The social dimension of health status measures in rheumatoid arthritis

Functional assessment measures in rheumatologic disorders

Rheumatologic disorders cause functional impairment and significantly affect health-related quality of life. Functional assessment and health-related quality of life scales are increasingly being used as outcome measures to assess the influence of the diseases and health outcome in clinical studies of patients with rheumatologic diseases. In this article, we review the functional assessment and health-related quality of life measures which have been commonly used as outcome measures in rheumatologic disorders. These measures are Short form-36 (SF-36), SF-12, Nottingham Health Profile, Sickness Impact Profile, EuroQol, SF-6D, Health Utilities Index mark 2 and 3, Stanford Health Assessment Questionnaire, Rheumatoid Arthritis Quality of Life Questionnaire, Arthritis Impact Measurement Scales, McMaster Toronto Arthritis Patient Preference Disability Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index, Lequesne Index, Knee Disability and Osteoarthritis Outcome Score, Knee Disability and Osteoarthritis Outcome Score-Physical Function Short-form, Hip Disability and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score-Physical Function SF, Fibromyalgia Impact Questionnaire, Psoriatic Arthritis Quality of Life Scale, Gout Assessment Questionnaires, Dougados Functional Index, Bath Ankylosing Spondylitis Functional Index, and Ankylosing Spondylitis Quality of Life Scale.

Improved quality of life with cardiac rehabilitation for post-myocardial infarction patients in Korea

BACKGROUND

Health-related quality of life (HRQOL) has been used as a primary health outcome in cardiac rehabilitation programs (CRP).

AIMS

This study aimed to evaluate the effects of an 8-week CRP on HRQOL and exercise capacity in myocardial infarction (MI) patients in Korea.

METHODS

After matching on gender, age, and left ventricular ejection fraction, 60 subjects with a first acute MI were allocated to either a CRP group (n=31) or a Control group (n=29). The 8-week CRP included hospital-based, supervised exercise training (three times per week, average intensity of 65% VO(2peak)) and individual education sessions. The Control group was instructed on a home-based exercise regimen without contact during the 8 weeks. At baseline and 8 weeks, HRQOL was assessed by the Quality of Life Index (QLI)-cardiac version III; exercise capacity by a treadmill test.

RESULTS

After adjusting for education level, the overall QLI, health/functioning and psycho/spiritual scores showed greater increases in the CRP group than the Control group (p=.014, p=.016, and p=.036, respectively). We observed significant improvements in VO(2peak) (p<.0001), anaerobic threshold (p<.0001), and maximal exercise duration (p<.0001) in the CRP group, compared to the Control group.

CONCLUSIONS

These findings suggest that the Korean CRP can lead to significant improvements in HRQOL outcomes and exercise capacity.

Functional status of patients with primary biliary cirrhosis

OBJECTIVES

Although autoimmune diseases can have a significant impact on the quality of life, there has been a relative paucity of data with respect to the functional status of patients with primary biliary cirrhosis (PBC).

METHODS

We conducted a case-control study of 182 patients ("cases") with PBC as well as 225 age- and sex-matched friend control subjects using a standardized instrument obtained from the National Health and Nutrition Examination Survey.

RESULTS

In all, 126 of 182 cases (69%) and 141 of 225 friend controls (62.6%) responded to this survey, a response rate comparable to or better than in similar previous studies of such instruments. Patients with PBC had a significantly reduced functional status score compared to their controls (p < 0.001). Interestingly, a lower level of education and the presence of arthritis and hypertension were significantly associated with these lower levels of functional capabilities. These data were subjected to multivariate analysis and confirmed. Age was not associated with impaired functional status in either the patients or controls.

CONCLUSIONS

Studies of this nature have potential implications for the well-being and management of patients with PBC, and focus on issues that can be addressed to help maintain functional status in this chronic disease.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Quality of life measures: use and abuse

Health status and quality of life measures are widely used in the clinical assessment of rheumatoid and other forms of arthritis. A range of measures is available, mainly as self-administered instruments. Most of these are reliable, valid and sensitive to change. They can be used to assess clinical status, evaluate effectiveness in randomized trials, define outcome and help to plan for health-care needs for people with arthritis. The instruments form a continuum with assessments of disease activity and functional disability. Some instruments are specifically designed for use in rheumatoid arthritis, other instruments are generic and can be used across a range of conditions including arthritis, and some generic instruments can be specifically scored to reflect the problems most prominent in arthritis. There are trade-offs between simplicity and sensitivity and between using familiar and unusual instruments. Against this background, the most widely used disease-specific measure remains the health assessment questionnaire (HAQ), and the most commonly employed generic measure is the SF-36. Evidence currently suggests focusing on these well-known and widely used measures. In both cases, the pain score is the predominant clinical assessment associated with poor health status measured using either instrument. HAQ scores also reflect unchanging aspects of patients' overall status, such as their degree of deprivation. It is sensible for all future clinical trials to include one disease-specific and one generic measure of health status.

