Preliminary development of the new individualized HDQoL questionnaire measuring quality of life in adult hypopituitarism

Psychometric validation of three new condition-specific questionnaires to assess quality of life, symptoms and treatment satisfaction of patients with aortic aneurysm

BACKGROUND

To evaluate the psychometric properties of three new condition-specific questionnaires designed to assess outcomes amongst patients under pre-operative surveillance for a small abdominal aortic aneurysm (AAA) or who have undergone aneurysm repair. These tools are the Aneurysm-Dependent Quality of Life measure (AneurysmDQoL), the Aneurysm Symptom Rating Questionnaire (AneurysmSRQ) and the Aneurysm Treatment Satisfaction Questionnaire (AneurysmTSQ).

RESULTS

The questionnaires were sent to 297 patients with abdominal aortic aneurysm (AAA) or who had undergone AAA repair (using open or endovascular technique) sampled from five UK NHS Trusts. Exploratory Factor Analysis was used to examine factor structure together with reliability analysis. A subset of 65 patients completed the questionnaires a second time four months later. One hundred and ninety-seven patients (178 men; 18 women) provided data for analysis (69% response rate): mean age was 75 years (range 60-95). Nineteen were under pre-operative surveillance for AAA and 178 had undergone AAA repair (70 open repair; 104 endovascular repair; 4 uncertain). Exploratory Factor Analysis of the AneurysmDQoL and the AneurysmTSQ each demonstrated a one-factor structure. The AneurysmSRQ demonstrated a six-factor structure (emotional, weight loss, lower limb, cognitive, general malaise and gastrointestinal symptoms) and a one-factor composite symptom scale. All scales have clean factor structures: item loadings above 0.40, no cross-loadings, and no factors with fewer than three items. Internal consistency reliability was excellent (α = 0.869-0.959) and test-retest reliability good (Intraclass correlation coefficient = 0.70-0.88).

CONCLUSIONS

The three new questionnaires have a clear structure and strong reliability and are now ready for use in clinical trials and routine practice, which will allow evaluation of responsiveness to change.

Design of new patient-reported outcome measures to assess quality of life, symptoms and treatment satisfaction in patients with abdominal aortic aneurysm

Background

No condition-specific patient-reported outcome measures exist for patients with abdominal aortic aneurysm (AAA). The aim of this work was to develop three questionnaires to assess quality of life (QoL), symptoms and treatment satisfaction in patients with AAA.

Methods

Semistructured interview techniques were used to explore patients' experiences of having an AAA in a series of focus groups and in-depth interviews. The information gathered was used to inform design and selection of items for the new tools; the overall structure of the new questionnaires was based on tools developed previously for patients with diabetes and other conditions.

Results

Fifty-four patients (51 men, 3 women; mean age 71·9 years) were recruited from four NHS Trusts to participate in focus groups or interviews, either while under surveillance, or following AAA repair (using open or endovascular techniques). The Aneurysm-Dependent Quality of Life Questionnaire (AneurysmDQoL) is an individualized measure of the impact of AAA on patients' QoL. Twenty-three domains were chosen specifically for their relevance to patients with AAA, with a further two overview items to assess overall QoL and the impact of AAA on QoL. The Aneurysm Symptom Rating Questionnaire (AneurysmSRQ) is a 44-item measure assessing physical and psychological symptoms reported by patients with AAA. The Aneurysm Treatment Satisfaction Questionnaire (AneurysmTSQ) contains 11 items, suitable for patients before and after surgical intervention.

Conclusion

The iterative development process reported here has confirmed that these three new tools have good face and content validity for patients with AAA.

Impact of adult growth hormone deficiency on daily functioning and well-being

Background

Adult Growth Hormone Deficiency (AGHD) is a debilitating condition resulting from tumors, pituitary surgery, radiation of the head, head injury, or hypothalamic-pituitary disease. This qualitative study was conducted to better understand the multi-faceted impacts and treatment effects of GHD on adult patients’ daily lives.

Seven focus groups and four telephone interviews were conducted in three countries. Eligible AGHD patients were age 22 or older who had started and stopped growth hormone treatment at least once as an adult. Transcripts were analyzed thematically.

Results

Thirty-nine patients were interviewed; majority etiology was pituitary disease or tumor (62%). Thirty-four patients (87%) were currently on growth hormone replacement therapy; therapy initiation mean age was 43 years. Analysis identified five domains of disease impact: 1) Psychological Health - changed body or self-image and negative emotional impacts; 2) Physical Health - problems with sleep/fatigue, sex drive, weight gain, hair, skin, muscle/bone loss; 3) Cognition - concentration or memory trouble; 4) Energy Loss and its negative impacts (productivity, exercise, chores, socialization, or motivation); and 5) Treatment Effect - treatment enhances quality of life, enabling patients to increase effort (exercise, chores, or work improvements). Energy and sleep are improved. Saturation of themes was reached after the sixth focus group. A conceptual model of GHD disease impacts was developed.

