Effectiveness of needs-based quality of life instruments

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Conceptualisation of a measurement framework for Needs-based Quality of Life among patients with multimorbidity

Background

Multimorbidity is both an individual and societal problem. For society, patients with multimorbidity increase healthcare costs. For the individual, living with multimorbidity is complex, and there is an inverse relationship between a patient's Quality of Life (QoL) and their number of chronic conditions. Numerous intervention studies target these problems, yet there is no multimorbidity-specific patient-reported outcome measure (PROM) developed specifically for this group with adequate measurement properties to assess QoL. This study explores what overall needs regarding QoL are affected by living with multimorbidity through qualitative interviews. With this, we conceptualise Needs-based QoL specifically for this group, ensuring high content validity (regarding relevance and comprehensiveness) of using the Needs-based approach to measure their QoL. This is essential as this preliminary study leads to the development of the MultiMorbidity Questionnaire (MMQ), a PROM measuring QoL among patients with multimorbidity.

Methods

This study draws upon qualitative interviews with fifteen patients with multimorbidity based on a semi-structured interview guide following the Needs-based approach. This approach allowed the patients to cover needs relevant for their QoL in relation to the complexities of living with multimorbidity. The transcribed interviews were thematically analysed, inspired by Braun and Clarke’s reflexive approach.

Results

Analysis of the interviews resulted in the construction of six intertwined domains relevant to patients with multimorbidity, covering their Needs-based QoL; “Physical ability”, “Self-determination”, “Security”, “Partner and social life”, “Self-image”, and “Personal finances”. “Physical limitations” and “Personal finances” were stated as core needs implicating the other domains.

Conclusion

This study shows six intertwined overall domains relevant for patients with multimorbidity regarding their Needs-based QoL; “Physical ability”, “Self-determination”, “Security”, “Partner and social life”, “Self-image”, and “Personal finances”. These needs are relevant in a Danish context, with a generally high standard of living. Based on this conceptual framework of Need-based QoL for patients with multimorbidity, we will develop items for a new patient-reported outcome measure called the MMQ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00489-0.

Measuring Quality of Life in Carers of People With Dementia: Development and Psychometric Evaluation of Scales measuring the Impact of DEmentia on CARers (SIDECAR)

BACKGROUND AND OBJECTIVES

A 2008 European consensus on research outcome measures in dementia care concluded that measurement of carer quality of life (QoL) was limited. Three systematic reviews (2012, 2017, and 2018) of dementia carer outcome measures found existing instruments wanting. In 2017, recommendations were published for developing reliable measurement tools of carers' needs for research and clinical application. The aim of this study was to develop a new instrument to measure the QoL of dementia carers (family/friends).

METHODS

Items were generated directly from carers following an inductive needs-led approach. Carers (n = 566) from 22 English and Welsh locations then completed the items and comparator measures at three time points. Rasch, factor, and psychometric (reliability, validity, responsiveness, and minimally important differences [MIDs]) analyses were undertaken.

RESULTS

Following factor analysis, the pool of 70 items was refined to three independent scales: primary SIDECAR-D (direct impact of caring upon carer QOL, 18 items), secondary SIDECAR-I (indirect impact, 10 items), and SIDECAR-S (support and information, 11 items). All three scales satisfy Rasch model assumptions. SIDECAR-D, I, S psychometrics: reliability (internal ≥ .70; test-retest ≥ .85); convergent validity (as hypothesized); responsiveness (effect sizes: D: moderate; I and S: small); MIDs (D = 9/100, I = 10/100, S = 11/100).

DISCUSSION AND IMPLICATIONS

SIDECAR scales demonstrate robust measurement properties, meeting COSMIN quality standards for study design and psychometrics. SIDECAR provides a theoretically based needs-led QoL profile specifically for dementia carers. SIDECAR is free for use in public health, social care, and voluntary sector services, and not-for-profit organizations.

