Longer term quality of life and outcome in stroke patients: is the Barthel index alone an adequate measure of outcome?

OBJECTIVES: To consider whether the Barthel Index alone provides sufficient information about the long term outcome of stroke. DESIGN: Cross sectional follow up study with a structured interview questionnaire and measures of impairment, disability, handicap, and general health. The scales used were the hospital anxiety and depression scale, mini mental state examination, Barthel index, modified Rankin scale, London handicap scale, Frenchay activities index, SF36, Nottingham health profile, life satisfaction index, and the caregiver strain index. SETTING: South east London. SUBJECTS: People, and their identified carers, resident in south east London in 1989-90 when they had their first in a life-time stroke aged under 75 years. INTERVENTIONS: Observational study. MAIN OUTCOME MEASURES: Comparison and correlation of the individual Barthel index scores with the scores on other outcome measures. RESULTS: One hundred and twenty three (42%) people were known to be alive, of whom 106 (86%) were interviewed. The median age was 71 years (range 34-79). The mean interval between the stroke and follow up was 4.9 years. The rank correlation coefficients between the Barthel and the different dimensions of the SF36 ranged from r = 0.217 (with the role emotional dimension) to r = 0.810 (with the physical functioning dimension); with the Nottingham health profile the range was r = -0.189 (with the sleep dimension, NS) to r = -0.840 (with the physical mobility dimension); with the hospital and anxiety scale depression component the coefficient was r = -0.563, with the life satisfaction index r = 0.361, with the London handicap scale r = 0.726 and with the Frenchay activities index r = 0.826. CONCLUSIONS: The place of the Barthel index as the standard outcome measure for populations of stroke patients is still justified for long term follow up, and may be a proxy for different outcome measures intended for the assessment of other domains.     

Impact of an interest in asthma on prescribing costs in general practice.

OBJECTIVE--To examine the effect on total prescribing costs and prescribing costs for respiratory drugs for practices with at least one general practitioner with a special interest in asthma. DESIGN--Postal questionnaire survey. SETTING--General practitioners in England and Wales. SUBJECTS--269 members of the General Practitioners in Asthma Group, of whom 103 agreed to participate. MAIN MEASURES--Individual practitioners' and their practices' PACT prescribing costs from the winter quarters of 1989-90 compared with average costs for their family health services authority (FHSA) and a notional national average of all FHSAs combined. RESULTS--The response rate was 57%; the average total prescribing costs for the practices of the 59 respondents were significantly lower than those of their respective FHSAs (mean difference 505 pounds per 1000 patients per quarter (95% confidence interval -934.0 to -76.2, p = 0.022) and lower than the national average. The average prescribing costs for respiratory drugs for the practices were significantly greater than those for their FHSA (195 pounds per 1000 patients per quarter (84.4 to 306.0, p = 0.001) and the national average. Both types of costs varied widely. CONCLUSION--An interest in asthma care in general practice is associated with higher average prescribing costs for respiratory drugs but no increase in overall prescribing costs compared with those for respective FHSAs and national averages. IMPLICATIONS--FHSAs and their medical advisors should not examine high prescribing costs for individual doctors or one therapeutic category but in the context of practice total costs.     

The construction of standard gamble utilities

Health effects for cost-effectiveness analysis are best measured in life years, with quality of life in each life year expressed in terms of utilities. The standard gamble (SG) has been the gold standard for utility measurement. However, the biases of probability weighting, loss aversion, and scale compatibility have an inconclusive effect on SG utilities. We determined their effect on SG utilities using qualitative data to assess the reference point and the focus of attention. While thinking aloud, 45 healthy respondents provided SG utilities for six rheumatoid arthritis health states. Reference points, goals, and focuses of attention were coded. To assess the effect of scale compatibility, correlations were assessed between focus of attention and mean utility. The certain outcome served most frequently as reference point, the SG was perceived as a mixed gamble. Goals were mostly mentioned with respect to this outcome. Scale compatibility led to a significant upward bias in utilities; attention lay relatively more on the low outcome and this was positively correlated with mean utility. SG utilities should be corrected for loss aversion and probability weighting with the mixed correction formula proposed by prospect theory. Scale compatibility will likely still bias SG utilities, calling for research on a correction.     

