Development of the satisfaction with inhaled asthma treatment questionnaire

For the management of a condition such as asthma, patients should feel confident with their medication, feel that the treatment is adequate in controlling symptoms and that side-effects of the treatment are minimal. As no comprehensive instrument to measure patient satisfaction with inhaled asthma medication existed, the Satisfaction with Asthma Treatment Questionnaire was developed. The procedures that were used are described, and the initial validation and reliability tests are reported. The study involved focus group meetings, development, testing and modification of a preliminary instrument, and testing of the revised instrument using different samples of patients with asthma. Factor analysis of the 26-item questionnaire identified four domains reflecting four aspects of satisfaction: effectiveness of treatment, ease of use, medication burden, and side-effects and worries. Cronbach's alpha showed evidence of internal consistency reliability. Test/retest reliability ranged from 0.66-0.74. Interscale correlations were moderate-to-high. Significant correlations were found between domain and overall scale scores and patients' overall level of satisfaction. The Satisfaction with Asthma Treatment Questionnaire is potentially a useful instrument for gaining insight into patient satisfaction with inhaled treatment for asthma.

Patients' health-related quality of life and utilities associated with different stages of amyotrophic lateral sclerosis

OBJECTIVES

Amyotrophic lateral sclerosis (ALS) is a devastating disease that has serious consequences in terms of impairments and disabilities, which are expected to impact on health-related quality of life (HRQL). The aim of the present study was to assess self-reported health status and HRQL, as well as patients' own valuation of their present health state in a sample of patients with different levels of severity of ALS.

METHODS

Structured interviews were conducted with 77 patients with different levels of disease severity. Patients completed a disease-specific health status measure (ALSAQ-40), a generic health status measure (EuroQol EQ-5D), visual analogue scale (VAS) rating of current health and a standard gamble (SG) exercise to provide health state utilities for their own health state.

RESULTS

The results from the ALSAQ-40 and EQ-5D descriptive system indicate that patients' HRQL decreases systematically with increasing severity of disease. Patients' mean VAS rating of their own health ranged from 0.74 for stage 1 (early) disease severity, to 0.37 for stage 4 (late stage) disease severity. Utilities elicited via SG were systematically higher than VAS scores and ranged from a mean of 0.79 for stage 1 disease severity to a mean of 0.45 for stage 4 disease severity.

Quality-adjusted survival (Q-TWiST) analysis of EORTC trial 30853: comparing goserelin acetate and flutamide with bilateral orchiectomy in patients with metastatic prostate cancer. European Organization for Research and Treatment of Cancer

BACKGROUND

The first data analysis of the European Organization for Research and Treatment of Cancer (EORTC) 30853 trial indicated a significantly longer time to progression and duration of survival for the maximal androgen blockade (MAB) treatment arm. However, the MAB treatment arm had a higher frequency of reported side effects.

METHODS

The quality-adjusted survival (Q-TWiST) method was applied to perform a secondary analysis of the EORTC 30853 trial in order to obtain a quality-adjusted survival (QAS) analysis. Two models with different definitions of the progression health state were used for the analysis. In the first model, progression was defined by both objective and subjective criteria, and in the second model only by increase in pain score. The approach was also extended to include an analysis using actual utility scores (Q-tility) of patients in the relevant health states.

RESULTS

Based on Q-tility scores obtained from a separate study of a cohort of prostate cancer patients, the QAS analysis resulted in a 5.2-month difference (95% CI, -1.1; 11.5 months) in favor of zoladex and flutamide, equal in magnitude to the benefit found in the unadjusted survival analysis.

CONCLUSIONS

A QAS analysis such as the Q-TWiST method may be preferred over the unadjusted approach in clinical trials where the health states are clearly distinct, and differ significantly in either duration or quality of life (QOL), or both. The second model, with progression defined as increase in pain score, made no difference to the results in this study because of the small difference in duration of the pain-progression health state between treatment arms. However, Q-tility scores from the separate cross-sectional study that was used in this Q-TWiST analysis showed that a subjective definition of health states better reflects differences in QOL between the health states that the patients experience during follow-up.

