Transplant failure does not compromise quality of life in end-stage renal disease

Seizure Freedom Reduces Illness Intrusiveness and Improves Quality of Life in Epilepsy

Background:

Chronic illnesses are associated with multiple stressors that compromise quality of life (QOL). Implicit in many of these stressors is the concept of illness intrusiveness: the disruption of lifestyles, activities, and interests due to the constraints imposed by chronic disease and its treatment. The purpose of this study was to examine illness intrusiveness and QOL in epilepsy in patients with different levels of seizure control.

Methods:

Cross-sectional data were obtained and compared between two groups of patients categorized by presence of seizures: seizure freedom or continued seizures (N=145). Standard instruments measured the following variables: illness intrusiveness, perceived personal control, subjective well-being, and disease specific QOL.

Results:

Illness intrusiveness varied inversely and significantly with seizure control. Complete seizure freedom, whether achieved by pharmacological or surgical treatment, was associated with the lowest levels of illness intrusiveness. Seizure freedom was also associated with increased perceived control, positive affect, self-esteem and QOL in epilepsy.

Conclusions:

The most robust benefits of decreased illness intrusiveness in epilepsy occur when treatment leads to complete seizure control. Therefore every effort should be made by health care providers to achieve seizure freedom to reduce illness intrusiveness and improve QOL in epilepsy.

Using the illness intrusiveness ratings scale to understand health-related quality of life in chronic disease

OBJECTIVE

Illness intrusiveness is a common, underlying determinant of quality of life in people affected by chronic disease. Illness intrusiveness results from disease- and treatment-induced disruptions to lifestyles, activities, and interests (i.e., interference with psychologically meaningful activity). This paper introduces the Illness Intrusiveness Ratings Scale (IIRS), a 13-item, self-report instrument. The IIRS can be scored to generate a total score or three subscale scores: relationships and personal development, intimacy, and instrumental. In addition to describing the IIRS, the paper presents the theoretical framework in which it is anchored, reviews the evidence, and reports psychometric properties.

METHODS

Qualitative literature review.

RESULTS

Findings support the IIRS's reliability (internal consistency and test-retest), validity (construct, criterion-related, and discriminant), sensitivity to change, and factorial invariance across numerous chronic-disease groups. The paper reports IIRS reliability coefficients and normative statistics for 36 chronic, medical and psychiatric patient populations.

CONCLUSION

The IIRS taps the extent to which disease- and treatment-related factors interfere with psychologically meaningful activity among people affected by chronic disease. It provides a valid, reliable measure that is easy to administer and unequivocally interpretable rendering it suitable for research designed to estimate the psychosocial impact of chronic disease and to document (and compare) the effectiveness of therapeutic interventions.

Factor structure and reliability of the Hungarian version of the Illness Intrusiveness Scale: invariance across North American and Hungarian dialysis patients

OBJECTIVES

The objectives of this study were to compare the factor structure and to assess the reliability of the Hungarian version of the Illness Intrusiveness Rating Scale (IIRS), testing internal validity and employing simultaneous confirmatory factor analysis (SCFA) in two large samples of North American versus Hungarian patients with end-stage renal disease (ESRD).

METHODS

Translation was conducted according to current recommendations. Following pilot testing, 365 maintenance haemodialysis patients completed the scale. Hungarian data were compared with IIRS data from North American ESRD patients undergoing maintenance hemodialysis to evaluate item bias (Group x Item ANOVA).

RESULTS

Confirmatory factor analyses indicated a good fit between the previously hypothesized three-factor model ("relationships and personal development", "intimacy", and "instrumental" life domains) of the original English version and the Hungarian translation. Although statistically significant (P<.05), the effect size for the Groups x Items interaction was not substantial. Internal consistency was very good (Cronbach's alpha=.80) for the total score, and, although somewhat lower than ideal, it was still in the acceptable range for the subscales (.64-.67). These numbers are similar to values reported for the original English version. Test-retest reliability was also acceptable.

CONCLUSION

The Hungarian translation of the IIRS has the same three-dimensional factor structure as the original English-language version does. Furthermore, it is sufficiently reliable for research applications. These features satisfy important requirements of cultural equivalence.

Illness intrusiveness among survivors of autologous blood and marrow transplantation

BACKGROUND

Illness-induced disruptions to lifestyles, activities, and interests (i.e., illness intrusiveness) compromise subjective well-being. The authors measured illness intrusiveness in autologous blood and bone marrow transplantation (ABMT) survivors and compared the results with survivors of solid organ transplants.

