Comparison of Quality of Well-Being scale and Functional Status Index in patients with atrial fibrillation

Cost-effectiveness analysis of surgical lung volume reduction compared with endobronchial valve treatment in patients with severe emphysema

BACKGROUND

Lung volume reduction, either by surgery or bronchoscopically by endobronchial valve treatment have been shown to be a cost-effective alternative compared with conservative therapy. However, there is no comparative analysis of lung volume reduction by surgery and bronchoscopic lung volume reduction using endobronchial valves.

OBJECTIVES

The aim of this retrospective study was to provide a cost-effectiveness analysis of lung volume reduction by surgery compared with bronchoscopic lung volume reduction using endobronchial valves.

METHODS

The effectiveness of lung volume reduction was assessed using forced expiratory volume in the first second (FEV1), residual volume (RV) and 6-minute walking distance (6MWD), measured at baseline and at 4 to 12 weeks. Cost unit accounting derived from SwissDRG was used as a surrogate of the costs from the payer's perspective.

RESULTS

In total, 67 patients (37 men and 30 women) with a mean age of 68.3 ± 7.4 years were included. Both clinical effectiveness and costs were comparable between surgical and bronchoscopic lung reduction. The incremental cost-effectiveness ratios (ICERs) for bronchoscopic compared with lung volume reduction by surgery for FEV1, RV and 6MWD were -101, 4 and 58, respectively. For RV and 6MWD, it could be shown that endobronchial valve treatment is justified as a probably cost-effective alternative to lung volume reduction by surgery. Endobronchial valve treatment resulted in an improvement of 0.25 quality-adjusted life years (QALYs) and an ICER of € 7657 per QALY gained.

CONCLUSION

A robust statement on the superiority of one of the two procedures in terms of cost-effectiveness cannot be made from the present study. Therefore, the study is not suitable for resource allocation. Two upcoming trials comparing lung volume reduction surgery and endobronchial valve treatment may be able to answer this question.

Health-Related Quality of Life Measurement in Public Health

Patient-reported outcomes are recognized as essential for the evaluation of medical and public health interventions. Over the last 50 years, health-related quality of life (HRQoL) research has grown exponentially from 0 to more than 17,000 papers published annually. We provide an overview of generic HRQoL measures used widely in epidemiological studies, health services research, population studies, and randomized clinical trials [e.g., Medical Outcomes Study SF-36 and the Patient-Reported Outcomes Measurement Information System (PROMIS^®)-29]. In addition, we review methods used for economic analysis and calculation of the quality-adjusted life year (QALY). These include the EQ-5D, the Health Utilities Index (HUI), the self-administered Quality of Well-being Scale (QWB-SA), and the Health and Activities Limitation Index (HALex). Furthermore, we consider hybrid measures such as the SF-6D and the PROMIS-Preference (PROPr). The plethora of HRQoL measures has impeded cumulative science because incomparable measures have been used in different studies. Linking among different measures and consensus on standard HRQoL measurement should now be prioritized. In addition, enabling widespread access to common measures is necessary to accelerate future progress. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Quality of well-being outcomes in the National Emphysema Treatment Trial

BACKGROUND

Surgical and medical treatments for emphysema may affect both quality and quantity of life. The purpose of this article is to report outcomes from the National Emphysema Treatment Trial (NETT) using an index that combines quality and quantity of life.

METHODS

This was a prospective randomized clinical trial. Following pulmonary rehabilitation, 1,218 patients with severe emphysema were randomly assigned to maximal medical therapy or to lung volume reduction surgery (LVRS). A generic quality-of-life measure, known as the Quality of Well-being Scale (QWB), was administered at baseline and again at 6, 12, 24, 36, 48, 60, and 72 months following treatment assignment.

RESULTS

At baseline, QWB scores were comparable for the Medical and LVRS groups. For both groups, scores significantly improved following the rehabilitation program. The QWB scores before death for patients in the LVRS group improved up to the year 2 visit, whereas scores for the Medical group dropped significantly following the baseline visit. Imputing zeros (0) for death, QWB scores decreased significantly for both groups. With or without scoring death as 0, the LVRS group achieved better outcomes, and the significant differences were maintained until the sixth year. Over 6 years of follow-up, LVRS produced an average of 0.30 quality-adjusted life years (QALYs), or the equivalent of about 3.6 months of well life.

