A review of health-related quality-of-life measures in stroke

Comparing the EQ-5D-5L and stroke impact scale 2.0 in stroke patients: an analysis of measurement properties

BACKGROUND

Stroke has evolved to become a chronic disease and a major public health challenge. To adequately capture the full disease burden of stroke patients, the assessment of health-related quality of life (HRQoL) and thus the performance of respective measures is increasingly relevant. The aim of this analysis was to compare the measurement properties of two self-report instruments, the EQ-5D-5L and the Stroke Impact Scale 2.0.

METHODS

The data used for the analysis was derived from a quasi-experimental case management study for mildly to moderately affected incident stroke and transient ischemic attack (TIA) patients aged ≥ 18 in Germany. Data was collected patient-individually at 3, 6 and 12 months after initial stroke. The EQ-5D-5L and SIS 2.0 were compared in terms of feasibility, ceiling and floor effects, responsiveness and known-groups validity (Kruskal-Wallis H and Wilcoxon rank-sum test).

RESULTS

A response for all three follow-ups is available for n = 855 patients. The feasibility of the EQ-5D-5L is determined as good (completion rate: 96.4-96.6%, ≥ one item missing: 3.2 - 3.3%), whereas the SIS 2.0 is moderately feasible (overall completion rate: 44.9-46.1%, ≥ one item missing in domains: 4.7 - 28.7%). The SIS 2.0 shows substantial ceiling effects in comparable domains (physical function: 10.4 - 13%, others: 3.5-31.3%) which are mainly larger than ceiling effects in the EQ-5D-5L index (17.1-21.5%). In terms of responsiveness, the EQ-5D-5L shows small to moderate change while the SIS 2.0 presents with moderate to large responsiveness. The EQ-5D-5L index, mobility, usual activities and Visual Analogue Scale show known-groups validity (p < 0.05). Content-related domains of the SIS 2.0 show known-groups validity as well (p < 0.05). However, it is compromised in the emotion domain in both measures (p > 0.05).

CONCLUSIONS

The EQ-5D-5L seems to be slightly more suitable for this cohort. Nonetheless, the results of both measures indicate limited suitability for TIA patients. Large-scale studies concerning responsiveness and known-groups validity are encouraged.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register, retrospective registration on 21.09.2022.

REGISTRATION ID

DRKS00030297.

Post-stroke Cognition is Associated with Stroke Survivor Quality of Life and Caregiver Outcomes: A Systematic Review and Meta-analysis

Disability arising from post-stroke cognitive impairment is a likely contributor to the poor quality of life (QoL) stroke survivors and their carers frequently experience, but this has not been summarily quantified. A systematic literature review and meta-analysis was completed examining the association between general and domain-specific post-stroke cognitive functioning and adult stroke survivor QoL, caregiver QoL, and caregiver burden. Five databases were systematically searched, and eligibility for inclusion, data extraction, and study quality were evaluated by two reviewers using a standardised protocol. Effects sizes (r) were estimated using a random effects model. Thirty-eight studies were identified, generating a sample of 7365 stroke survivors (median age 63.02 years, range 25-93) followed for 3 to 132 months post-stroke. Overall cognition (all domains combined) demonstrated a significant small to medium association with QoL, r = 0.23 (95% CI 0.18-0.28), p < 0.001. The cognitive domains of speed, attention, visuospatial, memory, and executive skills, but not language, also demonstrated a significant relationship with QoL. Regarding caregiver outcomes, 15 studies were identified resulting in a sample of 2421 caregivers (median age 58.12 years, range 18-82) followed for 3 to 84 months post-stroke. Stroke survivor overall cognitive ability again demonstrated a significant small to medium association with caregiver outcomes (QoL and burden combined), r = 0.17 (95% CI 0.10-0.24), p < 0.001. In conclusion, lower post-stroke cognitive performance is associated with significant reductions in stroke survivor QoL and poorer caregiver outcomes. Cognitive assessment is recommended early to identify those at risk and implement timely interventions to support both stroke survivors and their caregivers.

The relationship between neurological function trajectory, assessed by repeated NIHSS measurement, and long-term cardiovascular events, recurrent stroke, and mortality after ischemic stroke

BACKGROUND

Clinically significant changes in neurological deficits frequently occur after stroke onset, reflecting further neurological injury or neurological improvement. However, the National Institutes of Health Stroke Scale (NIHSS) score is only evaluated once in most studies, usually at stroke onset. Utilizing repeated measures of NIHSS scores to identify different trajectories of neurological function may be more informative and provide more useful predictive information. We determined the association of neurological function trajectories with long-term clinical outcomes after ischemic stroke.

METHODS

A total of 4025 participants with ischemic stroke from the China Antihypertensive Trial in Acute Ischemic Stroke were included. Patients were recruited from 26 hospitals across China between August 2009 and May 2013. A group-based trajectory model was used to identify distinct neurological function trajectories, as measured by NIHSS at admission, 14 days or hospital discharge, and 3 months. Study outcomes were cardiovascular events, recurrent stroke, and all-cause mortality during 3-24 months after ischemic stroke onset. Cox proportional hazards models were used to examine the associations of neurological function trajectories with outcomes.

