Generic versus disease-specific health status measures. An example using coronary artery disease and congestive heart failure patients

Patient-centered care in Coronary Heart Disease: what do you want to measure? A systematic review of reviews on patient-reported outcome measures

Background

The number of published articles on Patient-Reported Outcomes Measures (PROMs) in Coronary Heart Disease (CHD), a leading cause of disability-adjusted life years lost worldwide, has been growing in the last decades. The aim of this study was to identify all the disease-specific PROMs developed for or used in CHD and summarize their characteristics (regardless of the construct), to facilitate the selection of the most adequate one for each purpose.

Methods

A systematic review of reviews was conducted in MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews. PROQOLID and BiblioPRO libraries were also checked. PROMs were classified by construct and information was extracted from different sources regarding their main characteristics such as aim, number of items, specific dimensions, original language, and metric properties that have been assessed.

Results

After title and abstract screening of 1224 articles, 114 publications were included for full text review. Finally, we identified 56 PROMs: 12 symptoms scales, 3 measuring functional status, 21 measuring Health-Related Quality of Life (HRQL), and 20 focused on other constructs. Three of the symptoms scales were specifically designed for a study (no metric properties evaluated), and only five have been included in a published study in the last decade. Regarding functional status, reliability and validity have been assessed for Duke Activity Index and Seattle Angina Questionnaire, which present multiple language versions. For HRQL, most of the PROMs included physical, emotional, and social domains. Responsiveness has only been evaluated for 10 out the 21 HRQL PROMs identified. Other constructs included psychological aspects, self-efficacy, attitudes, perceptions, threats and expectations about the treatment, knowledge, adjustment, or limitation for work, social support, or self-care.

Conclusions

There is a wide variety of instruments to assess the patients’ perspective in CHD, covering several constructs. This is the first systematic review of specific PROMs for CHD including all constructs. It has practical significance, as it summarizes relevant information that may help clinicians, researchers, and other healthcare stakeholders to choose the most adequate instrument for promoting shared decision making in a trend towards value-based healthcare.

Semaglutide improves health-related quality of life versus placebo when added to standard of care in patients with type 2 diabetes at high cardiovascular risk (SUSTAIN 6)

AIM

To assess what drives change in health-related quality of life (HRQoL) in type 2 diabetes in the SUSTAIN 6 trial and identify potential mediators of the treatment effect of semaglutide on HRQoL scores.

MATERIALS AND METHODS

The Short Form (SF)-36v2® questionnaire [comprising physical component summary (PCS) and mental component summary (MCS)] was used to assess changes in HRQoL from baseline to week 104, by treatment, in a prespecified analysis. This post-hoc analysis assessed change in PCS and MCS using the following factors as parameter/covariate, using descriptive statistics and linear regressions: major adverse cardiac events, hypoglycaemia, gastrointestinal adverse events, at least one episode of nausea, vomiting or diarrhoea, and change in glycated haemoglobin (HbA1c), body weight, blood pressure, heart rate and estimated glomerular filtration rate.

RESULTS

Mean change in overall PCS score was +1.0 with semaglutide versus +0.4 with placebo, and +0.5 versus -0.2 for MCS. The treatment effect of semaglutide versus placebo (unadjusted estimate) was 0.7 [(95% confidence interval 0.1, 1.2); P = 0.018] on PCS and this was reduced when adjusted for change in HbA1c [0.4 (-0.2, 1.0), P = .167] and body weight [0.3 (-0.3, 0.9), P = .314]. The unadjusted treatment effect on MCS [0.7 (-0.0, 1.5), P = .054] was only reduced when adjusted for change in HbA1c [0.3 (-0.4, 1.1), P = .397]. When adjusting for all other parameters separately, the estimated effect of semaglutide on PCS and MCS qualitatively did not change.

CONCLUSIONS

Semaglutide improved HRQoL versus placebo; greater improvements with semaglutide versus placebo were possibly mediated, in part, by change in HbA1c and body weight. Clinicaltrials.gov: NCT01720446 (SUSTAIN 6).

Cross-Sectional and Longitudinal Construct Validity of the Generic KINDL-A(dult)B(rief) Questionnaire in Adults with Thrombophilia or with Hereditary and Acquired Bleeding Disorders

BACKGROUND/AIMS

The newly adapted generic KINDL-A(dult)B(rief) questionnaire showed satisfactory cross-sectional psychometric properties in adults with bleeding disorders or thrombophilia. This investigation aimed to evaluate its cross-sectional and longitudinal construct validity.

METHODS

After ethical committee approval and written informed consent, 335 patients (mean age 51.8 ± 16.6 years, 60% women) with either predominant thrombophilia (n = 260) or predominant bleeding disorders (n = 75) participated. At baseline, patients answered the KINDL-AB, the MOS 36-item Short-Form Health Survey (SF-36), and the EQ-5D-3L. A subgroup of 117 patients repeated the questionnaire after a median follow-up of 2.6 years (range: 0.4-3.5). A priori hypotheses were evaluated regarding convergent correlations between KINDL-AB overall well-being and specific subscales, EQ-5D-3L index values (EQ-IV), EQ-5D visual analog scale (EQ-VAS), and SF-36 subscales.

RESULTS

Contrary to hypothesis, baseline correlations between the KINDL-AB and EQ-IV/EQ-VAS were all moderate while, as hypothesized, several KINDL-AB subscales and SF-36 subscales correlated strongly. At follow-up, no significant changes in all three instruments occurred. Correlations between instruments over the follow-up were mostly moderate and partially strong. Contrary to hypothesis but consistent with no significant changes in health-related quality of life, convergent correlations between changes in KINDL-AB overall well-being, physical and psychological well-being, and EQ-IV/EQ-VAS were all weak.

CONCLUSIONS

While repeated measures of KINDL-AB showed moderate to strong correlations, changes in KINDL-AB overall well-being and subscales correlated more weakly than expected with changes involving two established instruments of generic health status.

Enhancing Postoperative Recovery of Cardiac Surgery Patients

The purpose of this trial was to determine the effectiveness of advanced practice nursing support on cardiac surgery patients’ during the first 5 weeks following hospital discharge. Patients ( N = 200) were randomly allocated to two groups: (a) an intervention group who received telephone calls from an advanced practice nurse (APN) familiar with their clinical condition and care needs, twice during the first week following discharge then weekly thereafter for 4 weeks, and (b) a usual care group. Measures of health-related quality of life (HRQL), symptom distress, satisfaction with recovery care, and unexpected health care contacts were obtained at 5 weeks following discharge. There were no significant group differences in HRQL, unexpected contacts with the health care system, or symptom distress. The provision of APN support via telephone followup after cardiac surgery is feasible. However, further randomized trials of single and multicomponent APN interventions are needed to prove effectiveness.