CONCLUSIONS

Compared with maximal medical therapy alone, patients undergoing maximal medical therapy plus LVRS experienced improved health-related quality of life and gained more QALYs.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00000606; URL: www.clinicaltrials.gov.

The hepatitis C self-management program: sustainability of primary outcomes at 1 year

OBJECTIVE

Chronic hepatitis C infection afflicts millions of people worldwide. Although antiviral treatments are increasingly effective, many hepatitis C virus (HCV) patients avoid treatment, do not complete or respond to treatment, or have contraindications. Self-management interventions are one option for promoting behavioral changes leading to liver wellness and improved quality of life. Our objective was to evaluate whether the effects of the HCV self-management program were sustained at the 12-month follow-up assessment.

METHODS

Veteran Affairs patients with hepatitis C (N = 134; mean age = 54.6 years, 95% male, 41% ethnic minority, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-hour self-management sessions were based on a cognitive-behavioral program with hepatitis C-specific modules. Outcomes including hepatitis C knowledge, depression, energy, and health-related quality of life were measured at baseline, 6 weeks, 6 months, and 12 months later. Data were analyzed using repeated measures ANOVA.

RESULTS

Compared with the information-only group, participants attending the self-management workshop improved more on HCV knowledge (p < .005), SF-36 energy/vitality (p = .016), and the Quality of Well-Being Scale (p = .036). Similar trends were found for SF-36 physical functioning and Center for Epidemiologic Studies Short Depression Scale.

CONCLUSION

Better outcomes were sustained among self-management participants at the 12-month assessment despite the intervention only lasting 6 weeks. HCV health care providers should consider adding self-management interventions for patients with chronic HCV.

The Lifestyle Interventions and Independence for Elders Study: design and methods

BACKGROUND

As the number of older adults in the United States rises, maintaining functional independence among older Americans has emerged as a major clinical and public health priority. Older people who lose mobility are less likely to remain in the community; demonstrate higher rates of morbidity, mortality, and hospitalizations; and experience a poorer quality of life. Several studies have shown that regular physical activity improves functional limitations and intermediate functional outcomes, but definitive evidence showing that major mobility disability can be prevented is lacking. A Phase 3 randomized controlled trial is needed to fill this evidence gap.

METHODS

The Lifestyle Interventions and Independence for Elders (LIFE) Study is a Phase 3 multicenter randomized controlled trial designed to compare a supervised moderate-intensity physical activity program with a successful aging health education program in 1,600 sedentary older persons followed for an average of 2.7 years.

RESULTS

LIFE's primary outcome is major mobility disability, defined as the inability to walk 400 m. Secondary outcomes include cognitive function, serious fall injuries, persistent mobility disability, the combined outcome of major mobility disability or death, disability in activities of daily living, and cost-effectiveness.

CONCLUSIONS

Results of this study are expected to have important public health implications for the large and growing population of older sedentary men and women.

The hepatitis C self-management programme: a randomized controlled trial

Chronic hepatitis C (HCV) infection afflicts millions of people worldwide. While antiviral treatments are effective for some patients, many either cannot or choose not to receive antiviral treatment. Education about behavioural changes like alcohol avoidance and symptom management, in contrast, is universally recommended, particularly in HCV-infected persons from disadvantaged groups where liver risk factors are most prevalent. Self-management interventions are one option for fostering improved HCV knowledge and health-related quality of life (HRQOL). One hundred and thirty-two patients with VA with HCV (mean age of 54.6, 95% men, 41% ethnic minority, 83% unmarried, 72% unemployed/disabled, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-h self-management sessions were based on cognitive-behavioural principles and were adapted from an existing self-management programme that has been efficacious with other chronic diseases. HCV-specific modules were added. Outcomes including HRQOL, HCV knowledge, self-efficacy, depression, energy and health distress were measured at baseline and 6 weeks later. Data were analysed using ANOVA. When compared to the information-only group, participants attending the self-management workshop improved more on HCV knowledge (P < 0.001), HCV self-efficacy (P = 0.011), and SF-36 energy/vitality (P = 0.040). Similar trends were found for SF-36 physical functioning (P = 0.055) and health distress (P = 0.055). Attending the self-management programme improved disease knowledge and HRQOL 6 weeks later in this disadvantaged population. The intervention can improve the health of people with hepatitis C, independent of antiviral therapy. Future research will study longer-term outcomes, effects on antiviral treatment and costs.