RESULTS

We identified three distinct subgroups of NIHSS trajectories: persistent severe (persistent high NIHSS scores during the 3-month follow-up), moderate (NIHSS scores started at around 5 and gradually reduced), and mild (NIHSS scores always below 2). The three trajectory groups had different clinical profiles and different risk of stroke outcomes at 24-month follow-up. Compared to the mild trajectory group, patients in the persistent severe trajectory group had a higher risk of cardiovascular events (multivariable-adjusted hazard ratios (95% confidence intervals) = 1.77 (1.10-2.86)), recurrent stroke (1.82 (1.10-3.00)), and all-cause mortality (5.64 (3.37-9.43)). Those with moderate trajectory had an intermediate risk: 1.45 (1.03-2.04) for cardiovascular events and 1.52 (1.06-2.19) for recurrent stroke.

CONCLUSION

Longitudinal neurological function trajectories derived from repeated NIHSS measurements during the first 3 months after stroke provide additional predictive information and are associated with long-term clinical outcomes. The trajectories characterized by persistent severe and moderate neurological impairment were associated with increased risk of subsequent cardiovascular events.

Factors Contributing to Sex Differences in Health-Related Quality of Life After Ischemic Stroke: BASIC (Brain Attack Surveillance in Corpus Christi) Project

Background Women have been reported to have worse health-related quality of life (HRQoL) following stroke than men, but uncertainty exists over the reasons for the sex difference. Methods and Results We included all ischemic strokes registered with the BASIC (Brain Attack Surveillance in Corpus Christi) project (May 2010-December 2016), a population-based stroke study, who completed a 90-day outcome interview. Information on baseline characteristics was obtained from medical records and in-person interviews. HRQoL was measured by the 12-item short-form Stroke Specific Quality of Life Scale. Multivariable Tobit regression was used to estimate the mean difference in overall HRQoL scores (range, 1-5; higher indicating better HRQoL) between sexes and to identify contributing factors to the differences. We included 1061 cases with complete data on HRQoL and covariates (median age, 67 years; 51% women). In unadjusted analyses, women had poorer overall HRQoL than men (mean difference, -0.26 [95% CI, -0.40 to -0.13]). Contributors to this difference included sociodemographic/prestroke factors (eg, age, race and ethnicity, prestroke function), risk factors/comorbidities (eg, history of stroke, Alzheimer disease/dementia), and initial stroke severity. Sociodemographic/prestroke factors explained 62% of the sex difference (mean difference, -0.08 [95% CI, -0.21 to 0.04]). In a fully adjusted model that included adjustment for all confounding factors, the sex difference was eliminated and became nonsignificant (mean difference, -0.03 [95% CI, -0.16 to 0.09]). Conclusions Poorer HRQoL in women compared with men was observed and explained by the combination of sociodemographic and prestroke factors, including physical function before stroke and stroke severity. The findings suggest potential subgroups of women who might benefit from more targeted interventions before and after stroke to improve HRQoL.

Health-Related Quality of Life and Its Related Factors in Survivors of Stroke in Rural China: A Large-Scale Cross-Sectional Study

Background

Stroke is a major health threat and the leading cause of mortality and disability in China. The aims of this study were to identify the possible influencing factors of health-related quality of life (HRQoL) and its domain-specific contents in stroke patients in rural areas in China.

Methods

A total of 1,709 stroke patients aged 36–79 years from the baseline data of Henan Rural Cohort study (n = 39,259) were included in the cross-sectional study. The Chinese version of the European Quality of Life Five Dimension (including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) Five Level Scale (EQ-5D-5L) and visual analog scale (VAS) were used to evaluate HRQoL in stroke patients. Tobit regression models, generalized linear models and binary logistic regression models were constructed to determine potential influencing factors of the EQ-5D utility index, as well as influencing factors of each domain and VAS score.

Results

The mean utility index and VAS scores of stroke patients were 0.885 (SD, 0.204), and 68.39 (SD, 17.31), respectively. Pain/discomfort (PD, 35.2%) and mobility (MO, 30.4%) were the most frequently reported issues. Regression models revealed that illiterate; a low monthly income; low physical activity intensity; and diabetes, anxiety, depression, or poor sleep quality were significantly associated with lower utility index and VAS scores among stroke patients. In addition, patients with stroke who were older, female, drinking, smoking, and consuming a high-fat diet, had a higher BMI, and lived with a stroke for a longer time, were also significantly associated with different dimensions of the EQ-5D.

Conclusion

Patients with stroke in rural areas in China had a low HRQoL. Factors associated with the EQ-5D utility index as well as each domain and VAS score, need to be considered by health providers in rural areas. Patients with stroke in rural areas need to be included in national basic public medical services and managed systematically by medical institutions.

Self-reported quality of life following stroke: a systematic review of instruments with a focus on their psychometric properties

PURPOSE

To evaluate the psychometric properties of common health-related quality-of-life instruments used post stroke and provide recommendations for research and clinical use with this diagnostic group.