Quality of life after radiation therapy of cerebral low-grade gliomas of the adult: results of a randomised phase III trial on dose response (EORTC trial 22844). EORTC Radiotherapy Co-operative Group

In 1985, the EORTC Radiotherapy Co-operative Group launched a randomised phase III study comparing high-dose (59.4 Gy in 6.5 weeks) versus low-dose (45 Gy in 5 weeks) radiotherapy with conventional techniques in patients diagnosed with low-grade cerebral glioma. The primary endpoint of the study was survival. No difference in survival was observed between the two treatment strategies. A quality of life (QoL) questionnaire consisting of 47 items assessing a range of physical, psychological, social, and symptom domains was included in the trial to measure the impact of treatment over time. Patients who received high-dose radiotherapy tended to report lower levels of functioning and more symptom burden following completion of radiotherapy. These group differences were statistically significant for fatigue/malaise and insomnia immediately after radiotherapy and in leisure time and emotional functioning at 7-15 months after randomisation. These findings suggest that for conventional radiotherapy for low-grade cerebral glioma, a schedule of 45 Gy in 5 weeks not only saves valuable resources, but also spares patients a prolonged treatment at no loss of clinical efficacy.

Quality of life as an endpoint in EORTC clinical trials. European Organization for Research and Treatment for Cancer

For more than 30 years the European Organization for Research and Treatment for Cancer (EORTC) has conducted, co-ordinated, and stimulated research on the experimental and clinical bases of treatment of cancer and related problems. For more than a decade the EORTC has included quality of life as an outcome measure in some of its trials. The number of clinical studies that include QOL as an evaluation endpoint has increased rapidly in the last few years, and is still increasing steadily. This necessitated a careful and critical evaluation of procedures and results so far in order to generate appropriate guidelines and procedures for incorporating QOL issues in all stages of the clinical trial process, including protocol writing, data collection, data analysis, and reporting of results. This paper provides an overview of the types and the design of studies, data management of quality of life assessment, compliance, missing data and lessons learned during the past years with respect to QOL assessments in the EORTC studies.

Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome

BACKGROUND

Operative procedures for primary rectal cancer from Japan combine pelvic nerve-preserving techniques with radical tumour resection to ensure optimal local tumour control with minimal bladder and sexual dysfunction. A prospective study was undertaken to evaluate morbidity and functional outcome of such a technique in Dutch patients.

METHODS

Forty-seven patients were operated on by a Japanese surgeon. Postoperative course was monitored. Voiding and sexual function were analysed using questionnaires completed by patients.

RESULTS

After operation, only prolonged paralytic ileus (five of 47 patients) and perineal wound dehiscence (five of 18) occurred more frequently than reported in literature. There were no deaths. No patient developed urinary incontinence. Three of 11 women and 19 of 30 men were sexually active. Two men were impotent after operation. Impotence was related to sacrifice of the inferior hypogastric plexus (P = 0.037). Preservation of the superior hypogastric plexus was crucial for ejaculation (P = 0.003).

CONCLUSION

A relationship between sacrifice of specific nerve structures and accompanying dysfunction was established. The nerve-preserving technique yields good results in terms of morbidity and functional outcome, and should be considered for adoption as a standard surgical procedure for primary rectal cancer.

A role for the sick role. Patient preferences regarding information and participation in clinical decision-making

OBJECTIVE

To assess whether patient preferences regarding information and participation in decision-making about treatment options are related to patient characteristics and the context of the decision. Other studies have compared decision-making preferences in patients with cancer and healthy subjects, or in different contexts among patients in the same group. This study combined these designs.

DESIGN

Questionnaire completed by the subjects.

SETTING

Outpatient clinic of a university hospital.

PARTICIPANTS

A consecutive sample of 55 patients with cancer treated at a radiotherapy clinic, 53 persons accompanying them, a consecutive sample of 53 patients visiting a surgical outpatient clinic for a nonmalignant condition and 36 persons accompanying them.

MAIN MEASURES

Preferences regarding information and participation in decision-making in general and with respect to 4 vignettes that described different diseases of varying seriousness, varying treatment options and side effects.

