Comparison of the Quality of Well-being Scale and the SF-36 results among two samples of ill adults: AIDS and other illnesses

The effect of CPAP on HRQOL as measured by the Quality of Well-Being Self Administered Questionaire (QWB-SA)

BACKGROUND

To examine the effect of continuous positive airway pressure (CPAP) on Health-related quality of life (HRQoL) as measured by the Quality of Well Being Self-Administered questionnaire (QWB-SA).

METHODS

Participants from The Apnea Positive Pressure Long-term Efficacy Study (APPLES); a 6-month multicenter randomized, double-blinded intention to treat study, were included in this analysis. The participants with an apnea-hypopnea index >10 events/hour initially randomized to CPAP or Sham group were asked to complete QWB-SA at baseline, 2, 4, and 6-month visits.

RESULTS

There were no group differences among either the CPAP or Sham groups. "Mean age was 52±12 [SD] years, AHI 40±25 events/hr, BMI 32±7.1 kg/m2, and Epworth Sleepiness Score (ESS) 10±4 of 24 points." QWB-SA scores were available at baseline, and 2, 4 & 6 months after treatment in CPAP (n 558) and Sham CPAP (n 547) groups. There were no significant differences in QWB scores among mild, moderate or severe OSA participants at baseline. Modest improvement in QWB scores was noted at 2, 4 and 6- months among both Sham and CPAP groups (P <0.05). However, no differences were observed between Sham CPAP and CPAP at any time point. Comparison of the QWB-SA data from the current study with published data in populations with chronic illnesses demonstrated that the impact of OSA is no different than the effect of AIDS and arthritis.

CONCLUSION

Although the QoL measured by the QWB-SA was impaired in OSA it did not have direct proportionality to OSA severity.ClinicalTrials.gov. Identifier: NCT00051363.

Quality of life among patients receiving palliative care in South Africa and Uganda: a multi-centred study

BACKGROUND

Quality of life (QOL) is a core outcome of palliative care, yet in African settings there is a lack of evidence on patients' levels of QOL. We aimed to describe QOL among patients with incurable, progressive disease receiving palliative care in South Africa and Uganda, to compare QOL in cancer and HIV, to determine how domains of QOL correlate with overall QOL, and compare levels of QOL in this population with those in other studies using the same tool.

METHODS

A cross-sectional survey was conducted using the Missoula Vitas Quality of Life Index (MVQOLI), a 26-item QOL questionnaire with five subscales (Function, Symptom, Interpersonal, Well being, Transcendent) covering physical, social, psychological and spiritual domains and one global QOL item. One item in each subscale assesses the subjective importance of the domain on a score from 1 (least important) to 5 (most important), used to weight the contribution of the subscale towards the Total QOL score. The tool was translated into 6 languages and administered to consecutively recruited patients at four facilities in South Africa and one in Uganda.

RESULTS

285 patients were recruited, with a mean age of 40.1; 197 (69.1%) were female. Patients' primary diagnoses were HIV (80.7%), cancer (17.9%) and other conditions (1.4%). The mean global QOL score was 2.81 (possible range 0 (worst) to 5 (best)); mean Total score 17.32 (possible range 0 to 30). Patients scored most poorly on Function (mean 0.21), followed by Well being (2.59), Symptoms (5.38), Transcendent (5.50), Interpersonal (9.53) (possible range for subscale scores -30 to 30). Most important to patients were: close relationships (mean 4.13), feeling at peace (4.12), sense of meaning in life (4.10), being active (3.84), physical comfort (2.58). Cancer patients were predominantly recruited at three of the sites; hence comparison with HIV-infected patients was restricted to these sites. HIV+ patients (n = 115) scored significantly worse than cancer patients (n = 50) on Well being (Z = -2.778, p = 0.005), Transcendence (Z = -2.693, p = 0.007) and Total QOL (Z = -2.564, p = 0.01). Global QOL score was most weakly correlated with Total QOL (r = 0.37) and the Transcendent subscale was most highly correlated (r = 0.77) (both p < 0.001). Patients receiving palliative care in South Africa and Uganda exhibited significantly poorer QOL compared to similar populations in the USA.

CONCLUSIONS

Feeling at peace and having a sense of meaning in life were more important to patients than being active or physical comfort, and spiritual wellbeing correlated most highly with overall QOL. It is therefore vital to identify and meet the psychological and spiritual care needs of patients, as well as to assess and treat pain and other symptoms. Our finding that patients scored most poorly on the Function domain warrants further research.

The psychological context of quality of life: a psychometric analysis of a novel idiographic measure of bladder cancer patients' personal goals and concerns prior to surgery

BACKGROUND

Over the past two decades, there has been an increasing focus on quality of life outcomes in urological diseases. Patient-reported outcomes research has relied on structured assessments that constrain interpretation of the impact of disease and treatments. In this study, we present content analysis and psychometric evaluation of the Quality of Life Appraisal Profile. Our evaluation of this measure is a prelude to a prospective comparison of quality of life outcomes of reconstructive procedures after cystectomy.

METHODS

Fifty patients with bladder cancer were interviewed prior to surgery using the Quality of Life Appraisal Profile. Patients also completed the EORTC QLQ-C30 and demographics. Analysis included content coding of personal goal statements generated by the Appraisal Profile, examination of the relationship of goal attainment to content, and association of goal-based measures with QLQ-C30 scales.

RESULTS

Patients reported an average of 10 personal goals, reflecting motivational themes of achievement, problem solving, avoidance of problems, maintaining desired circumstances, letting go of roles and responsibilities, acceptance of undesirable situations, and attaining milestones. 503 goal statements were coded using 40 different content categories. Progress toward goal attainment was positively correlated with relationships and activities goals, but negatively correlated with health concerns. Associations among goal measures provided evidence for construct validity. Goal content also differed according to age, gender, employment, and marital status, lending further support for construct validity. QLQ-C30 functioning and symptom scales were correlated with goal content, but not with progress toward goal attainment, suggesting that patients may calibrate progress ratings relative to their specific goals. Alternately, progress may reflect a unique aspect of quality of life untapped by more standard scales.

CONCLUSIONS

The Brief Quality of Life Appraisal Profile was associated with measures of motivation, goal content and progress, as well as relationships with demographic and standard quality of life measures. This measure identifies novel concerns and issues in treating patients with bladder cancer, necessary for a more comprehensive evaluations of their health-related quality of life.

Does farm worker health vary between localised and globalised food supply systems?

Significant environmental benefits are claimed for local food systems, but these biophysical indicators are increasingly recognised as inadequate descriptors of supply chain ethics. Social factors such as health are also important indicators of good practice, and are recognised by the organic and local food movements as important to the development of rounded sustainable agricultural practices. This study compared the self-reported health status of farm workers in the United Kingdom, Spain, Kenya and Uganda who were supplying distant markets with fresh vegetables. Workers on Kenyan export horticulture farms reported significantly higher levels of physical health than did Kenyan non-export farm workers and workers in the other study countries. Mean health levels for farm workers in the United Kingdom were significantly lower than relevant population norms, indicating widespread levels of poor health amongst these workers. These results suggest that globalised supply chains can provide social benefits to workers, while local food systems do not always provide desirable social outcomes. The causal mechanisms of these observations probably relate more to the social conditions of workers than directly to income.