METHODS

A systematic review of the psychometric properties of the five most commonly used quality-of-life measurement tools (EQ-5D, SF-36, SF-6D, AQoL, SS-QOL) was conducted. Electronic searches were performed in MEDLINE, CINAHL, and EMBASE on November 27th 2019. Two authors screened papers against the inclusion criteria and where consensus was not reached, a third author was consulted. Included papers were appraised using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist and findings synthesized to make recommendations.

RESULTS

A total of n = 50,908 papers were screened and n = 45 papers reporting on 40 separate evaluations of psychometric properties met inclusion criteria (EQ-5D = 19, SF-36 = 16, SF-6D = 4, AQoL = 2, SS-QOL = 4). Studies reported varied psychometric quality of instruments, and results show that psychometric properties of quality-of-life instruments for the stroke population have not been well established. The strongest evidence was identified for the use of the EQ-5D as a quality-of-life assessment for adult stroke survivors.

CONCLUSIONS

This systematic evaluation of the psychometric properties of self-reported quality-of-life instruments used with adults after stroke suggests that validity across tools should not be assumed. Clinicians and researchers alike may use findings to help identify the most valid and reliable measurement instrument for understanding the impact of stroke on patient-reported quality of life.

The Experience of Post-Stroke Pain and The Impact on Quality of Life: An Integrative Review

Background: Many people experience post-stroke pain (PSP). It is a long-term consequence of stroke that commonly goes unrecognised and untreated. As a result, an integrative review is needed to identify the primary factors that affect PSP and determine the impact on quality of life (QOL). Methods: An integrative review using a quantitatively led data synthesis, supported by qualitative evidence, was conducted. Results: Fourteen studies were identified and 2415 (968 females, 1447 males) people were included. Five primary themes were identified as effecting the experience of PSP; anxiety, depression, fatigue, cognitive function and physical function. Anxiety, depression and fatigue increase PSP. Pain, depression, fatigue and reduced physical function lower QOL. Conclusions: It is essential that clinicians recognise PSP in order to optimize QOL and function post-stroke. Further research is needed to employ a strategy to identify and objectively quantify PSP and its impact on QOL.

Validation of the Spanish Version of Newcastle Stroke-Specific Quality of Life Measure (NEWSQOL)

BACKGROUND

Stroke causes a wide variety of clinical manifestations that may have a negative impact on quality of life. Therefore, it is very important to use specific instruments for measuring quality of life in individuals who suffered a stroke. The aim of this study was to develop a psychometrically validated Spanish version of the Newcastle stroke-specific quality of life measure (NEWSQOL).

METHODS

A psychometric validation of the Spanish version of the NEWSQOL questionnaire was carried out in 159 patients. The reliability (intraclass correlation coefficient and Cronbach's alpha coefficient), validity (factorial analysis and Spearman's coefficient), feasibility (response rate), and the ceiling and floor effects were calculated.

RESULTS

Internal consistency showed that Cronbach's alpha coefficient was 0.93. The test-retest reliability was high or excellent for all domains (range 0.71-0.97 p < 0.001). The response rate of the questionnaire was 100% and the average administration time was 20.5 (±7.2) min. No ceiling effect was detected and two domains (pain and vision) may have a significant potential for floor effect. Construct validity showed that all the variables are important enough to keep them all in the questionnaire. Concerning convergent construct validity, a high correlation was found with the Nottingham Health Profile, the Barthel Index, and the Modified Rankin Scale.

CONCLUSION

The Spanish version of the NEWSQOL questionnaire is reliable, valid, and feasible to evaluate quality of life in the Spanish population.

Estimation of minimally important differences in the EQ-5D and SF-6D indices and their utility in stroke

Background

The aim of the present study was to estimate minimally important differences (MIDs) in EQ-5D and SF-6D indices and to explore the responsiveness of EQ-5D and SF-6D indices in stroke.

Methods

We used observational longitudinal survey data of EQ-5D and SF-36 that were administered to stroke patients at baseline and at 10 months. A range of MIDs for both indexes was estimated using anchor-based approaches. The modified Rankin scale and the Barthel index were used as an anchor.

Results

The MID estimates for EQ-5D ranged from 0.08 to 0.12 and those for SF-6D ranged from 0.04 to 0.14 in stroke patients. The MID values for these two utility measures differed in absolute magnitude, as the SF-6D index has wider range that that of the EQ-5D index.

Conclusions

The MID values for these two utility measures differed in absolute magnitude, as the SF-6D index has wider range that that of the EQ-5D index. These MID estimates may assist the interpretation of health related quality of life assessments related to health care intervention in stroke patients.

Health state descriptions to elicit stroke values: do they reflect patient experience of stroke?

Background

To explore whether stroke health state descriptions used in preference elicitation studies reflect patients’ experiences by comparing published descriptions with qualitative studies exploring patients’ lived experience.

Methods

Two literature reviews were conducted: on stroke health state descriptions used in direct preference elicitation studies and the qualitative literature on patients’ stroke experience. Content and comparative thematic analysis was used to identify characteristics of stroke experience in both types of study which were further mapped onto health related quality of life (HRQOL) domains relevant to stroke. Two authors reviewed the coded text, categories and domains.