Maximising Responses to Discrete Choice Experiments

Objective

To identify any differences in response and completion rates across two versions of a questionnaire, in order to determine the trade-off between a potentially higher response rate (from a short questionnaire) and a greater level of information from each respondent (from a long questionnaire).

Methods

This was a randomised trial to determine whether response rates and/or results differ between questionnaires containing different numbers of choices: a short version capable of estimating main effects only and a longer version capable of estimating two-way interactions, provided certain assumptions hold. Best-worst scaling was the form of discrete choice experimentation used. Data were collected by post and analysed in terms of response rates, completion rates and differences in mean utilities.

Results

Fifty-three percent of individuals approached agreed to take part. From these, the response to the long questionnaire was 83.2% and the short questionnaire was 85.1% (difference 1.9%, 95% CI -7.3, 11.2; p = 0.68). The two versions of the questionnaire provided similar inferences.

Discussion/conclusion

This trial indicates that, in a healthcare setting, for this complexity of questionnaire (i.e. four attributes and the best-worst scaling design), the use of 16 scenarios obtained very similar response rates to those obtained using half this number.     

Paper standard gamble: a paper-based measure of standard gamble utility for current health

OBJECTIVES: To develop and validate a paper-based instrument that is simple to administer and produces a reliable estimate of patient standard gamble (SG) utilities for current health status. METHODS: A 1-page paper questionnaire instrument, paper standard gamble (PSG), was designed to estimate SG utilities. We performed two studies to assess the validity of PSG. First we compared PSG and SG utilities for current health in patients with prostate cancer. They randomly received either PSG followed by SG or vice versa, always with an intervening SF-12. In the second validity study, we assessed the test-retest reliability of PSG by administering it to prostate cancer patients twice, at least 2 weeks apart. RESULTS: In the first study, utilities were assessed in 64 men (32 per SG/PSG order group). A paired-comparison t test suggested no difference between SG and PSG (mean difference = -0.007; 95% confidence interval (Cl), -0.022 to 0.008). The concordance correlation coefficient was 0.92 (95% Cl, 0.79 to 0.99). In the second study, test and retest PSGs were available for 184 patients. The concordance correlation coefficient was 0.88 (95% Cl, 0.73 to 0.94). CONCLUSIONS: These data suggest that PSG may serve as a reliable substitute for SG when current health utility is of interest. PSG may have particular advantages for acquisition of health-related quality-of-life data in longitudinal studies.     

简体中文版老年男性症状量表的信度、效度及适用性分析

目的研究简体中文版老年男性症状量表(Chinese version of the Aging Males'Symptoms scale,CN-AMS)应用于国内中老年男性迟发性性腺功能减退时的信度、效度及实际使用效果。方法受访人群包括33岁以下青年男性27人,40岁以上中老年男性81人。要求所有受访志愿者完成AMS量表填写及间隔4周后的复填,以验证CN-AMS量表的有效性。为了验证中老年受访者是否存在雄激素缺乏,在每次填写量表时抽取空腹晨血,检测血清总睾酮(total serum testosterone,TT)、性激素结合球蛋白(sex hormone binding globulin,SHBG)水平,计算出血清游离睾酮(calculated free testosterone,cFT)水平。统计学上采用α信度系数法(Cronbach’s alpha)和重测信度法(test-retest stability)验证CN-AMS量表的信度。重测信度法采用Pearson相关性(Pearson's correlation)分析重测相关系数。采用单项与总和相关效度分析(Pearson's correlation)验证CN-AMS量表的逻辑效度。结果 27位青年男性完成了量表填写及4周后的复填。81位中老年男性中有57人接受了重复抽血,其中46位完成量表复填。CN-AMS量表的Cronbach’sα信度系数和Pearson's correlation系数在青年组为0.86和0.91,老龄组是0.91和0.83,两组人群合并后的数值则是0.94和0.91,显示出很好的效度和内在结构一致性。以cFT 225 pmol/L作为诊断迟发性性腺功能减退(late onset hypogonadism in males,LOH)的血清学阈值。量表的敏感度为81%,特异性为44%。结论研究证明CN-AMS在中国中老年男性LOH筛查中具有良好的适用性,但其特异性并不高,不适合单独用于LOH的诊断。     