Reliability of the adult myopathy assessment tool in individuals with myositis

OBJECTIVE

The Adult Myopathy Assessment Tool (AMAT) is a 13-item performance-based battery developed to assess functional status and muscle endurance. The purpose of this study was to determine the intrarater and interrater reliability of the AMAT in adults with myositis.

METHODS

Nineteen raters (13 physical therapists and 6 physicians) scored videotaped recordings of patients with myositis performing the AMAT for a total of 114 tests and 1,482 item observations per session. Raters rescored the AMAT test and item observations during a followup session (mean ± SD 19 ± 6 days between scoring sessions). All raters completed a single, self-directed, electronic training module prior to the initial scoring session.

RESULTS

Intrarater and interrater reliability correlation coefficients were ≥0.94 for the AMAT functional subscale, endurance subscale, and total score (all P < 0.02 for Ho , ρ ≤0.75). All AMAT items had satisfactory intrarater agreement (kappa statistics with Fleiss-Cohen weights, with values κw = 0.57-1.00). Interrater agreement was acceptable for each AMAT item (κ = 0.56-0.89) except the sit up (κ = 0.16). The standard error of measurement and 95% confidence interval range for the AMAT total scores did not exceed 2 points across all observations (AMAT total score range 0-45).

CONCLUSION

The AMAT is a reliable, domain-specific assessment of functional status and muscle endurance for adult subjects with myositis. Results of this study suggest that physicians and physical therapists may reliably score the AMAT following a single training session. The AMAT functional subscale, endurance subscale, and total score exhibit interrater and intrarater reliability suitable for clinical and research use.

Functional health status in children and adolescents after Fontan: comparison of generic and disease-specific assessments

PURPOSE

The aim of this study was to compare associations between generic versus disease-specific functional health status assessments and patient and clinical characteristics for patients with severe congenital heart disease.

METHODS

This was a cross-sectional observational study involving 325 single ventricle patients, aged 10-18 years, after Fontan procedure. Enrolled patients underwent a medical history review, laboratory testing, and assessment of the functional health status by completion of the generic Child Report Child Health Questionnaire and the disease-specific Congenital Heart Adolescent and Teenage questionnaire. Correlated conceptually equivalent domains from both questionnaires were identified and their associations with patient and clinical variables were compared.

RESULTS

From the generic assessment, patients perceived marginally lower physical functioning (p = 0.05) but greater freedom from bodily pain compared with a normal population (p < 0.001). The equivalent physical functioning/limitations domain of the generic instrument, compared with the disease-specific instrument, had similar associations (higher multi-variable model R²) with medical history variables (R² = 0.14 versus R² = 0.12, respectively) and stronger associations with exercise testing variables (R² = 0.22 versus R² = 0.06). Similarly, the corresponding freedom from bodily pain/symptoms domains from both questionnaires showed a greater association for the generic instrument with medical history variables (R² = 0.15 versus R² = 0.09, respectively) and non-cardiac conditions (R² = 0.13 versus R² = 0.06). The associations of each questionnaire with echocardiographic results, cardiac magnetic resonance imaging results, and serum brain natriuretic peptide levels were uniformly weak (R² range <0.01 to 0.04).

CONCLUSIONS

Assessment of the physical functional health status using generic and disease-specific instruments yields few differences with regard to associations between conceptually similar domains and patient and clinical characteristics for adolescents after Fontan procedure.

Are repeated single-limb heel raises and manual muscle testing associated with peak plantar-flexor force in people with inclusion body myositis?

BACKGROUND

Repeated heel raises have been proposed as a method of ankle plantar-flexor strength testing that circumvents the limitations of manual muscle testing (MMT).

OBJECTIVE

The study objective was to examine the relationships among ankle plantar-flexion isometric maximum voluntary contraction (MVC), repeated single-limb heel raises (SLHRs), and MMT in people with myositis.

DESIGN

This was a cross-sectional study with a between-group design. The ability to complete 1 SLHR determined group assignment (SLHR group, n=24; no-SLHR group, n=19).

METHODS

Forty-three participants with myositis (13 women; median age=64.9 years) participated. Outcome measures included MVC, predicted MVC, Kendall MMT, and Daniels-Worthingham MMT.

RESULTS

The Kendall MMT was unable to detect significant ankle plantar-flexor weakness established by quantitative methods and was unable to discriminate between participants who could and those who could not perform the SLHR task. Ankle plantar-flexion MVC was not associated with the number of heel-raise repetitions in the SLHR group (pseudo R(2)=.13). No significant relationship was observed between MVC values and MMT grades in the SLHR and no-SLHR groups. However, a moderate relationship between MVC values and MMT grades was evident in a combined-group analysis (ρ=.50-.67).

LIMITATIONS

The lower half of both MMT grading scales was not represented in the study despite the profound weakness of the participants.

CONCLUSIONS

Both Kendall MMT and Daniels-Worthingham MMT had limited utility in the assessment of ankle plantar-flexor strength. Repeated SLHRs should not be used as a proxy measure of ankle plantar-flexion MVC in people with myositis.

Quality of life after abdominal wall reconstruction following open abdomen

BACKGROUND

Management of intra-abdominal hypertension with an open abdomen and planned ventral hernia results in decreased mortality. But, delayed abdominal wall reconstruction (DAWR) is necessary. Results after DAWR demonstrate acceptable recurrence, morbidity, and mortality rates. However, little is known about quality of life (QOL) after DAWR. The purpose of this study was to analyze QOL after DAWR.

METHODS

Patients who had DAWR>15 years were identified from operative logs of a trauma center. Patients were contacted, and a QOL assessment was administered in person or via telephone. The QOL assessment contained the Short-Form 36-Item Health Survey 1.0, the Posttraumatic Stress Disorder (PTSD) Checklist-Civilian Version, and the Centers for Epidemiologic Studies Depression Scale.

RESULTS

The QOL assessment was completed by 41 of 152 patients. The indication for open abdomen was injury in 37 (90%) and emergency operation in 4 (10%). Time to follow-up ranged from 9 months to 14.6 years after DAWR. Of 31 patients working before DAWR, 23% had not returned to work secondary to DAWR. Also, 65% screened positive for depression and 23% screened positive for PTSD. Compared with population norms Physical Component Scores were significantly lower for the study population (41.1±13.2, p<0.05).

CONCLUSION

Patients who undergo DAWR have decreased physical functioning and have a high prevalence of PTSD and depression. Consideration should be given to screening for depression and PTSD in this patient population.

Further validation of the short form versions of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ)

AIMS

To evaluate validity and responsiveness of PFDI and PFIQ short forms across four multi-center studies and develop conversion formulas between short and long versions.