Results

We included 35 studies: seven direct preference elicitation studies and 28 qualitative studies on patients’ experience. Fifteen coded categories were identified in the published health state descriptions and 29 in the qualitative studies. When mapped onto domains related to HRQOL, qualitative studies included a wider range of categories in every domain that were relevant to the patients’ experience than health state descriptions.

Conclusions

Variation exists in the content of health state descriptions for all levels of stroke severity, most critically with a major disjuncture between the content of descriptions and how stroke is experienced by patients. There is no systematic method for constructing the content/scope of health state descriptions for stroke, and the patient perspective is not incorporated, producing descriptions with major deficits in reflecting the lived experience of stroke, and raising serious questions about the values derived from such descriptions and conclusions based on these values.

Validity of the Neurology Quality-of-Life (Neuro-QoL) measurement system in adult epilepsy

Epilepsy is a chronic neurological disorder that results in recurring seizures and can have a significant adverse effect on health-related quality of life (HRQL). The Neuro-QoL measurement initiative is an NINDS-funded system of patient-reported outcome measures for neurology clinical research, which was designed to provide a precise and standardized way to measure HRQL in epilepsy and other neurological disorders. Using mixed-method and item response theory-based approaches, we developed generic item banks and targeted scales for adults and children with major neurological disorders. This paper provides empirical results from a clinical validation study with a sample of adults diagnosed with epilepsy. One hundred twenty-one people diagnosed with epilepsy participated, the majority of which were male (62%) and Caucasian (95%), with a mean age of 47.3 (SD=16.9). Baseline assessments included Neuro-QoL short forms and general and external validity measures. The Neuro-QoL short forms that are not typically found in other epilepsy-specific HRQL instruments include Stigma, Sleep Disturbance, Emotional and Behavioral Dyscontrol, and Positive Affect and Well-Being. Neurology Quality-of-Life short forms demonstrated adequate reliability (internal consistency range=.86-.96; test-retest range=.57-.89). Pearson correlations (p<.01) between Neuro-QoL forms of emotional distress (anxiety, depression, stigma) and the QOLIE-31 Emotional Well-Being subscale were in the moderate-to-strong range (r's=.66, .71 and .53, respectively), as were relations with the PROMIS Global Mental Health subscale (r's=.59, .74 and .52, respectively). Moderate correlations were observed between Neuro-QoL Social Role Performance and Satisfaction and the QOLIE-31 Social Function (r's=.58 and .52, respectively). In measuring aspects of physical function, the Neuro-QoL Mobility and Upper Extremity forms demonstrated moderate associations with the PROMIS Global Physical Function subscale (r's=.60 and .61, respectively). Neuro-QoL measures of perceived cognitive function (executive function and general concerns) produced moderate-to-strong correlations with the QOLIE-31 Cognition subscale (r's=.65 and .75, respectively) and moderate relations with the Liverpool Adverse Events Profile (r's=.51 and .69, respectively). Finally, the Neuro-QoL Fatigue measure demonstrated moderate associations with the QOLIE-31 Energy/Fatigue subscale (r=-.65), Liverpool Adverse Events Profile (r=.69), and the Liverpool Seizure Severity Scale (r=.50). Five Neuro-QoL short forms demonstrated statistically significant responsiveness to change at 5-7months, including Fatigue, Sleep Disturbance, Depression, Positive Affect and Well-Being, and Emotional and Behavioral Dyscontrol. Overall, Neuro-QoL instruments showed good evidence for internal consistency, test-retest reliability, convergent validity, and responsiveness to change over several months. These results support the validity of Neuro-QoL to measure HRQL in adults with epilepsy.

Validity, reliability and responsiveness of the EQ-5D in German stroke patients undergoing rehabilitation

PURPOSE

To analyse the psychometric properties of the EQ-5D in German stroke survivors undergoing neurological rehabilitation.

METHODS

The EQ-5D, the Hospital Anxiety and Depression Scale (HADS) and the Stroke Impact Scale (SIS) were completed before (210 subjects) and after (183 subjects) a patient education programme in seven rehabilitation clinics in Bavaria, Germany. A postal follow-up was conducted after 6 months. Acceptance, validity, reliability and responsiveness of the EQ-5D were tested. The SIS subscales were used as external anchors to classify the patients into change groups between the measurements.

RESULTS

The proportion of missing answers ranged from 4.7 to 8.6%. Between 16 and 19% reported no problems in any EQ-5D dimension. At baseline, correlations between EQ-5D index and the SIS subscales ranged from 0.15 (communication) to 0.60 (mobility). Correlations with the EQ VAS were slightly smaller. All scores were reliable in test-retest with intraclass correlations ranging from 0.67 to 0.81. EQ-5D index and EQ VAS were consistently responsive only to improvements in health, showing small- to medium effect sizes (0.27-0.42).

