Duration of condition is unrelated to health-state valuation on the EuroQoL

The feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone

OBJECTIVES

To assess the feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone, the first psychometric assessment of the EQ-5D-3L to be conducted in patients with stroke in Sub Saharan Africa.

METHODS

A prospective stroke register at two tertiary government hospitals recruited all patients with the WHO definition of stroke and followed patients up at seven days, 90 days and one year post stroke. The newly translated EQ-5D-3L, Barthel Index (BI), modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS), a measure of stroke severity, were collected by trained researchers, face to face during admission and via phone at follow up. Feasibility was assessed by completion rate and proportion of floor/ceiling effects. Internal consistency was assessed by inter item correlations (IIC) and Cronbach's alpha. Repeatability of the EQ-5D-3L was examined using test-retest, EQ-5D-3L utility scores at 90 days were compared to EQ-5D-3L utility scores at one year in the same individuals, whose Barthel Index had remained within the minimally clinical important difference. Known group validity was assessed by stroke severity. Convergent validity was assessed against the BI, using Spearman's rho. Responsiveness was assessed in patients whose BI improved or deteriorated from seven to 90 days. Sensitivity analyses were conducted using the UK and Zimbabwe value sets, to evaluate the effect of value set, in a subgroup of patients with no formal education to evaluate the influence of patient educational attainment, and using the mRS instead of the BI to evaluate the influence of utilising an alternative functional scale.

RESULTS

The EQ-5D-3L was completed in 373/460 (81.1%), 360/367 (98.1%) and 299/308 (97.1%) eligible patients at seven days, 90 days and one year post stroke. Missing item data was low overall, but was highest in the anxiety/depression dimension 1.3% (5/373). Alpha was 0.81, 0.88 and 0.86 at seven days, 90 days and one year post stroke and IIC were within pre-specified ranges. Repeatability of the EQ-5D-3L was moderate to poor, weighted Kappa 0.23-0.49. EQ-5D-3L utility was significantly associated with stroke severity at all timepoints. Convergent validity with BI was strong overall and for shared subscales. EQ-5D-3L was moderately responsive to both improvement Cohen's D 0.55 (95% CI:0.15-0.94) and deterioration 0.92 (95% CI:0.29-1.55). Completion rates were similar in patients with no formal education 148/185 (80.0%) vs those with any formal education 225/275 (81.8%), and known group validity for stroke severity in patients with no formal education was strong. Using the Zimbabwe value set instead of the UK value set, and using the mRS instead of the BI did not change the direction or significance of results.

CONCLUSIONS

The EQ-5D-3L for stroke in Sierra Leone was feasible, and responsive including in patients with no formal education. However, repeatability was moderate to poor, which may be due to the study design, but should add a degree of caution in the analysis of repeated measures of EQ-5D-3L over time in this population. Known group validity and convergent validity with BI and mRS were strong. Further research should assess the EQ-5D in the general population, examine test-retest reliability over a shorter time period and assess the acceptability and validity of the anxiety/depression dimension against other validated mental health instruments. Development of an EQ-5D value set for West Africa should be a research priority.

Whom should we ask? A systematic literature review of the arguments regarding the most accurate source of information for valuation of health states

To determine and critically evaluate the arguments in the published literature regarding the most accurate source of information for valuation of health states: values based on experienced health states (patient values) or values based on described health states (general public values).

Self-assessments and determinants of HRQoL in a German MS population

OBJECTIVES

The importance of health-related quality of life (HRQoL) in multiple sclerosis (MS) is widely acknowledged. In 2015, a multicenter study was launched to assess the HRQoL and coping styles of chronically ill persons in Germany. The aims of this paper were (i) to describe how persons affected by MS assess their HRQoL and (ii) find out sociodemographic and disease-specific determinants of HRQoL.

MATERIALS AND METHODS

A quantitative survey (optionally per paper-pencil or online) was conducted between March and October 2015 in Germany. Recruitment ways were as follows: Associations of the German Multiple Sclerosis Society (DMSG), medical practices specialized in neurology/MS, hospitals, public events, social networks, and self-help clearinghouses. To measure HRQoL, the Multiple Sclerosis International Quality of Life (MusiQoL) questionnaire and the short form of the Fear of Progression Questionnaire (FoP-Q) were used.