The effect of individually assessed preference weights on the relationship between holistic utilities and nonpreference-based assessment

In the assessment of health-related quality of life, nonpreference-based methods usually show only moderate correlations with utility-based measures. One cause may be that patients assign different weights to the various domains of health-related quality of life, for which nonpreference-based methods usually do not allow. Utilities reflect a weighted sum of these domains. The aim of this study is to assess whether the relationship between utility-based methods and nonpreference-based measures improves through the use of individual importance weights for the various domains of health-related quality of life. For this purpose, weights were obtained from 41 early-stage breast cancer patients, both before and during treatment, for seven pre-selected health status attributes representing important domains of health-related quality of life during chemotherapy. The importance weights were combined with the level of functioning on the attributes. These scores were regressed against patients' utilities for their actually experienced health state during chemotherapy, measured by means of a visual analog scale (VAS), a time trade-off (TTO), and a standard gamble (SG). Before weighting, the seven attribute scores were more strongly related to TTO and SG utilities than the nonpreference-based questionnaires. However, when they were combined with the importance weights, only the correlation with the SG utilities improved, and only so with the importance weights obtained before chemotherapy. In this study, assigning individually assessed preference weights to self-reported level of functioning did not result in stronger relationships with utilities. This revised version was published online in June 2006 with corrections to the Cover Date.     

Measuring the health of Scottish drug users

Information on how individuals perceive their own health is important for providing appropriate health‐related support and monitoring health over time. The Short Form 36 (SF‐36) Health Status Questionnaire is one of the most widely used generic measures of self‐perceived health status. Despite this, there has been no large‐scale research documenting the SF‐36 scores of problem drug users in the UK. The present paper has two aims: (1) to compare the self‐perceived health of a sample of problem drug users with that of a sample from the general population; and (2) to investigate differences between the self‐perceived health of various subgroups of problem drug users. In total, 1179 individuals starting a new episode of drug misuse treatment in Scotland were invited to complete a structured questionnaire that included the SF‐36. Out of these, 1033 (87.6%) agreed and 990 successfully completed all SF‐36 questions. The 990 completers were more likely than the 43 partial completers to be male [odds ratio (OR) = 0.45; 95% confidence interval (95% CI) = 0.24–0.85] and not in prison (OR = 0.36; 95% CI = 0.19–0.68). The reliability of the SF‐36 – measured by internal consistency – was very good (Cronbach's α > 0.7 for all eight dimensions). Comparing the respondents’ mean dimension scores with those of a sample from the UK general population revealed that the drug users’ health was consistently worse than that of the general population (> 20 points on seven out of the eight scales). Differences between the mean SF‐36 scores of various subcategories of respondents were analysed using t‐tests or an analysis of variance, as appropriate. The factors considered were: sex; age; imprisonment; relationship status; homelessness; and recent drug injection. Significant differences between particular groups of respondents were identified. Despite limitations with the data presented, the paper highlights the utility of the SF36 for drug misuse treatment providers.     

The discrepancy between risky and riskless utilities: a matter of framing?