CONCLUSIONS

The EQ-5D has shown reasonable validity, reliability and, more limited, responsiveness in stroke patients with mild to moderate limitations of functional status, allowing it to be used in clinical trials in rehabilitation.

Fluoxetine for the prophylaxis of poststroke depression in patients with stroke: a meta-analysis

BACKGROUND

Depression may affect patients' recovery and even their survival rate after stroke, but it is often overlooked or inadequately managed; data regarding the prophylactic efficacy and safety of fluoxetine are inconsistent in this setting.

OBJECTIVE

The objective of the study is to systematically assess the prophylactic efficacy and safety of fluoxetine for poststroke depression in patients with stroke.

METHODS

We searched electronic databases up to December 2009 for studies evaluating the prophylactic efficacy of fluoxetine in patients with stroke. The pooled odds ratio (OR), weighted mean difference (WMD), incremental efficiency and 95% confidence intervals (95% CI) were calculated.

RESULTS

We collected and evaluated a total of 385 patients identified from six trials. Meta-analysis demonstrated that fluoxetine reduced the incidence of poststroke depression (PSD) (OR = 0.25, 95% CI 0.11 to 0.56), helped recovery in neurological function (WMD = -4.72, 95% CI -8.31 to -1.13) and improved independence in activities of daily living (WMD = -8.04, 95% CI -13.40 to -2.68); fluoxetine is relatively safe in spite of the adverse events (OR = 0.88, 95% CI 0.31 to 2.49, p = 0.82). However, fluoxetine groups and control groups did not differ in change of scores for depression (WMD = -3.97, 95% CI -9.85 to 1.90, p = 0.19).

CONCLUSIONS

Fluoxetine was beneficial for the prophylaxis of poststroke depression in patients with stroke but not in reducing symptom severity of PSD.

Evaluation of the German translation of the Stroke Impact Scale using Rasch analysis

To assess the complex and heterogeneous consequences of stroke, currently comprehensive patient-centered measures, like the Stroke Impact Scale (SIS), are increasingly being developed. The purpose of this study was to evaluate the psychometric properties of the German translation of the SIS using Rasch analyses. A total of 196 patients with stroke from 16 study centers participated in the study. In tests for item fit, 7 of the 64 items displayed model misfit. Response categories of 25 items showed threshold disordering. Person separation reliability lay above.80 in six domains. No differential item functioning was detected with respect to age, gender, disability severity, and setting. The results provide support for validity and reliability of the SIS, and also point out issues for further improvement and adaptation of the SIS.

Health-related quality of life after stroke: reliability of proxy responses

A Danish version of the Stroke-Specific Quality of Life Scale (SSQOL-DK) has been developed for self-reporting; it contains 12 physical and psychosocial domains. The purpose of this study was (a) to assess the reliability of the proxy version of the SSQOL-DK and (b) to evaluate the influence of frequency of proxy contact on agreement. In all, 143 patients completed the SSQOL-DK 1 to 5 years post-stroke. A patient chosen proxy completed a proxy version of the same questionnaire. The proxy version showed satisfactory internal consistency (Cronbach's alpha = .85-.95). Agreement was generally high. Proxies rated the amount of trouble significantly smaller (higher score) than the patients only in the domain Social Roles. The amount of trouble in the domain Family Roles received significantly higher ratings from noncohabitant proxies when compared with patients (lower score). The proxy version of the SSQOL-DK appears to be reliable for use with stroke patients up to a few years following a stroke.

Evaluation of the methodological quality of systematic reviews of health status measurement instruments

A systematic review of measurement properties of health-status instruments is a tool for evaluating the quality of instruments. Our aim was to appraise the quality of the review process, to describe how authors assess the methodological quality of primary studies of measurement properties, and to describe how authors evaluate results of the studies. Literature searches were performed in three databases. One hundred and forty-eight reviews were included. The purpose of included reviews was to identify health status instruments used in an evaluative application and to report on the measurement properties of these instruments. Two independent reviewers selected the articles and extracted the data. Reviews were often of low quality: 22% of the reviews used one database, the search strategy was often poorly described, and in many cases it was not reported whether article selection (75%) and data extraction (71%) was done by two independent reviewers. In 11 reviews the methodological quality of the primary studies was evaluated for all measurement properties, and of these 11 reviews only 7 evaluated the results. Methods to evaluate the quality of the primary studies and the results differed widely. The poor quality of reviews hampers evidence-based selection of instruments. Guidelines for conducting and reporting systematic reviews of measurement properties should be developed.

