEM of 5 HRQoL indexes.

DESIGN

The National Health Measurement Study (NHMS) was a population-based survey. The Clinical Outcomes and Measurement of Health Study (COMHS) provided repeated measures.

SUBJECTS

A total of 3844 randomly selected adults from the noninstitutionalized population aged 35 to 89 y in the contiguous United States and 265 cataract patients.

MEASUREMENTS

The SF6-36v2™, QWB-SA, EQ-5D, HUI2, and HUI3 were included. An item-response theory approach captured joint variation in indexes into a composite construct of health (theta). The authors estimated 1) the test-retest standard deviation (SEM-TR) from COMHS, 2) the structural standard deviation (SEM-S) around theta from NHMS, and 3) reliability coefficients.

RESULTS

SEM-TR was 0.068 (SF-6D), 0.087 (QWB-SA), 0.093 (EQ-5D), 0.100 (HUI2), and 0.134 (HUI3), whereas SEM-S was 0.071, 0.094, 0.084, 0.074, and 0.117, respectively. These yield reliability coefficients 0.66 (COMHS) and 0.71 (NHMS) for SF-6D, 0.59 and 0.64 for QWB-SA, 0.61 and 0.70 for EQ-5D, 0.64 and 0.80 for HUI2, and 0.75 and 0.77 for HUI3, respectively. The SEM varied across levels of health, especially for HUI2, HUI3, and EQ-5D, and was influenced by ceiling effects. Limitations. Repeated measures were 5 mo apart, and estimated theta contained measurement error.

CONCLUSIONS

The 2 types of SEM are similar and substantial for all the indexes and vary across health.

Long-term effects of Hurricane Katrina on the psychological well-being of evacuees

Hurricane Katrina of August 2005 forced more than one million people to evacuate the Gulf Coast of the United States. This study examines the psychological health and well-being of a subset of evacuees to determine the prevalence of ongoing mental health problems. Interviews were conducted with 101 adults who evacuated to Louisville, Kentucky, and were living in the state at the one-year anniversary of the event or had recently returned to the Gulf Coast. The psychological health and well-being of respondents was evaluated using several well-validated measures. More than one-half met the criteria for post-traumatic stress disorder and a majority were suffering from depression and anxiety. The mean quality of life score was 0.6 on a scale from 0-1, suggesting that adaptation and return to pre-hurricane well-being had not occurred 12 months after the storm. The potential for long-term psychological damage exists in this sample of Hurricane Katrina evacuees. Results suggest other evacuees may also be at heightened risk.

Gender differences in health-related quality-of-life are partly explained by sociodemographic and socioeconomic variation between adult men and women in the US: evidence from four US nationally representative data sets

PURPOSE

The purpose of this study was to describe gender differences in self-reported health-related quality-of-life (HRQoL) and to examine whether differences are explained by sociodemographic and socioeconomic status (SES) differentials between men and women.

METHODS

Data were from four US nationally representative surveys: US Valuation of the EuroQol EQ-5D Health States Survey (USVEQ), Medical Expenditure Panel Survey (MEPS), National Health Measurement Study (NHMS) and Joint Canada/US Survey of Health (JCUSH). Gender differences were estimated with and without adjustment for sociodemographic and SES indicators using regression within and across data sets with SF-6D, EQ-5D, HUI2, HUI3 and QWB-SA scores as outcomes.

RESULTS

Women have lower HRQoL scores than men on all indexes prior to adjustment. Adjusting for age, race, marital status, education and income reduced but did not remove the gender differences, except with HUI3. Adjusting for marital status or income had the largest impact on estimated gender differences.

CONCLUSIONS

There are clear gender differences in HRQoL in the United States. These differences are partly explained by sociodemographic and SES differentials.

Quality of life assessment of patients with chronic liver disease in eastern India using a Bengali translation chronic liver disease questionnaire

AIMS

The aim of this study was to translate and validate chronic liver disease questionnaire (CLDQ) into Bengali using a standard protocol and use it to assess the impact of socioeconomic factors, etiology, disease severity and complications on the quality of life of patients.

METHODS

Formal translation of CLDQ to Bengali was done. Cronbach's alpha and test-retest was performed for reliability analysis. Patients with clinically stable chronic liver disease (CLD) without significant associated co-morbid states were administered Bengali CLDQ in the Liver Clinic. The clinical, biochemical and disease parameters were recorded for analysis.

RESULTS

Bengali CLDQ was administered to 100 patients with CLD. Cronbach's alpha of overall scores was 0.90 and test-retest correlation coefficient of average CLDQ was 0.86 (P<0.001). Patients with history of decompensation (96.51 vs. 109.61; P=0.039) and Child's C status (92.24 vs. 105.71; P=0.028) had significantly lower CLDQ scores. CLDQ scores showed a moderate inverse correlation with Child's status (r= -0.35) and a poor correlation with MELD score (r= -0.09).

CONCLUSION

Bengali translation of CLDQ was found to be reliable. History of decompensation, Child's C status was associated with worse CLDQ scores. Child's status may have some role in predicting quality of life of patients with CLD. MELD score had poor predictability of quality of life.