Health status and service needs of male inmates seriously ill with HIV/AIDS at two large urban jails

Male inmates with HIV/AIDS being served by case-management programs for those seriously ill in jails in Los Angeles (n = 34) and New Orleans (n = 20) are described and compared. At both sites, most were Black and poor with a history of substance abuse. Psychological functioning (Mental Health Inventory [MHI-5]) scores indicated poor mental health. Inmates reported an average of more than 10 symptoms, and at least 25% reported needing multiple medical, practical, and social services. These findings document a subpopulation of jail inmates who are seriously ill with HIV/AIDS, and they describe the potential care and service needs of such inmates. Given the chronicity of HIV/AIDS and the importance of strict adherence to treatment protocols, it is important not only to facilitate access to care and services for inmates but also to secure continuity of care and access to services when inmates are transferred to another facility or released into the community.

Critical evaluation of the use of research tools in evaluating quality of life for people with schizophrenia

Schizophrenia may lead to impairments in many aspects of life, including physical, cognitive, and role functioning. The subjective quality of life of people with schizophrenia has been shown to be lower than in the general population and appropriate patient-assessed health outcome measures are necessary to capture the distress and disability experienced by people living with a serious mental illness. Although psychiatry has been slow to become involved in quality of life measurement, the use of quality of life instruments has now been recognized as a means of evaluating the outcome of care interventions, in terms of symptoms and functioning. This paper evaluates the effectiveness of two widely used instruments: The Medical Outcomes Study Short Form Health Survey (SF-36) and The Lancashire Quality of Life Profile (LQoLP) in terms of reliability and validity in measuring the quality of life of people with schizophrenia. The LQoLP appeared to be best suited for evaluation of care programmes, whereas the SF-36 was more appropriate for medical trials, comparisons between patient groups, and assessment of the direct consequences of treatment on health and function. Subjective quality of life should, however, be considered to be distinct from clinical status and quality of life assessment should include the broadest range of indicators, to reflect the holistic ethos of mental health nursing.

Analysis of the short form-36 (SF-36): the beta-binomial distribution approach

Health-related quality of life (HRQoL) is an important indicator of health status and the Short Form-36 (SF-36) is a generic instrument to measure it. Multiple linear regression (MLR) is often used to study the relationship of HRQoL with patients' characteristics, though HRQoL outcomes tend to be not normally distributed, skewed and bounded (e.g. between 0 and 100). A sample of 193 patients with eating disorders has been analysed to assess the performance of the MLR under non-normality conditions. Normal distribution was rejected for seven out of the eight domains. A beta-binomial distribution is suggested to fit the SF-36 scores. The beta-binomial distribution is not rejected for five out of the eight domains. Thus, a beta-binomial regression (BBR) is suggested to analyse the SF-36 scores. Results using MLR and BBR have been compared for real and simulated data. Performance of the BBR is shown to be better than MLR in the HRQoL domains with few ordered categories and very similar to MLR in the more continuous domains. Moreover, the interpretation of the estimates obtained with BBR is clinically more meaningful. A common technique of statistical analysis is preferable for all the HRQoL dimensions. Therefore, the BBR approach is recommended not only to detect significant predictors of HRQoL when SF-36 is used, but also to analyse and interpret the effect of several explanatory variables on HRQoL. Further work is required to test the better performance of BBR against standard methods for other HRQoL outcomes, populations or interventions.

Transforming the SF-36 to account for death in longitudinal studies with three-year follow-up

BACKGROUND

Analyses of longitudinal health-related quality of life data often exclude participants who die, which limits the generalizability of the results. Methods to incorporate death as a valid score in the Medical Outcomes Study Short-Form (SF-36) have been suggested but need to be evaluated in other populations.

OBJECTIVES

We sought to apply a method of transforming the SF-36 Physical Component Score (PCS) to include death. A transformation to estimate the probability of being "healthy" in 3 years, based on the current PCS value, will be developed and validated.

SUBJECTS

Women in the Australian Longitudinal Study on Women's Health (ALSWH), ages 70-75 years at Survey 1 in 1996 (n = 12,432), were followed-up at 3 yearly intervals for 6 years.

RESULTS

The transformation derived from the ALSWH data provides evidence that the methodology for transforming the PCS to account for deaths is sound. The 3-year equation provided good estimates of the probability of being healthy in 3 years and the method allowed deaths to be included in an analysis of changes in health over time.

CONCLUSIONS

For longitudinal studies involving the SF-36 in which subjects have died, we support the recommendation that both the PCS and its transformed value which includes deaths should be analyzed to examine the influence of deaths on the study conclusions. Using study data to derive empirical parameters for the transformations may be appropriate for studies with follow-up intervals of other lengths.

Quality of Life of Patients with Advanced Cancer and Acquired Immune Deficiency Syndrome and their Family Caregivers

BACKGROUND

Although definitions of palliative care include quality of life as a central concern, little research has been published about both the quality of life of patients with advanced illness and their family members, and particularly the changes in their quality of life over time.

OBJECTIVES

The aims of this prospective longitudinal pilot study were to: (1) establish the reliability of multidimensional quality of life instruments based on patients with acquired immune deficiency syndrome (AIDS) and patients with cancer and caregivers; (2) identify differences in quality of life between patients with advanced AIDS and cancer, and their family caregivers with consideration of mortality, attrition, and compliance rates; and (3) examine differences in demographic variables and their potential confounding effect when measuring quality of life.

METHODS

The sample included 101 patients with advanced illness (63 patients with advanced AIDS and 38 with advanced cancer) and 81 family caregivers (43 caregivers for patients with AIDS and 38 caregivers for patients with cancer). Data collection involved the monthly completion of the McGill Quality of Life Questionnaire (MQOL) for patients, and the Quality of Life Scale (QLS) for family caregivers.

RESULTS

Reliability of the MQOL and QLS were established for patients with AIDS and patients with cancer and caregivers. Based on the MQOL, patients with advanced AIDS reported a lower total quality of life, and lower psychological quality of life, and a higher physical quality of life compared to patients with advanced cancer. There were no significant differences between patient groups on the one-item physical well-being subscale, or the existential well-being, and support subscales. Based on the QLS, AIDS caregivers reported greater overall quality of life, greater psychological well-being, and greater spiritual well-be- ing than cancer caregivers. There were no significant differences between AIDS and cancer caregivers with respect to physical or social well-being. From baseline entry into the study to third month of participation, there were no significant changes in total quality of life scores for patient or caregiver groups, although trends indicated a moderately high total quality of life over time for all patient and caregiver groups. Fourteen of 63 (22%) patients with AIDS patients died, while 19 of 38 (50%) patients with advanced cancer died after enrollment. Forty-six of 63 (73%) patients with advanced AIDS withdrew for various reasons other than death at some point during the 12 month time frame of the study, while 15 of 38 (39%) patients with advanced cancer withdrew. There were significant differences on all demographic variables for patients with advanced cancer and AIDS. Only religious affiliation was significantly related to quality of life for patients with AIDS, while gender was the only variable associated with quality of life for patients with cancer. There were significant differences on all demographic variables between caregivers with the exception of gender and living arrangements. Only the relationship between patients and caregivers and marital status were significantly associated with quality of life for cancer caregivers.

CONCLUSIONS

In palliative care research, the challenge is to design studies that will capture changes in the domains of quality of life over time, yet will minimize participant burden and subsequent attrition rates. By measuring quality of life as an outcome variable in palliative care, health professionals can identify changes in the domains of quality of life over time for various patient populations and their family caregivers, and respond with appropriate interventions, which promote or maintain their quality of life even as death approaches.