Quality of Life: Concept and Definition

This paper will consider 4 topics: (1) the definition of health-related quality of life, (2) the measurement of health-related quality of life, (3) the relationship between exercise and health-related quality of life in the general population, and (4) the relationship between exercise and health-related quality of life in patients with COPD. The paper presents data from the National Health Interview Survey, the San Diego COPD Rehabilitation Trials, and the National Emphysema Treatment Trial (NETT).

Cost-effectiveness of lung volume reduction surgery

Lung volume reduction surgery (LVRS) is a costly procedure that can improve quality and quantity of life. Given the prevalence of emphysema, the costs involved with its management, and resource constraints on all health care delivery systems, evaluating the cost-effectiveness of LVRS is important. In this article, we describe the purposes and principles of cost-effectiveness analysis and how those principles were applied in evaluating LVRS. We present the results of the cost-effectiveness analysis that was conducted alongside the National Emphysema Treatment Trial and other economic studies of LVRS and discuss how these should be interpreted in the context of current reimbursement guidelines.

Health-related quality of life in emphysema

Patients with emphysema may experience reduced health-related quality of life (HRQOL). HRQOL measures have evolved from two different measurement traditions: psychometric theory and decision theory. Psychometric methods typically create a profile of outcomes, whereas decision theory methods offer a summary score on a continuum ranging from 0.0 (for death or worst possible health) to 1.0 (for best possible health). Decision theory methods are better suited for cost-effectiveness studies. Generic HRQOL measures can be applied to any disease population, whereas disease-targeted measures are tailored to a specific clinical condition. Disease-targeted measures are typically more sensitive to clinical change, but cannot offer a comparison basis for different clinical conditions. This article reviews the measurement of HRQOL in patients with emphysema. The National Emphysema Treatment Trial (NETT) offers an example of the application of both generic and disease-targeted, as well as profile and decision theory, methods. The NETT illustrates how HRQOL measures can be used to assess outcomes and estimate cost-effectiveness in a major clinical trial.

Quality of life as an outcome measure in pulmonary diseases

Chronic obstructive pulmonary disease is a serious debilitating condition that is a major cause of death and disability in the modern world. There is no medical or surgical cure for chronic obstructive pulmonary disease and rehabilitation has become an accepted component of disease management and recommended in practice guidelines. Pulmonary rehabilitation programs are designed to restore patients to their highest level of functioning. Traditional physiological measures of lung function are of limited value in the evaluation of outcomes from rehabilitation and rarely capture the benefits of intervention. This review considers quality-of-life outcome measures. There are 2 major approaches to quality-of-life assessment: psychometric and decision theory. The psychometric approach is used to offer a profile summarizing different dimensions of quality of life. The decision theory approach attempts to weight the different dimensions of health in order to provide a single expression of health status. Measures can be classified as either generic or disease targeted. Generic measures can be used with any population, whereas disease-targeted measures are used for patients with a particular diagnosis. Finally, measures can be categorized by their probable uses. Most measures can be used to characterize populations and to study clinical change. However, only generic, decision theory-based measures can be used to evaluate cost-effectiveness. In this article, we review measures for chronic lung diseases in these different categories and identify those more suitable for particular purposes. We devote particular attention to methods designed for use in cost-effectiveness analysis.

The state of patient-reported outcomes in atrial fibrillation : a review of current measures

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting approximately 2.2 million people in the US. The presentation of AF ranges from asymptomatic to severely symptomatic. When symptomatic, AF has been shown to have an adverse impact on health-related quality of life (HR-QOL) and to result in increased healthcare costs. The objective of this analysis was to review the current AF literature on patient-reported outcomes (PROs) in order to evaluate the impact of AF on PROs and the applicability of current PRO measures in assessing AF outcomes.HR-QOL and symptoms were the most frequently assessed PROs; however, the sensitivity of the majority of the questionnaires for detecting subtle change is not known. For highly symptomatic patients, interventional procedures reduce symptoms and improve HR-QOL; however, this is a small cohort of patients with AF. For the most part, PROs are equivalent between pharmacological treatments or are not known for the large percentage of patients treated pharmacologically with antiarrhythmic or rate-controlling drugs.PRO assessment in AF patients is an area that needs continued development. AF-specific PRO measures are needed to assess the full range of patient symptoms and treatment outcomes. The impact of paroxysmal AF versus permanent AF is not well delineated, and sex and nationality differences are not known. In addition, the impact of AF on daily activities and HR-QOL is not clearly described.