METHODS

1,006 participants in four prospective studies of pelvic floor disorders completed long versions of the PFDI, PFIQ, and SF-36 (or SF-12) at baseline and 3 and 12 months after treatment. Responses were used to calculate scores for the short versions. We calculated correlations between scale versions using Pearson's correlation coefficient and compared their relative responsiveness using the standardized response mean.

RESULTS

PFDI and PFIQ short form scale scores demonstrated excellent correlations with long versions and similar responsiveness. Responsiveness was good to excellent for PFDI-20 urinary and prolapse scales, moderate for PFDI-20 colorectal scale and each of the PFIQ-7 scales, and poor for SF-36 (or SF-12) summary scores. Conversion formulas demonstrated excellent goodness of fit.

CONCLUSIONS

The long and short forms of the PFDI and PFIQ correlate well and have similar overall responsiveness in participants from four different prospective multicenter studies consisting of diverse patient populations with a broad range of pelvic floor disorders. The short forms provide a reliable and valid alternative in situations where reduced response burden is desired.

Adherence, asthma control, generic and disease-specific quality-of-life instruments in asthma

Prior studies have investigated the association between generic health-related quality of life and medication adherence. The objective of this study was to assess the association between medication adherence and health-related quality of life using both a disease-specific and generic metric in a community setting. Overall, the authors' study findings show no association between adherence and health-related quality of life, supporting the results by Cote and colleagues that factors other than medication adherence are important in explaining health-related quality of life. Furthermore, adherence was not significantly associated with asthma severity, although the strong association between asthma control and health-related quality of life, and asthma control and adherence indicates that asthma control is an important vital sign.

Structure of health-related quality of life among people with and without functional limitations

PURPOSE

The objective of this study was to assess the factor structure of nine health-related quality of life (HRQOL) survey items among people with and without disabilities or functional limitations (FL) and determine whether factor loadings were similar for the two groups.

METHODS

Data were from US states and territories in the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). Confirmatory factor analyses assessed fit of the data to a previously found factor structure.

RESULTS

A two-factor structure was confirmed, conceptually representing physical and mental health. Although this structure fit data for both people with and without FL, factor loadings were significantly different for the two groups. In all but one instance, factor loadings were higher for people with FL than for people without FL.

CONCLUSIONS

Results suggest that people with and without FL conceptualize physical and mental HRQOL similarly. However, the nine items analyzed appear to be a better reflection of the latent constructs of physical and mental HRQOL in the population of people with FL than those without FL.

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.

The correlation between health status and quality of life in southern Brazil

CONTEXT AND OBJECTIVE

The interconnections between quality of life and health status as assessed via questionnaires have not been thoroughly investigated. The objective of this study was to investigate a possible correlation between the constructs of general health status and quality of life as assessed by the Portuguese versions of two questionnaires recently adapted and tested in Brazil.

DESIGN AND SETTING

This was a cross-sectional study in which two self-administered questionnaires were used. This investigation was conducted at healthcare services associated with the Universidade de Caxias do Sul, Brazil.

METHODS

This study presents data from a sample of 120 volunteers who completed the Portuguese versions of the Personal Health Scale and the Multicultural Quality of Life Index questionnaires. Bivariate linear regression analysis and Pearson correlation coefficients were generated from the scores of the two questionnaires.

RESULTS

A significant correlation between the concepts of quality of life and health status as evaluated by the Portuguese versions of both questionnaires was observed. Almost all of the health-related questions displayed strong correlations with the overall concept of quality of life. The magnitude of this correlation accounted for almost half of the observed variance.

CONCLUSIONS

These findings indicate that, within this sample, health-related issues were key factors for the overall experience of wellbeing and quality of life. The similarities observed across the different groups indicate that the interrelation between health status and quality of life was homogenous, regardless of presence and/or type of ailments.

Triangulating patient and clinician perspectives on clinically important differences in health-related quality of life among patients with heart disease

OBJECTIVE

To use triangulation methodology to better understand clinically important differences (CIDs) in the health-related quality of life (HRQoL) of patients with heart disease.

DATA SOURCES/STUDY SETTING

We used three information sources: a nine-member expert panel, 656 primary care outpatients with coronary artery disease (CAD) and/or congestive heart failure (CHF), and the 46 primary care physicians (PCPs) treating these outpatients. From them, we derived CIDs for the Modified Chronic Heart Failure Questionnaire (CHQ) and the Medical Outcomes Study Short Form 36-Item Health Status Survey, Version 2 (SF-36).

STUDY DESIGN

The expert physician panel employed Delphi and consensus methods to obtain CIDs. The outpatients received bimonthly HRQoL interviews for 1 year that included the CHQ and SF-36, as well as retrospective assessments of HRQoL changes. Their PCPs assessed changes in the patient's condition at follow-up clinic visits that were linked to HRQoL assessments to determine change over time.

DATA COLLECTION/EXTRACTION METHODS

Patient- and PCP-assessed changes were categorized as trivial (no change), small, moderate, or large improvements or declines. Moderate or large changes in HRQoL reflect the added risk or investment associated with some treatment modifications. Estimates for each categorization were calculated by finding the mean change scores within anchored change classifications.

PRINCIPAL FINDINGS

The small CID for the CHQ domains was consistently one to two points using the patient-assessed change categorizations, but small CIDs varied greatly for the SF-36. PCP-assessed changes differed substantially from patient estimates for both the CHQ and SF-36, while the panel-derived estimates were generally larger than those derived from patients.

CONCLUSIONS

Triangulation methodology provides a framework for securing a deeper understanding of each informant group's perspective on CIDs for these patient-reported outcome measures. These results demonstrate little consensus and suggest that the derived estimates depend on the rater and assessment methodology.

Development of a headache-specific disability questionnaire for patients attending physiotherapy

Headaches are relatively common, often leading to impaired function and decreased quality of life. Physiotherapists and other manual therapists treat patients with headaches when musculoskeletal dysfunction is the likely source or a significant contributing factor. The aim of this study was to develop a specific disability measure for use in a population of patients presenting for physiotherapy treatment of headache. Patients (N=111) presenting to private physiotherapy practices in Victoria, Australia, for treatment of headaches completed a pre-existing, 16-item, headache disability questionnaire. Item responses were analysed separately to identify floor and ceiling effects and response rates, and by multivariate techniques to determine internal consistency and to identify unduly influential variables and underlying dimensions. Seven items from the original questionnaire were deleted due to significant floor effects, having low item-total correlations or after being judged unduly influential variables. The remaining nine items addressed the domains of pain severity, prevention of activity and reduction in ability to perform activities. The results of this study have led to the development of a valid and internally consistent questionnaire for measurement of the impact of headaches on patients receiving physiotherapy treatment. Further research is underway to examine the responsiveness and test-retest reliability of the questionnaire.