Conclusions

Untreated AGHD has significant negative impacts for patients, which treatment often improves. It is important for clinicians and researchers to understand these multiple impacts so that they can address them in individualized treatment plans and incorporate them when assessing treatment outcomes.

Expanded endonasal approach using vascularized septal flap reconstruction for skull base tumors has a negative impact on sinonasal symptoms and quality of life

BACKGROUND

Endoscopic transsphenoidal surgery is currently the optimal treatment for skull base tumors. This study was designed to assess patient's sinonasal symptoms and quality of life (QoL) after resection of pituitary adenoma or skull base tumors using vascularized septal flap (VSF) reconstruction.

METHODS

Patients with pituitary adenoma underwent the transnasal transsphenoidal endoscopic approach (TTEA; n = 38), and patients with other benign parasellar tumors underwent the expanded endonasal approach (EEA; n = 17) with VSF. Assessment of sinonasal symptoms and QoL by the 36-item Short-Form (SF-36) and the 31-item Rhinosinusitis Outcome Measure (RSOM-31) were performed before and 3 months after surgery.

RESULTS

At baseline, the total seven-sinonasal symptom score (T7SSS) was similar between both groups. After surgery, T7SSS significantly increased in EEA but not in TTEA patients. EEA patients reported more smell loss (40.1 ± 26.2; p < 0.05) and posterior nasal discharge (49.3 ± 30.1; p < 0.05) than TTEA patients (21.6 ± 30.9 and 22.5 ± 27.5, respectively). At baseline, both groups had poorer SF-36 compared with the general population. TTEA patients had poorer QoL (on general health, vitality, and mental health) than EEA patients. After surgery, TTEA patients showed impaired physical role and bodily pain compared with baseline, and EEA patients showed impaired physical role and mental health. At baseline, RSOM scores were similar in TTEA and EEA groups. After surgery, EEA but not TTEA patients reported poorer nasal and general symptoms.

CONCLUSION

The EEA with VSF produces more sinonasal symptoms than pituitary surgery, surgery for skull base and pituitary tumors has negative impact on QoL, and functioning tumors have no further negative effect on sinonasal symptoms and QoL.

Quality of life instruments for skull base pathology: systematic review and methodologic appraisal

BACKGROUND

Several quality of life (QOL) instruments exist for skull base pathology, however, there have been no attempts to appraise and systematically review these instruments.

METHODS

We systematically reviewed MEDLINE, EMBASE, Central, AMED, Health and Psychosocial Instruments, and PsychoInfo for anterior or central skull base QOL instruments to January 2010. We queried experts, bibliographies, and meeting proceedings from the North American Skull Base Society from 2005 to 2009. Included instruments were evaluated for instrument characteristics, item generation and reduction, field testing, and measurement properties using predefined criteria.

RESULTS

We identified 9 QOL instruments: 7 measuring QOL for pituitary pathology, 1 for midface pathology, and 1 for anterior skull base pathology. Eight of the 9 instruments have had some psychometric testing. None demonstrated all of the predefined psychometric properties.

CONCLUSIONS

There are several QOL instruments for patients with skull base pathology. None of these instruments met all predefined requirements, and further instrument development is needed.

Development of a disease-specific quality-of-life questionnaire for anterior and central skull base pathology--the skull base inventory

OBJECTIVES/HYPOTHESIS

Anterior and central skull base lesions and their surgical treatment (endoscopic or open approaches) can affect quality of life. A disease-specific instrument is needed to compare quality of life for different surgical approaches.

STUDY DESIGN

Items were generated using a composite strategy consisting of chart review, systematic review of skull base instruments, expert interviews, and qualitative analysis of patient focus groups. A cross-sectional survey study was performed to reduce items based on an item impact score.

METHODS

Charts of 138 patients who underwent skull base surgery were reviewed to identify physical items and domains. Five experts were interviewed for item and domain identification. Thirty-four patients were recruited into eight focus groups based on their surgical approach (open or endoscopic) and tumor location (anterior or central). Items were generated using a composite approach and then reduced into a final questionnaire using item impact scores.

RESULTS

Chart review identified 47 physical items. Systematic review revealed nine relevant instruments with 217 relevant items. Experts identified 11 domains with 69 additional items. Qualitative analysis of focus groups generated 49 items. A total of 382 items were identified and reduced to 77 items after eliminating overlapping and irrelevant items. Further item reduction using item impact scores yielded 41 items.

CONCLUSIONS

The Skull Base Inventory is a disease-specific quality-of-life instrument. Psychometric properties have yet to be tested. It may serve to compare quality of life for endoscopic or open procedures.