On the generalizability of statistical expressions of health related quality of life instrument responsiveness: a data synthesis

Responsiveness statistics have been suggested as criteria for selecting health-related quality of life (HRQoL) instruments or for calculating the required sample size. This paper raises questions about the stability of estimates of instrument responsiveness. The questions are examined by use of data synthesis. A literature search identified instances where two HRQoL instruments were used concurrently on two or more occasions. An effect size difference between the instruments was calculated. The distribution of the differences in the effect size between pairs of instruments used conjointly in different applications was used as an indicator of variation in responsiveness. The effect size for all possible published uses of generic and disease-specific HRQoL instruments was also examined. Responsiveness was found to be subject to considerable variation. Disease-specific instruments were found to be consistently more responsive than generic instruments. The authors suggest use of responsiveness data should be restricted to expanding pilot study results.

Morbidity and health-related quality of life among ambulant elderly citizens

Health-related quality of life (HRQL) was analyzed in relation to 16 different diagnoses common for ambulant, community living 76-year-old urban citizens participating in the longitudinal population study of elderly in Göteborg (H 70), Sweden. HRQL of the total sample was good, but was impaired by illness, mostly in the form of anginal pain, urinary incontinence, locomotor and mental disorders. The HRQL of those suffering from e.g. chronic lung disorders or under treatment for hypertension or cancer, however, seemed to be little influenced. Sleep was impaired regardless of being ill or healthy, except for anginal pain, upper extremity disorders and back pain which had a significantly detrimental impact on sleep. The degree of female complaints surpassed those of men for pain, emotions, sleep and mobility, and for household activities and hobbies. Within the separate diagnostic groups, however, gender differences were few. Generally, HRQL decreased with multimorbidity. In the emotional and social dimensions, however, HRQL was very little influenced until health was much impaired (reaching 4 or more diagnoses). The studied diagnoses did not explain more than up to 1/3 of the QL decrease, thus suggesting that factors other than health have an impact or that ill health is considered an acceptable component of aging. However, most of the diagnoses seemed to cause much distress in common daily life, especially anginal pain, urinary incontinence, locomotor problems, visual impairment, and mental disorders.

A comparison of patients with late-stage rheumatoid arthritis and osteoarthritis of the shoulder using self-assessed shoulder function and health status

OBJECTIVE

To compare the function and health status of individuals with advanced rheumatoid arthritis (RA) and osteoarthritis (OA) of the shoulder using standardized patient self-assessment tools.

METHODS

A group of patients with late-stage arthritic involvement of the shoulder was evaluated at the time of initial presentation using 2 questionnaires, one focusing on shoulder function and other on overall health status.

RESULTS

There was substantial variability in the shoulder function and health status within each diagnostic group; however, both groups demonstrated significant deficits in their Simple Shoulder Test responses and in many of their Health Status Questionnaire-Short Form 36 scores. While the patients with RA tended to have somewhat greater impairment of shoulder function, many of the differences were not statistically significant. By contrast, most health status parameters were significantly more impaired in the patients with RA.

CONCLUSIONS

Among patients with late-stage shoulder arthritis, the overall health status of those with RA is significantly worse than those with OA. Differences in health status may be important in selecting the optimal management for individual patients with late-stage shoulder arthritis. Self-assessment questionnaires are effective in characterizing these differences.

Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument

Despite an increasing reliance on the use of health status measures to assess and evaluate medical care, no single instrument is currently available for use with the broad range of patients with musculoskeletal disorders of the extremities that is commonly seen in clinical practice. In this paper, we report on the development of the Musculoskeletal Function Assessment instrument, a 100-item self reported health status instrument that is designed to meet this need. The instrument was developed in two phases. During the first phase, items were selected on the basis of interviews with 135 patients and 12 clinicians and from reviews of existing health status instruments. The items then were grouped into categories. During the second phase, the instrument was tested for reliability and content validity using a sample of 327 patients with one of five musculoskeletal disorders of the upper and lower extremities (fractures, soft-tissue injuries, repetitive motion disorders, osteoarthritis, and rheumatoid arthritis). The patients were selected from both community and academic sites. Content validity also was demonstrated, based on a review of item selection procedures, expert opinion, and the distribution of scores on the instrument.

Tacit models of disability underlying health status instruments

In recent years much attention has been paid to the development of measures of subjective health status yet, although statistical criteria of reliability and validity have been quite rigourously tested, there has been little consideration of the different theories of disability which underlie the design. The sociology of disability may illuminate such tacit theories. It is suggested that the development of health status questionnaires has not been one of simple rational accumulation in response to methodological advances. Through an examination of the content of health assessment questionnaires, four distinct models of disability are identified. These are shown to influence not only the focus of the content and phrasing of the questions but also, crucially, the way that they perform and how responsive they are to change. The models (the functional, subjective distress, comparative and dependence) are illustrated and discussed in terms related to research design.