More Unnecessary Imaginary Worlds - Part 1: The Institute for Clinical and Economic Review's Evidence Report on Janus Kinase (JAK) Inhibitors in Rheumatoid Arthritis

Previous commentaries in the Formulary Evaluation section of INNOVATIONS in Pharmacy have pointed to the lack of credibility in modeled claims for cost-effectiveness and associated recommendations for pricing by the Institute for Clinical and Economic Review (ICER). The principal objection to ICER reports has been that their modeled claims fail the standards of normal science: they are best seen as pseudoscience. The purpose of this latest commentary is to consider the recently released ICER evidence report for Janus Kinase (JAK) Inhibitors. As ICER continues, in the case of JAK Inhibitors, to apply its modeled cost utility framework with consequent recommendations for pricing adjustments, these recommendations also lack credibility. In contrast with previous ICER evidence reports, the present report adopts only a 12-month timeframe, one due, in large part, to ICER being unable to justify assumptions to drive its construction of imaginary worlds beyond 12 months. This commentary emphasizesagain, why the ICER methodology fails to meet the standards of normal science. Claims made by ICER for the competing JAK Inhibitor therapies lack credibility, are impossible to evaluate, let alone replicate across treatment settings. Even so, it is important to examine a number of key elements in the ICER invention of the 12-month JAK Inhibitor imaginary world. While this does not imply any degree of acceptance of the ICER methodology, one element that merits particular attention is thefailure of the ICER modeling to meet logically defensible measurement standards in its application of generic health related quality of life (HRQoL) ordinal metrics to create its QALY claims. The failure to meet the required standards of fundamental measurement means that the cost-per-QALY claims are invalid. This raises the issue of the application of Rasch Measurement Theory (RMT) in instrument development and the potential role of patient centric outcome (PCO) instruments that represent the patient voice in value claims. The case made here is that the ICER approach should be abandoned as an unnecessary distraction. If we are to meet standards for the discovery of new facts in therapy response then our focus must be on proposing credible, evaluable and replicable claims within disease states. Instruments, such as the Rheumatoid Arthritis Quality of Life (RAQoL)questionnaire that build on the common construct that QoL is the extent to which human needs are fulfilled should be the basis for value claims. HRQoL Instruments that are clinically focused and reflect the value calculus of providers and not patients in measuring response by symptoms and activity limitations are irrelevant. This puts to one side the belief that incremental cost-per-QALY models, the construction of imaginary worlds are, in any sense, a 'gold standard'; a meme embraced by the health technology assessment profession. Claims for incremental cost per QALY outcomes and recommendations for pricing and access driven by willingness to pay thresholds are irrelevant to formulary decisions.

The Impact of Living with Parkinson's Disease: Balancing within a Web of Needs and Demands

This study explores the impact of living with Parkinson's disease (PD). Nineteen persons (11 women) aged 55–84 diagnosed with PD 3–27 years ago participated. Data were collected through semistructured interviews, which were recorded, transcribed verbatim, and analysed by qualitative content analysis. Four categories represented the impact of living with PD: “Changed prerequisites for managing day-to-day demands,” “Loss of identity and dignity,” “Compromised social participation,” and “The use of practical and psychological strategies.” There was a shift from an internal to an external locus of control in managing, control, competence, relatedness, and autonomy. According to self-determination theory, a shift towards extrinsically motivated behaviours may occur when these basic needs are thwarted, leading to compensatory strategies or needs substitutes with negative consequences on health and well-being. We suggest a needs-based approach as an important starting point to better understand the consequences of living with PD and to explore the means for people with PD to acquire an improved quality of life on their own terms. In conclusion, our findings suggest for a shift in focus, from a biomedical to a needs-based approach to understand the impact of living with PD and facilitate more person-centred care and person-centred outcome measurement.

[Prospective validation of the Spanish version of the Short Form-Liver Disease Quality of life]

Health-Related Quality of Life (HRQL) assessed by a specific, validated, brief test is an important measure of the health status perceived by patients diagnosed with chronic liver disease.