Underlying dimensions of the five health-related quality-of-life measures used in utility assessment: evidence from the National Health Measurement Study

BACKGROUND

Preference-weighted health-related quality-of-life (HRQoL) indexes produce a summary score from discrete health states determined by questions falling into several attributes, such as pain and mobility. Values of HRQoL are used alongside other health outcomes to monitor the health of populations.

OBJECTIVE

The purpose of this study was to examine among US adults, the underlying factor structure of HRQoL attribute scores across 5 indexes of HRQoL: EuroQol-5 Dimension, Health Utilities Index Mark 2, Health Utilities Index Mark 3, Short Form-6 Dimension, and Quality of Well-Being Scale Self-Administered form.

METHODS

The National Health Measurement Study surveyed a nationally representative sample of 3844 noninstitutionalized adults aged 35 to 89 years residing in the continental US. Simultaneous data on all 5 indexes were collected cross-sectionally from June 2005 to August 2006. Exploration of underlying dimensions of HRQoL was done by categorical exploratory factor analysis of HRQoL indexes' attribute scores. Item response theory was applied to explore the amount of information HRQoL attributes contribute to the underlying latent dimensions.

RESULTS

Three main dimensions of HRQoL emerged: physical, psychosocial, and pain. Most HRQoL index attributes contributed to the physical or psychosocial dimension. The 3 dimensions were correlated: 0.47 (physical and psychosocial), 0.57 (physical and pain), 0.46 (psychosocial and pain). Some HRQoL index attributes displayed relatively more unique variance: HUI3 hearing, speech, and vision, and some contributed to more than 1 dimension The identified factor structure fit the HRQoL data well (Comparative Fit Index = 0.98, Tucker-Lewis Index = 0.98, and Root Mean Square Error of Approximation = 0.042).

CONCLUSIONS

The attributes of 5 commonly used HRQoL indexes share 3 underlying latent dimensions of HRQoL, physical, psychosocial, and pain.

Association between utility and treatment among patients with prostate cancer

PURPOSE

To analyze the association between utility, treatment, and generic and prostate-specific health-related quality of life (HRQoL) among patients with prostate cancer.

METHODS

In this longitudinal cohort study, we recruited 201 (>or=45 years) newly diagnosed patients with prostate cancer from urology clinics of an urban academic hospital. Participants completed Quality of Wellbeing (QWB-SA), generic (SF-36), and prostate-specific (UCLA-PCI) HRQoL surveys prior to treatment and up to 24 months post-treatment. Clinical and demographic data were obtained via medical chart review, and utility scores were computed using QWB-SA. To analyze the relationship between treatment and utility, we used linear mixed effects models, after adjusting for covariates and propensity score. Similar models were used to examine the association between generic and prostate-specific HRQoL and utility.

RESULTS

Mean baseline utility was comparable between radical prostatectomy (RP) and external beam radiation therapy (EBRT) groups (0.73 vs. 0.69, P=0.1750). Mixed effects models indicated that RP was associated with higher utility at 24 month (OR=1.12, P=0.027), after controlling for covariates. RP was associated with improved functioning for role physical, role emotional, vitality, mental health and bodily pain, and impaired urinary function. Higher scores on generic health subscales were indicative of higher utility. Also, for prostate-specific HRQoL, higher scores on bowl function, sexual function, urinary bother, and bowel bother were associated with higher utility.

CONCLUSIONS

Treatment appears to have significant association with post-treatment utility. Thus, utility assessment provides an important quantitative tool to support patient and physician clinical treatment decision-making process in prostate cancer care.

Quality of life instruments and definitions in individuals with spinal cord injury: a systematic review

STUDY DESIGN

A systematic review.

OBJECTIVE

To critically review quality of life (QOL) instruments used with spinal cord injury (SCI) populations.

SETTING

Vancouver, Canada.

METHODS

A systematic literature review was conducted for publications assessing the measurement properties of QOL outcome measures. Pre-established criteria were used to evaluate the measurement properties.

RESULTS

Fourteen articles reporting on 13 QOL instruments met the inclusion criteria, including the Patient Reported Impact of Spasticity Measure (PRISM), Quality of Well-being Scale, Qualiveen, Sickness Impact Profile (SIP68), Short Form (SF)-36, SF-36V, SF-12, SF-6D, Quality of Life Index, Quality of Life Profile for Adults with Physical Disabilities (QOLP-PD), Satisfaction with Life Scale, Sense of Well-being Index (SWBI), and the World Health Organization Quality of Life-BREF scale (WHOQOL-BREF). The SF-36 and WHOQOL-BREF have been widely used and validated. The SIP68, QOLP-PD, SF-36V, and SWBI are promising with limited investigation. The Qualiveen and PRISM performed well and are specific to SCI complications.

CONCLUSION

The WHOQOL-BREF is presently the most acceptable and established instrument to assess QOL after SCI. The SIP68, QOLP-PD, SF-36V, and SWBI are promising; however, require further evaluation of their measurement properties.