The effect of diagnosis with HIV infection on health-related quality of Life

We sought to understand how diagnosis with HIV affects health-related quality of life. We assessed health-related quality of life using utility-based measures in a Department of Veterans Affairs (VA) clinic and a University-based clinic. Respondents assessed health-related quality of life regarding their current health, and retrospectively assessed their health 1 month prior to and 2 months after diagnosis with HIV infection. Sixty-six patients completed the study. The overall mean utilities for health 1 month before and 2 months after diagnosis were 0.87 (standard error 0.037), and 0.80 (0.043) (p<0.005 by rank sign test), but the effect of diagnosis differed between the two clinics, with a substantial decrease in the university clinic and a small non-significant decrease in the VA clinic. The overall mean utility for current health was 0.85 (0.034), assessed on average 7.5 years after diagnosis. When asked directly whether diagnosis of HIV decreased health-related quality of life, 47% agreed, but 35% stated that HIV diagnosis positively affected health-related quality of life. Diagnosis with HIV decreased health-related quality of life at 2 months on average, but this effect diminished over time, and differed among patient populations. Years after diagnosis, although half of the patients believed that diagnosis reduced health-related quality of life, one-third reported improved health-related quality of life.

The impact of four common lumbar spine diagnoses upon overall health status

BACKGROUND CONTEXT

The Short Form 36 (SF-36) health survey has been shown to be a valid instrument when used to measure the self-reported physical and mental health of patients. The impact of lumbar spinal disorders can be assessed as the difference between the SF-36 scale scores and age- and gender-specific population norms.

PURPOSE

To establish the impact upon the self-reported health status of patients with one of four common lumbar spinal diagnoses.

STUDY DESIGN

A cross-sectional, observational assessment of the health status of spine patients.

METHODS

Data from patients presenting to the participating centers of the National Spine Network with low back pain or leg pain were collected prospectively using the Health Status Questionnaire 2.0. A database search identified patients with either herniated nucleus pulposus with radicular pain (HNP), lumbar spinal stenosis without deformity (SPS), degenerative spondylolisthesis (DS), and painful disc degeneration/spondylosis (DDD). The mean SF-36 scale scores were generated for each of the diagnostic groups. The impact of these diagnoses on health status was determined as the calculated difference from the age- and gender-specific population norms for each of the eight health scale scores. These scores, usually negative in this population, represent how far below normal these patients are. The analysis was stratified according to the age of the patients (<40 years, 40-60 years, >60 years). Analysis of variance and pair-wise comparison with Bonferroni correction were used to assess the significance of differences across diagnosis and age groups.

RESULTS

Data from a total of 4,442 patients were available for this study. All four diagnostic groups had large, negative impact scores for the eight general health scales with the greatest impact upon the three scales that best measure physical health. The greatest impact on these physical health scales (physical functioning, role-physical, and bodily pain) was seen in the HNP diagnostic group. The younger age groups (<40 years and 40-60 years) had the greatest physical impairment when compared with the age- and gender-specific population norms. Analysis of variance showed a significant relationship between diagnosis and SF-36 scores, and between age groups and SF-36 scores.

CONCLUSIONS

All four lumbar spine disorders have a significant negative impact on all eight of the SF-36 scales. The greatest negative impact was seen in those scales that measure physical health (role limitations due to physical symptoms [RP], physical functioning [PF], and bodily pain [BP]). The HNP diagnostic group experienced a significantly greater impact upon these three scales. This diagnostic group had the youngest patients, whose baseline physical functional status would be expected to be the most optimal. When we stratified by age in all the diagnostic groups, the greatest negative impact scores for physical health were seen in the <40 years and 40-60 years age groups. These patients were also more likely to perceive their health as poor, experience decreased energy, and have more social impairment when compared with their age/gender norms.

A comparative review of health-related quality-of-life measures for use in HIV/AIDS clinical trials

With the advent of highly active antiretroviral therapy (HAART), HIV-infected patients are living longer and are concerned not only with a treatment's ability to extend their life but also with the quality of the life they are able to lead. Regulatory authorities are also paying closer attention to the use of health-related quality-of-life (HR-QOL) measures in clinical trials and to the subsequent claims that are made based on the results. This paper reviews existing HR-QOL measures reported in the HIV/AIDS literature since 1990 and identifies those most worthy of consideration for use in future clinical trials.A comprehensive review following predefined selection criteria was conducted. Generic and HIV-targeted measures were assessed for content and practicality for the clinical trial setting. The generic measures were additionally reviewed for the ability to produce preference-based index scores and for the existence of normative general population data. Three generic and six HIV-targeted measures met these selection criteria and were then assessed more fully in terms of their development (HIV-targeted measures), psychometric properties and appropriateness for use in clinical trials.It was determined that each of the selected generic measures (i.e. Medical Outcomes Study [MOS] 36-Item Short Form Survey Instrument [SF-36], EQ-5D, Health Utilities Index [HUI]) could serve as a useful adjunct to an HIV-targeted measure in a trial. The Functional Assessment of HIV Infection (FAHI) and MOS-HIV health survey were deemed the two most appropriate HIV-targeted measures. Each of the measures can be self-administered in < or = 10 minutes and there was ample evidence of their excellent psychometric properties. However, they would not be optimal in all HIV-infected subgroups (e.g. treatment naive vs advanced; adolescents vs older adults) targeted for clinical trial interventions. Although there is no one best HR-QOL measure for use in HIV/AIDS clinical trials, based on our review criteria we identified three generic and two HIV-targeted candidate measures. However, these measures have their limitations and it is clear that greater consensus needs to develop regarding more effective and efficient approaches to HR-QOL measurement in HIV/AIDS clinical trials. Along with the increasingly complex HR-QOL measurement task resulting from changes in the HIV-infected population and shifts in the HR-QOL burden associated with HIV infection and its treatment over the past 25 years, it is increasingly important that HR-QOL outcomes become viable endpoints in HIV/AIDS clinical trials.

Women's quality of life is decreased by acute cystitis and antibiotic adverse effects associated with treatment

Background

Although acute cystitis is a common infection in women, the impact of this infection and its treatment on women's quality of life (QOL) has not been previously described.

Objectives: To evaluate QOL in women treated for acute cystitis, and describe the relationship between QOL, clinical outcome and adverse events of each of the interventions used in the study.

Methods

Design. Randomized, open-label, multicenter, treatment study.

Setting. Two family medicine outpatient clinics in Iowa.

Patients. One-hundred-fifty-seven women with clinical signs and symptoms of acute uncomplicated cystitis.

Intervention. Fifty-two patients received trimethoprim/sulfamethoxazole 1 double-strength tablet twice daily for 3 days, 54 patients received ciprofloxacin 250 mg twice daily for 3 days and 51 patients received nitrofurantoin 100 mg twice daily for 7 days.

Measurements. QOL was assessed at the time of enrollment and at 3, 7, 14 and 28 days after the initial visit. QOL was measured using a modified Quality of Well-Being scale, a validated, multi-attribute health scale. Clinical outcome was assessed by telephone interview on days 3, 7, 14 and 28 using a standardized questionnaire to assess resolution of symptoms, compliance with the prescribed regimen, and occurrence of adverse events.