RESULTS

A total of 1220 individuals with MS participated in the study. Frequent problems reported were related to activities of daily living as well as sentimental and sexual life. Multiple regression analyses identified disease severity and comorbidity-in different directions (positive and negative)-as the strongest factors in predicting activities of daily living, symptoms, sentimental and sexual life, and reject. The demographic variables sex, age, education, and employment status also have different impact on the HRQoL.

CONCLUSIONS

Using HRQoL measures can be feasible outcomes in addition to clinical assessments of MS and other chronic diseases and can help better managing the care. Some challenges have to be taken into account involving patients and the limitations of our empirical study.

Development of a cross-cultural item bank for measuring quality of life related to mental health in multiple sclerosis patients

OBJECTIVE

Quality of life (QoL) measurements are considered important outcome measures both for research on multiple sclerosis (MS) and in clinical practice. Computerized adaptive testing (CAT) can improve the precision of measurements made using QoL instruments while reducing the burden of testing on patients. Moreover, a cross-cultural approach is also necessary to guarantee the wide applicability of CAT. The aim of this preliminary study was to develop a calibrated item bank that is available in multiple languages and measures QoL related to mental health by combining one generic (SF-36) and one disease-specific questionnaire (MusiQoL).

METHODS

Patients with MS were enrolled in this international, multicenter, cross-sectional study. The psychometric properties of the item bank were based on classical test and item response theories and approaches, including the evaluation of unidimensionality, item response theory model fitting, and analyses of differential item functioning (DIF). Convergent and discriminant validities of the item bank were examined according to socio-demographic, clinical, and QoL features.

RESULTS

A total of 1992 patients with MS and from 15 countries were enrolled in this study to calibrate the 22-item bank developed in this study. The strict monotonicity of the Cronbach's alpha curve, the high eigenvalue ratio estimator (5.50), and the adequate CFA model fit (RMSEA = 0.07 and CFI = 0.95) indicated that a strong assumption of unidimensionality was warranted. The infit mean square statistic ranged from 0.76 to 1.27, indicating a satisfactory item fit. DIF analyses revealed no item biases across geographical areas, confirming the cross-cultural equivalence of the item bank. External validity testing revealed that the item bank scores correlated significantly with QoL scores but also showed discriminant validity for socio-demographic and clinical characteristics.

CONCLUSION

This work demonstrated satisfactory psychometric characteristics for a QoL item bank for MS in multiple languages. This work may offer a common measure for the assessment of QoL in different cultural contexts and for international studies conducted on MS.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validation of the EuroQol quality of life questionnaire on stroke victims

OBJECTIVE

To validate a quality of life scale, EuroQoL, on stroke patients.

METHOD

67 patients were scored simultaneously for EuroQoL-5 Dimensions (EQ-5D), NIH Stroke Scale (NIHSS) and modified Barthel Index (mBI). Pearson test was used to correlate each scale. Additionally, 31 patients were examined by two independent evaluators on the same day through application of EQ-5D. Kappa statistics were used to evaluate interobserver agreement.

RESULTS

EQ-5D showed good correlation with both stroke severity (NIHSS, r= -0.404, P<0.001) and degree of impairment on activities of daily living (mBI, r=0.512, P<0.001). We noticed a good interobserver agreement (k>0.60) in all dimensions evaluated (P<0.01).

CONCLUSION

We demonstrated that EQ-5D is reproducible and valid on evaluation of quality of life in patients post stroke in Brazil.

Surgical treatment of endometriosis in private practice: cohort study with mean follow-up of 3 years

STUDY OBJECTIVE

To describe our experience with surgical treatment of endometriosis.

DESIGN

Observational cohort study (Canadian Task Force classification II-2).

SETTING

Private hospital.