Antidepressant prophylaxis for poststroke depression: a meta-analysis

Given the high incidence of poststroke depression, its serious sequelae, and inherent problems with diagnosis, prophylactic use of antidepressants may be a viable management strategy in patients experiencing stroke. The purpose of this study was to assess the prophylactic effects of antidepressants in nondepressed patients with stroke. A meta-analysis of randomized placebo-controlled trials evaluating the prophylactic effects of antidepressants in nondepressed patients with stroke was conducted. Literature searches in MEDLINE, PubMed, CINAHL, PsycINFO, EMBASE, Cochrane library, and CNKI from 1950 to August 2006 were used to identify the relevant studies. Outcome measures included the occurrence rate of newly developed poststroke depression cases and severity of depressive symptoms as indicated by mean depression rating scale scores. The effect size was presented as rate difference or weighted mean difference. From 10 randomized clinical trials, a total of 703 nondepressed patients after stroke were identified. The pooled occurrence rate of newly developed poststroke depression cases in the intervention and control groups were 12.54 (41/327) and 29.17% (91/312), respectively (pooled rate difference=-0.17, 95% confidence interval: -0.26 to -0.08). Prophylactic effects of antidepressants were not related to duration of use {coefficient of Pearson's correlation [gamma]=0.57, P=0.11}. In conclusion, antidepressant prophylaxis is associated with a significant reduction in the occurrence rate of newly developed poststroke depression, suggesting antidepressants may be considered along with other vascular preventive strategies in the management of stroke patients.

Content comparison of health-related quality of life measures used in stroke based on the international classification of functioning, disability and health (ICF): a systematic review

OBJECTIVE

To examine and compare the contents of health-related quality of life (HRQoL) measures used in stroke, based on the ICF as the frame of reference.

DESIGN

We conducted a systematic literature review to select current generic and condition-specific HRQoL measures applied in stroke. We examined the contents of the selected measures by linking the concepts within the instruments' items to the ICF.

RESULTS

The systematic literature review resulted in the selection of six generic and seven stroke-specific HRQoL measures. Within the selected instruments we identified 979 concepts. To map these concepts, we used 200 different ICF categories. None of the ICF categories is contained in all of the instruments. The most frequently used category is 'b152 Emotional functions' contained in 53 items from 10 instruments. Stroke-specific measures more often address 'Mental functions', while the selected generic instruments more often include Environmental Factors.

DISCUSSION

The present study provides an overview on current HRQoL measures in stroke with respect to their covered contents and provides valuable information to facilitate the selection of appropriate instruments for specific purposes in clinical as well as research settings.

Treatment effects of antidepressants in patients with post-stroke depression: a meta-analysis

BACKGROUND

Appropriate treatment of post-stroke depression (PSD) is critically important, considering the negative impact of PSD. Data regarding the treatment efficacy of antidepressants in patients with PSD are conflicting, and the time-dependent effects of antidepressant treatment in this population are unknown.

OBJECTIVE

To systematically assess treatment effects of antidepressants in patients with PSD, incorporating data from recent studies.

METHODS

A meta-analysis of randomized placebo-controlled trials (RCTs) of antidepressants in patients with PSD was conducted, using published studies from 1984 to 2006. Outcome measures of antidepressant treatment included response rate, depression rating scale scores, recovery of neurologic impairments, and improvements in activities of daily living (ADLs) after stroke. The effect size was presented as rate difference (RD) and weighted mean difference for dichotomous outcomes and continuous outcomes, respectively. Pooled effect sizes were calculated by both fixed-effects and random-effects models.

RESULTS

A total of 1320 patients who met inclusion criteria were identified from 16 RCTs. The pooled response rates in the active and placebo groups were 65.18% (234/359) and 44.37% (138/311), respectively. The pooled RD was 0.23 (95% CI 0.03 to 0.43), indicating a significantly higher response rate in the active group compared with the placebo group. From baseline to endpoint, patients in the active group had significantly greater improvement in depressive symptoms compared with patients in the placebo group. Longer duration of treatment was positively correlated with the degree of improvement in depressive symptoms (Spearman's correlation, [rho] = -0.93, p = 0.001). No consistent evidence was found for positive antidepressant effects on the recovery of neurologic impairments and improvements in ADLs.

CONCLUSIONS

The results of this meta-analysis suggest that use of antidepressants among patients with a diagnosis of PSD is associated with improvement in depressive symptoms. Longer durations of antidepressant treatment may be associated with greater reductions in depressive symptoms.

Issues in selecting outcome measures to assess functional recovery after stroke

Most patients who survive a stroke experience some degree of physical recovery. Selecting the appropriate outcome measure to assess physical recovery is a difficult task, given the heterogeneity of stroke etiology, symptoms, severity, and even recovery itself. Despite these complexities, a number of strategies can facilitate the selection of functional outcome measures in stroke clinical trial research and practice. Clinical relevance in stroke outcome measures can be optimized by incorporating a framework of health and disability, such as the International Classification of Functioning, Disability, and Health (ICF). The ICF provides the conceptual basis for measurement and policy formulations for disability and health assessment. All outcome measures selected should also have sound psychometric properties. The essential psychometric properties are reliability, validity, responsiveness, sensibility, and established minimal clinically important difference. It is also important to establish the purpose of the measurement (discriminative, predictive, or evaluative) and to determine whether the purpose of the study is to evaluate the efficacy or effectiveness of an intervention. In addition, when selecting outcome measures and time of assessment, the natural history of stroke and stroke severity must be regarded. Finally, methods for acquiring data must also be considered. We present a comprehensive overview of the issues in selecting stroke outcome measures and characterize existing measures relative to these issues.

