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PubMed1994

Measuring oral health status: theoretical and methodological challenges.

Development of oral health status indexes poses a set of theoretical and methodological challenges. Although the amount of work done on oral health indexes is far less that that done on general health indexes, to date those developed share many of the same theorectical assumptions. For the most part they have shared the dominant biomedical paradigm and the underlying theory of illness. These theories significantly influence both the instruments developed to measure oral health and the methods of measurement adopted. More recently alternative, holistic theories of illness have been proposed and there has been a shift from instruments focused on the provider to those focused on the patient and a move from objective to subjective measures of oral health. Furthermore the relationship between oral health and general health has received insufficient attention. The paper examines the relationship between the theories of illness, methods of measurement, and oral health indexes and suggests that other holistic, patient centered, paradigms, using qualitative methods, should also be considered in the construction or oral health indexes.

Attitude to Health↗
PubMed1986

The rational zero point for an illness index with ratio properties.

To be of greatest use for the measurement of significant variations in treatment outcomes, a health status index should have ratio properties. Previous attempts to construct such a scale using the magnitude estimation technique have failed, principally because of an inappropriate choice for the zero point. By rejecting death as the logical zero point for a scale of social preference and choosing instead the absence of that being measured (dysfunction and discomfort), the authors attained reliable values from patients, for an illness index, using magnitude estimation. This type of scale allows comparative judgments between treatment methods to be made with greater validity. It should aid in the wise allocation of health care resources.

Adolescent↗
PubMed1987

Perceived health status among the new urban homeless.

Homelessness may be the leading social problem in the United States in the mid 1980s. While there may be anywhere from 250,000 to three million homeless persons, few empirically based published studies are available concerning the correlates of mental and physical health status among the homeless. Los Angeles, where the present study was conducted, has been designated by the U.S. Department of Housing and Urban Development to have one of the largest homeless populations (34,000-50,000) in the U.S. The current study is based on 269 in-depth interviews with homeless men and women in Los Angeles County, California. The homeless were found to be younger, better educated and disproportionately non-white compared to the profiles of the skidrow homeless of the past decades. Nearly half the men were veterans of military services, including 30% who were veterans of the Vietnam War. Respiratory infections and hypertension were the most prevalent health problems. The data suggest that a large segment of the homeless persons were depressed, 15.6% reported lifetime prevalence of hospitalization for emotional or nervous problems, and 12.6% reported hospitalization for substance abuse disorders. Multiple regression was utilized to test the validity of a perceived health status index as measured among the homeless and to identify the correlates of health. The health index reflect primarily an affliction by a chronic disease, the severity of an acute condition, the duration of depressed mood, and the alcoholism symptomatology. Length of unemployment, education, gender, and number of nights spent in a shelter were the best predictors of poor health in this population. Evidence from this study, as well as others, suggests that efforts should be made to avoid using the term homeless metaphorically. The causes of homelessness are multiple and complex and the resulting subgroups among the homeless population have different problems which require a variety of strategies to meet their needs.

Adult↗
PubMedDate not supplied

Quality-of-life measurements: origin and pathogenesis.

Despite extensive growth in recent years, the field of "quality-of-life" appraisal still evokes debate about basic perception of the concept and is accompanied by a plethora of indexes for measurement. One prime reason for the problems is that the measurements have been transferred from two separate sources - medical health status indexes and social-science population indexes - neither of which was designed for appraising the particular personal distinctions of the way people feel about their own quality of life. When regulatory and commercial incentives were offered for measuring patients' quality of life, it became appraised with the indexes available from the medical and psychosocial sources, even though neither set of indexes was specifically intended for that purpose. They are not developed from the basic principle that a person's "quality of life" is a state of mind, not a state of health, which is uniquely perceived by that person, and which will not be appropriately appraised unless the most cogent personal components are allowed suitable expressions. An approach that lets patients state their own opinions directly can offer the "face validity" or "common sense" that now seems absent from the generally applied measurements.

Humans↗
PubMed1976

Neglected aspects of the quality of life.