Utilities differ according to whether they are derived from risky (gamble) and riskless (visual analog scale, time-tradeoff) assessment methods. The discrepancies are usually explained by assuming that the utilities elicited by risky methods incorporate attitudes towards risk, whereas riskless utilities do not. In (cumulative) prospect theory, risk attitude is conceived as consisting of two components: a decision-weight function (attentiveness to changes in, or sensitivity towards, chance) and a utility function (sensitivity towards outcomes). The authors' data suggest that a framing effect is a hitherto unrecognized and important factor in causing discrepancies between risky and riskless utilities. They collected risky evaluations with the gamble method, and riskless evaluations with difference measurement. Risky utilities were derived using expected-utility theory and prospect theory. With the latter approach, sensitivity towards outcomes and sensitivity towards chance are modeled separately. When the hypothesis that risky utilities from prospect theory coincide with riskless utilities was tested, it was rejected (n = 8, F(1,7) = 132, p = 0.000), suggesting that a correction for sensitivity towards chance is not sufficient to resolve the difference between risky and riskless utilities. Next, it was assumed that different gain/loss frames are induced by risky and riskless elicitation methods. Indeed, identical utility functions were obtained when the gain/loss frames were made identical across methods (n = 7), suggesting that framing was operative. The results suggest that risky and riskless utilities are identical after corrections for sensitivity towards chance and framing.     

Preference-based measurement of health-related quality of life (HRQL) in children with chronic musculoskeletal disorders (MSKDs).

BACKGROUND: Health-related quality of life can be measured by patients' health preferences (utilities or values). No method for measuring health state preferences has been standardized for children with arthritis or other musculoskeletal disorders (MSKDs). Such a method is needed for economic evaluations of current and new pediatric treatments. OBJECTIVES: 1) To assess the feasibility of utility measurements in children with MSKDs, 2) to test the validity of the Health Utility Index (HUI) for these children, 3) to assess whether rating scale values can be mathematically converted into meaningful standard gamble (SG) utilities, and 4) to study whether parents can act as proxies for their children with respect to health state preferences. METHODS: Eighty parents of children with MSKDs were consecutively sampled. Their children, if 8 years of age or older (n = 55), were studied concurrently. Utilities of current health states were obtained by using the SG and the HUI in random order. In addition, health state preferences were assessed using categorical and analog rating scales. Traditional nonutility measures of health status (the Childhood Health Assessment Questionnaire [CHAQ] and the Activities Scale for Kids [ASK]) were also completed. Intraclass correlation coefficients (ICCs) were calculated to assess concordance between the different utility measures and also between the ratings of the parents and their children. RESULTS: Children 8 years of age or older were able to express the strength of their health state preferences using the HUI and rating scales. Children older than 10 years of age were able to use the SG method. The health state utilities of the parents were higher than those of their children. The utilities varied widely depending on the elicitation method. The expected high agreement between the SG and the HUI was not found (ICC = 0.028 for parents, ICC = 0.016 for patients). Unlike the SG, the global utilities derived from the HUI agreed better with preferences derived from rating scales (ICC = 0.23-0.25) and correlated with traditional health status measures (with CHAQ, r = -0.56; with ASK, r = 0.46) both for parents and children. It was not possible to mathematically convert rating scale preferences into SG utilities. The SG utilities were unrelated to results from the rating scales, the CHAQ, and the ASK. Especially for parents, the SG utilities were very high, even when ratings of the other measures indicated poor health. CONCLUSIONS: Although it is possible to measure health utilities for children with MSKDs, the results are highly method dependent. The properties of the HUI in this population are more like those of the traditional health status measures rather than those of the SG. Preferences derived from rating scales, although easily performed, cannot readily be converted into SG utilities. Parents' ratings for their children are impaired by risk aversion.     

Nutrition knowledge,attitudes and practices among senior medical students in Taiwan.

Nutrition is an important issue in medical training, but the nutritional knowledge, attitudes and practices of medical students in Taiwan have not been elucidated.

This investigation was a need assessment that examined knowledge, attitude and practices of medical students in selected areas of nutrition. A national sample of 528 senior medical students from nine medical colleges in Taiwan participated in this study by completing a questionnaire.