Results

Patients experiencing a clinical cure had significantly better QOL at days 3 (p = 0.03), 7 (p < 0.001), and 14 (p = 0.02) compared to patients who failed treatment. While there was no difference in QOL by treatment assignment, patients experiencing an adverse event had lower QOL throughout the study period. Patients treated with ciprofloxacin appeared to experience adverse events at a higher rate (62%) compared to those treated with TMP/SMX (45%) and nitrofurantoin (49%), however the difference was not statistically significant (p = 0.2).

Conclusion

Patients experiencing cystitis have an increase in their QOL with treatment. Those experiencing clinical cure have greater improvement in QOL compared to patients fail therapy. While QOL is improved by treatment, those reporting adverse events have lower overall QOL compared to those who do not experience adverse events. This study is important in that it suggests that both cystitis and antibiotic treatment can affect QOL in a measurable way.

Comparing SF-36 scores across three groups of women with different health profiles

BACKGROUND

The widespread use of the Medical Outcomes Study (MOS) 36-item Short-Form Health Survey (SF-36) facilitates the comparison of health-related quality of life (HRQL) across independent studies.

OBJECTIVES

To compare the scores of eight scales and two summary scales of the SF-36 across participants in the Women's Healthy Eating and Living (WHEL) trial, the Women's Health Initiative-Dietary Modification trial (WHI-DM), and the MOS, and to illustrate the use of effect sizes for interpreting the importance of group differences.

METHODS

WHEL and WHI-DM are both multi-center dietary interventions; only data from the UC Davis sites were used in our study. WHEL participants had a recent history of breast cancer, WHI-DM participants were healthy, postmenopausal women, and women in the MOS had a history of hypertension, diabetes, heart disease, or depression. General linear models were used to identify statistically significant differences in scale scores. Meaningful differences were determined by effect sizes computed using a common within-group standard deviation (SD) and SDs from normative data.

RESULTS

After adjusting for age and marital status, SF-36 scores for the WHI-DM and WHEL samples were similar and both had statistically significantly higher scores than the MOS sample. Relative to the WHEL or WHI-DM studies, MOS scores for scales related to the physical domain were clearly meaningfully lower whereas scale scores related to the mental health domain were potentially meaningfully lower.

CONCLUSIONS

The HRQL of breast cancer survivors is comparable to that of healthy women and better than that of women with chronic health conditions, particularly with respect to physical health. This study illustrated the use of ranges of effects sizes for aiding the interpretation of SF-36 scores differences across independent studies.

Comparison of preference-based utilities of the 15D, EQ-5D and SF-6D in patients with HIV/AIDS

OBJECTIVE

This article compares preference-based utilities from the multiattribute utility instrument 15D with those derived from the EQ-5D and the Short Form 36 (SF-6D) in patients with HIV/AIDS. In particular, we wanted to examine if the finer descriptive system of the 15D would result in better discriminative capacity or responsiveness.

METHODS

In a prospective observational study of 60 Norwegian patients with HIV/AIDS from two hospitals, the authors compared scores, assessed associations with disease staging systems, and assessed test-retest reliability and responsiveness of the instruments.

RESULTS

On average, the 15D gave higher utility scores than the other two measures, the mean utility scores were: 15D--0.86, SF-6D--0.73, and EQ-5D Index--0.77. Test-retest reliability was acceptable for all measures, with intraclass correlation coefficients between 0.78 and 0.94. The correlation between scores of the 3 scales was substantial (p = 0.74-0.80). There was no major difference in responsiveness between the measures.

CONCLUSIONS

The different measures gave different utility values in this sample of patients with HIV/AIDS, although many of the measurement properties were similar. There was no evidence for better discriminative capacity or responsiveness for the 15D, than for the two other multiattribute measures.

Mental health status of clients from three HIV/AIDS palliative care projects

Objective:To describe mental health status and its correlates among clients of three palliative care programs targeting underserved populations.

Methods:Mental Health Inventory (MHI-5) scores of clients from programs in Alabama (n= 39), Baltimore (n= 57), and New York City (n= 84) were compared.

Results:Mean MHI-5 scores did not differ among sites and were indicative of poor mental health. Significant differences were noted among sites with regard to client sociodemographics, physical functioning, and perceptions of interpersonal relations. Results of multivariate regression models estimated for each site suggest variation in the relative importance of potential predictors among sites. Whereas poorer mental health was primarily associated with history of drug dependence at Baltimore and more physical symptomatology at New York, better mental health was most strongly correlated with more positive perceptions of interpersonal relationships at Baltimore and increasing age and more positive perceptions of meaning and purpose in life at New York.

Significance of results:The data presented suggest the importance of assessing clients' history of and current need for mental health services. Evidence of a relationship between positive perceptions of meaning and purpose and better psychological function underscores the importance of existential issues for the overall well-being of those who are seriously ill.

Comorbidity of chronic diseases

Although much research has been done on the impact of chronic illness on quality of life, still relatively little is known about the role of comorbidity. Given the growing number of (older) people with multiple chronic conditions, more information is needed on the effects of specific disease combinations for preventive purposes. In a nationwide representative sample of 1673 non-institutionalized chronic disease patients (recruited in 56 general practices) in The Netherlands, we assessed the separate and joint effects of cardiovascular disease, cancer, arthritis, chronic respiratory disease, diabetes mellitus, and thyroid dysfunction on physical and mental functioning. Data on medical diagnoses were provided by the general practitioners; data on physical and mental functioning were collected by a patient survey (SF-36). Compared to reference data of the general population, physical functioning appeared to be worse in all six diagnostic groups, whereas mental functioning was more or less comparable. Patients with arthritis or those suffering from comorbidity reported the lowest levels of physical functioning. Synergistic effects of combinations of diabetes, cardiovascular disease and/or chronic respiratory disease were found, indicating that patients suffering from these disease combinations run a higher risk of physical disability than could be expected from their separate effects.

Physical and Psychosocial Health in Family Caregiving: A Comparison of AIDS and Cancer Caregivers

The objectives of this study were to compare cancer and AIDS family caregivers in regard to their physical and emotional health. The sample consisted of 26 caregivers of persons with cancer or AIDS. Study participants completed a questionnaire that included measures of depression, grief, symptoms of stress, caregiving demands, interpersonal relationships, health status, and quality of life. The data revealed that both AIDS and cancer caregivers reported high levels of stress and depression as compared to community norms. No significant differences were found between AIDS and cancer caregivers for any of the scale scores; however, the two groups differed on several individual subscales. Cancer caregivers demonstrated higher social functioning and were more likely to report that the work of caregiving itself disrupted their ability to socially engage with others. In contrast, AIDS caregivers were more likely to report that their own health limited their ability to socialize. Even though AIDS caregivers experienced less family support than cancer caregivers, they reported more rewards from caregiving. Results suggest that support delivered to caregivers emphasize a more inclusive approach to program delivery, versus a disease-specific perspective, in order to increase the depth and breath of services provided to families undertaking these challenges.

Quality of life and its correlates in HIV/AIDS male outpatients receiving highly active antiretroviral therapy in Taiwan

Long-term care of human HIV and AIDS cases has raised quality of life (QoL) issues. The aim of this study was to identify QoL in HIV/AIDS male outpatients receiving highly active antiretroviral therapy (HAART) and its correlates in Taiwan. In total, 41 HIV/AIDS male outpatients receiving HAART yet presenting few symptoms of infection, were recruited for the study. Their QoL levels were measured with the Taiwan version of the Short Form of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF). The relationships between QoL and demographic characteristics, social support, negative stressors, depression, characteristics of HIV infection, attitude toward HIV infection, and adverse effects of HAART, were examined. The results of the analysis reveal that multiple factors affect QoL for HIV/AIDS male outpatients receiving HAART, including severity of depression, deterioration of work function, inconvenience resulting from medication schedules and medical appointments, lack of social support, negative stressors, and adverse effects of HAART. The results provide screening factors so that clinicians can intervene to improve the QoL for their HIV patients.