Cost effectiveness of lung volume reduction surgery

Lung volume reduction surgery (LVRS) is a costly new procedure that could influence quality of life and survival for persons who have severe emphysema. This article reviews the history of LVRS from an economic and policy perspective and provides estimates of the cost effectiveness of LVRS derived from the National Emphysema Treatment Trial, a recently completed multicenter evaluation of LVRS, compared with medical care. Estimates of the potential impact of LVRS on the national health care budget are provided. The high cost and uncertainty regarding the long-term cost effectiveness of LVRS warrant further evaluation after public and private health insurers make coverage decisions for this procedure, particularly if it is adopted as part of the standard of care.

Comparative responsiveness of generic and specific quality-of-life instruments

We assessed the relative responsiveness of generic and specific quality of life instruments in 43 randomized controlled trials that compared head-to-head 31 generic and 84 specific instruments. Using weighted effect size as the metric of responsiveness, we assessed the impact of instrument type, disease category, and magnitude of underlying therapeutic effect on responsiveness, and assessed the responsiveness of specific instruments relative to the corresponding domains of generic measures. In studies with a nonzero therapeutic effect, specific instruments (mean = 0.57) were significantly more responsive than generic instruments (mean = 0.39, P =.01), and than the corresponding domains of generic instruments (mean = 0.40, P =.03). Studies with low, medium, and high therapeutic effects showed a corresponding gradation in responsiveness differences between specific and generic instruments. We conclude that, overall, specific instruments are more responsive than generic tools, and that investigators may come to misleading conclusions about relative instrument responsiveness if they include studies in which the magnitude of the underlying therapeutic effect is zero.

Evaluating health-related quality of life outcomes in clinical trials of antiepileptic drug therapy

PURPOSE

To provide an overview of condition-specific health-related quality of life (HRQL) assessment in clinical trials of antiepileptic drug (AED) therapy in adults. We describe the key measurement issues in HRQL evaluation, identify the instruments that have been used in this population, summarize the psychometric characteristics of these instruments, propose areas of HRQL most likely to change with treatment, and offer recommendations for further research.

METHODS

We conducted a comprehensive review of the literature using repeated searches of the MEDLINE database together with a review of reference lists from published papers. Psychometric information on the instruments was gathered from published literature.

RESULTS

Three epilepsy-specific HRQL measures were identified: the Epilepsy-Surgery Inventory (ESI-55), the Liverpool Assessment Battery, and the Quality of Life in Epilepsy Inventory (QOLIE, the 89-, 31-, and 10-item versions). One new measure, the Epilepsy Foundation of America (EFA) Concerns Index was also found. The psychometric characteristics of these instruments are discussed in relationship to performance or expected performance in a clinical trial setting. A review of descriptive studies and trials to date suggests that subscales reflecting the psychological and social domains of HRQL may be most sensitive to treatment designed to increase seizure-free periods, reduce seizure severity, and minimize undesirable side effects.

CONCLUSIONS

Although evaluation of HRQL outcomes in clinical trials of epilepsy is still in its infancy, several reliable and valid condition-specific measures are available for understanding the impact of disease and treatment on HRQL. Further research is needed to determine minimal clinically important change scores and to assess the psychometric stability of measures across cultures and mode of administration (self, interview, telephone). Studies of patient preferences for health outcomes in the form of utilities will provide needed data for evaluating the cost-effectiveness of new treatments.

Performance of a self-administered mailed version of the Quality of Well-Being (QWB-SA) questionnaire among older adults

OBJECTIVES

The Quality of Well-Being questionnaire is a measure of health-related quality of life (HRQoL) that has several desirable properties. Its widespread use has been hindered because it is difficult to administer. To overcome this limitation, a new self-administered form has recently been developed. This study examined the feasibility of using the Quality of Well-Being-Self-Administered (QWB-SA) questionnaire in an older population.

METHODS

The Quality of Well-Being-Self-Administered questionnaire was sent to 430 community-dwelling individuals aged 65 years and older who were randomly selected from primary care physicians' offices. Response patterns, scaling distributions, and the acceptability of the survey were examined for all respondents. The results of the QWB-SA questionnaire were compared to the Sickness Impact Profile (SIP) and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) for those individuals who also had completed the latter two surveys approximately 10 months earlier and whose health had not changed substantially in the meantime.