AIM

To prospectively validate the SF-LDQOL (Short Form-Liver Disease Quality of Life) instrument in Spanish, in patients diagnosed with liver disease of diverse etiologies and distinct severity levels, attended at the Hospital Universitari de Bellvitge (Barcelona).

METHODS

This observational, longitudinal study was conducted by using the SF-LDQOL in outpatients diagnosed with chronic liver disease. This instrument contains the generic SF-36 test, and 9 liver disease-specific dimensions. We also evaluated socio-demographic features, the number of missing responses, and internal consistency (Cronbach's alpha), as well as Pearson's correlation between SF-36 and SF-LDQOL scores on specific dimensions by means of a multi-trait multi-method technique. The sample consisted of 340 patients.

RESULTS

In 6 out of 9 liver disease-specific dimensions, reliability coefficients for internal consistency exceeded 0.70. The convergent validity of these items was acceptable in 8 out of 9 dimensions, with a scaling success of 100% in each item. Missing items were under 1.5% in all dimensions, except for Sexual Functioning.

CONCLUSIONS

The Spanish version of the SF-LDQOL has, in general, good psychometric properties, making it a useful instrument for clinical practice in a population of patients diagnosed with chronic liver disease, with or without liver transplantation.

Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy

BACKGROUND CONTEXT

Given the unsustainable costs of the US health-care system, health-care purchasers, payers, and hospital systems are adopting the concept of value-based purchasing by shifting care away from low-quality providers or hospitals. Legislation now allows public reporting of these quality rankings. True measures of quality, such as surgical morbidity and validated questionnaires of effectiveness, are burdensome and costly to collect. Hence, patients' satisfaction with care has emerged as a commonly used metric as a proxy for quality because of its feasibility of collection. However, patient satisfaction metrics have yet to be validated as a measure of overall quality of surgical spine care.

PURPOSE

We set out to determine whether patient satisfaction is a valid measure of safety and effectiveness of care in a prospective longitudinal spine registry.

STUDY DESIGN

Prospective longitudinal cohort study.

PATIENT POPULATION

All patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center.

OUTCOME MEASURES

Patient-reported outcome instruments (numeric rating scale [NRS], Oswestry disability index [ODI], neck disability index [NDI], short-form 12-item survey [SF-12], Euro-Qol-5D [EQ-5D], Zung depression scale, and Modified Somatic Perception Questionnaire [MSPQ] anxiety scale), return to work, patient satisfaction with outcome, and patient satisfaction with provider care.

METHODS

All patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center were enrolled into a prospective longitudinal registry. Data collected on all patients included demographics, disease characteristics, treatment variables, readmissions/reoperations, and all 90-day surgical morbidity. Patient-reported outcome instruments (NRS, ODI, NDI, SF-12, EQ-5D, Zung depression scale, and MSPQ anxiety scale), return to work, patient satisfaction with outcome, and patient satisfaction with provider care were recorded at baseline and 3 months after treatment. Receiver-operating characteristic (ROC) curve analysis was performed to determine whether extent of improvement in quality of life (SF-12 physical component summary [PCS]) and disability (ODI/NDI) accurately predicted patient satisfaction versus dissatisfaction. Standard interpretation of area under the curve (AUC) was used: less than 0.7, poor; 0.7 to 0.8, fair; and greater than 0.8, good accuracy. Multivariate logistic regression analysis was performed to determine if surgical morbidity (quality) or improvement in disability and quality of life (effectiveness of care) were independently associated with patient satisfaction.