Cognitive reorganization and stigmatization among persons with HIV

BACKGROUND

A diagnosis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a life-changing event, where persons must deal with a life-threatening, debilitating disease and its associated stigma and isolation. Studies over the past decade have shown that writing and talking about stressful and traumatic experiences, such as a life-threatening illness, causes emotions surrounding the trauma to change and to become cognitively reorganized. The result is a reduction in inhibition and change in basic cognitive and linguistic processes, which have contributed to meaningful behavioural, psychological, and physical health benefits across a variety of populations.

AIMS

To describe the construction of the Integrated Model of Health Promotion for persons with HIV/AIDS, and present initial empirical support of the model from a feasibility pilot study of women with HIV/AIDS.

APPROACH

The Integrated Model of Health Promotion is described and relevant literature in the field is reviewed. The model is implemented in a feasibility pilot study utilizing the emotional writing disclosure intervention.

RESULTS

Participants in the experimental condition demonstrated a promising pattern of cognitive reorganization, a reduced perception of stigma, and an improvement in mental health scores compared with the control condition.

CONCLUSION

Implications of these findings are discussed within the framework of the Integrated Model of Health Promotion. The model explores health and behavioural benefits associated with emotional writing in individuals with HIV/AIDS. The limited sample size of this pilot study precludes testing for significance. Further studies are required prior to the development of practice guidelines.

Estimation and comparison of derived preference scores from the SF-36 in lung transplant patients

The purpose of this study was to estimate and compare preference scores derived from MOS Short Form-36 (SF-36) data for a sample of lung transplant patients using three methodologies: Fryback et al. (Med Decis Making 1997; 17: 1-9), Nichol et al. (Med Decis Making 2001; 21: 105-112) and Brazier et al. (J Health Econ 2002: 21: 271-292). Data were gathered from 99 lung transplant recipients using a mail survey, which included the SF-36 and other health-related quality of life (HRQL) measures. The mean preference score for the sample was 0.643 (range 0.43-0.83), 0.765 (range 0.36-1.0), and 0.697 (range 0.33-1.00) for Fryback, Nichol and Brazier methods, respectively. Correlations between the derived scores and visual analogue ratings of health (0.58-0.68) and pulmonary symptoms (-0.59 to -0.62) were moderate to good and in the expected directions. The mean preferences of patients grouped by levels of dyspnea, depression symptoms, illness burden, and self-rated general health differed significantly with all methods and supported the construct validity of the derived scores as measures of preference. The Nichol and Brazier scores, both derived with standard gamble utilities, were generally higher than Fryback scores, which are not utility-based. Given the popularity of the SF-36, these three methods could be useful where direct elicitation of preferences is not feasible. Researchers must be cognizant of the derivation method used, as absolute preference levels, hence quality adjusted life years (QALYs), will differ by method.

Impact of indinavir on the quality of life in patients with advanced HIV infection treated with zidovudine and lamivudine

OBJECTIVE

In AIDS Clinical Trial Group (ACTG) study 320, triple-combination antiretroviral therapy including indinavir significantly slowed progression to acquired immunodeficiency syndrome or death, compared with treatment with dual nucleoside reverse-transcriptase inhibitors (NRTIs) alone, in zidovudine-experienced patients with advanced human immunodeficiency virus (HIV) infection. We examined the impact of indinavir on quality of life in participants from this study.

METHODS

A total of 1156 protease inhibitor- and lamivudine-naive patients stratified by CD4 cell count (<or=50 and 51-200 cells/mm(3)) were randomized to receive zidovudine (or stavudine) and lamivudine, with or without indinavir. Health-related quality of life was measured using the ACTG QoL601-602 questionnaire, which assesses general health status measured on a visual analogue scale and 8 specific health-related domains. Quality-adjusted survival time was estimated using the visual analogue scale for general health.

RESULTS

Mean changes in general health scores after 24 weeks were +2.9 in the triple-therapy group versus -0.2 in the dual-therapy group (P=.018). By week 24, scores in all specific domains were higher with triple-drug therapy than dual-drug therapy, with statistically significant differences in role function, energy, and pain scores. Benefits of triple-drug therapy were largely confined to patients with CD4 cell counts of <or=50 cells/mm(3). Quality-adjusted survival time did not differ significantly between the 2 treatment groups.

CONCLUSIONS

Triple-drug therapy with indinavir and 2 NRTIs resulted in a significant improvement in general health status after 24 weeks, especially in patients with low CD4 cell counts. Patients receiving triple-drug therapy also had significantly better role function, energy, and pain scores than did patients treated with dual-drug therapy.

Performance of a generic health-related quality of life measure in a clinic population with rheumatic disease

OBJECTIVE

To assess the performance of a generic health-related quality of life (HRQOL) measure in a rheumatology clinic population.

METHODS

Participants (n = 619) with fibromyalgia, rheumatoid arthritis, or osteoarthritis receiving care from rheumatologists completed mailed questionnaires that included the Behavioral Risk Factor Surveillance System (BRFSS) HRQOL measure and condition-specific measures assessing disability, pain, fatigue, and helplessness. The BRFSS assesses global health and number of days in the past 30 of poor physical or mental health or activity limitation. The overall sample was described, followed by comparison of adjusted scores on all HRQOL measures by diagnosis.

RESULTS

Participants reported mild difficulty with activities of daily living, marked pain and fatigue, and moderate helplessness. Participants reported a mean of 8 or more days out of 30 of poor physical and mental health and activity limitations; more than 40% reported poor or fair health. Participants with fibromyalgia reported more ill health on condition-specific measures and the BRFSS HRQOL measures than did participants with osteoarthritis or rheumatoid arthritis.

CONCLUSION

The BRFSS HRQOL measure is a brief, easily administered, generic health indicator that shows differences among rheumatic disease diagnoses.

Commentary on using the SF-36 or MOS-HIV in studies of persons with HIV disease

The purpose was to compare and comment on use of the SF-36 and MOS-HIV instruments in studies of persons with HIV disease. Three medical information databases were searched to identify examples of HIV studies that included the MOS-HIV or SF-36. Thirty-nine and 14 published articles were identified for illustration in comparing the use of the MOS-HIV and SF-36 in HIV disease, respectively. Support for the reliability and construct validity of the MOS-HIV and SF-36 was found. Ceiling and floor effects were reported for both the MOS-HIV and SF-36; however, ceiling effects were more common for the MOS-HIV, in part due to fewer items in the physical, social, and role functioning domains. The MOS-HIV measures three domains hypothesized to be associated with the health deterioration of HIV disease not measured by the SF-36; however, these domains may not assess aspects of HIV disease that typify the majority of the persons with HIV disease today. National norms for the U.S. adult population (and other nations) are available for the SF-36. In addition, the SF-36 has been used in a wide variety of patient populations, enabling comparisons of HIV-infected persons with persons with other health conditions. No national norms for the MOS-HIV are available. We conclude that there is currently insufficient evidence in the literature to recommend the use of the MOS-HIV over the SF-36 in HIV-infected persons. Although the SF-36 is not targeted at HIV, it may be preferable to use the SF-36 over the MOS-HIV due to fewer ceiling effects, availability of national norms, and the vast amount of data for other populations in the U.S. and around the world. Head-to-head comparisons demonstrating the unique value of the MOS-HIV over the SF-36 are clearly needed. More importantly, additional work needs to be directed at comparing the MOS-HIV and other putatively HIV-targeted instruments to one another to help demarcate aspects of HRQOL that are truly generic versus specific to HIV disease. Using both a generic and targeted HRQOL measure is a good general strategy, but this has not been a typical practice in studies of HIV because the MOS-HIV is so similar in content to the SF-36.