RESULTS

Three hundred and one older adults (70%) responded. The mean QWB-SA questionnaire score was 0.7035. The scores were not skewed, and there were no floor or ceiling effects. The mean time to complete the QWB-SA questionnaire was 14.2 minutes, which was significantly shorter than for the SIP (19.3 minutes) but significantly longer than for the SF-36 (12.5 minutes). Subjects rated their satisfaction with the QWB-SA questionnaire somewhat lower than for the SIP and similar to SF-36. Correlations between the QWB-SA questionnaire and the SIP and SF-36 were moderate and were generally stronger for measures of physical health than for other domains such as mental health.

CONCLUSIONS

The self-administered QWB questionnaire was acceptable to older respondents, and it correlated with other measures of health-related quality of life. It can be considered as a candidate for some research applications among older adults.

Comparison of Quality of Well-Being scale and NYHA functional status classification in patients with atrial fibrillation. New York Heart Association

BACKGROUND

There is an increased need to provide appropriate outcomes evaluations. Although designed as a clinical assessment tool, the New York Heart Association (NYHA) classification is often used as an outcome measure. In this study the performance of the NYHA classification is compared with that of the Quality of Well-being scale (QWB), a standard outcome instrument.

METHODS

Subjects from a clinical trial were administered both the NYHA classification and the QWB. Scores for patients with NYHA classification I, II, and III were compared by use of an ordinal regression model.

RESULTS

There were significant differences in mean QWB score by NYHA classification (p < 0.0001). However, each NYHA classification score was associated with a wide range of QWB scores, limiting the potential usefulness of the NYHA classification as an outcome measure.

CONCLUSIONS

The NYHA classification is not a sensitive measure of health-related quality of life, and its use as an outcome measure, although providing some insights, may result in misleading findings. The NYHA classification should not be used as the sole outcome measure.

Validity of the Quality of Well-Being Scale for patients with Alzheimer's disease

The Quality of Well-Being (QWB) Scale is a utility-weighted measure of health-related quality of life that can be used in clinical trials, population studies, and cost/utility analyses. This article reports evidence for the validity of the QWB in patients with Alzheimer's disease. The subjects were 211 patient-spouse dyads and control dyads recruited from the University of California, San Diego, Alzheimer's Disease Research Center (ADRC) and from community referrals. Among these, three quarters were patients, and one quarter were age- and gender-matched controls. Patient data were obtained by caregiver proxy. Analyses demonstrated that the QWB was strongly associated with dementia ratings and behavioral problems. Caretakers of patients with low QWB scores also reported using more respite time. The authors conclude that the general QWB score allows data from Alzheimer's disease studies to be used in comparative cost/utility analysis.

Cross-sectional study of quality of life and symptoms in chronic renal disease patients: the Modification of Diet in Renal Disease Study

The purposes of this study were to measure health-related quality of life in the Modification of Diet in Renal Disease clinical trial; correlate quality of life measures with demographic, medical, and laboratory variables; and compare quality of life in various chronic diseases. The 1,284 patients enrolled in the baseline period of the Modification of Diet in Renal Disease study who completed at least one measurement of quality of life or symptoms served as the subjects of this study. The Quality of Well-Being (QWB) scale, which was a general health-related quality of life index, the Symptom Checklist-90R (SCL-90R), which provided a global measure of mental health, and the Patient Symptom Form, which assessed the frequency of symptoms specific to this population, were used as measurements. The mean +/- SD QWB score was 0.74 +/- 0.09. Using multivariate analysis, there was a significant negative correlation between the overall QWB score and age and female gender, and a significant positive correlation between the QWB and level of education, income, and glomerular filtration rate (GFR). For the SCL-90R subscores, the mean normalized Global Symptom Index was 49.7 +/- 9.6, the Positive Symptom Total was 47.9 +/- 10.4, and the mean Positive Symptom Distress Index was 51.3 +/- 12.6. Using multivariate analysis, significant inverse relationships were seen between each of the SCL-90R subscores and income, serum albumin level, and GFR. The most commonly reported medical symptoms in this cohort included tiring easily, weakness, lack of pep or energy, difficulty sleeping, and abdominal bloating or gas. Symptoms in which the severity index score had a negative correlation with GFR included tiring easily, weakness, lack of pep and energy, muscle cramps, easy bruising or bleeding, bad taste in mouth, and hiccoughs. In conclusions, patients with moderate to advanced renal insufficiency have a reduced quality of life and an increased frequency and severity of both symptoms and psychological distress, with the magnitude of these changes negatively correlated with GFR.