Health status indexes have focused on physical function such as the activities of daily living, perhaps because the National Health Survey provides data of this sort or because it is the object of rehabilitation programs. In an attempt to elicit values concerning loss of function, 150 health workers were asked to assign weights from zero to 10 for 50 abilities or functions. Serious methodological problems were encountered in finding terms describing functional loss that were simple and meaningful to a wide range of workers. In addition, an open-ended request was made to identify other functions not included in the list. The largest average values were assigned to ability to use one's mental abilities, to see, to think clearly, to love and be loved in return, to make decisions for oneself, to live at home, to walk, to maintain contact with family and friends, and to talk. Some of the functional loss implied in these responses may not be amenable to cure or rehabilitation but may be preventable and thus needs to be included in outcome measures.

Activities of Daily Living↗
PubMed2003

Health-related quality of life measure based on the minimum data set.

OBJECTIVES: To introduce a health-related quality of life measure for home care and institutional long-term care settings based on the Minimum Data Set (MDS) and the Health Utilities Index Mark 2 (HUI2). METHODS: Health attributes of Health Related Quality of Life (HRQOL) were identified, and suitable constructs were determined. Items from the MDS were mapped to the HUI2. Scores for the Minimum Data Set Health Status Index (MDS-HSI) were calculated using the HUI2 scoring function. Measurement properties are examined and reported. HRQOL scores were compared across study populations and to an external reference population. Random samples were drawn from long-term care clients in private households (n = 377), supportive housing apartments (n = 80), two residential care facilities (n = 166), and a chronic care hospital (n = 274) in Ontario, Canada. All sampled residents were assessed for health-related items using the MDS. RESULTS: The MDS-HSI results provide preliminary evidence of good validity. Institutional populations had lower overall HRQOL scores than community populations. Comparisons to existing Canadian national data support construct validity. CONCLUSIONS: The MDS-HSI provides a summary outcome measure and an indicator of health status in the six supporting attributes. Longitudinal research is required to assess the sensitivity of the measure to changes overtime. Further research is also required to establish the consistency between the preference weights used in this application of the HUI2 and those that would be derived from a frail elderly population.

Activities of Daily Living↗
PubMedDate not supplied

A comparison of preference assessment instruments used in a clinical trial: responses to the visual analog scale from the EuroQol EQ-5D and the Health Utilities Index.

OBJECTIVES: To compare preference assessments that were made by using the EuroQol EQ-5D and the Health Utilities Index Mark II. SUBJECTS: 561 patients in a randomized trial of tirilazad mesylate for aneurysmal subarachnoid hemorrhage. MEASURES: Three preference assessments (a value score for the EuroQol instrument and value and utility scores for the Health Utilities Index) made three months after randomization. The averages for each of the three scores, stratified by clinical outcomes and attributes of the Health Utilities Index health status classification system, were compared. To evaluate potential sources of difference between the instruments, the authors estimated two alternative Health Utilities Index scoring rules that were based on patient responses to the EuroQol instrument. RESULTS: Patients' ratings of their current health made by using the 100-point visual analog scale from the EuroQol instrument were more similar to the utility scores for the Health Utilities Index than they were to the value scores for the Health Utilities Index. The biggest differences between the visual analog scores for the EuroQol instrument and the utility scores for the Health Utilities index were seen at higher levels of functioning. CONCLUSION: For states representing higher levels of functioning, differences were seen between patients' self-ratings obtained by using the EuroQol instrument and the patients' utility scores on the Health Utilities Index; for states representing lower levels of functioning, substantial agreement was observed between these two scores. Differences observed at the higher levels of functioning suggest that further research is needed to determine whether the Health Utility Index's assignment of a score of 1.0 to the reference state representing being healthy is appropriate.

Activities of Daily Living↗
PubMedDate not supplied

Race, rural residence, and control of diabetes and hypertension.