Quality of well-being in older people with osteoarthritis

OBJECTIVE

To examine the sensitivity of the Quality of Well-Being Scale (QWB) as a measure of health-related quality of life (HRQOL) in people with osteoarthritis (OA).

METHODS

The QWB was administered, along with the Arthritis Impact Measurement Scale (AIMS) and other health measures. Health care utilization data were also obtained.

RESULTS

People with OA had a mean QWB score of 0.643. The QWB scores were significantly correlated with total AIMS scores, self-rated health status, health care costs, depression scores, and most AIMS subscales. In addition, changes in QWB scores after 1 year were significantly correlated with changes in total AIMS scores and some AIMS subscales.

CONCLUSION

The QWB appears to be a useful and sensitive generic, utility-based measure of HRQOL in people with OA.

Validation of the World Health Organization quality of life instrument in patients with HIV infection

We studied the reliability and validity of the World Health Organization quality of life (WHOQOL) assessment instrument in patients with human immunodeficiency virus (HIV) infection. WHOQOL-BREF was used to assess 136 HIV-infected outpatients. The results were analyzed and compared with data from 213 healthy persons. The Cronbach's alpha for internal consistency ranged from 0.74 to 0.85 across domains in HIV-infected patients. The test-retest reliability ranged from 0.64 to 0.79 across domains at average 4-week retest interval. Factor analysis identified four major factors: social, psychological, environment, and physical, consistent with the four domains of the instrument. The scores of all four domains correlated positively with self-evaluated health status and happiness (r range: 0.52-0.60 and 0.55-0.73 across domains, respectively), and correlated negatively with the number and severity of symptoms (r range: -0.40 to -0.47 and -0.41 to -0.52, respectively). The scores of physical, psychological and social domains, but not the environment domain, discriminated between healthy persons and HIV-infected patients (all p < 0.01). We conclude that the WHOQOL-BREF can be a useful quality-of-life instrument in patients with HIV infection.

A meta-analysis of utility estimates for HIV/AIDS

The authors performed a meta-analysis to derive pooled utilities for HIV/AIDS and to assess the relative importance of study design characteristics in predicting utilities. Twenty-five articles were identified reporting 74 unique utilities elicited from 1956 respondents. The authors used a hierarchical linear model to perform the meta-analysis, with disease stage, elicitation method, respondent type, and the upper-bound and lower-bound labels for the utility scale as the independent variables. Disease stage (P = 0.016) and respondent type (P = 0.014) were significant predictors of utility. Elicitation method was of marginal significance (P = 0. 052). Bounds were not significant. Pooling utilities, the authors estimate a utility of 0.70 for AIDS, 0.82 for symptomatic HIV and 0.94 for asymptomatic HIV when the time tradeoff method is used to elicit utilities from patients and the scale ranges from death to perfect health. The pooled utilities reported here should be of great use to researchers performing cost-utility analyses of interventions for HIV/AIDS.

Health status and health-related quality of life associated with hemophilia

The hemophilias are a group of disorders associated with a chronic burden of morbidity and early mortality. Improvements in these adverse features have been achieved by the use of clotting factor concentrates within comprehensive centers of specialized care providing home infusion programs. Offsetting effects from transfusion-transmitted hepatitis and HIV infection are in recent decline. The net impact of these changes merits assessment. To test the a priori hypotheses that increasing severity of factor VIII deficiency would be associated with an increasing burden or morbidity and that hepatitis and HIV positivity would impair health status further, a cross-sectional study of a population-based cohort was undertaken in a regional hemophilia program in Ontario, Canada. A survey was made of mild, moderate, and severe hemophiliacs over 13 years of age who self-reported their health status using a standard 15-item questionnaire. The responses were converted to levels in the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3) health status classification systems to form multi-element vectors from which single-attribute morbidity and overall health-related quality of life utility scores were determined. The burden of morbidity was greater in hemophiliacs than in the general population and correlated with the category of disease (mild < moderate < severe). Hepatitis and HIV positivity conferred additional burdens of morbidity, which were mainly in the attributes of mobility (HUI2), ambulation (HUI3), and pain (HUI2/3), all of these differences reaching levels of statistical significance. Despite demonstrable improvements in the safety, effectiveness, and utilization of clotting factor concentrates, hemophiliacs continue to experience an important burden of morbidity. Measurement of this burden, as reported here, provides a basis for future economic evaluation of the costs and consequences of health care interventions provided to this population.

Importance of access to research information among individuals with spinal cord injury: results of an evidenced-based questionnaire

OBJECTIVE

To assess the interests and accessibility of patients with a spinal cord injury (SCI) to information in different areas of SCI.

SETTING

Spinal Program, Toronto Western Hospital, University Health Network.

METHODS

An interest assessment survey and the SF-36 (short form-36) questionnaire were mailed to SCI patients living in the community. The interest assessment examined patients' interest in information in many areas related to SCI, their current knowledge in these areas and the accessibility of different information formats.

RESULTS

Fourteen patients (45%) completed the questionnaires. Regardless of physical or mental health status, all patients expressed a high level of interest in SCI research and clinical trials. An Internet website proved to be the most preferred, accessible and comfortable information format for these patients. Patients expressed a lower interest in support groups and organizations. Results from the SF-36 showed poor social functioning was related to interest in support groups, and poor general health perception was related to interest in occupational and physical therapy.

CONCLUSION

The majority of SCI patients have a high interest in accessing SCI research information. The Internet is a favorable, comfortable and accessible tool for providing this information and will benefit all SCI patients. These results suggest that a significant number of patients with SCI would benefit from an accessible Internet-based information database that is relevant to the SCI patients population.

Quality of life of patients with Fabry disease

This paper is the first of its kind to study the impact of Fabry disease (FD) in affected males, and shows that FD is associated with a significant decline in several domains. Using the medical outcomes study (MOS) SF-36 and a FD-specific questionnaire, we compared the observations found among these patients with that obtained for the general US population and other chronic disease states, including Gaucher disease (GD) (another lysosomal storage disorder), end-stage renal disease, stoke and AIDS. Patients with FD have a score profile most similar to patients with AIDS. In comparison with patients with GD, Fabry patients score substantially lower across all domains. Using simple linear regression, potential predictors of health-related quality of life (HRQOL) for Fabry patients were also determined. As in the general population, stroke, cardiac problems and renal disease lead to substantial decrement in HRQOL. In addition, two disease specific symptoms (acroparesthesia and anhidrosis) and pain are also predictors of decreased quality of life. Currently, no specific therapy for FD exists. As enzyme therapy for FD becomes increasingly available, it will be interesting to evaluate the therapy's impact on the quality of life of patients.