Impact of stroke on health-related quality of life in the noninstitutionalized population in the United States

BACKGROUND AND PURPOSE

Stroke is a major cause of long-term disability in the United States. This study examined the national impact of stroke on health-related quality of life (HRQoL) and disparities in HRQoL across different demographic groups.

METHODS

Combined 2000 and 2002 Medical Expenditure Panel Survey data were used, which include quality-of-life measures based on the short-form generic measures (SF-12) and the EuroQol Group measures (EQ-5D index and EQ VAS) for 39,680 adults aged >18 years. Stratified analysis and ordinary least square regressions were used to compare HRQoL scores between stroke and nonstroke populations.

RESULTS

The study included 1040 noninstitutionalized stroke survivors. After adjustment for sociodemographics, risk factors, and comorbidities, stroke survivors had statistically significantly lower mean scores for mental health (-4.1%), physical health (-7.9%), health utility (-6.9%), and self-rated health (-7.2%) (all P<0.01). In general, stroke did not affect differences in HRQoL among age or gender groups. However, racial and ethnic disparities in HRQoL were greater among stroke survivors than nonstroke individuals, particularly in health utility scores for black vs white participants (-0.06 in stroke survivors and -0.02 in the nonstroke population, P<0.01) and Hispanic versus non-Hispanic participants (-0.11 in stroke survivors and -0.01 in the nonstroke population).

CONCLUSIONS

Stroke significantly impairs HRQoL in the United States. The findings suggest that racial and ethnic disparities in HRQoL among stroke survivors are more pronounced than in the nonstroke population. The burden of nonfatal stroke, especially among racial and ethnic minorities, should be recognized more widely.

The SEIQoL-DW is a valid method for measuring individual quality of life in stroke survivors attending a secondary prevention clinic

OBJECTIVES

This paper examines the applicability and construct validity of the Schedule for the Evaluation of Individual Quality of Life-Direct Weight (SEIQoL-DW) for measuring quality of life in stroke survivors living at home that attend a secondary prevention clinic.

PARTICIPANTS AND METHODS

Forty-six individuals attending a secondary prevention clinic following a stroke or transient ischaemic attack participated in a semi-structured interview to complete a range of outcome measures. Assessments of cognitive impairment, disability, and handicap were conducted using the Mini mental State Examination (MMSE), Barthel Index (BI), and Rankin Scale (RS). Measures to assess quality of life included perceived health status (PHS), Visual Analogue Mood Scale (VAMS), the Hospital Anxiety and Depression Scale (HADS), and the SEIQoL-DW. The construct validity of the SEIQoL-DW was assessed by correlation with the other measures.

RESULTS

According to the cues elicited from the SEIQoL-DW, participants nominated 'relationships with family and friends' as the most important life domain, followed by 'social and leisure activities', and 'health'. Spearman's rho correlation coefficients demonstrated significant relationships between the SEIQoL-DW index scores, PHS (r = 0.35, p = 0.016), VAMS (r = 0.419, p = 0.004), and the HADS anxiety (r = -0.546, p < 0.0001) and depression (r = -0.701, p < 0.0001) subscale scores.

CONCLUSIONS

The SEIQoL-DW demonstrated reasonable construct validity for use in assessing individual quality of life in a group of individuals following stroke or TIA that attend a secondary prevention clinic.

Measuring health-related quality of life in older patient populations: a review of current approaches

The changing demographic profile of the world's population towards old age and evidence of people living for longer with less time spent in ill health highlight the importance of addressing quality-of-life (QOL) assessment issues for older people. The assessment of health-related QOL (HR-QOL) has received considerable attention in the last 2-3 decades, with a wide variety of assessment instruments available. These instruments can be either generic or disease specific, health profiles or preference based. The literature was reviewed systematically to identify studies measuring HR-QOL in older patient groups. A total of 37 studies were identified, 11 of which were randomised, controlled trials/evaluations, 14 were prospective studies that did not involve a randomised, controlled intervention, and 12 were cross-sectional studies. Studies were summarised in terms of the study aim, patient population characteristics, the instrument used to measure HR-QOL, and HR-QOL findings. A majority of studies used a generic HR-QOL instrument, the single most commonly used being the 36-Item Short-Form Health Survey. In many cases, a second disease-specific measure was used in combination with the generic measure. In a majority of studies involving interventions, significant improvements in HR-QOL were noted. In prospective studies, a negative impact of health conditions (e.g. myocardial infarction and chronic heart failure) was also identified using HR-QOL assessments. None of the studies in this review used HR-QOL measurement instruments that were old-age specific. Using instruments that are not specific to a particular age group enables comparisons to be made with other age groups, i.e. younger or middle-aged groups. However, the questionnaire items of HR-QOL instruments tend to be phrased predominantly in relation to physical function and thus may inadvertently discriminate against older persons, whose physical function is likely to be not as good as that of younger people. Particular issues in the assessment of HR-QOL in older patient populations include the persistent finding of a poor relationship between QOL and disability/disease severity, the dynamic nature of QOL, and the importance of valid proxy ratings for those unable to make decisions or communicate for themselves. It is important, therefore, that assessment of HR-QOL incorporates issues of importance to individual older people by broadening the scope of the measurement instruments, thus representing more validly the HR-QOL status of older patient groups. Future research in HR-QOL must incorporate the perspective of the individual in order to enable valid conclusions to be derived based on content that is relevant to the individual being assessed, thus informing management decisions, policy and practice more meaningfully.