RESULTS

Older patients and men were more likely to let the physician make decisions regarding their treatment. Patients, as compared with nonpatients (their companions), were more likely to prefer a passive role regarding treatment decisions. No differences were seen between patients with cancer and patients with nonmalignant conditions. Also, no effect was observed in relation to the decision-making situations described in the vignettes. Of the patients who preferred more information, a substantial proportion still preferred a passive decision-making role.

CONCLUSION

The lack of strong predictors of a preferred decision-making role implies that clinicians need to assess every patient individually to determine what role he or she prefers. The finding that the patients preferred a more passive role than their companions suggests that the "sick role" influences the preference regarding participation more strongly than the type of decision to be made or the presence of a life-threatening disease. This hypothesized shift in preference among subjects who are sick implies that these patients need encouragement to participate.

Quality of life as an outcome measure in cancer clinical trials

In the past decade, increasing attention has been given to more systematic and quantitative ways of evaluating explicitly the impact of diseases and medical interventions on quality of life. A substantial part of this research pertained to the field of cancer where cure is not always possible and treatments are mostly intrusive. This paper will address two broad issues. The first part focuses on the general issues related to the evaluation of quality of life, such as its concept, the purpose and design of the study and assessment criteria, particularly in the context of a cancer clinical trial. The second part focuses specifically on quality-of-life issues in urinary tract cancer.

Surveillance versus adjuvant chemotherapy in stage I non-seminomatous testicular cancer: a decision analysis

In stage I non-seminomatous testicular cancer, the decision between surveillance and adjuvant chemotherapy rests heavily upon the valuation of quality of life. Decision analysis was used to assess at what relapse rate adjuvant chemotherapy is preferred when patients' and clinicians' evaluations are considered. Probabilities were obtained from the literature and from experts. Evaluations of the disease states were obtained from patients (n = 68) and clinicians (n = 50). Results from the model were compared with a treatment preference question, asking for the relapse rate directly. Adjuvant chemotherapy was preferred at relapse rates above 50% when patient evaluations were used. The evaluations of the disease states had a strong impact on the decision. Using clinician evaluations, adjuvant chemotherapy was preferred at relapse rates above 73%. The relapse rates from the treatment preference question were lower: 46% for patients and 35% for clinicians. The results indicate that when patient preferences are accounted for, adjuvant chemotherapy should be considered more often.

Tradeoffs between quality and quantity of life: development of the QQ Questionnaire for Cancer Patient Attitudes

The patient's perspective is of prime concern in weighing the benefits and side effects of oncologic treatment. Little is known about patients' preference and attitudes. The authors developed a short questionnaire to assess patient attitudes concerning trade-offs between quality of life and length, or quantity, of life (the QQ Questionnaire). The questionnaire turned out to be feasible for use in various groups of cancer patients. In a factor analysis, the questionnaire was shown to consist of two factors, a Q(uality) and a L(ength) factor. Values of Cronbach's alpha for the Q and L scales (consisting of four items each) were 0.68 and 0.79, respectively. Younger patients and patients who have children assigned relatively more importance to striving for prolonged survival. Contrary to our expectation, no association was found between scores on the two scales and time tradeoff utility scores. The QQ Questionnaire can be used in research settings to study patient attitudes and the stability and determinants of patients' preferences.

The 'utility' of the visual analog scale in medical decision making and technology assessment. Is it an alternative to the time trade-off?

Methods often used for the valuation of health states are the time trade-off (TTO) and the visual analog scale (VAS). The VAS is easier than the TTO and can be self-administered; however it usually leads to lower scores. In the literature a power transformation of group mean VAS scores to TTO scores has been proposed. We were able to replicate this finding of a power function. We found coefficients that were very similar to those from the literature, for 183 cancer patients. The relationship existed independently of disease state and health status.

The "utility" of the Time Trade-Off method in cancer patients: feasibility and proportional Trade-Off

We examined the feasibility and the proportional trade-off assumption of the Time Trade-Off method. Utilities were assessed of the actual health states of 54 testicular and 72 colorectal cancer patients, treated with the curative intent and 29 incurable colorectal cancer patients. Three periods of time were used to assess proportionality: the subject's life expectancy and two shorter periods. Results showed the method to be feasible in curatively treated patients, though the use of life expectancy posed difficulties in some very old subjects. This same difficulty was encountered in patients with symptomatic incurable disease. A two step procedure is proposed as a solution. The proportional trade-off assumption was violated. Utilities for the longer period were smaller than those for the shorter periods. Life expectancy and trade-off did not correlate, though. Remarkable was that many patients were unwilling to trade at all. The implications of the findings are discussed.

