Development of a disease specific health related quality of life measure for adults and adolescents with cystic fibrosis

Can health-related quality of life predict survival in adults with cystic fibrosis?

RATIONALE

Advances in the management of cystic fibrosis have led to a significant improvement in survival, although marked differences between individuals are still observed. The value of patient-reported health-related quality of life scores in predicting survival in adults with cystic fibrosis is unknown.

OBJECTIVES

To evaluate whether patient-reported health-related quality of life could predict survival in cystic fibrosis.

METHODS

From 1996 to 1997 a consecutive series of 223 patients were recruited to evaluate the Cystic Fibrosis Quality of Life Questionnaire. Demographic (age, sex), clinical (FEV(1)% predicted, body mass index, diabetes, B. Cepacia complex, intravenous access device, nutritional and lung transplant status) and health-related quality of life variables were recorded (Cystic Fibrosis Quality of Life Questionnaire and the SF-36). These data were used as baseline measures to explore the prognostic association of health-related quality of life and subsequent survival.

MEASUREMENTS AND MAIN RESULTS

At the census date (December 31, 2006) 154 (69.1%) adults were alive, 66 (29.6%) had died, and three (1.3%) were lost to follow-up. Cox proportional hazards models and bootstrapping procedures examined if health-related quality of life domains predicted survival after adjusting for the demographic and clinical factors. The physical functioning domain of the Cystic Fibrosis Quality of Life Questionnaire and the pain domain of the Short Form-36 had the strongest statistical associations with survival.

CONCLUSIONS

Aspects of patient-reported quality of life serve as prognostic measures of survival beyond a number of previously known factors in cystic fibrosis. This needs to be investigated further in a larger longitudinal study.

A feasibility study of home telemedicine for patients with cystic fibrosis awaiting transplantation

Sixteen patients with cystic fibrosis were randomized to either telemedicine or standard care alone. All patients were terminally ill. Patients in the telemedicine group had an ISDN line installed in their home and were given a videoconferencing unit connected to their home television set. Eleven subjects completed the baseline assessment and seven patients completed the study (4 on telemedicine and 3 in the control arm). Telemedicine patients had weekly videoconferences from home for a clinical assessment, psychological support and the opportunity for discussion with any member of the multidisciplinary team. A total of 71 home videoconferences were conducted during the study. Anxiety levels were measured before and after the conferences. After six months there were no significant differences in quality of life, anxiety levels, depression levels, admissions to hospital or clinic attendances, general practitioner calls or intravenous antibiotic use between the two groups. However, there was a significant improvement in perception of body image for those in the telemedicine group and the patients liked and valued the service. The use of telemedicine can enhance the support that a specialist unit can provide for the patient and their family, and may reduce outpatient clinic attendances.

The effects of cystic fibrosis on couples: marital satisfaction, emotions, and coping strategies

An earlier diagnosis and better overall multidisciplinary care enable people suffering from Cystic Fibrosis (CF) to have a life expectancy of 40. Consequently, new populations and questions about the development of the life of couples have arisen. This study by questionnaires takes a first look at marital adjustment, anxiety, depression, and emotion focused, social support focused, and problem focused coping strategies in 16 CF patients and their partners. As a whole, the couples' marital adjustment level was good; it was higher for men who were patients than men who were partners, and vice versa for women. Anxiety was high for at least one partner in 10 of the couples; depression, for at least one partner in seven of them. The participants seem to use coping strategies to a lesser extent than the general population. The results are discussed in terms of how the quality of life as a couple with one partner suffering from CF is affected by the proper mutual adjustment of the partners.

Systematic review of health-related quality of life measures for children with respiratory conditions

Patient-reported outcomes (PROs) are increasingly used in both clinical trials and clinical care to evaluate patient benefits. The purpose of this review was to identify currently available PROs for children with pulmonary conditions and to make recommendations regarding future development and application of these measures. Systematic searches were conducted and disease-specific health-related quality of life (HRQOL) measures, a type of PRO, were identified for asthma, cystic fibrosis (CF), vocal cord dysfunction and sleep-related breathing disorders. Psychometric properties, age-appropriateness, respondent burden and minimal clinically importance difference scores were evaluated in accordance with the Food and Drug Administration guidelines. For both asthma and CF there are several psychometrically sound, well-established measures; however, for vocal cord dysfunction and sleep-related breathing disorders there are no measures children can complete for themselves. In summary, this review indicated that although significant progress has been made, there are still a number of pulmonary conditions for which there is no disease-specific HRQOL measure.

Validation of the Danish version of the revised cystic fibrosis quality of life questionnaire in adolescents and adults (CFQ-R14+)

BACKGROUND

Quality of life is an important parameter in the evaluation of quality and outcome of health care and treatment, especially in patients with chronic disorders. The aim of this study was to assess the validity and reliability of the Danish version of the revised disease-specific health-related quality of life questionnaire for adolescents and adults with cystic fibrosis (CFQ-R14+).

METHODS

A total of 196 cystic fibrosis (CF) patients completed the CFQ-R14+ (response rate 71%). Forced expiratory volume in 1 s in percentage of predicted (FEV(1)%) and body mass index (BMI) were included as measures of health status.

RESULTS

Internal consistency coefficients ranged from 0.54 to 0.95. Eight out of the twelve scales had alpha coefficients above 0.7. Test-retest correlations ranged from 0.42 to 0.88 and they were significant in eight scales. All the CFQ-R+14 scales except the digestive symptoms scale discriminated significantly (p<0.05) between patients with mild, moderate, and severe disease. Nine out of the twelve scales discriminated significantly (p<0.05) between nourished (BMI> or =19) and malnourished (BMI<19) patients. Significant differences between participants and non-responders were found for age, sex and FEV(1) (higher age, more males and lower FEV(1) among non-responders). All of the scales met standards for floor effects (<15% of the responders with the lowest score) but five of the scales failed to meet standards for ceiling effects (>15% of the responders with the highest score).

CONCLUSION

The Danish CFQ-R14+ is a reliable and valid instrument for measuring the health-related quality of life in Danish adolescents and adults with CF, though with the exception from a few of its subscales.

Psychological interventions for people with cystic fibrosis and their families

BACKGROUND

With increasing survival estimates for cystic fibrosis (CF) long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adjustments and quality of life. We are unaware of any relevant systematic reviews.

OBJECTIVES

Assess whether psychological interventions for CF provide significant psychosocial and physical benefits in addition to standard care.

SEARCH STRATEGY

Trials were identified from two Cochrane trial registers (CF and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search: September 2007.

SELECTION CRITERIA

Randomised controlled trials of a broad range of psychological interventions in children and adults with CF and their immediate family.