METHODS

Forty-four of 64 consecutive ABMT survivors referred to the University of Toronto ABMT long-term follow-up clinic completed the Illness Intrusiveness Ratings Scale (IIRS), the Affect Balance Scale (ABS), the Atkinson Life Happiness Rating (ATKLH), the Beck Hopelessness Scale (BHS), and the Center for Epidemiologic Studies Depression (CES-D) Scale. Mean time from ABMT to evaluation was 4.6 +/- 2.8 years. All patients were in remission or had stable disease at the time of evaluation. Autologous blood and bone marrow transplantation patients' IIRS scores were compared with scores reported by recipients of kidney (n = 357), liver (n = 150), lung (n = 77), and heart (n = 60) transplants.

RESULTS

Mean IIRS score for the 44 ABMT patients was 37.2 +/- 17 (maximum possible score, 91; minimum possible score, 13). Higher IIRS scores correlated with lower scores on the ABS (r = -0.54; P < 0.0001), and ATKLH (r = -0.44; P = 0.004), and with higher scores on the BHS (r = 0.58; P < 0.0001) and CES-D (r = 0.48; P < 0.0001). The authors compared IIRS scores from the ABMT survivors with scores from recipients of solid organ transplants. Scores were corrected for age, gender, and time from transplant to evaluation. Corrected mean IIRS scores for the marrow (37.5), kidney (38.9), heart (40.0), lung (30.1), and liver (32.3) transplant recipients differed significantly (P < 0.0001 by analysis of covariance). Higher scores among marrow, kidney, and heart transplant survivors were caused by increased scores in the instrumental domain of the IIRS that measures disruptions in health, work, financial situation, and active recreation.

CONCLUSIONS

Despite achieving a remission after ABMT, patients continue to experience illness intrusiveness compromising subjective well-being.

Structure of lifestyle disruptions in chronic disease: a confirmatory factor analysis of the Illness Intrusiveness Ratings Scale

BACKGROUND

The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations.

OBJECTIVE

To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses.

METHODS

IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group).

RESULTS

Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to "Relationships and Personal Development," "Intimacy," and "Instrumental" life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores.

CONCLUSIONS

IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.

An economic analysis of kidney transplantation

Kidney transplantation is the most cost-effective treatment modality for end-stage renal disease (ESRD). Nonetheless, in keeping with the managed care mandate, expense has become an increasingly significant issue. Over $11 billion is now spent each year on ESRD treatment. Medicare per capita annual payments exceed $36,000 per beneficiary. Transplant procedure charges and outcomes vary dramatically across the United States. The average charge for a kidney transplant is approximately $82,000. Graft and patient survival rates are highly variable, even among the most active programs in the US. Individual transplant programs must implement approaches to contain their costs and assure quality. At the Mayo Clinic, our mean charge for a kidney transplant ($53,510) in 1996 was 27.2% below expected, given national medical inflation over the past decade. Unfortunately, the net operating income associated with our kidney transplant program has been severely eroded in an increasingly brutal economic environment.

A review of health-related quality-of-life measures used in end-stage renal disease

Health-related quality of life (HRQOL) is a critical issue in the treatment of end-stage renal disease (ESRD) patients. The variety of symptoms, comorbidities, and treatments of ESRD over the course of its chronic disease trajectory necessitate comprehensive assessment of the impact of interventions on HRQOL. A literature review of ESRD HRQOL studies was performed to provide an overview of the instruments used and to provide recommendations for HRQOL assessment in future studies. Instruments were classified based on the health domains they assess and whether they are generic or disease targeted. The instruments were judged in terms of their comprehensiveness, reliability, and validity.

Psychosocial impact of laryngectomy mediated by perceived stigma and illness intrusiveness

In addition to prolonging life, successful treatment by laryngectomy also results in functional disability (loss of speech) and physical disfigurement (stoma). It was hypothesized that these after-effects contribute to perceived stigma which, in turn, compromises quality of life. The hypothesis that the psychosocial impact of perceived stigma operates through illness intrusiveness--illness-induced disruptions that interfere with continued involvements in valued activities and interests--was tested. Data were collected from 51 laryngectomy recipients via standardized interviews. As hypothesized, results indicated that: 1. both perceived stigma and illness intrusiveness are related to psychosocial well-being and emotional distress; 2. illness intrusiveness mediates the relation between perceived stigma and psychosocial outcomes; 3. the psychosocial impact of illness intrusiveness is most devastating in the context of highly stigmatized self-perception; and 4. unique profiles of illness intrusiveness across individual life domains may be associated with specific psychosocial outcomes. Findings are discussed in relation to the hypothesis that illness intrusiveness is a common underlying determinant of the psychosocial impact of chronic illness.