Changes in health state utilities with changes in body mass in the Diabetes Prevention Program

Health utilities are measures of health-related quality of life (HRQL) used in cost-effectiveness research. We evaluated whether changes in body weight were associated with changes in health utilities in the Diabetes Prevention Program (DPP) and whether associations differed by treatment assignment (lifestyle intervention, metformin, placebo) or baseline obesity severity. We constructed physical (PCS-36) and mental component summary (MCS-36) subscales and short-form-6D (SF-6D) health utility index for all DPP participants completing a baseline 36-item short form (SF-36) HRQL assessment (N = 3,064). We used linear regression to test associations between changes in body weight and changes in HRQL indicators, while adjusting for other demographic and behavioral variables. Overall differences in HRQL between treatment groups were highly statistically significant but clinically small after 1 year. In multivariable models, weight change was independently associated with change in SF-6D score (increase of 0.007 for every 5 kg weight loss; P < 0.001), but treatment effects independent of weight loss were not. We found no significant interaction between baseline obesity severity and changes in SF-6D with changes in body weight. However, increases in physical function (PCS-36) with weight loss were greater in persons with higher baseline obesity severity. In summary, improvements in HRQL are associated with weight loss but not with other effects of obesity treatments that are unrelated to weight loss. Although improvements in the SF-6D did not exceed commonly reported thresholds for a minimally important difference (0.04), these changes, if causal, could still have a significant impact on clinical cost-effectiveness estimates if sustained over multiple years.

Measuring health-related quality of life in population-based studies of coronary heart disease: comparing six generic indexes and a disease-specific proxy score

Purpose

To compare HRQoL differences with CHD in generic indexes and a proxy CVD-specific score in a nationally representative sample of U.S. adults.

Methods

The National Health Measurement Study, a cross-sectional random-digit-dialed telephone survey of adults aged 35–89, administered the EQ-5D, QWB-SA, HUI2, HUI3, SF-36v2™ (yielding PCS, MCS, and SF-6D), and HALex. Analyses compared 3,350 without CHD (group 1), 265 with CHD not taking chest pain medication (group 2), and 218 with CHD currently taking chest pain medication (group 3), with and without adjustment for demographic variables and comorbidities. Data on 154 patients from heart failure clinics were used to construct a proxy score utilizing generic items probing CVD symptoms.

Results

Mean scores differed between CHD groups for all indexes with and without adjustment (P < 0.0001 for all except MCS P = 0.018). Unadjusted group 3 versus 1 differences were about three times larger than for group 2 versus 1. Standardized differences for the proxy score were similar to those for generic indexes, and were about 1.0 for all except MCS for group 3 versus 1.

Conclusions

Generic indexes capture differences in HRQoL in population-based studies of CHD similarly to a score constructed from questions probing CVD-specific symptoms.

Readability estimates for commonly used health-related quality of life surveys

PURPOSE

To estimate readability of seven commonly used health-related quality of life instruments: SF-36, HUI, EQ-5D, QWB-SA, HALex, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and the NEI-VFQ-25.

METHODS

The Flesch-Kincaid (F-K) and Flesch Reading Ease (FRE) formulae were used to estimate readability for every item in each measure.

RESULTS

The percentage of items that require more than 5 years of formal schooling according to F-K was 50 for the EQ-5D, 53 for the SF-36, 80 for the VFQ-25, 85 for the QWB-SA, 100 for the HUI, HALex, and the MLHFQ. The percentage of items deemed harder than "easy" according to FRE was 50 for the SF-36, 67 for the EQ-5D, 79 for the QWB-SA, 80 for the VFQ-25, 100 for the HUI, HALex, and the MLHFQ.

CONCLUSIONS

All seven surveys have a substantial number of items with high readability levels that may not be appropriate for the general population.

Predicting EuroQol (EQ-5D) scores from the patient-reported outcomes measurement information system (PROMIS) global items and domain item banks in a United States sample

Background

Preference-based health index scores provide a single summary score assessing overall health-related quality of life and are useful as an outcome measure in clinical studies, for estimating quality-adjusted life years for economic evaluations, and for monitoring the health of populations. We predicted EuroQoL (EQ-5D) index scores from patient-reported outcomes measurement information system (PROMIS) global items and domain item banks.

Methods

This was a secondary analysis of health outcome data collected in an internet survey as part of the PROMIS Wave 1 field testing. For this study, we included the 10 global items and the physical function, fatigue, pain impact, anxiety, and depression item banks. Linear regression analyses were used to predict EQ-5D index scores based on the global items and selected domain banks.

Results

The regression models using eight of the PROMIS global items (quality of life, physical activities, mental health, emotional problems, social activities, pain, and fatigue and either general health or physical health items) explained 65% of the variance in the EQ-5D. When the PROMIS domain scores were included in a regression model, 57% of the variance was explained in EQ-5D scores. Comparisons of predicted to actual EQ-5D scores by age and gender groups showed that they were similar.

Conclusions

EQ-5D preference scores can be predicted accurately from either the PROMIS global items or selected domain banks. Application of the derived regression model allows the estimation of health preference scores from the PROMIS health measures for use in economic evaluations.