Evaluation of new measures of the impact of hypothyroidism on quality of life and symptoms: the ThyDQoL and ThySRQ

OBJECTIVES

This article reports the psychometric properties of two new condition-specific questionnaires: 1) the 18-item Underactive Thyroid-Dependent Quality of Life Questionnaire (ThyDQoL) individualized measure of perceived impact of hypothyroidism on quality of life (QoL); and 2) the 15-item Underactive Thyroid Symptom Rating Questionnaire (ThySRQ), in which patients rate symptom bother.

METHODS

A cross-sectional survey was conducted of 110 adults with overt and subclinical hypothyroidism, 103 treated with thyroxine. Patients, the majority of whom (81%) were women, were recruited from primary care (57%) and from hospital clinics (43%). The mean age of patients was 55.1 (SD 14.3) years. Respondents rated personally applicable ThyDQoL life domains for importance and impact of hypothyroidism, and ThySRQ symptom bother.

RESULTS

Completion rates were high (>98%). All 18 ThyDQoL domains were rated as negatively impacted by hypothyroidism and important for QoL. The ThyDQoL had high internal consistency reliability (Cronbach's alpha = 0.949 [N = 97]), factor analysis indicated that applicable domains could be combined into an overall Average Weighted Impact score, for which the sample mean, -3.11 (2.2), showed considerable negative impact of hypothyroidism on QoL (maximum possible range -9 to +3). There is good preliminary evidence to justify shortening the ThyDQoL to 14 domain-specific items. For the ThySRQ Cronbach's alpha was 0.808 (N = 95). Highest symptom bother ratings were for hair problems, weight gain, depression, cold, and tiredness.

CONCLUSIONS

Both the ThyDQoL and ThySRQ are highly acceptable to patients with hypothyroidism and have good internal consistency reliability. Their sensitivity to change now needs to be evaluated in clinical trials.

Feedback on the FDA's February 2006 draft guidance on Patient Reported Outcome (PRO) measures from a developer of PRO measures

I believe that the FDA guidelines have already had an impact in encouraging good practice in the use of PROs. There are, however, important improvements that need to be made to the guidelines, particularly in the use of health status and quality of life terminology. It is essential to distinguish between health status and quality of life and to use both terms. Nothing is to be gained and a great deal will be lost if the term quality of life (which has been misused as an umbrella term in the past) is abandoned and replaced with the term health status. Patients want us to consider their quality of life as well as their health. To abandon the term would be to forget about their quality of life and focus only on their health. Patients are well able to tell us what quality of life means to them and to rate the impact of a condition on their quality of life if we use individualised quality of life measures and individualised condition-specific quality of life measures to allow them to do so. Although my experience with PRO measures would support many of the recommendations in the guidelines there are others that I would not fully agree with or would contradict on the basis of my own research evidence. I have provided references to that research and hope that the FDA will feel able to do the same when they finalize their guidelines.

Psychometric properties of two measures of psychological well-being in adult growth hormone deficiency

Background

Psychometric properties of two measures of psychological well-being were evaluated for adults with growth hormone deficiency (GHD): the General Well-being Index, (GWBI) – British version of the Psychological General Well-being Index, and the 12-item Well-being Questionnaire (W-BQ12).

Methods

Reliability, structure and other aspects of validity were investigated in a cross-sectional study of 157 adults with treated or untreated GHD, and sensitivity to change in a randomised placebo-controlled study of three months' growth hormone (GH) withdrawal from 12 of 21 GH-treated adults.

Results

Very high completion rates were evidence that both questionnaires were acceptable to respondents. Factor analyses did not indicate the existence of useful GWBI subscales, but confirmed the validity of calculating a GWBI Total score. However, very high internal consistency reliability (Cronbach's alpha = 0.96, N = 152), probably indicated some item redundancy in the 22-item GWBI. On the other hand, factor analyses confirmed the validity of the three W-BQ12 subscales of Negative Well-being, Energy, and Positive Well-being, each having excellent internal reliability (alphas of 0.86, 0.86 and 0.88, respectively, N from 152 to 154). There was no sign of item redundancy in the highly acceptable Cronbach's alpha of 0.93 (N = 148) for the whole W-BQ12 scale. Whilst neither questionnaire found significant differences between GH-treated and non-GH-treated patients, there were correlations (for GH-treated patients) with duration of GH treatment for GWBI Total (r = -0.36, p = 0.001, N = 85), W-BQ12 Total (r = 0.35, p = 0.001, N = 88) and for all W-BQ12 subscales: thus the longer the duration of GH treatment (ranging from 0.5 to 10 years), the better the well-being. Both questionnaires found that men had significantly better overall well-being than women. The W-BQ12 was more sensitive to change than the GWBI in the GH-Withdrawal study. A significant between-group difference in change in W-BQ12 Energy scores was found [t(18) = 3.25, p = 0.004, 2-tailed]: patients withdrawn from GH had reduced energy at end-point. The GWBI found no significant change.

Conclusion

The W-BQ12 is recommended in preference to the GWBI to measure well-being in adult GHD: it is considerably shorter, has three useful subscales, and has greater sensitivity to change.