DATA COLLECTION AND ANALYSIS

Two authors independently selected relevant trials and assessed their methodological quality.

MAIN RESULTS

The review includes 13 studies (five new at this update) representing data from 529 participants. Studies mainly assessed behavioural and educational interventions:1. gene pre-test education counselling for relatives of those with CF;2. biofeedback, massage and music therapy to assist physiotherapy;3. behavioural and educational interventions to improve dietary intake and airway clearance;4. self-administration of medication and education to promote independence, knowledge and quality of life; and5. systemic interventions promoting psychosocial functioning.A substantial proportion of outcomes were educational or behavioural relating to issues of adherence, change in physical status or other specific treatment concerns during the chronic phase of the disease. Some evidence was found for relative's acceptance of a genetic test for carrier status when using home-based rather than clinic-based information leaflets and testing. There is some evidence that behavioural interventions improve emotional outcomes in people with CF and their carers, and that psychoeducational interventions improve knowledge in the short term. There was no consistent effect on lung function, although one small study showed that biofeedback-assisted breathing re-training helped improve some lung function measurements. Some studies point to educational and behavioural interventions aiding nutrition and growth in people with CF. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process.

AUTHORS' CONCLUSIONS

Currently no clear evidence exists on the best psychological interventions to help people with CF and their carers manage the disease. Trials of interventions to improve adherence to treatment are needed. Multicentre approaches, with consequent funding implications, will increase the sample size of trials and enhance the power and precision of their findings.

Costs, quality of life and treatment compliance associated with antibiotic therapies in patients with cystic fibrosis: a review of the literature

BACKGROUND

Cystic fibrosis is the most common incurable hereditary disease in the US. Persistent respiratory infection is the leading cause of morbidity and mortality in cystic fibrosis patients.

OBJECTIVE

This study aimed to review the literature on economic and quality of life outcomes and treatment compliance associated with antibiotic therapies for cystic fibrosis patients.

METHODS

A systematic literature review was conducted using keyword searches of the MEDLINE database and selected conference abstracts. The review covered studies published between January 1990 and May 2007.

RESULTS/CONCLUSIONS

Evidence suggests that inhaled tobramycin, a key chronic suppressive therapy, can reduce other healthcare costs. The main determinants of the cost of care include disease severity and respiratory infection. Costs vary widely by country. There is evidence that inhaled tobramycin and oral azithromycin improve quality of life and that treatment setting and patient convenience may also impact on quality of life. Antibiotic treatment compliance varied significantly and depended on the method of measurement, with more subjective measures tending to be higher. This review concludes by offering directions for future research.

Self-reported physical and psychological symptom burden in adults with cystic fibrosis

Symptom burden is a key component of health-related quality of life in patients with cystic fibrosis (CF). To examine symptom prevalence and characteristics of adults with CF, we administered the Memorial Symptom Assessment Scale (MSAS), a previously validated measure of symptom burden, to CF patients enrolled in the Project on Adult Care in CF. The mean age of the 303 respondents (response rate 91%) was 32.8 years (range, 19-64); 58% were female, and their mean baseline pulmonary function (FEV(1) % predicted) was 69% (SD 28%). The median number of symptoms reported was 10, and there was no difference in the number of symptoms reported based on age, gender, or FEV(1). The most prevalent symptoms were cough (94%), shortness of breath (77%), and lack of energy (77%). Lack of energy and irritability caused the highest level of distress. MSAS symptom subscales were only moderately correlated with symptom status domains from existing CF health-related quality of life measures. Factor analysis led to the development of three distinct MSAS CF-symptom subscales, each with high internal validity. These findings show that adults with CF have a high symptom burden, particularly with respiratory and psychological symptoms, and that the new MSAS CF-specific subscales are a reliable measure of symptom distress in the CF population.

Validation of the Italian version of the Cystic Fibrosis Quality of Life Questionnaire (CFQoL), a disease specific measure for adults and adolescents with cystic fibrosis

BACKGROUND

Disease specific, health-related quality of life (HRQoL) measurement is important in cystic fibrosis (CF). This work aimed to translate the original English Cystic Fibrosis Quality of Life Questionnaire (CFQoL) into Italian, evaluate the linguistic translation and to psychometrically evaluate the Italian version of the CFQoL.

METHODS

The linguistic translation followed the international guidelines of forward and backward translation. Psychometric evaluation of the Italian CFQoL involved the assessment of construct validity, internal reliability, concurrent validity, known groups validity and test-retest reliability.

RESULTS

The instrument was acceptable to adolescents and adults with CF and demonstrated robust psychometric properties. Principle components analysis indicated that the factorial structure was essentially similar to the original, and the internal reliability of each domain was good (Cronbach alpha coefficients 0.73 to 0.91). Appropriate domains of the CFQoL and SF-36 correlated well indicating good concurrent validity (r=0.68-0.80). Consistent with theoretical expectations some domains were able to discriminate between disease severity groups. Test-retest reliability, assessed by intraclass correlation coefficients, was found to be excellent (ICC 0.83 to 0.98).

CONCLUSIONS

The Italian CFQoL is a valid and reliable measure. Its use in individual patient monitoring and research should complement traditional clinical outcome measures.

Health-related quality of life in adults with cystic fibrosis: the role of coping

OBJECTIVE

This study examined the role of coping in explaining health-related quality of life (HRQoL) in cystic fibrosis (CF).

METHODS

Coping, quality of life, and clinical variables were assessed. The CF Coping Scale measures four ways of coping: optimistic acceptance, hopefulness, distraction, and avoidance. The Cystic Fibrosis Quality of Life Questionnaire (CFQoL) comprises 9 domains: physical, social, treatment, chest symptoms, emotional, body image, relationships, career, and future. Step-wise multiple regression and path analysis were used to model the associations between coping and CFQoL domains, taking into account important demographic and clinical factors.

RESULTS

One hundred and sixteen people with CF were recruited to the study. Their mean FEV(1)% predicted and BMI were 59.3% and 21.2 kg/m(2), respectively. Mean scores were highest for optimism and lowest for distraction coping. Coping had an inequitable influence across the CFQoL domains: it had negligible influence on domains that incorporate symptoms and aspects of physical functioning but considerable influence on psychosocial domains. Optimism and distraction were strongly associated with emotional responses, social functioning, and interpersonal relationships. A high level of optimism was associated with a better HRQoL and high levels of distraction with a poorer HRQoL. For some domains, optimism and distraction had a counterbalancing effect so the difference between them could be an important predictor of HRQoL.

CONCLUSION

Coping has emerged as an important factor in explaining some quality-of-life domains but not others. This has important implications especially when employing HRQoL as an outcome measure in clinical trials.