PURPOSE: African Americans are at increased risk for diabetes mellitus and hypertension, and rural residents have historically had decreased access to care. It is unclear whether living in a rural area and being African American confers added risks for diagnosis and control of diabetes and hypertension. The purpose of this study was to examine the prevalence of diagnosed diabetes and hypertension, as well as control of both conditions, among rural and urban African Americans and whites. METHODS: We conducted an analysis of the Third National Health and Nutrition Examination Survey (1988-1994). Non-Hispanic African Americans and non-Hispanic white adults 20 years and older were classified according to rural or urban residence (n = 11,755). Investigated outcomes were previously diagnosed diabetes mellitus and hypertension and control of diabetes and hypertension. RESULTS: The prevalence of diagnosed diabetes was 4.5% for urban whites, 6.5% for rural whites, 6.0% for urban African Americans, and 9.5% for rural African Americans. Among patients with diagnosed diabetes, 33% of rural whites, 43% of urban whites, 45% of urban African American, and 61% of rural African Americans had glycosylated hemoglobin (HbA(1c)) levels of 8% or higher (P < .01). Among patients with diagnosed hypertension, 11% of rural whites, 13% of urban whites, 20% of urban African Americans, and 23% of rural African Americans had diastolic blood pressure greater than 90 mmHg (P < .01). In regression models controlling for relevant variables, including body mass index, health status, access to care, education, income, and insurance, compared with rural African Americans, rural and urban whites were significantly more likely to have better glycemic control and diastolic blood pressure control. Urban African Americans also had better diabetes control than rural African Americans. CONCLUSIONS: In this nationally representative sample, rural African Americans are at increased risk for a lack of control of diabetes and hypertension.

Adult↗
PubMed2003

Adjustment for comorbidity in studies on health status in ESRD patients: which comorbidity index to use?

Health status can be an important outcome in studies on patients with end-stage renal disease (ESRD). In these studies, adjustment for prognostic factors, such as comorbidity, often has to be made. None of the comorbidity indices that are commonly used in research on ESRD patients has been validated for studies on health status. This study evaluated three existing indices (Khan, Davies, and Charlson) and four indices specifically developed for use in studies on health status. In a large prospective multi-center study (NECOSAD-2), new ESRD patients were included (n = 1041). Comorbidity was assessed at the start of dialysis. Health status was assessed with the physical and mental component summary score of the SF-36 (PCS and MCS), the symptoms dimension of the KDQOL-SF, and the Karnofsky Scale. Patient data were randomly allocated to a modeling or a testing set. The new indices were developed in the modeling set. The three existing indices explained about the same percentage of variance in the PCS (7 to 8%), MCS (1 to 3%), symptoms (2 to 4%), and Karnofsky (10 to 12%). The new indices performed better than the existing indices in the modeling population (13% PCS, 10% MCS, 10% symptoms, 18% Karnofsky), but not in the testing population (8% PCS, 1% MCS, 3% symptoms, 8% Karnofsky). Individual comorbidities explained more variance in PCS (10 to 15%), MCS (1 to 7%), symptoms (6 to 11%), and Karnofsky (11 to 18%) than comorbidity indices. The Khan, Davies, and the Charlson indices will adjust to the same extent for the potential confounding effect of comorbidity in studies with health status as an outcome. Separate comorbidity diagnoses will adjust best for comorbidity.

Aged↗
PubMed2001

Self-rated health status: a new vital sign for primary care?

Self-reported health status ratings depend on whether one references health problems or health behaviors. Pessimistic health perceptions may indicate underlying emotional distress or predict mortality. This study explores the association between a single-item health status question and self-reported health problems or behaviors among women in a Wisconsin family medicine clinic. All women who present for health maintenance complete a health history form that includes a single item health status rating. Health status ratings from 251 randomly selected records were compared with certain reported demographics, health behaviors (e.g. smoking, exercise), health concerns, depression and anxiety symptoms, vital signs and body mass index. Health status ratings of fair or poor were found to be associated with race, marital and employment status, obesity, exercise, and depressive symptoms. Smokers were 4.22 times more likely to report a less favorable health category than non-smokers. Implications for future research are discussed.

Adolescent↗
PubMed1997

Quality of life as an outcome measure.