On a 10-point scale, the average score of students on general and clinical nutritional knowledge was 5.99 +/? 1.51 and 5.15 +/? 1.77, respectively. The percentage of correct answers from questionnaires in both areas was 60% and 52%, respectively. Seventy-seven percent or more of the students reported that they either agreed or strongly agreed with four positive-attitude statements and either disagreed or strongly disagreed with two out of three negative-attitude statements. Between 30% and 61% of the students reported that they practice on nutrition-related individual behaviors.

The knowledge, attitudes and practices of senior medical students in Taiwan suggest the need for education strategies to improve competence in the area of nutrition.     

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.     

青少年社交自我效能感和满意度对移动社交网络使用与交往焦虑的作用

探讨社交自我效能感与社交满意度在移动社交网络使用与交往焦虑间的作用,为寻求移动社交网络使用改善青少年社交能力的路径提供参考.方法 采用移动社交网络过度使用问卷、手机移动社交网络使用偏好影响因素问卷和交往焦虑量表,按照年级整群分层方式选取全国11所中学和大学的2 056名学生进行调查,采用SPSS 18.0和偏差校对非参数百分位Bootstrap置信区间法进行分析.结果 青少年移动社交网络使用与社交自我效能感和交往焦虑呈正相关(r值分别为0.354和0.318,P值均<0.01),社交自我效能感与社交满意度呈正相关(r=0.224,P<0.01).移动社交网络使用对交往焦虑具有正向预测作用(β=0.187,P<0.01),社交自我效能感和社交满意度对交往焦虑具有负向预测作用(β值分别为-0.370和-0.090,P<0.01).移动社交网络使用可以分别通过社交自我效能感和社交自我效能感→社交满意度2条间接路径对交往焦虑产生中介效应(直接效应为0.152,95%CI=0.119~0.185).结论 移动社交网络使用可以通过社交自我效能感和社交满意度降低青少年的交往焦虑,改善和提高社会交往能力.     

Association between Health-Related Quality of Life and Body Mass After Adjustable Gastric Banding: A Nonlinear Approach

ObjectiveTo estimate the relationship between health utilities and body mass index (BMI) among a cohort of obese patients who underwent laparoscopic adjustable gastric banding (LAGB).MethodsWe used a cross-sectional survey to ascertain demographic, clinical, and health utility data from patients who had undergone LAGB in Washington State from 2004 to 2010. The EuroQol five-dimensional (EQ-5D) questionnaire was used for health utility estimation. We calculated adjusted EQ-5D questionnaire indices across BMI categories by using a two-part model. We also used logistic regression to examine the relationship between BMI and the likelihood of reporting problems on each of the EQ-5D questionnaire dimension.ResultsData were obtained from 790 subjects. The mean adjusted EQ-5D questionnaire indices for all obese BMI categories were significantly lower than those in the normal weight category. The relationship between BMI and EQ-5D questionnaire indices was nonlinear. Respondents classified as morbidly obese II (BMI > 50 kg/m²) had the greatest decrement (−0.15, 95% confidence interval −0.28 to −0.01) in EQ-5D questionnaire indices. The association between EQ-5D questionnaire indices and BMI at the time of the survey was weaker after adjusting for weight loss after LAGB. Respondents with higher BMI were more likely to report having problems in the mobility, usual/activity, pain/discomfort, and anxiety/depression dimensions (trend test, P < 0.05), but not for the self-care dimension (trend test, P = 0.08).ConclusionsThe EQ-5D questionnaire has a negative and nonlinear relationship with BMI for obese patients who had LAGB. The relationship is confounded by weight loss. Within the EQ-5D questionnaire dimensions, patients are more likely to report having problems in the mobility, usual/activity, pain/discomfort, and anxiety/depression dimensions in higher BMI categories, but not in the self-care dimension.     