PATIENTS

One hundred sixty-three patients with histologically confirmed endometriosis who had completed a preoperative questionnaire, had available intraoperative findings and photographic documentation, and had been followed up to 6 years.

INTERVENTION

Laparoscopic electrosurgical excision of endometriotic implants.

MEASUREMENTS AND MAIN RESULTS

Patients completed a visual analogue scale (VAS) for 6 components of endometriosis-related symptoms. The EuroQol Group EQ-5D questionnaire was used for evaluation of quality of life. Long-term follow up was performed using a questionnaire and review of patient medical records. Mean (SD; 95% confidence interval) patient age at surgery was 31.01 (8.5; 29.7-32.3) years. The primary symptom at initial consultation was dysmenorrhea in 94 patients (57.67%, nonmenstrual pelvic pain in 44 (27%), dyspareunia in 11 (6.75%), menorrhagia in 8 (4.9%), infertility in 4 (2.45%), and pelvic mass in 2 (1.23%). Thirty-three patients (20%) had undergone previous surgery because of endometriosis. At surgery, endometriosis was stage I in 50 patients (30.67%), stage II in 65 (39.88%), stage III in 23 (14.11%), and stage IV in 25 (15.34%). Other surgical procedures performed with the index surgery were cystoscopy in 48 patients (29.45%), laparoscopic ovarian cystectomy in 24 (14.72%), laparoscopic hysterectomy in 15 (9.2%), laparoscopic appendectomy in 9 (5.5%), sigmoidoscopy in 6 (3.68%), laparoscopic oophorectomy in 6 (3.68%), extensive laparoscopic adhesiolysis in 5 (3.07%) bowel resection in 2 (1.25%), laparoscopic myomectomy in 1 (0.61%), and bladder resection in 1 (0.61%). Surgery proceeded to laparotomy in 6 patients (3.68%). Major surgical complications included bowel perforation, severe pelvic pain 1 week after laparoscopic excision, and temporary numbness of the right side of the perineum in 1 patient each. Minor postoperative complications included urinary tract infection in 3 patients and port site infections that resolved with oral antibiotic therapy in 2 patients. Follow-up was 37.82 (20.09; 34.74-40.92) months. Surgical excision of endometriosis had a positive effect on endometriosis-related symptoms. Four pain scores were reduced, with statistically significant differences (p<.001 and p<.05): dysmenorrhea, pelvic pain not related to menstruation, dyspareunia, and dyschezia. The positive effect of surgical excision on patient quality of life was demonstrated by a statistically significant difference on the EQ-5D index (p<.001) and the EQ-5D VAS (p<.001). Thirty-two (20%) patients underwent a second procedure after the index surgery. Endometriosis stage affects the probability of requiring further surgery because of recurrent symptoms. There was evidence of endometriosis at histologic analysis in only 13 (40.62%) patients who required further surgery.

CONCLUSION

Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life as measured by both the EQ-5D index and the EQ-5D VAS, with a low complication rate.

Health-related quality of life in patients with narcolepsy

BACKGROUND

To evaluate the health-related quality of life (HRQoL) in patients suffering from narcolepsy.

METHODS

Subjects included 75 narcoleptic patients diagnosed at the Hephata Klinik, Germany, who met the International Classification of Sleep Disorders (ICSD) criteria for narcolepsy. A standardized telephone interview was used to inquire about the disease and its burdens to the patients. HRQoL was recorded using the 36-item short-form Medical Outcomes Study (SF-36) as well as the Euroqol (EQ-5D). Frequency and factors of influence on decreased HRQoL were evaluated by using bivariate and multivariate analyses.

RESULTS

Patients with narcolepsy had considerably lower scores on all eight domains of the SF-36 compared to the general German population. In particular, scores were poor for the dimensions "physical role", "vitality", and "general health perception". Forty-eight percent of the patients reported problems in at least one of the EQ-5D items; most frequent were problems in the dimension "usual activity" (63.8%), "pain/discomfort" (61.7%) and "anxiety/depression" (41.1%). Difficulty maintaining "self-care" was documented only by 6.8%. The mean VAS score was 60.7%. Interestingly, signs and symptoms of narcolepsy, except for irresistible sleep episodes (p<0.03), had only a minor impact on HRQoL. Multivariate analyses confirmed a strong influence of employment status, living with a partner, excessive daytime sleepiness (EDS) and professional advancement.