Patient-reported outcomes in cystic fibrosis

Over the past 20 years, there has been tremendous progress in the area of patient-reported outcomes (PROs). A PRO instrument is defined as any measure of a patient's health status that is elicited directly from the patient and assesses how the patient "feels or functions with respect to his or her health condition." The advances seen in clinical research regarding PROs has been mirrored in research in cystic fibrosis (CF). A large number of instruments have been used for both therapeutic and nontherapeutic clinical research for many chronic conditions. This review will summarize a history of the development of PROs and how PROs are viewed by the U.S. Food and Drug Administration. We will then review the current state of the art of patient-reported outcomes in CF, specifically addressing the evaluation of different PRO instruments in terms of their reliability and validity. Finally, we will delineate further areas for development of PROs in CF. We believe that the future of CF research will incorporate a more diverse selection of PRO outcome measures; these outcome measures ultimately may be incorporated into clinical care to standardize symptom assessment and provide information regarding the need for specific clinical interventions to improve the quality of care delivered to these patients.

[Validity and reliability of the St George's Respiratory Questionnaire in adults with cystic fibrosis]

OBJECTIVE

To study self-perceived quality of life in adults with cystic fibrosis (CF), and to assess the validity of the St George's Respiratory Questionnaire (SGRQ) for use in these patients.

PATIENTS AND METHODS

We studied 37 adults with CF who were in stable condition as indicated by their respiratory and nutritional status. Disease severity was assessed by spirometry in conjunction with a modified National Institutes of Health (NIH) scoring system and the Bhalla scale. Nutritional status was evaluated by measuring height and weight, calculating body mass index, analyzing bioelectric impedance, and performing various laboratory tests. The patients' quality of life was assessed using the SGRQ.

RESULTS

SGRQ scores were higher (indicating poorer quality of life) among patients with CF than in the general population or among patients with chronic obstructive pulmonary disease. Internal consistency coefficients indicated the SGRQ had good reliability (Cronbach alpha 0.864). Women with CF tended to score higher than men, although this difference was not statistically significantly. A statistically significant relationship was observed between SGRQ score and severity of pulmonary impairment (the more severe the impairment, the worse the patient's quality of life). Statistically significant positive relationships were found between SGRQ domains and age, body mass index, and body fat percentage. Significant negative relationships were found between these domains and the modified NIH score, the Bhalla score, forced expiratory volume in 1 second (expressed as a percentage of predicted), and somatomedin C and zinc levels.

CONCLUSIONS

Self-perceived quality of life is worse among adults with CF than in the general population or among patients with chronic obstructive pulmonary disease. The SGRQ is a valid instrument for analyzing health-related quality of life in adults with CF as it discriminates very well between different degrees of severity of pulmonary impairment and also have an appropriate intern consistency.

Oral anti-pseudomonal antibiotics for cystic fibrosis

BACKGROUND

Pseudomonas aeruginosa is the most common bacterial pathogen causing infection in the lungs of people with CF and appropriate antibiotic therapy is vital. Antibiotics for exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit the quality of life of people with CF due to ease of treatment and avoidance of hospitalisation.

OBJECTIVES

To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with CF, colonised with Pseudomonas aeruginosa, in the: (1) treatment of an exacerbation of respiratory tract infection; and (2) long-term treatment in chronic infection.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We contacted pharmaceutical companies for information on relevant trials and checked reference lists of identified trials. Most recent search: March 2007.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, with other combinations of inhaled, oral or intravenous antibiotics, or with placebo or usual treatment for exacerbations and long-term treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, extracted data and assessed quality. We contacted trialists to obtain missing information.

MAIN RESULTS

We included four trials examining exacerbations (197 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. In our analysis, we were unable to identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating an exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this.

AUTHORS' CONCLUSIONS

We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon known effectiveness against local strains and upon individual preference.

Quality of life in paediatric gastrointestinal and liver disease: a systematic review

OBJECTIVES

To identify and appraise all studies relating to and instruments developed to measure quality of life (QOL) in children with gastrointestinal or liver diseases.

METHODS

A literature search was undertaken using MEDLINE, EMBASE, CINAHL, and PsycINFO to identify relevant articles published up to the end of 2005. These were reviewed by both authors and data were extracted using a standardised form. Articles were excluded if no attempt was made to measure QOL, they did not relate to children ages <17 years, they did not relate to gastrointestinal or liver diseases, or they were review articles. Quality of life instruments identified were rated according to proposed criteria.

RESULTS

From a total of 2379 articles identified in the initial search, a total of 2309 were excluded, leaving 70 included studies. These were assigned to the following categories: inflammatory bowel disease, n = 17; cystic fibrosis, n = 20; liver disease, n = 11; surgery, n = 15; and miscellaneous, n = 7. These studies describe the impact that these diseases have on the QOL of affected children. A total of 11 disease-specific QOL instruments and 1 generic instrument with a chronic disease module were identified, but only 5 of these fulfilled the proposed quality criteria and can be recommended for future use.

CONCLUSIONS

Chronic gastrointestinal and liver diseases can have an enormous effect on the QOL of affected individuals and their families. A number of disease-specific paediatric QOL instruments have been developed and validated. Quality of life is an important outcome that should be incorporated into clinical practice and measured when treatments are evaluated. Future research should explore how QOL can best be improved in children in whom it is severely impaired.

Clinical trials in cystic fibrosis

In patients with cystic fibrosis (CF), clinical trials are of paramount importance. Here, the current status of drug development in CF is discussed and future directions highlighted. Methods for pre-clinical testing of drugs with potential activity in CF patients including relevant animal models are described. Study design options for phase II and phase III studies involving CF patients are provided, including required patient numbers, safety issues and surrogate end point parameters for drugs, tested for different disease manifestations. Finally, regulatory issues for licensing new therapies for CF patients are discussed, including new directives of the European Union and the structure of a European clinical trial network for clinical studies involving CF patients is proposed.

Percepção de qualidade de vida de pessoas com fibrose cística: um estudo sobre a adequação dos instrumentos de medida

INTRODUÇÃO: Avaliações de qualidade de vida (QV) na fibrose cística (FC) são tão importantes quanto a avaliação da condição clínica do paciente. Porém, há divergências sobre conceitos e teorias de QV. METODOLOGIA: Onze pacientes brasileiros com FC maiores de 18 anos responderam a perguntas sugeridas pela OMS para a exploração conceitual da QV. A pesquisa foi orientada pela abordagem da grounded theory, e os dados sofreram análise qualitativa. RESULTADOS: Apesar da diversidade de domínios valorizados pelos entrevistados estar de acordo com o caráter multidimensional da QV, há domínios ainda não presentes nas escalas. CONCLUSÕES: Nenhuma escala atualmente disponível abrange todos os aspectos valorados pelos pacientes, o que aponta para a importância de questões idiossincráticas e culturais para a QV na FC. O esclarecimento da relação entre saúde e QV ainda depende de pesquisas futuras.