Health status and life satisfaction among breast cancer survivor peer support volunteers

Two measures of health-related quality of life (HRQOL), the Medical Outcomes Survey Short Form 36 (SF-36) and the Satisfaction with Life Domains Scale for Cancer (SLDS-C), were compared to examine the relationship between health status and life satisfaction among breast cancer survivors (BCSs). A total of 586 BCSs, all of whom were volunteers in peer support programs, met inclusion criteria and completed the self-report measures. Significant correlation coefficients were shown between life satisfaction and measures of health status. SF-36 scores were significantly higher for physical functioning, emotional well-being, and vitality subscales compared to population norms. BCSs expressed greatest dissatisfaction with their sexual ability, physical strength, and bodies in general. Small age differences were found. Results suggest that incorporating multiple measures of HRQOL contribute to the understanding and measurement of the effects of cancer on perceived health status and life satisfaction.

Association between obesity and functional status in patients with spine disease

STUDY DESIGN

A cross-sectional study of 15,974 patients with spine disease from 26 members of the National Spine Network.

OBJECTIVES

To use functional status measures and clinical parameters to evaluate the association between obesity and health status among patients with spine conditions.

SUMMARY OF BACKGROUND DATA

With 22.5% of Americans overweight, obesity is a significant health concern. However, the functional impact caused by obesity in spine patients remains unknown.

METHODS

Functional status was measured on 15,974 patients on an initial visit using a general physical health measure (SF-36 Physical Component Summary score) and a disease-specific measure (Oswestry Disability Index). Obesity was measured using body mass index (kg/m2). Patients were categorized into four groups according to body mass index: normal range (<25.0 kg/m2, n = 5732), Grade 1 obesity (25.0-29.9 kg/m2, n = 5845), Grade 2 obesity (30.0-39.9 kg/m2, n = 3836), and Grade 3 obesity (>/=40.0 kg/m2, n = 561). The associations between SF-36 Physical Component Summary and Oswestry Disability Index scores and body mass index were evaluated in a multivariate linear regression model. Clinical presentation data were derived from patient and clinician reports and were compared across body mass index categories.

RESULTS

In the four obesity categories, the PCS scores were 32.6 (normal range body mass index), 30.8 (Grade 1), 28.2 (Grade 2), and 25.9 (Grade 3) (P < 0.001). The SF-36 Physical Component Summary score of the general U.S. population is 50.0. The Oswestry Disability Index scores across the four body mass index groups were 39.0, 41.6, 46.6, and 52.2, respectively (P < 0.001). Compared with nonobese patients, obese patients were more likely to have radicular pain and neurologic signs (P < 0.01). Furthermore, obese patients had more comorbidities and were more likely to be receiving worker's compensation. After adjusting for clinical and demographic factors, each increased level of obesity was associated with a 1-1.5-point worsening in both the SF-36 Physical Component Summary and Oswestry Disability Index scales (P < 0.05).

CONCLUSIONS

General and disease-specific functional health status was significantly worse for patients with a higher body mass index. Obese patients also displayed more severe pain symptoms than nonobese spine patients.

Transforming self-rated health and the SF-36 scales to include death and improve interpretability

BACKGROUND

Most measures of health-related quality of life are undefined for people who die. Longitudinal analyses are often limited to a healthier cohort (survivors) that cannot be identified prospectively, and that may have had little change in health.

OBJECTIVE

To develop and evaluate methods to transform a single self-rated health item (excellent to poor; EVGGFP) and the physical component score of the SF-36 (PCS) to new variables that include a defensible value for death.

METHODS

Using longitudinal data from two large studies of older adults, health variables were transformed to the probability of being healthy in the future, conditional on the current observed value; death then has the value of 0. For EVGGFP, the new transformations were compared with some that were published earlier, based on different data. For the PCS, how well three different transformations, based on different definitions of being healthy, discriminated among groups of patients, and detected change in time were assessed.

RESULTS

The new transformation for EVGGFP was similar to that published previously. Coding the 5 categories as 95, 90, 80, 30, and 15, and coding dead as 0 is recommended. The three transformations of the PCS detected group differences and change at least as well as the standard PCS.

CONCLUSION

These easily interpretable transformed variables permit keeping persons who die in the analyses. Using the transformed variables for longitudinal analyses of health when deaths occur, either for secondary or primary analysis, is recommended. This approach can be applied to other measures of health.

[Self-perception of health in non-institutionalised elderly]

OBJECTIVE

To evaluate the self-perception of health (SH) of non-institutionalised over-65s. To relate this SH to age, sex, social and economic level, and use of health services.

DESIGN

Descriptive cross-sectional study on a sample stratified by age and sex.

SETTING

City of Avila.Participants. 425 interviews representative of the census of the over-65s, using the SF-36 Health Questionnaire and a complementary questionnaire to gather information on social and economic levels and use of health services.

MAIN RESULTS

The QWB well-being index was at 0.67 (0.69 men; 0.65 women), dropping with age (0.70 in < 70s; 0.59 in > 84 years old). The highest scores on the questionnaire were in the dimensions social function (81.1) and emotional role (79.8); and the worst in general health (51.9) and vitality (58.5), with men always having higher scores (p < 0.05, except in physical function [p = 0.05] and general health [p = 0.47]). At greater ages the scores were worse, with physical function (-50.6%) and physical role (-45.7%) more affected by age, and mental health (-12.1%), general health (-16.1%) and emotional role (-17.8%) less affected. Men perceived their health as more stable than women did (63.7% vs. 44.6%; p < 0.001). There was self-perception of better health, the higher the social and economic levels (p < 0.05 in all dimensions), the greater the educational level reached (p < 0.05 except in social function) and the less the health services were used (p < 0.05, except for mental health-hospital admission).

CONCLUSIONS

The Index of Well-being of our elderly people is comparable to that recorded in other samples. Men had self-perception of better health than women and saw their health as more stable. SH gets significantly worse with age. Higher economic and social levels and less use of health services are related to better SH.

Health-related quality of life and virologic outcomes in an HIV clinic

OBJECTIVE

The purpose of this study was to describe the relationship between viral load and health-related quality of life (HRQOL) in a cohort of persons with human immunodeficiency virus (HIV) infection.

DESIGN

We evaluated HRQOL measurements in a clinical cohort of HIV-positive patients recruited from a university-associated HIV primary care clinic. HRQOL instruments included the medical outcomes survey-short form-36(MOS-SF-36) from which mental and physical component summary scores (MCS and PCS) and subscale scores were calculated.

RESULTS

Significant negative associations were found between viral load and SF-36 PCS, physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), role-emotional (RE), and vitality (VT). Similar negative associations were found between CD4 cell count and SF-36 summary and subscale scores, with the notable exception of bodily pain. Multivariate analyses controlling for the effects of CD4 cell count and other clinical variables indicated viral load as an independent predictor of SF-36 PCS, RP, BP and VT scores.

CONCLUSIONS

The relationship between viral load, a measure of HIV disease activity, and several dimensions of the SF-36, a patient-focused measure of HRQOL, appears to be strong and independent of CD4 cell count. These findings suggest that having a lower viral load positively impacts the quality of life of HIV-positive patients.

Simulated effect of tobacco tax variation on population health in California

OBJECTIVES

This study simulated the effects of tobacco excise tax increases on population health.

METHODS

Five simulations were used to estimate health outcomes associated with tobacco tax policies: (1) the effects of price on smoking prevalence; (2) the effects of tobacco use on years of potential life lost; (3) the effect of tobacco use on quality of life (morbidity); (4) the integration of prevalence, mortality, and morbidity into a model of quality adjusted life years (QALYs); and (5) the development of confidence intervals around these estimates. Effects were estimated for 1 year after the tax's initiation and 75 years into the future.