Quality-adjusted life years lost to arthritis: effects of gender, race,and social class

OBJECTIVE

To estimate the public health impact of self-reported arthritis in terms of Quality-Adjusted Life Years.

METHOD

The Quality of Well-being Scale (QWB) is a general measure of health-related quality of life that scores levels of wellness on a continuum between death (0.0) and optimum functioning (1.0). Values for the QWB were imputed for the National Health Interview Survey. These estimates were adjusted for mortality based on the life tables. Age-specific estimates were obtained for those reporting arthritis and compared to estimators for the population not reporting arthritis. These estimates were broken down by race (white versus nonwhite), gender and socioeconomic status.

RESULTS

The expected life years lost because of arthritis were 1.86 (95% confidence interval 1.40-2.32 years). Arthritis was reported more often among those of lower income, those living in rural areas, those of lower educational attainment, and older respondents. Men and women did not differ in rates of reporting arthritis, but men with arthritis had lower QWB scores than women with arthritis.

CONCLUSION

Arthritis has a significant public health impact.

Quality of well-being in late-life psychosis

Research in mental health has generally used evaluation and outcome measures different from those applied in other medical specialties. We evaluated the utility of a general health measure, the Quality of Well-Being (QWB) scale, in older patients with psychosis. The QWB and standardized rating scales for assessing psychopathology, cognitive impairment, physical comorbidity, and neuroleptic-induced tardive dyskinesia were administered to 85 patients with functional psychoses (mostly schizophrenia or schizoaffective disorder) and 39 normal comparison subjects over age 45. The patients were more impaired than normal comparison subjects on the QWB and other rating scales. The QWB score was affected more by severity of positive symptoms than by any non-psychopathology-related variables. The patients' QWB scores were similar to those of previously studied ambulatory patients with AIDS. Use of the QWB scale may allow direct comparisons of the impact of different psychiatric and physical disorders on the quality of life.

Comparison of two methods of calculating quality-adjusted life years

This paper compares two methods for calculating QALYs using quality of life data from a clinical trial. The methods produced similar results in the population as a whole, but they gave different results in a large subset. Different methods for calculating QALYs may give different results, and care should be taken to select the correct method.

The Health Consequences of Injury Questionnaire

OBJECTIVE

To study the properties of a new survey instrument, the Health Consequences of Injury Questionnaire (HCIQ), for measuring the impact of injury on health and to compare the new instrument with the more detailed, previously developed Quality of Well-being (QWB) scale.

METHODS

The HCIQ is a three-page health status questionnaire, suitable for self-administration. Similar to the QWB scale, the HCIQ measures health on a unitary scale where 1 represents optimum health and 0, death. The HCIQ was developed and studied in representative samples of injured adults from an Australian population. The HCIQ was administered concurrently with the QWB instrument to a sample of injured subjects, and the QWB scale scores were compared with estimated scores from the HCIQ using QWB scale weightings. The reliability of the HCIQ was tested on a further sample of injured subjects using a mailed test-retest design.

RESULTS

Of the 211 subjects in the validity sample, 98 completed both the HCIQ and the QWB scales. The intraclass correlation coefficient for the scores obtained from the two questionnaires was 0.86 (95% CI = 0.66-1.00). The mean difference between the scores was 0.04 +/- 0.09 (SD). The HCIQ had a median completion time of 15 minutes. Of the 129 subjects in the reliability study, 53 completed the HCIQ on both postal administrations. The reliability coefficient was 0.90 (95% CI = 0.62-1.00).

CONCLUSION

The HCIQ is a practical and reliable questionnaire for identifying the health consequences of injury that, when used with QWB weights, successfully predicts the QWB score.

Effects of offering advance directives on quality adjusted life expectancy and psychological well-being among ill adults

Two hundred and four patients from various clinical services at the San Diego Veterans' Administration Medical Center and the University of California, San Diego Medical Center were randomly assigned to either experimental (offered the opportunity to execute an Advance Directive regarding the level of care they wanted to receive if incapacitated) or control (no Advance Directive offered) conditions. Patients were given a baseline interview and re-interviewed at specific intervals (3 months, 6 months, 1 year and 2 years after baseline, and every 6 months thereafter). Outcome measures included the Qualitty of Well-being Scale, a measure of health status, and the General Well-being Index, a measure of psychological well-being. All differences between the health status and psychological well-being of experimental and control groups 3.5 years after the randomization were non-significant. Methodological implications of including mortality as part of the outcomes are discussed.