It is important to identify unknown and unquantified benefits and risks of therapeutic intervention that are reflected in the quality of life. This is especially important when the benefit : risk analysis is not clearly in favour of treatment. Quality of life is defined and target areas identified. The steps in the measurements of quality of life are discussed, including the validity, repeatability and sensitivity to change of existing methods; their acceptability, analytical problems; the presentation of the results; and the use of the results in economic evaluations. The Sickness Impact Profile, the Nottingham Health Profile and the Quality of Well-Being scale are compared for the assessment of patients with angina. The advantages and disadvantages of each is discussed together with the results from a double-blind trial of treatment in angina where the Sickness Impact Profile was employed. Generic and disease-specific instruments are compared. The advantages and disadvantages of economic evaluations employing quality-of-life outcomes are discussed. Methods should be employed that withstand rigorous scientific evaluation. Both a health profile and a summary statistic such as a Health Status Index should be measured. If different treatments are to be compared, a randomised controlled trial should be employed. If the more expensive treatment is likely to be superior then costs should be collected and a cost-utility analysis performed.

Angina Pectoris↗
PubMed1990

Economic assessments in randomized controlled trials.

When comparing costs and benefits of different medical strategies, cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis may be used. Both direct and indirect costs and benefits must be considered. Integrating survival with a measure of quality of life such as a health status index permits calculation of quality of life adjusted years of survival (QALYS). In any trial where it is expected that a more expensive treatment is the most effective, a full economic assessment should be made. Examples are provided from the use of verapamil and propranolol in hypertension, naftidrofuryl in stroke and auranofin in the treatment of rheumatoid arthritis.

Cost-Benefit Analysis↗
PubMed1995

Quality of life in treated hypertension: a case-control community based study.

The aim of this case-control community study was to determine whether there was a difference in quality of life between hypertensive subjects and matched normotensive controls. Cases aged 40-79 years were randomly selected from a hypertensive register and matched with controls for age, sex, ethnicity and health centre. Cases had phase V diastolic blood pressure (DBP) > or = 100 mm Hg or systolic blood pressure (SBP) > or = 180 mm Hg, or were on anti-hypertensive medication. Controls had DBP < or = 90 mm Hg and no record of raised BP or anti-hypertensive treatment within the past year. Quality of life was measured by self-administered questionnaire. Data from 90 matched pairs, average age 62 years, with 47% men, were analysed; 80 hypertensive subjects were on anti-hypertensive medication. Hypertensive subjects showed an impairment in well-being compared with controls. They had a lower Health Status Index, had more sickness absence from work, greater symptomatic complaint and impaired psychological well-being. Relatives also reported a poorer quality of life in the hypertensive subjects. This impairment could be a result of the disease, adverse effects of drug treatment or to the effects of labelling.

Adult↗
PubMed2001

Quality of life measured with a generic instrument (Short Form-36) improves following pulmonary rehabilitation in patients with COPD.

STUDY OBJECTIVES: The purpose of this study was to evaluate the effects of a 3-week comprehensive pulmonary rehabilitation program on quality of life as measured by the Short Form-36 (SF-36) in patients with COPD. DESIGN AND SETTING: We report on the outcomes of 37 consecutive patients referred for pulmonary rehabilitation at a respiratory specialty medical center. PATIENTS: Thirty-seven patients (mean age, 66 years) with COPD and severe airflow limitation (mean +/- SE FEV(1), 29.6 +/- 1.8% of predicted) were studied. INTERVENTIONS: Rehabilitation consisted of a 3-week pulmonary rehabilitation program incorporating 12 exercise sessions, each of which included bicycle ergometer exercise training, upper-extremity training, strength training, and stretching, along with psychosocial counseling and education. MEASUREMENTS AND RESULTS: The Health Status Index (SF-36) and 6-min walk test were completed before and after rehabilitation. There was an improvement in five of the nine quality-of-life subscales of the SF-36 following pulmonary rehabilitation. Although there was an improvement in functional capacity as measured by the 6-min walk, there was no correlation between improvement in quality of life and improvement in functional capacity. There was no correlation between FEV(1) and improvement in walk distance, but there was a correlation between FEV(1) and improvement in SF-36 physical function and energy/fatigue subscales. CONCLUSION: Health-related quality of life assessed by the SF-36, a general measure of quality of life, improves following an intensive 3-week pulmonary rehabilitation program. Use of the SF-36 allows comparison of the results of pulmonary rehabilitation to therapeutic interventions in patients with other medical disorders.