RESULTS

In California, a $0.50 tax increase and price elasticity of -0.40 would result in about 8389 QALYs (95% confidence interval [CI] = 4629, 12,113) saved the first year. Greater benefits would accrue each year until a steady state was reached after 75 years, when 52,136 QALYs (95% CI = 38,297, 66,262) would accrue each year. Higher taxes would produce even greater health benefits.

CONCLUSIONS

A tobacco excise tax may be among a few policy options that will enhance a population's health status while making revenues available to government.

Health-related quality of life outcomes measures

OBJECTIVE

To review critically the features of measures of generic health-related quality of life (HRQOL) for disability outcomes research.

DATA SOURCES

A search of electronic databases, summary reviews, books, and government documents was performed. Comment and experiences from participants of a conference on outcomes research were also incorporated.

STUDY SELECTION

English language literature from scientists from a broad range of disciplines and research settings, including medicine, nursing, social science, and public health, and health services research and practice.

DATA EXTRACTION

A critical review of measures that have been or might be used to measure disability outcomes.

DATA SYNTHESIS

Commonly used generic measures of HRQOL can be applied to disability outcomes research with some caveats. Three common tools are the Medical Outcomes Study Short-Form Health Survey (SF-36), Sickness Impact Profile (SIP), and Quality of Well-Being (QWB) scale. The SF-36 and SIP have been used with some success in research with people with disability. The QWB scale has been used less frequently.

CONCLUSION

Most studies using generic HRQOL tools are of groups with specific impairments rather than heterogeneous groups of people with disability. None of the tools appears to measure HRQOL without some potential biases (eg, inappropriate wording) for people with disability, but more specific testing of these problems is needed. Also needed are studies to determine whether these tools can measure meaningful longitudinal changes.

Functional aerobic impairment in adolescents seropositive for HIV: a quasiexperimental analysis

OBJECTIVE

To determine the degree to which cardiorespiratory insufficiency limits physical performance in adolescents seropositive for human immunodeficiency virus (HIV).

DESIGN

Quasiexperimental, case series design.

SETTING

Rehabilitation physiology laboratory.

PARTICIPANTS

Seventeen adolescents (12 women, 5 men; age, 18 +/- 2 yr; weight, 74.7 +/- 19.3 kg; height, 170 +/- 9 cm) with HIV infection (viral load, 22,043 +/- 55,869 copies/mL; CD4 count, 499 +/- 210/mL) who were free of comorbid conditions limiting treadmill performance.

MAIN OUTCOME MEASURES

Spirometric measurements of oxygen uptake and anaerobic threshold obtained from a peak exercise treadmill test using the modified Bruce protocol.

RESULTS

Measured peak oxygen consumption (VO2) was 42% +/- 19% lower than expected (p < .025), suggesting a significant functional aerobic impairment (FAI) or peak VO2 less than 73% of expected values. Peak VO2 was only slightly higher (p < .05) than the oxygen uptake requirements for the most intense activities of daily living (ADL). Anaerobic threshold was only slightly higher (p < .05) than minimum ADL intensities.

CONCLUSIONS

Cardiorespiratory insufficiency and FAI limited the ability to perform even low levels of physical activity in these adolescents with mild HIV seropositivity. Disability identified by quantification of FAI may affect implementation of the American with Disabilities Act and public health policy.

Functional decline among older adults: comparing a chronic disease cohort and controls when mortality rates are markedly different

In studies of functional status decline in older persons, the strategy for handling deaths during follow-up may influence policy implications. We compared 301 older ESRD dialysis patients with 322 controls to determine whether functional decline over 3 years among dialysis patients exceeded that of "normal aging." We used two different statistical methods and, for each, compared results when deaths were excluded and then included in the analysis. Dialysis patients incurred a larger follow-up mortality rate and were more impaired at baseline. Findings based on functional transition over time, assessed by a nominal variable, were sensitive to whether or not deaths were included in the analysis. However, findings based on nonparametric methods for an ordinal scale (functional impairment) were not sensitive to whether or not deaths were included in the analysis. Analyzing data with and without deceased subjects may be the most comprehensive approach to comparing two cohorts over time.

The impact of spinal problems on the health status of patients: have we underestimated the effect?

STUDY DESIGN

A prospective study of 17,774 patients who consulted spine centers in which the impact of spinal disorders and comorbidities on physical functional status were evaluated.

OBJECTIVES

To quantify the effect spinal diagnoses have on patients' physical functional status (SF-36 Physical Component Summary [PCS] score) compared with other common conditions and to quantify the effects of comorbidities on physical functional status in spine patients.

SUMMARY OF BACKGROUND DATA

The burden of spinal conditions on a patient's function and the role that comorbidities play in this affliction are poorly quantified in the literature.

METHODS

Data from the Health Survey Questionnaire were prospectively gathered through the National Spine Network, a nonprofit consortium of spine-focused practices. Each patient's SF-36 score was summarized into a single PCS score. The correlation between diagnosis and comorbidity and PCS score was assessed using multivariate linear regression.

RESULTS

The study patients were a mean of 47.5 years of age, 54.7% were female, 52.3% had lumbosacral diagnoses, and 82.0% had had 3 or more months of pain. The population had a mean PCS score of 30.4 +/- 9.95 (SD) compared with 50.0 +/- 10.00 for the general United States population. The more comorbidities in a patient, the lower the PCS score (Spearman rank correlation = -0.27). The five comorbid conditions that lowered the PCS the most included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), renal failure, rheumatoid arthritis, and lupus (all P <0.001). In multiple linear regression analysis, age, gender, diagnosis, and comorbidity explained 12.1% of the variance in PCS score.

CONCLUSIONS

The PCS score is greatly affected in patients with spinal problems. The study population's PCS (30.4) was lower or similar to the PCS for patients with other illnesses reported in the literature: CHF (31.0), COPD (33.9), SLE (37.1), cancer (38.4), primary total hip arthroplasty (29.0), primary total knee arthroplasty (32.6), and glenohumeral degenerative joint disease (35.2). Further, the presence of comorbidity in spine patients adds to the burden of spinal conditions on functional status.

Medical Outcomes Study Short Form 36: a possible source of utilities?

General health-status questionnaires such as the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) are frequently used to measure health-related quality of life. The SF-36, in its current form, cannot be used to measure individuals' utilities or preferences for their health state. Recently, several investigators have explored the possibility of obtaining utilities from the SF-36. This article reviews the SF-36 survey, selected measures of utility, and the differences between health-status and utility measures, with an emphasis on use of SF-36 results to derive utility scores. We searched the literature from January 1966 to July 1999 using MEDLINE and HEALTHSTAR. The terms SF-36, health-status instruments, utilities, and preferences were searched to identify studies that had used both the SF-36 and a utility-based instrument. We first discuss studies that were specifically designed to find a predictive equation to obtain utilities from SF-36 scores. We then discuss studies that examined the correlation between the SF-36 and a utility-based instrument but that were not intended to develop a predictive equation as their primary objective. The studies that have tried to derive utilities from the SF-36 using a predictive equation have used different methodologies; to date, no reliable method has been appropriately validated. The poor correlation reported in most of the studies attests to the complex relationship between utility-based instruments and the SF-36. More work is needed to elucidate if utilities can be obtained from the SF-36.