The portuguese version of the personal health scale: a validation study in southern Brazil

The Personal Health Scale is a concise instrument for comprehensive culture-informed and self-rated assessment of general health status and well-being. It is composed of 10 questions that appraise different health dimensions collated from the international literature, including aspects ranging from somatic and psychological domains to social functioning and insight.

PURPOSE

In this investigation, results of a study conducted in Southern Brazil to test and validate the Portuguese version of the Personal Health Scale (PHS-Pt) are presented.

METHOD

This study analyzes data from a sample of 120 Brazilian volunteers (90 patients and 30 health care professionals). All patients completed the Portuguese version of the Personal Health Scale under a minimal guidance by trained examiners, who followed standardized instructional procedures.

RESULTS

The internal consistency of the PHS-Pt attained a Cronbach's a of 0.75 among patients and of 0.69 among health care professionals. The test-retest reliability correlation coefficient yielded a score of 0.82. Furthermore, the PHS-Pt was able to detect a significant discriminating validity between the 2 evaluated samples (P < .001).

CONCLUSIONS

The original English version of the Personal Health Scale was successfully adapted to Portuguese as methodologically demonstrated herein. The PHS-Pt constitutes a reliable and trustworthy research instrument for evaluating health status in Brazil, since it is appropriately designed to distinguish different groups of volunteers regarding their health status.

Reliability and validity of functional health status and health-related quality of life questionnaires in children with recurrent acute otitis media

In this study the reliability and validity of generic and disease-specific questionnaires has been assessed focusing on responsiveness. This is part of a study on the effects of recurrent acute otitis media (rAOM) on functional health status (FHS) and health-related quality of life (HRQoL) in 383 children with rAOM participating in a randomized clinical trial. The following generic questionnaires were studied: 1. RAND general health rating index, 2. Functional Status Questionnaire (FSQ Generic and FSQ Specific), 3. TNO-AZL Infant Quality of Life (TAIQOL), and the following disease-specific questionnaires: 1. Otitis Media-6 (OM-6), 2. Numerical rating scales (NRS) for child and caregiver (NRS Child and NRS Caregiver), and 3. a new Family Functioning Questionnaire (FFQ). Reliability was good to excellent (Cronbach’s α range 0.80–0.90, intraclass correlation coefficient range 0.76–0.93). Moderate to strong correlations were found between the questionnaires as well as between questionnaires and relevant clinical indicators (r = 0.29–0.49), demonstrating construct validity. Discriminant validity for children with few versus frequent episodes of acute otitis media per year was good for most questionnaires (P < 0.004) but poor for the otitis media-related subscales of the TAIQOL (P = 0.10–0.97) and both NRS (P = 0.22 and 0.48). Except for the TAIQOL subscales, change scores were significant (P < 0.003) for generic and disease-specific questionnaires. Effect sizes were somewhat higher for disease-specific compared to generic questionnaires (0.55–0.95 versus 0.32–0.60) except for the TAIQOL subscales, which showed very poor sensitivity to change. Anchor-based methods resulted in a somewhat larger range of estimates of MCID than distribution-based methods. Combining distribution-based and anchor-based methods resulted in similar ranges for the minimally clinical important differences for generic and disease-specific questionnaires: 2–15 points on a 0–100 scale. Apart from the generic TAIQOL subscales, both generic and disease-specific questionnaires used in this study showed good psychometric qualities and responsiveness for use in clinical studies on children with rAOM.

Identifying heart failure patients at high risk for near-term cardiovascular events with serial health status assessments

BACKGROUND

Identification of heart failure outpatients at increased risk for clinical deterioration remains a critical challenge, with few tools currently available to assist clinicians. We tested whether serial health status assessments with the Kansas City Cardiomyopathy Questionnaire (KCCQ) can identify patients at increased risk for mortality and hospitalization.

METHODS AND RESULTS

We evaluated 1358 patients with heart failure after an acute myocardial infarction in the Eplerenone's Neurohormonal Efficacy and Survival Study, a multicenter randomized trial that included serial KCCQ assessments. Cox proportional-hazards models were used to examine whether changes in KCCQ scores during successive outpatient visits were independently associated with all-cause mortality and cardiovascular mortality or hospitalization. Change in KCCQ (deltaKCCQ) was linearly associated with all-cause mortality (hazard ratio [HR], for each 5-point decrease in deltaKCCQ, 1.11; 95% CI, 1.04 to 1.19) and the combined outcome of cardiovascular mortality or hospitalization (HR for each 5-point decrease in deltaKCCQ, 1.12; 95% CI 1.07 to 1.18). In Kaplan-Meier survival analysis, all-cause mortality among patients with deltaKCCQ of < or = -10, > -10 to < 10, and > 10 points was 26%, 16%, and 13%, respectively (P=0.008). After multivariable adjustment, the linear relationship between deltaKCCQ and both all-cause mortality and combined cardiovascular death and hospitalization persisted (HR, 1.09; 95% CI, 1.00 to 1.18; and HR, 1.11; 95% CI, 1.05 to 1.17 for each 5-point decrease in deltaKCCQ, respectively).

CONCLUSIONS

In heart failure outpatients, serial health status assessments with the KCCQ can identify high-risk patients and may prove useful in directing the frequency of follow-up and the intensity of treatment.

Validation of a structured questionnaire as an instrument to measure chronic pain in dogs on the basis of effects on health-related quality of life

OBJECTIVE

To validate the use of a novel questionnaire as an instrument for measurement of chronic pain in dogs through its impact on health-related quality of life (HRQL).

ANIMALS

108 dogs with chronic degenerative joint disease and 26 healthy dogs.

PROCEDURES

Questionnaire responses were subjected to factor analysis (FA) and questionnaire scores to discriminant analysis to evaluate construct validity. Questionnaire scores were used to explore the potential of this instrument for minimizing respondent bias and for evaluative purposes.

RESULTS

FA results revealed a sensible factor structure accounting for 65% of the variance in data, with factors identifiable as domains of HRQL in dogs affected by chronic pain. Further evidence for construct validity was provided when questionnaire scores were used to discriminate, on the basis of 218 questionnaires, between dogs with clinician-awarded pain scores of 0 and dogs with pain scores >or= 1 (88% discrimination, with 95% of no-pain group dogs and 87% of some-pain group dogs correctly categorized). Use of the questionnaire provided minimized respondent bias.

CONCLUSIONS AND CLINICAL RELEVANCE

Validation of the questionnaire as an instrument for discriminative and evaluative measurements of orthopedic chronic pain through its impact on HRQL in dogs was provided. Use of the questionnaire, with further testing and refinement, may support improved clinical decision making, facilitate development of evidence-based therapeutic options for chronic diseases, and help veterinarians and owners define humane end points in dogs.