Illness intrusiveness and the psychosocial impact of lifestyle disruptions in chronic life-threatening disease

Chronic life-threatening and disabling conditions, such as end-stage renal disease (ESRD), introduce significant psychosocial stressors and adaptive demands. The concept of illness intrusiveness is introduced to represent the illness-induced disruptions to lifestyle, activities, and interests that can compromise psychosocial well-being and contribute to emotional distress in chronic disease. A theoretical model is presented to specify the nature, determinants, and psychosocial consequences of illness intrusiveness and the causal pathways through which these factors are interrelated. Evidence in support of this analysis is reviewed and includes relevant findings from several chronic conditions including renal failure. The article concludes with suggested strategies and tactics for minimizing illness intrusiveness in ESRD. It is hoped that effective minimization of illness intrusiveness can assist affected individuals in achieving a high quality of life.

Measuring, managing, and improving quality in the end-stage renal disease treatment setting: peritoneal dialysis

Peritoneal dialysis is now performed as an end-stage renal disease modality in nearly 70,000 patients worldwide. The use of this modality varies widely from less than 5% of all end-stage renal disease patients in Japan to over 95% of patients in Mexico. In addition to medical and psychosocial factors, modality selection involves many other factors, including financial reimbursement, educational deficiencies, resource availability, social mores, and cultural habits. Survival on chronic peritoneal dialysis is similar to that on hemodialysis, although older diabetic patients on peritoneal dialysis may have a higher mortality rate. Hospitalizations and transfer off modality are more common in patients on chronic peritoneal dialysis compared with patients on hemodialysis. The important factors contributing to outcome in patients on chronic peritoneal dialysis are unknown. Results of the Baxter Best-Demonstrated Practice Program suggest that process of care has a strong impact on outcome, at least in retention of patients on chronic peritoneal dialysis. Quality of life is another outcome that has been poorly assessed in chronic peritoneal dialysis patients. Available studies suffer from a lack of standardization of instruments used, no control groups, no random patient allocation to modalities, and short-term, small population groups. When chronic peritoneal dialysis and hemodialysis are compared, subjective quality of life is generally higher with chronic peritoneal dialysis. For objective quality of life, the balance of studies favor hemodialysis. It is clear that there is a dearth of information available on many aspects of delivery of chronic peritoneal dialysis. Future research should target patient factors that are important in morbidity and mortality with chronic peritoneal dialysis, facility factors ("process of care") that are important in morbidity and mortality with chronic peritoneal dialysis, quality of life in chronic peritoneal dialysis patients, and how to measure quality of life accurately and serially. If these issues can be addressed, algorithms could be developed to help the physician to match the end-stage renal disease patient to the treatment modality that will provide the highest quality of life, the least morbidity, and the longest survival.

Medical and social outcome in adolescents with end-stage renal failure

Clinical information was collected on 118 adolescents who developed ESRF at age 143 months or older and were treated between 1966 and 1986 at the Toronto Hospital for Sick Children. The cumulative survival rate in transplanted patients (N = 109) was 80.1% after 15 years. Survival rates after four years were 93.9% in transplanted and 46.9% in nontransplanted patients (P less than 0.001). No patient receiving dialysis alone (N = 9) was followed longer than four years. Nine patients received three transplants and had an 89% survival rate. Six of these had a functioning graft at end of the follow-up. The cumulative survival of the entire group was 76.4% at eighteen years. Forty-two (35.6%) patients had a height below the third percentile. Functional status obtained by a structure telephone interview with a member of the present treating nephrology service was good (G) or excellent (E) for 66.7% of all patients (73.5% of transplant patients (N = 68) and 45% of dialysis patients (N = 20). Hemodialysis patients functioned less well [25% G/E (N = 12)] than peritoneal dialysis patients [75% G/E (N = 8)]. Most patients achieved an appropriate level of formal education although more slowly than normal adolescents. Only 11 patients were neither enrolled in an educational institution nor employed. We conclude that aggressive treatment for adolescents with ESRF is an appropriate application of health care resources.

Quality of life after organ transplantation

Organ transplants are being conducted with increasing frequency. It is generally known that these procedures increase length of life, but less is known about the quality of that life. In this paper, the literature pertaining to quality of life of patients with kidney, pancreas, heart, heart-lung, liver and bone marrow transplants is reviewed. On the basis of this review, it seems that quality of life after kidney and heart transplantation is very good, when compared to the pretransplant state. However, more research is required to examine quality of life of recipients of other types of transplantation. There are many issues that pertain to measurement of quality of life that remain to be addressed. These include: definitions of quality of life, dimensions of quality of life, expectations of quality of life and clinical assessment of quality of life.