Nutritional status, perceived body image and eating behaviours in adults with cystic fibrosis

BACKGROUND & AIMS

Achieving and maintaining an ideal nutritional status is the primary aim of the nutritional management of cystic fibrosis (CF). It is unclear how nutritional interventions impact on patients' perceptions and behaviours concerning body image and eating. This work aimed to provide a psychosocial profile and compare CF patients receiving (a) enteral tube feeding, (b) nutritional supplements, (c) no nutritional interventions, and (d) healthy controls.

METHODS

A cross-sectional questionnaire design was employed. Age, gender, lung function, and body mass index were recorded. Subjects completed measures of eating attitudes, perceived and desired body shape, body image, self-esteem and quality of life (QoL).

RESULTS

A minority of CF patients reported disordered eating. Those receiving nutritional interventions engaged in less dieting behaviour. All CF groups, especially intervention groups, received more pressure from others to eat. For females, control groups desired to be slimmer whereas intervention groups desired to be heavier. Healthy males were content with their body whereas CF males wished to be heavier. Patients receiving enteral tube feeding were less satisfied with their body image, reported lower self-esteem and poorer QoL.

CONCLUSION

Body image and eating behaviours are important considerations of nutritional interventions for maintaining QoL.

Monitoring quality of life in outpatients with cystic fibrosis: feasibility and longitudinal results

BACKGROUND

To investigate the feasibility of monitoring quality of life (QL) with cystic fibrosis (CF) in a clinical setting, to explore changes in subjective health and to describe the impact of multiple medical and psychosocial factors on the patients' QL.

METHODS

108 adolescent and adult outpatients (age 15-47 years, FEV(1) 20-125% of the predicted) answered the Questions on Life Satisfaction repeatedly parallel to each pulmonary function test (2-16 assessments per patient within 18 months). Multiple regression analysis determined the contribution of medical and psychosocial factors to the patients' QL.

RESULTS

Good acceptance of the instrument was observed. The completion time was between 5 and 29 min per assessment (median 11 min). QL remained quite stable (r(tt)=.69) with the previous QL score predicting most of the variance of the present score. Additionally, a longer interval between assessments, new colonization with Pseudomonas aeruginosa, infection exacerbations, partnership, vocation and living separately from parents significantly predicted QL at the second assessment. Pulmonary function varied independently of QL.

CONCLUSIONS

Medical factors such as pulmonary exacerbation and social living circumstances have an impact on the QL of patients with CF. Repeated QL assessments in clinical routine are feasible and useful to recognize the individual patient's adaptation to the disease.

Gender differences in health-related quality of life of adolescents with cystic fibrosis

Background

Female patients with cystic fibrosis (CF) have consistently poorer survival rates than males across all ages. To determine if gender differences exist in health-related quality of life (HRQOL) of adolescent patients with CF, we performed a cross-section analysis of CF patients recruited from 2 medical centers in 2 cities during 1997–2001.

Methods

We used the 87-item child self-report form of the Child Health Questionnaire to measure 12 health domains. Data was also collected on age and forced expiratory volume in 1 second (FEV₁). We analyzed data from 98 subjects and performed univariate analyses and linear regression or ordinal logistic regression for multivariable analyses.

Results

The mean (SD) age was 14.6 (2.5) years; 50 (51.0%) were female; and mean FEV₁ was 71.6% (25.6%) of predicted. There were no statistically significant gender differences in age or FEV₁. In univariate analyses, females reported significantly poorer HRQOL in 5 of the 12 domains. In multivariable analyses controlling for FEV₁ and age, we found that female gender was associated with significantly lower global health (p < 0.05), mental health (p < 0.01), and general health perceptions (p < 0.05) scores.

Conclusion

Further research will need to focus on the causes of these differences in HRQOL and on potential interventions to improve HRQOL of adolescent patients with CF.

Comparison of hospital and home intravenous antibiotic therapy in adults with cystic fibrosis

AIM AND OBJECTIVE

This study aimed to compare home and hospital treatment for clinical outcome and quality of life in adult cystic fibrosis patients receiving i.v. antibiotics for acute respiratory exacerbations.

BACKGROUND

Cystic fibrosis patients require intravenous (i.v.) antibiotic therapy to treat acute respiratory exacerbations. Traditionally, patients would be admitted to hospital to complete a 14-day course of i.v. antibiotics. The option of home i.v. antibiotic therapy for acute respiratory exacerbations has become an expectation of cystic fibrosis patients.

DESIGN AND METHOD

Comparison of hospital and home i.v. antibiotic therapy in adults with cystic fibrosis for clinical outcomes and quality of life was studied using a quasi-experimental design. A pre- and post-test was used to measure clinical outcomes of forced expiratory volume in one second (FEV(1)), forced vital capacity (FVC), oxygen saturations (SaO(2)), body mass index (BMI) and quality of life using the Cystic Fibrosis Quality of Life (CFQoL) questionnaire.

RESULTS

Thirty adult cystic fibrosis patients (15 hospital and 15 home) were recruited to the study once they had chosen where they undertook their treatment. When the groups were compared for clinical outcomes, the hospital group showed greater improvement in FVC. There were no differences in quality of life when the hospital and home groups were compared, although changes achieved with treatment showed differences. In the home group, there were improvements in all nine quality of life domains, with statistically significant improvement in five domains, whereas in the hospital group there were improvements in eight out of nine quality of life domains, with only two showing statistically significant improvement.

RELEVANCE TO CLINICAL PRACTICE

Lung function improved more in the hospital group, suggesting that acute respiratory exacerbations were not as effectively treated at home, although there appeared to be greater quality of life when undertaking home treatment. The CFQoL questionnaire was able to detect transient changes in health status during the course of i.v. antibiotics.

CONCLUSION

If the patient's right to choose where they receive treatment is to be supported, taking into account quality of life further research is required to determine the reasons for home care being less clinically effective in treating acute respiratory exacerbations in cystic fibrosis patients.

Development and validation of The Cystic Fibrosis Questionnaire in the United States: a health-related quality-of-life measure for cystic fibrosis

BACKGROUND

The Cystic Fibrosis Questionnaire (CFQ) is a disease-specific instrument that measures health-related quality of life (HRQOL) for adolescents and adults with cystic fibrosis (CF) > or = 14 years, consisting of 44 items on 12 generic and disease-specific scales. Versions of the CFQ are also available for children with CF and their parents. This study evaluated the psychometric properties of the CFQ in a national study at 18 CF centers in the United States.