IMPACT FOR HUMAN MEDICINE

Information gained here may provide improved measurements of clinical change in animal studies that use dogs with naturally occurring chronic pain to evaluate novel human treatment protocols.

Predicting quality of life six months after traumatic injury

BACKGROUND

Many factors are known to impact quality of life (QoL) after injury, but predictors of diminished QoL and the time course of recovery remain incompletely understood. This study examines predictors and correlates of QoL measured by the Short Form-36 (SF-36) one and six months postinjury.

METHODS

Adults with nonneurologic blunt injury were prospectively enrolled. Demographic, injury, and socioeconomic data were collected. Patients were assessed with functional and psychologic measures. In all, 196 patients had 1-month data and 123 had 6-month data available. Scores were compared at each time point and also to population norms using t-tests. Multiple regression techniques were used to identify associations between the physical and mental component scores (PCS & MCS) of the SF-36 and patient characteristics.

RESULTS

PCS scores improved significantly (32.8 +/- 0.9 versus 41.3 +/- 1.0, p < 0.05) whereas MCS scores (47.5 +/- 1.1 versus 47.2 +/- 1.1, p = NS) did not. Both remained significantly below population norms. Functional Independence Measure (FIM) at one month was predictive of PCS at 6 months. Posttraumatic stress disorder (PTSD) was predictive of lower MCS, and depression was associated with poor MCS. Injury Severity Score was not associated with PCS or MCS.

CONCLUSIONS

Overall physical and mental QoL measured by the SF-36 remains significantly below population norms 6 months after traumatic injury. It is possible to identify patients at risk for diminished QoL early during recovery by screening for functional status, PTSD, social support, and depression. Interventions to address these areas should be further studied with respect to their impact on long-term QoL.

Physician-estimated disease severity in patients with chronic heart or lung disease: a cross-sectional analysis

BACKGROUND

We evaluated how well physicians' global estimates of disease severity correspond to more specific physician-rated disease variables as well as patients' self-rated health and other patient variables.

METHODS

We analyzed baseline data from 1662 primary care patients with chronic cardiac or pulmonary disease who were enrolled in a longitudinal study of health-related quality of life (HRQoL). Each patient's primary physician rated overall disease severity, estimated the two-year risk of hospitalization and mortality, and reported the use of disease-specific medications, tests, and subspecialty referrals. Patient variables included sociodemographic characteristics, psychosocial factors, self-rated health, and both generic and disease-specific HRQoL.

RESULTS

Physicians rated 40% of their patients "about average", 30% "worse", and 30% "better" than the typical patient seen with the specific target disorder. The physician's global estimate of disease severity was strongly associated (P < 0.001) with each of the five more specific elements of physician-rated disease severity, but only marginally associated with patient self-rated health. Multivariable regression identified a set of patient variables that explained 16.4% of the variance in physician-rated disease severity.

CONCLUSION

Physicians' global ratings may provide disease severity and prognostic information unique from and complementary to patient self-rated health and HRQoL measures. The elements influencing physician-rated disease severity and its predictive validity for clinical outcomes warrant prospective investigation.

Is a generic quality of life instrument helpful for evaluating women with urinary incontinence?

OBJECTIVES

The aim of this study was to determine whether a generic health outcome instrument would be helpful for evaluating women with stress urinary incontinence (UI) combined with or without urge UI.

METHODS

A total of 109 women with UI and 80 controls participated in the study. Health-related quality of life (QOL) was measured using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) and the Incontinence Quality of Life (I-QoL) questionnaire.

RESULTS

Among eight domains of the SF-36 questionnaire, only four domains, namely, 'role-physical functioning' (p<0.05), 'vitality' (p<0.05), 'mental health' (p<0.05) and 'bodily pain' (p<0.05) were significantly different between the groups. Comparing the I-QoL sores in the two groups, patients with UI had significantly poorer subscale scores of I-QoL than the controls (p<0.05 for all domains). When women with UI were subdivided into groups of stress and mixed UI, only 2 domains of the SF-36 questionnaire, 'role-physical functioning' (p<0.05) and 'bodily pain' (p<0.05), were significantly different. The mixed UI group had higher scores only on these two domains compared to the stress UI group. In the 'role-physical functioning' domain, there was no significant difference between the mixed UI group and the controls. In 'bodily pain' domain, there was no significant difference between the stress UI group and the controls. The mixed group had the highest scores observed. Patients with mixed UI had significantly lower total scores compared to those with stress UI, including the subscale score of 'avoidance behavior' of the I-QoL. Among eight domains of the SF-36, only 'physical functioning' (r = 0.281, p<0.01) and 'social functioning' (r = 0.239, p<0.05) were weakly correlated with 'psychological impact' of the I-QoL.

CONCLUSION

Our findings show that the generic QOL instrument is not sensitive measure of QOL in women with UI.

Health-related quality of life in patients with inflammatory bowel disease measured with the short form-36: psychometric assessments and a comparison with general population norms

BACKGROUND

We compared health-related quality of life (HRQOL) in a population-based cohort of Norwegian patients with inflammatory bowel disease (IBD) with a normal reference population by means of the short form-36 (SF-36) questionnaire, including the effect of age, sex, educational status, and symptom severity and the psychometric properties of the questionnaire.

METHODS

The SF-36 was self-administered and was answered by the patients at the hospital at 2 occasions that were 6 months apart.

RESULTS

Five hundred fourteen patients with IBD were eligible for analysis: 348 with ulcerative colitis (UC) and 166 with Crohn's disease (CD). The comparison group consisted of 2323 Norwegian people. The dimension scores for SF-36 were significantly lower in 6 of 8 dimensions for patients with UC and in 7 of 8 dimensions for patients with CD than for the reference population. In both patients with UC and patients with CD, we found lower scores in elderly patients, which also was found in the background population. Women scored lower than men in all dimension scores. In both patients with UC and patients with CD, there was a statistically significant reduction in HRQOL score with increasing symptoms. The SF-36 has satisfactory reliability and discriminant ability for scores for all dimensions in both patients with UC and patients with CD. However, when measuring responsiveness, the figures were generally low. This finding, together with the high ceiling effects, may indicate that the SF-36 has limitations regarding detecting deterioration or improvement over time.

CONCLUSION

We have shown that HRQOL in a Norwegian population-based cohort of patients with IBD, measured with the SF-36, is lower than that of a Norwegian reference population. In general, the SF-36 was found to have satisfactory psychometric properties in this IBD population.