Quality of life after combined kidney-pancreas or kidney transplantation in diabetic patients with end-stage renal disease

The quality of life after a successful combined kidney-pancreas transplantation was studied in 17 diabetic patients with end-stage renal disease (ESRD) and in 11 patients who experienced a failure of one or both grafts. The control group comprised 23 patients who received a kidney transplantation only. The aspects of quality of life chosen for study were: physical, psychological and social wellbeing, daily activities, level of functioning and global quality of life evaluation. Additionally, future expectations, the perceived burden of treatment, and main reason for undergoing organ replacement therapy were evaluated. In only one aspect of quality of life did patients with a successful combined transplantation score significantly better than patients with a kidney transplantation, i.e., mobility in daily functioning and activities (p = 0.03). Patients with a failure of one or both grafts reported significantly more fatigue (p = 0.02), less energy (p = 0.04), and more social isolation (p = 0.05) than patients who had well-functioning grafts. The mean duration of hospitalization following combined transplantation is twice that for kidney transplantation only 10 vs 5 weeks. Although the combined transplantation group found the first 3 months after transplantation more burdensome (p = 0.04) and more often wondered whether it had been worth all the trouble (p = 0.05), they indicated the same willingness as the group with a kidney transplant only to undergo another transplantation under similar circumstances. Although the recipients of a kidney transplant had not been offered the choice of a combined transplantation, their reasons for transplantation did not, in essence, differ from those of recipients of a combined transplantation. In both groups the main motivation to opt for organ replacement therapy was the burden of dialysis, to stop the progressive deterioration of their health, and to experience a better quality of life.

Choices in oncology: factors that influence patients' treatment preference

Medical treatment of cancer often entails a trade-off between outcomes of two different attributes: quality of life (QOL) and length of life (LL). This process of weighing advantages and disadvantages seems to be influenced by different factors. The main purposes of this study were (a) to investigate the relative importance of different factors on the trade-off and (b) to explore the relationship between these importance ratings and personal characteristics. We asked 199 patients with cancer to indicate to what degree they consider a number of factors to be of importance if they had to choose between two treatment modalities that differ in their expected outcomes concerning QOL and LL. The seven factors were their age at the time of decision, having a partner, having children, inability to work due to side-effects of the treatment, the nature of the side-effects, disease-related life expectancy and baseline QOL. The results indicate that six of the seven factors were of considerable to great importance when a treatment choice had to be made. The negative effects of treatment on the ability to work did not seem to be a very important consideration. Patient age and education were positively associated with importance ratings.

Utility assessment in cancer patients: adjustment of time tradeoff scores for the utility of life years and comparison with standard gamble scores

The standard gamble (SG) and the time tradeoff (TTO), two frequently used methods of utility assessment, have often been found to lead to different utilities for the same health state. The authors investigated whether adjustment of TTO scores for the utility of life years (risk attitude) eliminated this difference. In addition, the association between risk attitude and sociodemographic and medical variables was studied. In 30 disease-free testicular cancer patients, SG and TTO were used to assess the utilities of four health profiles relevant to testicular cancer. Utility of life years was estimated from certainty equivalents (CEs). SG scores were significantly higher than unadjusted TTO scores for all profiles. As the majority of patients (85%) were risk-averse, CE-adjusted TTO scores were higher than unadjusted scores, and were not significantly different from those obtained from the SG for three of the four profiles. However, adjusted scores were still slightly but consistently lower than SG scores. Possible explanations for this discrepancy are discussed. An association was found between risk aversion and medical treatment: patients who had received chemotherapy for their cancers were more risk-averse than were patients who had been in a surveillance protocol only. As risk aversion can have an impact on treatment decisions, it is important to assess the risk posture of the patient to whom the decision pertains.

Psychological effects of routine follow up on cancer patients after surgery

OBJECTIVES

To assess the subjective value that patients with cancer place on regular follow up after operation; to see what effects regular follow up visits have on the patient's physical and psychological wellbeing; and to find out which variables influence patients wellbeing and attitudes to follow up.