RESULTS

Four hundred twenty-two (84%) patients completed all questionnaires 3 months after surgery during the reviewed time period (mean age 55±14 years). Lumbar surgery was performed in 287 (68%) and cervical surgery in 135 (32%) patients. There were 51 (12.1%) 90-day complications, including 21 (5.0%) readmissions and 12 (2.8%) return to operating room. Three hundred fifty-eight (84.8%) patients were satisfied with provider care and 288 (68.2%) with their outcome. Satisfaction with provider care: In ROC analyses, extent of improvement in quality of life (SF-12) and disability (ODI/NDI) differentiated satisfaction versus dissatisfaction with care with very poor accuracy (AUC 0.49-0.69). In regression analysis, 3-month morbidity (odds ratio [95% confidence interval]: 1.45 [0.79-2.66]), readmission (0.66 [0.24-1.80]), improvement in quality of life (SF-12 PCS), or improvement in general health (health transition index) were not associated with satisfaction with care. Satisfaction with outcome: In ROC analyses, improvement in quality of life (SF-12) and disability (ODI/NDI) failed to differentiate satisfaction with good accuracy (AUC 0.76). Neither 90-day morbidity (1.05 [0.46-2.34]) nor 90-day readmission (0.27 [0.04-2.04]) was associated with satisfaction with outcome in regression analysis.

CONCLUSIONS

Patient satisfaction is not a valid measure of overall quality or effectiveness of surgical spine care. Patient satisfaction metrics likely represent the patient's subjective contentment with health-care service, a distinct aspect of care. Satisfaction metrics are important patient-centered measures of health-care service but should not be used as a proxy for overall quality, safety, or effectiveness of surgical spine care.

The development and validation of a new coeliac disease quality of life survey (CD-QOL)

BACKGROUND

Previous studies on coeliac disease (CD)-related quality of life (QOL) have been limited by their use of a 'generic' rather than coeliac disease-specific assessment instruments.

AIM

To develop and psychometrically validate a new coeliac disease-specific instrument, the CD-QOL.

METHODS

Through a series of focus groups, we elicited items from patients that related to the specific nature of their disease and its impact on their basic needs. Through expert review, cognitive debriefing with patients and pilot testing, a scale was developed, refined and administered to 387 patients on a gluten-free diet from both community-based support groups and a tertiary care referral centre. Finally, a formal validation study was conducted to assess the psychometric properties of the CD-QOL.

RESULTS

The final CD-QOL has 20 items across four clinically relevant subscales (Limitations, Dysphoria, Health Concerns, and Inadequate Treatment). The CD-QOL has high internal consistency, reliability, and psychometric validation indicates both convergent and discriminate validity.

CONCLUSIONS

The CD-QOL is a reliable and valid measure of coeliac disease related QOL. As a new disease-specific instrument, it is likely to be a useful tool for evaluating patients with this disorder.

Validation of the Japanese version of the Quality of Life-Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA)

OBJECTIVE

To evaluate validity and reliability of the Japanese version of the Quality of Life-Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA).

DESIGN

Observational study; cross-sectional, longitudinal.

METHODS

Seventy-five adults with growth hormone deficiency completed the SF-36 (a generic health-related QOL scale) and the QoL-AGHDA before growth hormone replacement therapy and approximately 3 weeks later (when the therapy began). A sample (n=1000) of controls from the general population was also studied. We computed rates of missing data, measured reproducibility and internal consistency reliability, and tested for known-groups validity, concurrent validity, unidimensionality (by principle component analysis), and content validity.

RESULTS

Rates of missing data were low (0-1.4%). The mean of QoL-AGHDA scores in the patients was 8.2 (SD, 6.4). The scores were reproducible (k=0.41-0.78), and internally consistent (alpha=0.91) and the scale was unidimensional. QoL-AGHDA scores were associated with SF-36 scores as hypothesized. Scores were significantly higher in the patients than in controls (8.1+/-0.7, and 5.6+/-0.2, P<0.001). Discrimination between patients and controls was slightly better using scores on the "General Health" and "Role Physical" subscale of the SF-36 as explanatory variables than using QoL-AGHDA scores.

CONCLUSIONS

The QoL-AGHDA's reliability, validity, and rates of missing data were satisfactory, and the scale was confirmed to be unidimensional. However, because some subscales of the SF-36 were better for discriminating patients from controls, the content validity of the QoL-AGHDA may need to be re-evaluated.