Health-related quality-of-life tools in heart failure

Heart failure is one of the most debilitating chronic conditions that is likely to make ever-increasing demands on doctors' time over the next 10 years. Both the incidence and prevalence of the disease are predicted to rise substantially, defying the general downward trend reported in other cardiovascular disorders. Although momentous advances have been achieved in controlling the disease, patient-reported outcomes including health-related quality of life require more attention in patient-centered healthcare and clinical trials. There are many studies that use generic and condition-specific tools in heart failure patients. This special report provides a concise digest of condition-specific health-related quality-of-life tools in heart failure from a clinical perspective.

A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease

OBJECTIVE

On the eight scales of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), Version 2, we compared the clinically important difference (CID) thresholds for change over time developed by three separate expert panels of physicians with experience in quality of life assessment among patients with chronic obstructive pulmonary disease (COPD), asthma, and heart disease.

STUDY DESIGN

We used a modified Delphi technique combined with a face-to-face panel meeting within each disease to organize and conduct the consensus process among the expert panelists, who were familiar with the assessment and evaluations of health-related quality of life (HRQL) measures among patients with the panel-specific disease.

PRINCIPAL FINDINGS

Each of the expert panels first determined the magnitude of the smallest numerically possible change on each SF-36 scale, referred to as a state change, and then built their CIDs from this metric. All three panels attained consensus on the scale changes that constituted small, moderate, and large clinically important SF-36 change scores. The CIDs established by the heart disease panel were generally greater than the CIDs agreed on by the asthma and COPD panels.

CONCLUSIONS

These panel-derived thresholds reflect possible differences in disease management among the represented panel-specific diseases, and are all greater than the minimal CID thresholds previously developed for the SF-36 scales among patients with arthritis. If confirmed among patients with the relevant diseases and those patients' physicians, these disease-specific CIDs could assist both researchers and practicing clinicians in the use and interpretation of HRQL changes over time.

Minimal important difference thresholds and the standard error of measurement: is there a connection?

Several recently published investigations have examined the relationship between the magnitude of the standard error of measurement (SEM) and established thresholds for a minimal clinically important difference (MCID) or a minimal important difference (MID) for change scores on health-related quality of life (HRQOL) or health status measures. These investigations, however, have resulted in differing SEM criteria for the MCID or MID. This study reviews and compares two sets of studies: (1) three investigations using a disease-specific HRQOL measure among patient samples with the chronic disease (heart disease, chronic obstructive pulmonary disease, or asthma) that have consistently demonstrated a 1 SEM correspondence with the established MCIDs or MIDs and (2) three investigations among patients referred to physical therapists with back, lower extremity, and neck pain showing that approximately 2.3 SEMs estimated the established MCID standards for three different measures of health status. Chronic disease patients were classified to have a MCID or MID if their global change ratings for the better or the worse were 1, 2, or 3 on a Likert scale ranging from 1 (almost the same, hardly any better, or worse at all) to 7 (a very great deal better or worse). Back pain patients, however, needed average global transition scores of 5, 6, or 7 (a good, a great, or a very great deal better) on the same 7-point Likert scale in order to experience an MCID in their condition. Charting these change levels against their respective SEM-MID criteria provides insight and promise for linking SEM-based criteria to MCID standards for other HRQOL and health status measures.

Effects of exercise training on aerobic capacity and quality of life in individuals with heart failure

PURPOSE

The purpose of this study was to determine whether subjects with chronic heart failure, who completed a 12-week rehabilitation program, would have significantly greater quality of life, better aerobic fitness, less difficulty with symptoms of heart failure, greater self-efficacy for exercise, and higher daily activity levels when compared with subjects in a control group.

METHODS

Thirty-one males, aged 64 +/- 10 years with left ventricular ejection fraction of 29 +/- 7%, were randomized to a moderate intensity supervised aerobic exercise program (n = 15) or a control group (n = 16). Twenty-seven subjects completed at least 1 follow-up assessment.

RESULTS

After 12 weeks there were significant differences in the change scores for perceived physical function (using RAND Corporation's 36-item short form) (P =.025) and peak oxygen uptake (P =.019) between the exercise and control groups with the exercise group experiencing improved physical function and fitness.

CONCLUSIONS

Exercise training in adults with heart failure increases exercise tolerance and perceived physical function. Improved heart failure symptoms, self-efficacy for exercise, or increased physical activity may not be associated with enhancement of exercise tolerance.

Quality of life and coping following minimally invasive direct coronary artery bypass (MIDCAB) surgery

Minimally invasive direct coronary artery bypass (MIDCAB) surgery has been shown to be a promising technique for surgical treatment of single or double vessel disease. However, little is known about quality of life, mood state or coping in this group of patients. The records of 55 consecutive patients who underwent MIDCAB surgery at Harefield Hospital between April 1999 and May 2001 were reviewed. In order to assess quality of life, mood state and coping, patients were contacted by telephone to conduct a semi-structured interview and were subsequently sent four questionnaires. The measures used were the Hospital Anxiety and Depression Scale, the Short Form Health Survey, the WHOQoL-BREF and the COPE. Forty-eight patients were contacted by telephone, forty-four of whom returned the completed questionnaires. Overall ratings of quality of life were excellent for the majority of patients, and rates of anxiety and depression were lower than previously found following coronary artery bypass surgery. It is concluded that following MIDCAB surgery quality of life and mood state outcomes are encouraging. However, a prospective, longitudinal study is now required to further elucidate the relationship between quality of life, mood state and coping and to identify predictive factors for physical and psychological outcome following this new surgical technique.

Clinically important differences in health status for patients with heart disease: an expert consensus panel report

BACKGROUND

The purpose of the study was to develop clinically important difference (CID) standards for patients with coronary artery disease and congestive heart failure that identify small, moderate, and large intraindividual changes with time in a modified version of the Chronic Heart Failure Questionnaire (CHQ) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, version 2). Prior work in ascertaining important difference standards for the CHQ have centered on patient-perceived changes. No important difference standards for the SF-36 have been published for patients with heart disease. This development of CIDs would facilitate the use of health status measures in daily clinical decision-making.

METHODS

We used a modification of the RAND Appropriateness Method to assemble and guide a 9-member consensus panel of physicians with substantial experience in using the CHQ or the SF-36 among patients with heart disease.

RESULTS

On the basis of their own experience using these measures and an extensive review of articles describing the development and use of these instruments, the expert panel achieved consensus on small, medium, and large clinically relevant changes in scores for the CHQ and SF-36. The CID standards established by this panel were slightly higher than the minimal important difference standards previously established for the CHQ using patient-perceived changes.

CONCLUSIONS

The CID standards established by this expert panel provide an important and useful tool for determining whether routine clinical health status assessments will benefit patients and enhance physicians' decision-making capacity in clinical settings.

Relationship of Age and Sex to Health-Related Quality of Life in Patients With Heart Failure

• Background Although health-related quality of life is diminished among patients with chronic heart failure, few investigators have examined interactions of age and sex with health-related quality of life longitudinally.