CONCLUSIONS

HRQoL is considerably reduced in patients, with narcolepsy affecting the different dimensions to various degrees. Factors other than clinical signs and symptoms are associated also with poor HRQoL. Measures should be taken to integrate those factors into healthcare guidelines in order to improve the quality of life in patients with narcolepsy.

Validation of the Multiple Sclerosis International Quality of Life questionnaire

This study aims to validate the Multiple Sclerosis (MS) International Quality of Life (MusiQoL) questionnaire, a multi-dimensional, self-administered questionnaire, available in 14 languages, as a disease-specific quality of life scale that can be applied internationally. A total of 1992 patients with different types and severities of MS from 15 countries were recruited. At baseline and day 21 ± 7, each patient completed the MusiQoL, a symptom checklist and the short-form (SF)-36 QoL questionnaire. Neurologists also collected socio-demographic, MS history and outcome data. The database was randomly divided into two subgroups and analysed according to different patient characteristics. For each model, psychometric properties were tested and the number of items was reduced by various statistical methods. Construct validity, internal consistency, reproducibility and external consistency were also tested. Nine dimensions, explaining 71% of the total variance, were isolated. Internal consistency and reproducibility were satisfactory for all the dimensions. External validity testing revealed that dimension scores correlated significantly with all SF-36 scores, but showed discriminant validity by gender, socio-economic and health status. Significant correlations were found between activity in daily life scores and clinical indices. These results demonstrate the validity and reliability of the MusiQoL as an international scale to evaluate QoL in patients with MS. Multiple Sclerosis 2008; 14: 219—230. http://msj.sagepub.com

Coping and quality of life in one hundred and thirty five subjects with multiple sclerosis

INTRODUCTION

and objective The aim of this study was to compare coping strategies and quality of life (QoL) in multiple sclerosis (MS), as they relate to the course of the disease (relapsing-remitting (RR), secondary progressive (SP), primary progressive (PP)), while taking depression and anxiety into account.

METHODS

A total of 135 MS subjects were seen for a semi-structured interview in order to collect socio-demographic and clinical information, after which there was an assessment of their mental and cognitive states (Mini International Neuropsychiatric Interview (MINI), Montgomery and Asberg Depression Rating Scale (MADRS), Depressive Mood Scale (EHD), Hamilton Anxiety (HAMA), Frontal Assessment Battery (FAB)). All subjects then completed three self-report questionnaires; two about coping strategies (Ways of Coping Checklist (WCC), Coping with Health, Injuries and Problems Scale (CHIP)) and one about QoL (SEP59).

RESULTS

The mental health (depression and anxiety) and the psychological and social dimensions of QoL were relatively unaffected. However, after controlling for age and disability, the disease course had a strong effect on both mental health and QoL, with the poorest condition for SPMS and the best condition for PPMS. The SPMS patients tend to use emotional coping strategies extensively, while the PPMS patients use more instrumental strategies.

DISCUSSION

Our study clearly demonstrated that psychological and social well-being were substantially affected by the disease course. These results encourage us to develop interventions focused on coping strategies and which are better adapted to individual patients.

Self-reported chronic conditions and EQ-5D index scores in the US adult population

OBJECTIVE

To examine the unique health-related quality of life (HRQoL) decrements associated with common chronic conditions in the general US adult population.

METHODS

Data were obtained from a study aimed at establishing a US population-based set of preference weights for the health states defined by the EQ-5D. The EQ-5D is a brief, self-completed instrument for describing and valuing HRQoL. As part of that study, along with the EQ-5D items, data regarding socio-demographic characteristics and chronic medical conditions were collected. The EQ-5D has five dimensions, from which an index score can be calculated that falls on a scale where 0.0 = death and 1.0 = perfect health. Ordinary least squares regression models were conducted using the EQ-5D index score as the dependent variable to estimate the association between each chronic condition and the index score after adjusting for socio-demographic variables. The population sampling weights were applied in the analyses to adjust for the over-sampling of the minority groups.