PARTICIPANTS

The CFQ-teen/adult was administered to 212 patients with CF ranging in age from 14 to 53 years. Test-retest reliability was assessed in a subset of patients over a 10- to 14-day interval.

RESULTS

Multitrait analysis indicated a majority of items (95%) correlated more highly with their intended scale than a competing scale, supporting the conceptual model. Internal consistency coefficients indicated the CFQ scales had good reliability (Cronbach alpha = 0.67 to 0.94), and test-retest stability was acceptable (rs = 0.45 to 0.90). Validity was demonstrated by examining relationships between the CFQ, age, pulmonary function, and body mass index. As expected, the CFQ was inversely correlated with age, with older adults reporting lower CFQ scores than younger adults, better nutritional status was positively correlated with several weight-related scales, and the measure differentiated between individuals with varying levels of disease severity. Strong associations were also found between the CFQ and similar scales on the Short Form-36 Health Questionnaire, a well-known generic HRQOL measure.

CONCLUSIONS

The results demonstrated that the CFQ-teen/adult is a reliable and valid measure of HRQOL for individuals with CF. It may be utilized in clinical trials to assess the effects of new therapies, to document the progression of disease, and to inform clinical practice.

Reliability and validity of the PORPUS, a combined psychometric and utility-based quality-of-life instrument for prostate cancer

BACKGROUND

Although utility-based quality-of-life instruments are often used in economic evaluations and psychometric instruments in treatment evaluations, these are complementary approaches to assessing outcomes. In this study we developed and tested these two forms of quality-of-life instruments, both based on a single, validated, health classification system.

OBJECTIVES

To assess the measurement properties (reliability and validity) of two newly developed psychometric and utility-based instruments for assessing outcomes associated with prostate cancer.

METHODS

141 men with cancer of the prostate (CaP), treated with radical prostatectomy, radiation therapy, hormonal therapy, and/or chemotherapy were assessed with both instruments and other standard psychometric and utility-based instruments.

RESULTS

Analyses indicate the test instruments are reliable and valid. Full-scale correlations between the instruments and standard instruments indicate validity, as do correlations of key subscales, and an evaluation of linear associations with the UCLA-Prostate Cancer Symptom Scales.

CONCLUSION

Evidence from this study supports the reliability and construct validity of the tested instruments. Prostate cancer outcomes can now be assessed by a combination of psychometric and utility-based methods, allowing a ready comparison of derived outcomes.

Quality of life measures for fecal incontinence and their use in children

BACKGROUND

Fecal incontinence is a common problem within society from childhood through to the elderly. Its clinical assessment has focussed on severity and frequency of soiling episodes but it is increasingly recognized to have an impact on physical, psychological and social well-being (quality of life [QOL]). This is likely to be particularly important in childhood. The aim of the present study was to critically evaluate the development and application of disease-specific QOL measures, focusing particularly on their use in children.

METHODS

Generally recognized disease-specific QOL measures for fecal incontinence were identified and their generation and validation were critically evaluated.

RESULTS

Six instruments were identified: Ditesheim and Templeton QOL Scoring System, Manchester Health Questionnaire, Hirschsprung's Disease/Anorectal Malformation Quality of Life Questionnaire (HAQL), Gastrointestinal Quality of Life Index (GIQLI), Fecal Incontinence TyPE Specification, and the Fecal Incontinence Quality of Life Scale (FIQL). Although the FIQL appeared to be the better tool for adults with fecal incontinence because it was brief and had the best validity and reliability, it needed further modification to become appropriate for use in children. In particular, items relating to sexual activity were inappropriate.

CONCLUSION

Neither the FIQL nor other disease-specific instruments met basic psychometric standards for use in children with fecal incontinence. Substantial revision of currently available instruments will be required to meet the needs of this population.

Measuring and reporting quality of life outcomes in clinical trials in cystic fibrosis: a critical review

Good quality clinical trials are essential to inform the best cystic fibrosis (CF) management and care, by determining and comparing the effectiveness of new and existing therapies and drug delivery systems. The formal inclusion of quality of life (QoL) as an outcome measure in CF clinical trials is becoming more common. Both an appropriate QoL measure and sound methodology are required in order to draw valid inferences about treatments and QoL. A review was undertaken of randomised controlled trials in cystic fibrosis where QoL was measured. EMBASE, MEDLINE and ISI Web of Science were searched to locate all full papers in the English language reporting randomised controlled trials in cystic fibrosis, published between January 1991 and December 2004. All Cochrane reviews published before December 2004 were hand searched. Papers were included if the authors had reported that they had measured QoL or well being in the trial. 16 trials were identified. The interventions investigated were: antibiotics (4); home versus hospital administration of antibiotics (1); steroids (1); mucolytic therapies (6); exercise (3) and pancreatic enzymes (1). Not one trial evaluated in this review provided conclusive results concerning QoL. This review highlights many of the pitfalls of QoL measurement in CF clinical trials and provides constructive information concerning the design and reporting of trials measuring QoL.

Associations between clinical variables and quality of life in adults with cystic fibrosis

BACKGROUND

The disease progression of cystic fibrosis (CF) is marked by an increase in clinical conditions and therapeutic interventions, which have the potential to affect health-related quality of life (HRQoL). This cross-sectional study explored associations between clinical variables and HRQoL.

METHODS

HRQoL was measured using the Cystic Fibrosis Quality of Life (CFQoL) questionnaire, which consists of nine domains: physical, social, treatment, chest symptoms, emotional functioning, concerns for the future, relationships, body image, and career concerns. The CFQoL was completed by 223 adults with CF. Clinical and demographic data collected were: age, gender, FEV1% predicted, BMI, Burkholderia cepacia status, lung transplant status, diabetic status, level of nutritional intervention, and presence of an intravenous access device. Multiple regression using forward selection was used to construct models relating these variables to each HRQoL domain.

RESULTS

Despite many of the variables being inter-related, some variables were associated with CFQoL domains even in the presence of other important clinical factors. FEV1% predicted was weakly positively associated with all nine domains. Strong evidence emerged that patients who had received a lung transplant reported a higher HRQoL in physical and social functioning, chest symptoms, and treatment issues. Females tended to report a lower quality of life for chest symptoms and career issues, but higher values for body image. Patients with an access device expressed more career concerns. There was no evidence of an association between B. cepacia and any of the nine CFQoL domains. The model for the body image domain explained a high percentage of the variance (R2=30%): negative body image was associated with lower BMI, having an access device, diabetes, and enteral feeding.

CONCLUSIONS

While important associations were identified, much of the variance in HRQoL remains unexplained. Other clinical and psychosocial variables merit investigation. A longitudinal study is required to investigate how the disease trajectory and associated treatments affect an individual's quality of life.