• Objectives To examine differences in health-related quality of life among 4 groups of patients with heart failure on the basis of age (&lt;65 years and &gt;65 years) and sex and to evaluate relationships of age and sex to changes in health-related quality of life during 6 months.

• Methods Patients from 2 outpatient clinics in an urban county hospital were interviewed at baseline and 26 weeks later. Health-related quality of life was measured by using the Minnesota Living With Heart Failure Questionnaire and the Chronic Heart Failure Questionnaire.

• Results A total of 165 patients (52% women; mean age, 57.6 years) completed interviews at baseline and 26 weeks later. At baseline, patients younger than 65 years had poorer health-related quality of life scores on total scales and some subscales than did older patients. Women had poorer scores than did men on some scales, particularly the emotional subscales. At 26 weeks, patients younger than 65 had poorer total health-related quality of life on 1 scale than did patients 65 and older, and women had poorer scores than did men on 1 total scale. With demographic and clinical factors controlled for, women younger than 65 had improvements in health-related quality of life on some scales.

• Conclusions Women younger than 65 years had relatively poorer initial health-related quality of life that improved after 26 weeks.

Validity and internal consistency of a whiplash-specific disability measure

STUDY DESIGN

Cross-sectional study of patients with whiplash-associated disorders investigating the internal consistency, factor structure, response rates, and presence of floor and ceiling effects of the Whiplash Disability Questionnaire (WDQ).

OBJECTIVES

The aim of this study was to confirm the appropriateness of the proposed WDQ items.

SUMMARY OF BACKGROUND DATA

Whiplash injuries are a common cause of pain and disability after motor vehicle accidents. Neck disability questionnaires are often used in whiplash studies to assess neck pain but lack content validity for patients with whiplash-associated disorders. The newly developed WDQ measures functional limitations associated with whiplash injury and was designed after interviews with 83 patients with whiplash in a previous study.

METHODS

Researchers sought expert opinion on items of the WDQ, and items were then tested on a clinical whiplash population. Data were inspected to determine floor and ceiling effects, response rates, factor structure, and internal consistency. Packages of questionnaires were distributed to 55 clinicians, whose patients with whiplash completed and returned 101 questionnaires to researchers.

RESULTS

No substantial floor or ceiling effects were identified on inspection of data. The overall floor effect was 12%, and the overall ceiling effect was 4%. Principal component analysis identified one broad factor that accounted for 65% of the variance in responses. Internal consistency was high; Cronbach's alpha = 0.96.

CONCLUSIONS

Results of the study supported the retention of the 13 proposed items in a whiplash-specific disability questionnaire. Dependent on the results of further psychometric testing, the WDQ is likely to be an appropriate outcome measure for patients with whiplash.

Effects of computerized guidelines for managing heart disease in primary care

BACKGROUND

Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care).

OBJECTIVE

To assess the effects of computer-based cardiac care suggestions.

DESIGN

A randomized, controlled trial targeting primary care physicians and pharmacists.

SUBJECTS

A total of 706 outpatients with heart failure and/or ischemic heart disease.

INTERVENTIONS

Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients.

MEASUREMENTS

Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines.

RESULTS

Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients.

CONCLUSIONS

Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.

Correlates of health-related quality of life among lower-income, urban adults with congestive heart failure

BACKGROUND

Improving health-related quality of life (HRQL) is a primary goal in the treatment of patients with congestive heart failure (CHF), yet few studies have explored correlates of HRQL among CHF patients.

OBJECTIVES

We report on the association of demographic and pathophysiologic measures, social-cognitive measures, and environmental variables with HRQL as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), Chronic Heart Failure (CHQ), and a single question of perceived overall health (PH).

METHODS

Cross-sectional data were obtained from the baseline interview and electronic medical records of 212 patients 50 years of age and older who were enrolled during the first 7 months of a medication adherence study.

RESULTS

Mean age was 63; 32% were male; 53% were black; the mean Charlson comorbidity score was 3.7; and the mean New York Heart Association class was 2.1. Correlations between KCCQ and CHQ subscale scores and PH ranged from 0.16 to 0.37. Multivariate regression analyses showed that the pathophysiologic measures ejection fraction and comorbidity were not associated with any of the HRQL measures. Overall PH was associated with greater age and more positive health beliefs. Persons of greater age, males, and black respondents had higher CHF-specific HRQL scores, as did persons reporting more positive health beliefs, greater income, social support, and communication with their physician. Variance explained ranged from 14 to 33%.

CONCLUSION

These cross-sectional data highlight the potential significance of social and behavioral factors in CHF-specific HRQL.

Transitions in Health Status in Older Patients with Heart Failure

BACKGROUND

We aimed to determine transitions in health perception and functional status in older Medicare patients with heart failure.

METHODS

We used 1991 to 1994 data from the Medicare Current Beneficiary Survey, a database that combines Medicare claims with yearly longitudinal surveys. We identified 872 patients 65 years or older in 1991 with a diagnostic code of heart failure.

RESULTS

At baseline, 58% of the patients rated their general health perception as "fair" or "poor." Over 1 year, 18% of the patients died. Transition matrices revealed that health perception, activities of daily living, and instrumental activities of daily living were strong correlates of mortality; that dramatic changes in health status were relatively uncommon over 1 year among survivors; and that decline was common in patients with "excellent" or "very good" health perception. The prior year's health status and comorbidity were powerful predictors of the subsequent year's health status.

CONCLUSION

Many older patients with heart failure have worsening health status over time. Measures of prior health status can help predict chances of functional recovery.

Comparison of quality of life measures in heart failure

BACKGROUND

Although numerous health-related quality-of-life instruments are available to measure patients' quality of life, few studies have compared these measures directly to determine how they function in the same group of patients.

OBJECTIVE

The purpose of this study was to empirically compare psychometric properties of the Chronic Heart Failure Questionnaire (CHQ), the Minnesota Living with Heart Failure Questionnaire (LHFQ), and the General Health Survey Short-form-12 (SF-12).

SAMPLE

A convenience sample of 211 patients with heart failure completed baseline questionnaires; 165 patients completed the entire 26-week study.

METHODS

Patients completed telephone interviews at baseline and at 4, 8, and 26 weeks after baseline. To compare mode of administration, a subset of patients (n = 173) completed face-to-face and telephone interviews.

RESULTS

Patients reported low-to-moderate health-related quality-of-life overall. Reliability of the three instruments was satisfactory. Responsiveness to changing condition, as evaluated by analysis of variance, receiver operating curve characteristics, and the minimal clinically important difference method, indicated that the CHQ and LHFQ were more responsive to changing conditions than the SF-12. No major differences were noted between the scores of the face-to-face interviews and the baseline telephone interviews. The LHFQ and SF-12 were easier and took less time to administer than the CHQ.