RESULTS

Approximately three-fifths (62.5%) of the study sample reported having at least one of the 18 chronic medical conditions; sinusitis(24.8%), hypertension (23.5%), and arthritis (21.5%) were the most commonly reported conditions. The chronic conditions that had the greatest negative association with EQ-5D index scores were depression and arthritis.

CONCLUSION

Unique associations were found between several chronic conditions and HRQoL after accounting for the presence of other conditions and socio-demographic characteristics. The results of this study provide an indication of the relative HRQoL decrements associated with various chronic conditions in the general US adult population. The major limitation of this analysis is the uncertainty of the causal relationship between chronic conditions and HRQoL due to the cross-sectional nature of the study data. In addition, because it was unknown how well the conditions were managed, caution is needed in interpreting study results regarding the relative impact of chronic conditions on HRQoL.

Quality of life measures for the palliative care of people severely affected by multiple sclerosis: a systematic review

Although there is increasing interest in measuring the quality of life (QoL) of people with multiple sclerosis (MS), relatively little is known about the issues of importance to people severely affected by MS. In the first of two systematic reviews, we searched the literature to identify measures that have been used to assess health-related QoL in people with MS, and described their measurement properties in terms of validity, reliability, responsiveness to change, and appropriateness for QoL assessment in people severely affected by MS. In the second review, we identified care domains important to people with MS, by reviewing survey, focus group and interview studies involving people with MS and/or their caregivers. Forty-six studies evaluating 12 disease-specific and ten generic QoL measures for patients, and one disease-specific measure for caregivers, satisfied all inclusion criteria. Sixteen focus group or interview studies and 51 questionnaire-based studies evaluated domains of care important to people with MS, and seven qualitative and 11 questionnaire-based studies assessed domains of care important to their caregivers. From these studies, we identified 15 domains of care important to people with MS and 12 domains important to caregivers. QoL measures differed markedly in their coverage of these care domains. Moreover, each measure fulfilled some but not all criteria of validity, reliability, responsiveness, and appropriateness. Further work is needed to clarify the domains of care relevant to people with severe MS, and to measure health-related QoL in this population.

Self-valuation and societal valuations of health state differ with disease severity in chronic and disabling conditions

OBJECTIVES

We sought to determine the relationship between self-reported ratings of health-related quality of life (HRQoL) by people with 3 chronic and disabling conditions and population estimates of those health states and to model factors that might explain the disagreement between these 2 ratings.

RESEARCH DESIGN

A cross-sectional postal survey was sent in which each participant completed a set of questionnaires addressing HRQoL. Data from self-valuation on a visual analog scale (VAS) was compared with a population-based VAS-equivalent valuation, using the EQ-5D instrument. Different ways of scaling the 2 VAS scores were also explored. Data were analyzed using descriptive statistics and analysis of covariance.

SUBJECTS

A community sample of 1036 people took part in the study (rheumatoid arthritis n = 142, stroke n = 585, multiple sclerosis n = 309). MEASUREMENT INSTRUMENT: The EQ-5D health state profile and accompanying visual analog scale were used.

RESULTS

Self-ratings were significantly different than the population-based ratings, and agreement was poor, both on the original scale of the data and by analyses of rescaled data. On the original scales the mean difference was 0.13 (95% confidence interval 0.117-0.143). Diagnosis, health state severity, and its square explained 35.3% of the variation in the differences between self and population ratings with a curvilinear relationship suggesting that the differences increased as the health state worsened, but at a decreasing rate as health state severity increased.

CONCLUSIONS

This study provides evidence that EQ-5D population valuation estimates of treatment benefit for people with disabling and chronic conditions may well be inaccurate representations of the degree of change actually experienced by the individual with the condition. The varying magnitude of difference between the 2 forms of valuation has important implications for interpreting shifts in health status valuation following interventions for these populations.