Quality of life in cystic fibrosis: the impact of gender, general health perceptions and disease severity

BACKGROUND

Disease progression in cystic fibrosis (CF) is marked by deterioration across a number of physiological systems. In addition, there is evidence that females have a worse prognosis than males. The current work assesses the impact of both these factors on health related quality of life (HRQoL).

METHODS

Two hundred and twenty-three adolescents and adults completed the cystic fibrosis quality of life (CFQoL) questionnaire with a further 185 approached and not responding by non-completion of the questionnaire. The CFQoL is divided into nine domains: physical, social, treatment, chest symptoms, emotional functioning, concerns for the future, relationships, body image, and career. Measurement of objective clinical status included, body mass index (BMI), and percentage of predicted forced expiratory volume in one second (FEV1). General health perceptions (GHP) were also measured.

RESULTS

Patients were sub-divided by gender and disease severity (mild > 70% FEV1, moderate 40-69% and severe < 40%). Factorial analysis of variance indicated significant main effects for FEV1 (F = 587.98, P < or = 0.001) and BMI (F = 17.29, P < or = 0.001) as a function of disease severity. Post hoc tests revealed significant two-group differences for FEV1 and BMI between disease severity groups. No differences were observed for gender across FEV1 or BMI. Differences emerged across most CFQoL domains for disease severity, with the exception of concerns for the future, which was consistently low throughout. Gender differences emerged for chest symptoms, emotional functioning, concerns for the future, body image and career. With the exception of body image, females exhibited poorer HRQoL. Pearson correlations indicated that females' perception of health was more closely related to clinical status than males.

CONCLUSIONS

Disease severity has an impact on HRQoL in adolescents and adults with CF. Some differences emerged between males and females, with females generally reporting poorer HRQoL. Evidence indicated that males and females perceived their health status differently, with females having a more accurate perception of objective clinical health status.

Validation of the SF-36 for the assessment of quality of life in adolescents and adults with cystic fibrosis

BACKGROUND

Generic health-related quality of life measures are often applied to disease groups without assessment of their psychometric properties. The current work assesses the properties of the Short Form 36-item (SF-36) questionnaire in a British sample of adolescents and adults with cystic fibrosis (CF).

METHODS

Two hundred and twenty-three adolescents and adults with CF completed the SF-36 with a further 185 approached and not responding by non-completion of the questionnaire. The structure and internal reliability of the instrument was assessed by principal components analysis, Cronbach alpha coefficients and item to domain correlations. Differences between disease severity groups were assessed by analysis of variance.

RESULTS

Factor analysis of the SF-36 scores broadly confirmed domain structures for the SF-36. Cronbach alpha coefficients were high (range 0.82-0.91) and item-to-same domain correlations were stronger than item-to-unrelated domain correlations. Examination of differences between mild, moderate and severe disease states revealed four significant main effects for: physical functioning, role limitation due to physical functioning, general health perceptions and energy and vitality. The analysis also revealed the presence of numerous ceiling effects across domains.

CONCLUSIONS

The domain structure of the SF-36 was demonstrated to be robust. However, the discriminatory ability of the measure was disappointing. The presence of ceiling effects and the low frequency of differences between intermediate disease severity groups indicated that the SF-36 was not discriminatory with respect to mild disease states or progression of illness.

The psychosocial and psychiatric side of cystic fibrosis in adolescents and adults

Increasing numbers of cystic fibrosis (CF) patients are surviving into adulthood. An understanding of the psychiatric and psychosocial aspects of CF in adults and adolescents is therefore more important than ever. There is a large body of evidence indicating that the psychological and psychosocial functioning of people with CF is similar to that of well people, until the disease becomes severe. However, there is also evidence that patients do suffer an increased likelihood of psychiatric problems, such as depression, and of scoring poorly on physical functioning measures of quality of life. Studies have found conflicting evidence as to any association between degree of respiratory impairment and psychological functioning. Coping styles seem to have a large effect upon the quality of life of CF patients. People with cystic fibrosis can have problems with sexuality, platonic relationships and independence. Families of patients also suffer problems, which can affect the patients themselves. Non-compliance is a complicated problem with many patients. New treatments for people with CF are emerging, such as lobe transplants from live donors and gene therapy, with possible new psychosocial problems resulting. Furthermore, older studies are becoming increasingly inapplicable as treatment and prognosis changes. Therefore, more research is needed in this field.

The impact of treatment of pulmonary exacerbations on the health-related quality of life of patients with cystic fibrosis: does hospitalization make a difference?

OBJECTIVES

To investigate the impact of pulmonary exacerbations on the health-related quality of life (HRQOL) of patients with cystic fibrosis (CF) and to elucidate factors that are associated with changes in HRQOL post-exacerbation.

STUDY DESIGN

Participants completed questionnaires at a pre-exacerbation visit, at the beginning of the exacerbation, and at the post-exacerbation visit. To measure HRQOL, we used the Child Health Questionnaire-Parent Form (PF-50) and the Medical Outcomes Study Short Form-36 (SF-36). We examined demographic, clinical, and treatment-related predictor variables for association with change in Physical Summary (PhS) and Psychosocial Summary (PsS) HRQOL scores after an exacerbation.

RESULTS

We collected data from 48 subjects. Patients experiencing exacerbations who were treated as outpatients had a mean (SD) age of 19.5 (12.7) years and a mean pre-exacerbation forced expiratory volume in 1 second (FEV(1)) of 70% (36%) of predicted; 53% were female. Patients treated as inpatients had a mean age of 14.6 (5.5) years and a mean FEV(1) of 56% (24%); 56% were female. In univariate analyses, exacerbations were associated with a statistically significant decrease in FEV(1) (-10.0%) and PhS scores (-4.5 points). PsS scores did not significantly change with exacerbations (-0.7 points). In multivariable analyses examining change between pre-exacerbation and post-exacerbation visits, no variables were significantly associated with change in PhS scores. However, not being hospitalized for the exacerbation was associated with deterioration in PsS scores, and being hospitalized was associated with improvement in PsS scores (beta coefficient: 9.4; P <.01) by the post-exacerbation visit. Results were similar from the exacerbation to the post-exacerbation visit.

CONCLUSION

In patients with CF, on average, pulmonary exacerbations affect physical HRQOL more than psychosocial HRQOL. Being hospitalized for exacerbations is associated with improvement in psychosocial HRQOL after exacerbations, whereas not being hospitalized is associated with deterioration.