CONCLUSIONS

While all three instruments were reliable and valid, the CHQ and LHFQ were more sensitive than the SF-12 in detecting clinically important changes over time.

Assessing the health of adult daughter former caregivers for elders with Alzheimer's disease

Past research is varied in assessing the effect of caregiving on health, particularly caregivers in the postcaregiving phase. The variation may be due, in part, to methodological issues, including the use of health measures not psychometrically tested. The study examines the Medical Outcomes Study Short Form 36 (SF-36) health survey with 102 former caregivers whose family member was deceased for at least one year at the time of the study and had been identified as having Alzheimer's disease or a related disorder. The SF-36 measures eight dimensions of physical and mental health and has been tested on a variety of populations, though not with former daughter caregivers. Confirmatory Factor Analysis supported the factorial validity of the SF-36 for this population, indicating it is a promising tool for understanding postcaregiver health.

Discriminant properties of commonly used quality of life measures in heart failure

Health-related quality of life (HRQL) instruments have been used to measure HRQL in heart failure patients, but how different instruments compare in the same groups of patients is not known. The purpose of this study was to compare the reliability and validity of three HRQL measures in 211 heart failure patients recruited from clinics affiliated with an urban hospital. Two disease-specific instruments, the chronic heart failure questionnaire (CHQ) and the living with heart failure questionnaire (LHFQ), and one generic instrument, the short-form 12 (SF-12), were administered. Patients reported moderate to low HRQL scores. Floor or ceiling effects were noted in the disease-specific instruments. Internal consistency reliabilities of the CHQ and LHFQ were satisfactory. Construct, convergent, and discriminant validity were supported for each instrument. Each scale and subscale, except for the SF-12 mental component scale, differentiated between patients with New York Heart Association (NYHA) class I, II, and III plus IV; the LHFQ physical subscale was the only measure to differentiate between patients with NYHA class III and IV. All three instruments were satisfactory for measuring HRQL, but the disease-specific instruments were preferable to the generic instrument. The decision of which instrument to use depends on the purpose of the study.

Use of the SF36 general health status survey to document health-related quality of life in patients with coronary artery disease: effect of disease and response to coronary artery bypass graft surgery

OBJECTIVE

The purpose of this study was to determine if the SF36 general health status survey has the sensitivity to detect physical function impairments before surgery and the expected improvement in health-related quality of life variables after elective coronary artery bypass graft (CABG) surgery.

DESIGN

A prospective, nonrandomized study design was used.

OUTCOME MEASURES

The SF36 general health status survey comprises 36 multiple choice questions sorted into 8 categories, or subscales, that describe overall health status. The scores of this survey were used to measure the outcome.

INTERVENTION

The SF36 was administered before surgery and at 12-month follow-up. Patients were also queried about the occurrence of angina with normal activities of daily living.

RESULTS

Before surgery (n = 81), scores for all SF36 subscales (with the exception of mental health) were lower than published normative data, indicating the disease burden of coronary artery disease. At 12-month follow-up, scores in 6 of 8 subscales improved significantly; general health and role-emotional scores did not change. These changes in SF36 scores at follow-up paralleled a decreased occurrence of angina; before CABG surgery, 75% of patients (61 of 81) had angina; at 12-month follow-up, only 3.7% of patients (3 of 81) had angina.

CONCLUSIONS

The SF36 can be used effectively to document changes in health-related quality of life variables in patients with coronary artery disease after CABG surgery.

Changes in the quality of life: a major goal of cardiac rehabilitation

BACKGROUND

Quality of life (QOL) is a major goal in the context of preventive and therapeutic cardiology. In this article, quality of life concepts are reviewed, factors limiting QOL in cardiac disease are identified, methods of measurement are explored, and clinically significant changes are defined. The changes effected by cardiac rehabilitation are considered, together with their physiological and psychological correlates. A final section suggests avenues for future research.

METHODS

Relevant articles were identified by computer literature searches and review of extensive personal files.

FINDINGS

In the past, there has been an excessive focus on extending the length rather than the quality of the cardiac patient's life. The overall QOL is a broad concept, influenced by personal perceptions, coping mechanisms, and environmental constraints. The ideal test instrument would be reliable, valid, and responsive to clinical change. Potential options include a Gestalt-type instrument, a disease-specific instrument, a function-specific instrument, or a detailed generic questionnaire. There have been relatively few comparisons between these potential approaches. Currently, the Standard Gamble (Gestalt-type), and Living With Heart Failure Questionnaire (disease-specific type), and the Medical Outcomes Study Short-Form 36 (SF-36) Health Survey (generic-type) are among the most popular approaches. Problems arise in distinguishing a clinically important from a statistically significant change; commonly a score change of 1 standard error of the mean is regarded as clinically important. Correlations of scores with clinical, physiological, and psychological change are sometimes weak, in part because of floor and ceiling effects. Nevertheless, potential gains in QOL provide a stronger argument for preventive and therapeutic programs than do increases in longevity.

CONCLUSIONS

The current literature supports the value of QOL measurements in the management of patients with cardiac disease. However, further research is needed to determine the optimum test instrument, and the best method of interpreting resultant scores.

Criteria for assessing the tools of disability outcomes research

To recommend instrument assessment criteria, deriving from psychometric textbooks and articles and disability and research experts, for reviewing and assessing surveys and questionnaires for disability outcomes research. Traditional criteria are recommended, including psychometric properties of validity, reliability, and sensitivity to change, as are newer statistical methods for assessing scaling properties, such as Rasch analysis. Special consideration is needed for generic instruments that may be poorly scaled for disability research. Pragmatic aspects of data collection, including acceptability and disability accommodation, also are recommended.

Identifying meaningful intra-individual change standards for health-related quality of life measures

Although numerous measures have been developed for the evaluation of health-related quality of life (HRQoL), strategies for identifying meaningful intra-individual change in these measures have not kept pace with instrument development. As a result, clinical trial researchers, quality assurance assessment teams and practising clinicians are without established standards to evaluate individual patient change in HRQoL measures as improved, stable or declined. This article reviews and critiques the methods that have been applied to establish intra-individual HRQoL change standards. These methods include within-person and between-persons anchor-based studies, as well as distribution-based techniques using the effect size, the standard error of measurement, the mean squared error or individual slope coefficients derived from hierarchical linear modelling. Practical approaches to improving and advancing HRQoL change evaluations that enhance the interpretation of intra-individual change are provided. Two future methodological challenges in this area of HRQoL research are examined: (1) the development of individual change standards for generic HRQoL measures; and (2) the incorporation of individual clinical assessments into the process for establishing significant intra-individual change standards.