Aged↗
PubMed2003

Patients' perceptions of quality of life after treatment for early prostate cancer.

PURPOSE: Treatment for early prostate cancer produces problematic physical side effects, but prior studies have found little influence on patients' perceived health status. We examined psychosocial outcomes of treatment for early prostate cancer. PATIENTS AND METHODS: Patients with previously treated prostate cancer and a reference group of men with a normal prostate-specific antigen (PSA) level and no history of prostate cancer completed questionnaires. Innovative scales assessed behavioral consequences of urinary dysfunction, sexuality, health worry, PSA concern, perceived cancer control, treatment decision making, decision regret, and cancer-related outlook. Urinary, bowel, and sexual dysfunction were assessed with symptom indexes; health status was assessed by the Physical and Mental Summaries of the Short Form (SF-12) Health Survey. RESULTS: Compared with men without prostate cancer, prostate cancer patients reported greater urinary, bowel, and sexual dysfunction, but similar health status. They reported worse problems of urinary control, sexual intimacy and confidence, and masculinity, and greater PSA concern. Perceptions of cancer control and treatment decisions were positive, but varied by treatment: prostatectomy patients indicated the highest and observation patients indicated the lowest cancer control. Bowel and sexual dysfunction were associated with poorer sexual intimacy, masculinity, and perceived cancer control; masculinity and PSA concern were associated with greater confidence in treatment choice; and diminished sexual intimacy and less interest in PSA were associated with greater regret. CONCLUSION: The lack of change in global measures of health status after treatment for early prostate cancer obscures important influences in men's lives; cancer diagnosis and treatment complications may result in complex outcomes. Aggressive treatment may confer confidence in cancer control, yet be countered by diminished intimate relationships and masculinity, which accompany sexual dysfunction.

Adult↗
PubMedDate not supplied

Quality-adjusted life years, utility theory, and healthy-years equivalents.

Decisions about medical treatments and the settings of health programs are not purely technical, but also involve issues of value such as the evaluation of trade-offs between quality of life (morbidity) and quantity of life (mortality). The most commonly used measure of outcome in such cases is the quality-adjusted life year (QALY). The authors show that QALYs, being a health status index, do not stem directly from the individual's utility function and thus only partly reflect the individual's true preferences. This might lead to the choice of the nonpreferred alternative due to the misrepresentation of the individual's preferences. Two examples illustrate this claim. An alternative measure of outcome, the healthy-years equivalent (HYE), is described. This measure stems directly from the individual's utility function and thus fully reflects his/her preferences. It combines outcomes of both morbidity and mortality and thus can serve as common unit of measure for all programs, allowing comparisons across programs. Different ways of measuring the HYE are discussed.

Cost-Benefit Analysis↗
PubMed2005

Five-year survival, quality of life, and individual costs of 303 consecutive medical intensive care patients--a cost-utility analysis.

OBJECTIVE: To assess long-term survival, health-related quality of life, and associated costs 5 yrs after discharge from a medical intensive care unit. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a German university hospital. PATIENTS: Three hundred and three consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between November 1997 and February 1998 with an intensive care unit length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and individual intensive care unit and hospital costs were prospectively recorded. Primary outcomes included 5-yr survival, functional status, health-related quality of life (Medical Outcome Short Form, SF-36), effective costs per survivor, and costs per life year and per quality-adjusted life year gained. Of 303 patients, 44 (14.5%) died in the hospital. Among the remaining 259 patients, 190 (73%) survived the 5-yr follow up and 173 patients (91%) completed the questionnaire. Baseline demographics including gender, age, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and admission diagnosis were similar between hospital and long-term survivors (p > .05 for all). The health status index of those patients surviving the 5-yr follow-up was 0.88, independent of patients' severity of illness. The average effective costs per survivor were 8.827 for intensive care unit costs and 14.130 for intensive care unit and hospital costs. Mean costs per life year and per quality-adjusted life year gained amounted to 19.330 and 21.922 , respectively. Increasing severity of illness was associated with higher costs. CONCLUSIONS: Considering the severity of illness and the patients' outcome, the costs associated with both life year and quality-adjusted life year gained were within generally accepted limits for other potentially life-saving treatments.

APACHE↗