Validation of the Dutch cystic fibrosis questionnaire (CFQ) in adolescents and adults

BACKGROUND

This study assesses the reliability and validity of the Dutch version of a disease-specific measure of health-related quality of life (HRQOL) for adolescents and adults with CF (CFQ-14+). The 47-item CFQ-14+ covers nine domains, three symptom scales and one health perception scale.

METHODS

To assess psychometric characteristics of the CFQ-14+, cross-sectional (homogeneity, discriminative and construct validity) and test-retest designs were used. Eighty-four adolescents and adults with CF (mean age: 21.4 years, range 14.0-46.5 years) and a wide range of lung function (mean FEV1: 59.9% predicted, range 15-121%) completed the questionnaire during a routine visit.

RESULTS

Internal consistency was acceptable for most domains of the CFQ-14+ (alpha = 0.43-0.92) and test-retest reliability was high for all domain scores (0.72-0.98). Several domains of the CFQ-14+ were able to differentiate between individuals with varying disease severity and between nourished and malnourished patients. Construct validity of the questionnaire was fair, with moderate to strong correlation between physically orientated domains and pulmonary function (rs = 0.36-0.62).

CONCLUSION

The results demonstrate that the CFQ-14+ questionnaire is a well-validated measure of HRQOL assessment in adolescents and adults with CF.

The Caregiver Quality of Life Cystic Fibrosis (CQOLCF) scale: modification and validation of an instrument to measure quality of life in cystic fibrosis family caregivers

OBJECTIVE

Modify the Caregiver Quality of Life Index-Cancer (CQOLC) scale (Weitzner, Jacobsen et al. Qual Life Res 2000; 8: 55-63) as the Caregiver Quality of Life Cystic Fibrosis (CQOLCF) scale, validate it with cystic fibrosis (CF) family caregivers, and assess caregiver quality of life QOL with patient disease severity.

METHODS

Following modifications, 100 family caregivers were administered the CQOLCF. Construct validity was assessed by the Medical Outcomes Study Short Form (SF-36) and the Beck Depression Inventory (BDI). Pulmonary function scores and hospitalizations assessed relationship between caregiver QOL and patient disease severity.

RESULTS

Split-half reliability was 0.862 and internal consistency (Cronbach's alpha) was 0.909. As expected, there were relatively high correlations with the mental health (0.634) and emotional distress (-0.687); and low correlations with physical health (0.049). ANCOVA examined differences in the CQOLCF totals based on disease severity, controlling for age. Significant mean differences existed (days hospitalized F = 3.010, sig. = 0.022).

DISCUSSION

The CQOLCF appears to be a valid, reliable, and internally consistent disease-specific scale with CF family caregivers. Future research recommendations include administering the CQOLCF to an increased study sample to explore item factor analysis.

The experience of receiving a diagnosis of cystic fibrosis after age 20: implications for social work

Using the phenomenological approach of Van Manen, this study explored the lived experience of receiving a diagnosis of cystic fibrosis as an adult. Ten essential themes were generated from the stories of 36 participants: Awareness of Death, Change, Difference, Distraction, Family Indifference, Intrusion, Isolation, Normalizing, Time, and Uncertainty. Themes associated with gender, illness severity, and medical care were also developed. Although themes were similar to those in the chronic illness literature, late-diagnosis of CF was found to be a unique experience. Participants sought personal relationships with caregivers and educational materials targeted to their needs. Implications for social work are discussed.

Quality of life in children and adolescents with cystic fibrosis: implications for optimizing treatments and clinical trial design

Health related quality of life (QOL) as an outcome measure in clinical trials is becoming increasingly important. Trials should not only be able to demonstrate the pharmacologic activity of a therapy, but of equal importance, they should demonstrate clinical effectiveness that is of significant benefit to the patient. QOL measurement provides a way of incorporating the child/parent's perspective of how cystic fibrosis (CF) and its therapies impact on their lives. Several validated generic instruments have been employed to measure QOL in adolescents and adults. QOL assessment is more difficult in children and, therefore, has been employed less often in children with CF. Difficulties arise with the issue of whether children can report their own experiences directly, or whether a parent or clinician should report on behalf of the child. A child-centered approach is imperative since the literature indicates that children are able to report on their own QOL. An additional complication has been the use of adult measures with children. These are often inappropriate in their complexity, use of language, response scales, and time frame. The evaluation of pharmacologic therapies can profit from QOL measurement. The effectiveness of a drug and any adverse effects that impact on daily life can be assessed from the child/parent's viewpoint. Home therapy versus hospital therapy and drug delivery systems, are additional areas where QOL as an outcome measure is valuable. There have been relatively few appropriately powered trials in CF, and only a minority of these have evaluated QOL as an outcome measure. This review highlights areas where QOL measurement is appropriate. It focuses on the pharmacologic trials that have employed QOL assessment for antibiotic, mucociliary clearance, anti-inflammatory, and nutritional therapies. Methodological issues of incorporating QOL assessment into trials center on cross-cultural and data interpretation issues. QOL measurement in CF has been patchy and largely unreliable. The notion that improved symptoms equate with improved QOL is erroneous. Measurement of how symptoms impact on QOL is essential. Currently, the development and validation of CF specific measures (across the CF age range) provides optimism for appropriate QOL measurement in clinical trials, and for future meta-analysis and systematic reviews.

The revised German Cystic Fibrosis Questionnaire: validation of a disease-specific health-related quality of life instrument

BACKGROUND

The assessment of health related quality of life (HRQOL) has increasingly been recognized as an important adjunct to medical outcome parameters in the monitoring of cystic fibrosis (CF) patients and in clinical studies. The Cystic Fibrosis Questionnaire (CFQ) is a disease-specific HRQOL instrument for CF patients developed in France. Translations are currently being validated in four different countries. The aim of the present study was to validate the German adaptation of the CFQ-14+.

METHOD

On the basis of results from a first dataset (n = 197 CF adolescent and adult patients), revisions were made and retested in a second sample of 103 patients.

RESULTS

The final revised version showed good construct validity. The same nine HRQOL domains as in the French original CFQ-14+ emerged from the analyses as structurally robust scales. The internal consistencies of the HRQOL scales ranged from 0.71 to 0.94. The instrument's clinical validity was supported by severely ill patients reporting lower HRQOL than less severely ill patients on most scales.

CONCLUSION

We conclude that the evidence supports the validity and reliability of the instrument. An important future area of application is the use in comparative multi-center international studies.

Psychological interventions for cystic fibrosis

BACKGROUND

As survival estimates for cystic fibrosis (CF) steadily increase long-term management has become an important focus for intervention. Psychological interventions are largely concerned with emotional and social adjustments, adherence to treatment and quality of life, however no systematic review of such interventions has been undertaken for this disease.