DESIGN

Survey by questionnaire.

SETTING

University Hospital Leiden, the Netherlands.

SUBJECTS

127 Patients who had been operated on for cancer.

INTERVENTIONS

67 Patients were assessed one month before a routine follow up visit, and 60 on the day of the follow up; 46 of the second group were assessed again two weeks later.

MAIN OUTCOME MEASURES

Answers to questions about physical and psychological wellbeing.

RESULTS

Most patients were in favour of regular follow up visits at the hospital, and thought that the advantages outweighed the disadvantages. There were more reports of psychological than physical distress one month beforehand, but these were significantly less two weeks after the appointment compared with one month before (p = 0.003) and on the day of the appointment (p < 0.001). Regular follow up visits do not temporarily increase physical or psychological distress; rather there is a temporary decrease, less fear of recurrence, and less perception of any disadvantages. Women in general, and those with breast cancer in particular and patients with a lower educational standard in particular, had significantly more psychological complaints.

CONCLUSIONS

Regular follow up visits are in general welcomed by patients who have had operations for cancer.

Test-retest reliabilities of two treatment-preference instruments in measuring utilities

The authors assessed the test-retest reliabilities of two treatment-preference instruments recently applied to the measurement of the utilities of health states after different treatment modalities for cancer. The first instrument measures the strengths of preferences concerning a choice between a wait-and-see policy, and treatment with radiotherapy after an initial surgical breast-conserving procedure for early breast cancer. The second measures the strengths of preferences concerning a choice between two hypothetical surgical treatment outcomes in cancer of the rectum with different probabilities of expected five-year survival. Both measure the strength of a subject's treatment preference given probabilities of treatment-related costs and benefits. The subjects were radiotherapy technicians (n = 20) and cancer patients (n = 20) who were interviewed in weeks 2 and 4 of radiotherapy. The test-retest reliabilities of both instruments were inconsistent and moderately high, with Spearman's rank correlations ranging from 0.38 to 0.81 and weighted kappas ranging from 0.38 to 0.69. To investigate whether the start of treatment with radiotherapy influenced the utilities that patients assigned to health states, the same procedure was applied in another, comparable, group of patients with cancer (n = 20). For this group, the first assessment was made prior to the start of treatment and the second during the second week of radiation therapy. The scores of this group of patients indeed appeared to be less stable than the scores of the patients assessed in weeks 2 and 4 of radiotherapy. However, the instability of the scores could have been the result of test bias.

The impact of breast-conserving treatment and mastectomy on the quality of life of early-stage breast cancer patients: a review

In recent years, doubt has been shed on the necessity of mastectomy for women with early-stage breast cancer. Apart from purely medical studies comparing (radical) mastectomy to less intruding surgical treatment, a number of studies (N = 18) have been published investigating the impact of breast-conserving treatment versus mastectomy on quality of life. We review these studies with respect to medical issues (treatment modality, stage of disease), methodologic issues (design, measurement moment, sample size), and results (psychologic discomfort, changes in life patterns, fears and concerns). It is concluded that there is no solid proof of a better psychologic adjustment after breast-conserving treatment and that there are no substantial differences between the different treatment modalities in changes of life patterns and fears and concerns. However, the results with respect to body image and sexual functioning favor the use of breast-conserving treatment.

Effect of peri-operative chemotherapy on the quality of life of patients with early breast cancer

Since chemotherapy is assumed to have a negative impact on quality of life, the impact of peri-operative chemotherapy on physical, psychological and social well-being and on the activity level of patients with early stage breast cancer was investigated. 24 women received peri-operative chemotherapy and 29 did not. They were interviewed 2 months and at a mean of 12 months post-surgery. Although the treated group reported more fatigue and considered hair loss a severe side-effect, no differences were found in overall physical and physiological well-being, perceived social interaction and activity level at 2 months. 1 year after surgery no differences were found between the two groups. Although no substantial effects of peri-operative chemotherapy on quality of life were demonstrated, patients almost unanimously considered peri-operative chemotherapy the most burdensome aspect of the treatment because of alopecia.