The Burden of Stroke Scale (BOSS) provides valid and reliable score estimates of functioning and well-being in stroke survivors with and without communication disorders

BACKGROUND AND OBJECTIVE

This study describes the conceptual foundation and psychometric properties of the Burden of Stroke Scale (BOSS), a patient-reported health status assessment designed to quantify the physical, cognitive, and psychological burden of stroke.

METHODS

Qualitative research methods were used to develop a 112-item pilot version of the instrument. The pilot version was administered to healthy controls (n=251) and stroke survivors with (n=135) and without (n=146) communication disorders on a single occasion for the purposes of reducing the global item pool, describing the resulting scale properties, examining the dimensionality of the burden of stroke construct, and examining the known-groups validity of the instrument.

RESULTS

Sixty-four items were retained, comprising 12 internally consistent and unidimensional scales. Principal components analysis revealed three second-order factors (Physical Activity Limitations, Cognitive Activity Limitations, and Psychological Distress) comprising the Burden of Stroke construct. Comparisons between groups revealed that stroke survivors reported greater activity limitations and psychological distress on all scales relative to controls, and that stroke survivors with communication disorders reported greater activity limitations on swallowing, communication, cognition, and social relations scales relative to non-communicatively disordered stroke survivors.

CONCLUSION

These findings support the internal consistency of the BOSS scales, the hypothesized dimensionality of the burden of stroke construct, and the known-groups validity of the instrument.

Measurement properties of the short form (SF)-12 applied to patients with stroke

The purpose of this study was to examine the reliability and validity of the Short Form (SF)-12 and to determine its ability to detect changes in health related quality of life (HRQOL) following stroke. The study involved a cohort of 90 patients admitted with an ischemic stroke to a hospital in the northeastern United States. The items of the SF-12 were found to be reliable (alpha=0.833-0.894) and to load on a physical and mental component. Three months post-stroke the physical component summary (PCS) scores of the SF-12 were significantly less than population norms. The PCS scores were also lower after stroke (3 month=42.5, 12 month=46.3) than before stroke (48.8). Mental component summary (MCS) scores did not differ significantly from population norms or across time (range=53.6 to 54.9). We conclude that the reliability and validity of the SF-12, as well as its brevity and capacity to document changes in the physical component of HRQOL, provide support for its use in patients with stroke.

Response shift influenced estimates of change in health-related quality of life poststroke

OBJECTIVE

The interpretability of changes in perceived health status over time is threatened if people experience a response shift. This study assessed whether the recovery process following stroke altered individuals' perceptions of past health status and the impact that change in internal standards (response shift) had on ratings over time. We hypothesized that individuals with stroke would experience changes in internal standards, not experienced by the control group. Two other hypotheses related to objective criterion measures also were tested.

STUDY DESIGN AND SETTING

Individuals were recruited through a randomized trial of acute poststroke care. Health status was evaluated at baseline (within the first week poststroke), 6 and 24 weeks later using the EQ VAS. At 6 and 24 weeks, subjects were asked to retrospectively re-evaluate their health status for the preceding evaluation using the then test technique.

RESULTS

The pattern of mean scores was indicative of changes in internal standards among individuals with stroke but not for the control group. Memory had an impact on estimates of response shift. Hypotheses related to the objective criterion measures were not supported.

CONCLUSION

The results suggest that there was a change in internal standards, and that measures of improvement in health status are different based on prospective as compared to retrospective ratings. Further understanding of the impact of recall on the assessment of response shift using the then test is needed to validate the use of this technique.

Measuring quality of life in chronic illness: the functional assessment of chronic illness therapy measurement system

We focus on quality of life (QOL) measurement as applied to chronic illness. There are 2 major types of health-related quality of life (HRQOL) instruments-generic health status and targeted. Generic instruments offer the opportunity to compare results across patient and population cohorts, and some can provide normative or benchmark data from which to interpret results. Targeted instruments ask questions that focus more on the specific condition or treatment under study and, as a result, tend to be more responsive to clinically important changes than generic instruments. Each type of instrument has a place in the assessment of HRQOL in chronic illness, and consideration of the relative advantages and disadvantages of the 2 options best drives choice of instrument. The Functional Assessment of Chronic Illness Therapy (FACIT) system of HRQOL measurement is a hybrid of the 2 approaches. The FACIT system combines a core general measure with supplemental measures targeted toward specific diseases, conditions, or treatments. Thus, it capitalizes on the strengths of each type of measure. Recently, FACIT questionnaires were administered to a representative sample of the general population with results used to derive FACIT norms. These normative data can be used for benchmarking and to better understand changes in HRQOL that are often seen in clinical trials. Future directions in HRQOL assessment include test equating, item banking, and computerized adaptive testing.