OBJECTIVES

To describe the extent and quality of effectiveness studies utilising psychological interventions for CF and whether these interventions provide significant psychosocial and physical benefits in addition to standard care.

SEARCH STRATEGY

Relevant trials were identified from searches of Ovid MEDLINE, the Cochrane trial registers for CF and Depression, Anxiety and Neurosis Groups and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search: April 2003.

SELECTION CRITERIA

This review included RCTs and quasi-randomised trials. Study participants were children and adults diagnosed with CF, and their immediate family members. Psychological interventions were from a broad range of modalities and outcomes were primarily psychosocial, although physical outcomes and cost effectiveness were also considered.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected relevant trials and assessed their methodological quality. For binary and continuous outcomes a pooled estimate of treatment effect was calculated for each outcome.

MAIN RESULTS

This review is based on the findings of eight studies, representing data from a total of 358 participants. Studies fell into four conceptually similar groups: (1) gene pre-test education counselling for relatives of those with CF (one study); (2) biofeedback, massage and music therapy to assist physiotherapy (three studies); (3) behavioural intervention to improve dietary intake in children up to 12 years (three studies); and (4) self-administration of treatments to improve quality of life in adults (one study). Interventions were largely educational or behavioural, targeted at specific treatment concerns during the chronic phase. No completed studies concentrating on complex treatment approaches were found. There is some evidence that behavioural interventions can improve emotional outcomes in people with CF and their carers. There was no consistent effect on lung function although one small study showed that biofeedback assisted breathing re-training was associated with improvement in some measures of spirometric lung function. Insufficient evidence is available at this point for interventions aimed at other aspects of the disease process.

REVIEWER'S CONCLUSIONS

Multicentre approaches are required to increase the sample sizes of studies in the psychosocial field and to enhance the power and precision of the findings. This has consequent implications for funding.

Questions on life satisfaction for adolescents and adults with cystic fibrosis: development of a disease-specific questionnaire

STUDY OBJECTIVES

The development and psychometric properties of an additional disease-specific module of the Questions on Life Satisfaction for adolescents and adults with cystic fibrosis (FLZ(M)-CF) are described. The Questions on Life Satisfaction (FLZ(M)) instrument allows the respondent to rate the subjective importance and her/his satisfaction with different domains of life.

METHODS

A preliminary 16-item version of the scale was employed in a study with 243 German patients with cystic fibrosis (CF) [16 to 58 years of age; FEV(1), 15 to 121% of predicted], together with the "general life satisfaction" module and the "satisfaction with health" module of the FLZ(M). Item elimination according to the principle of least common variance resulted in the final nine-item version.

RESULTS

Cronbach alpha for the FLZ(M)-CF was 0.80; the split-half reliability was 0.72. Convergent validity of the scale was indicated by Pearson correlations of r = 0.75 with the generic satisfaction with health scale of the FLZ(M), r = 0.30 with FEV(1)%, and r = - 0.26 with daily time for home therapy. The scale discriminated significantly between patients with and without need for assistance in daily life and between patients with and without a partner.

CONCLUSIONS

The FLZ(M)-CF is a reliable and valid instrument, and it is short enough to be used as screening instrument. The combination of generic and disease-specific scales within the FLZ(M) allows comprehensive measurement of life satisfaction for patients with CF who are > 15 years old.

Effects of tobramycin solution for inhalation on global ratings of quality of life in patients with cystic fibrosis and Pseudomonas aeruginosa infection

In a previously published placebo-controlled trial, tobramycin solution for inhalation (TSI) was shown to improve lung function and other outcomes in patients with cystic fibrosis (CF). The objectives of the current study were to examine the effects of TSI on global ratings of health-related quality of life (HRQOL) by patients (or their parents) and physicians blind to group assignment, and to determine whether any perceived benefits persisted over time. The global ratings of HRQOL in 520 patients with CF and chronic Pseudomonas aeruginosa infection were analyzed retrospectively. Patients were randomly assigned to receive 24 weeks of placebo or treatment with TSI 300 mg b.i.d., both administered in cycles of 28 days on drug (or placebo) followed by 28 days off, for a total of three cycles. After each on-drug cycle, patients or parents, and physicians, were asked to rate whether the patient's condition was better, unchanged, or worse. There was strong agreement between the paired patient/parent and physician global HRQOL ratings across the three cycles. Regression analyses demonstrated that patients in the TSI group were significantly more likely to report improvements in HRQOL than were patients in the placebo group. This effect was found to be both immediate (end of on-drug cycle 1) and delayed (end of subsequent on-drug cycles 2 and 3) (P < 0.05). In addition, change in forced expired volume in 1 sec (FEV(1)) % predicted values was a significant predictor of improvement in HRQOL ratings by patients and parents. After controlling for change in FEV(1) % predicted, physician ratings showed significant improvement only at the end of cycle 1. Finally, controlling for initial lung disease severity, longitudinal growth models revealed that patients on TSI and their physicians reported higher HRQOL ratings than did placebo patients and their physicians across the three cycles; however, the magnitude of this effect decreased over time. Results of this study provided consistent evidence that TSI was associated with improved global ratings of HRQOL completed by both patients or parents, and physicians. Although these results are promising, they are limited by the use of a single-item rating of health. Future studies of the effects of TSI should utilize a well-validated, disease-specific measure of HRQOL.

Impact of recent pulmonary exacerbations on quality of life in patients with cystic fibrosis

OBJECTIVE

To compare the health-related quality of life (HRQOL) of people with cystic fibrosis (CF) to the general population, and to determine the relationship between HRQOL and clinical and demographic factors.

DESIGN

Cross-sectional analysis of observational cohort.

SETTING

Outpatient clinics of a Midwestern CF center.

SUBJECTS

One hundred sixty-two subjects with CF aged 5 to 45 years.

MAIN OUTCOME MEASURES

Physical and psychosocial summary scores and individual scale scores for the Child Health Questionnaire and Short Form-36.

RESULTS

Compared with the general population, people with CF reported similar scores for most psychosocial measures, but lower scores for most physical measures, with the lowest scores on the general health perceptions scale. In multivariable analyses, pulmonary exacerbations in the past 6 months were strongly associated with the physical (p = 0.001) and psychosocial (p = 0.0003) scores. The physical score fell, on average, 6 points per exacerbation and the psychosocial score fell 3 points. Lung function, nutrition, 6-min walk distance, age, gender, and insurance status were not significantly associated with HRQOL in this study population. Those who declined to participate had significantly lower FEV(1) percent predicted and nutritional indexes. Our findings may not be generalizable to the entire CF population.

CONCLUSION

Recent pulmonary exacerbations have a profound negative impact on HRQOL that is not explained by differences in lung function, nutritional status, or demographic factors.