Development and validation of a questionnaire for the assessment of physical activity in epidemiological studies in Sub-Saharan Africa

OBJECTIVE: To develop and validate a questionnaire for measuring physical activity within Sub-Saharan Africa. Methods We designed the Sub-Saharan Africa Activity Questionnaire (SSAAQ), based upon existing questionnaires and an activity survey carried out in Cameroon. The questionnaire targeted past-year occupation, walking/cycling and leisure-time activities, and was administered by trained interviewers on two occasions, 10-15 days apart to 89 urban and rural consenting Cameroonians aged 19-68 years. Reliability was assessed by inter-interview comparison and repeatability coefficients (standard deviation of the test-retest difference). Validation was performed against a 24-hour heart rate monitoring and accelerometer recording. RESULTS: The questionnaire was highly reproducible (rho = 0.95; P < 0.001). The inter-interview difference did not differ significantly from 0, with a repeatability coefficient of 0.46-1.46 hours. Total energy expenditure from the questionnaire was significantly correlated to heart rate monitoring (rho = 0.41-0.63; P < 0.05) and accelerometer measures (rho = 0.60-0.74; P < 0.01). Subject's self ranking of their activity did not match the questionnaire's quartiles of activity. CONCLUSIONS: The present study presents the design and confirms the reliability and validity of SSAAQ in a rural and urban population of Cameroon and shows that subject's self ranking of activity might not accurately serve epidemiological purpose.     

Relation of physicians' predicted probabilities of pneumonia to their utilities for ordering chest x-rays to detect pneumonia.

To investigate the relation between physicians' predicted probabilities of pneumonia and their utilities for ordering chest x-rays to detect pneumonia, the authors studied 52 physicians who ordered chest x-rays of 886 patients presenting to an emergency department with fever or respiratory complaints. Physicians estimated the probability of pneumonia prior to obtaining the results of the chest x-ray. Utilities were assessed by asking physicians to consider a hypothetical patient presenting with acute respiratory symptoms, with unknown chest x-ray status, and to rank on a scale from +50 ("best thing I could do") to -50 ("worst thing I could do") their rating scale utilities for not diagnosing pneumonia and not ordering a chest x-ray when the patient had pneumonia (i.e., missing a pneumonia), and for diagnosing pneumonia and ordering a chest x-ray when the patient did not have pneumonia (i.e., ordering an unnecessary x-ray). The utility for ordering an unnecessary x-ray was negatively correlated with average predicted probability (r = -0.1495, p = 0.29), whereas the utility for missing a pneumonia was positively correlated with average predicted probability (r = 0.2254, p = 0.11), although the correlations were not statistically significant. Relative chagrin, defined as the difference in these utilities, was significantly inversely correlated with average predicted probability (r = -0.2992, p less than 0.035), even after adjusting for the prevalence of pneumonia seen by each physician (partial r = -0.42, p less than 0.0027). It is concluded that physicians who experienced greater regret over missing a pneumonia than over ordering an unnecessary x-ray estimated lower probabilities of pneumonia for patients for whom they ordered x-rays.(ABSTRACT TRUNCATED AT 250 WORDS)     

Judgment skills,a missing component in health literacy: development of a tool for asthma patients in the Italian-speaking region of Switzerland

Background

Health literacy has been recognized as an important factor influencing health behaviors and health outcomes. However, its definition is still evolving, and the tools available for its measurement are limited in scope. Based on the conceptualization of health literacy within the Health Empowerment Model, the present study developed and validated a tool to assess patient’s health knowledge use, within the context of asthma self-management.

Methods

A review of scientific literature on asthma self-management, and several interviews with pulmonologists and asthma patients were conducted. From these, 19 scenarios with 4 response options each were drafted and assembled in a scenario-based questionnaire. Furthermore, a three round Delphi procedure was carried out, to validate the tool with the participation of 12 specialists in lung diseases.

Results

The face and content validity of the tool were achieved by face-to-face interviews with 2 pulmonologists and 5 patients. Consensus among the specialists on the adequacy of the response options was achieved after the three round Delphi procedure. The final tool has a 0.97 intra-class correlation coefficient (ICC), indicating a strong level of agreement among experts on the ratings of the response options. The ICC for single scenarios, range from 0.92 to 0.99.

Conclusions

The newly developed tool provides a final score representing patient’s health knowledge use, based on the specialist’s consensus. This tool contributes to enriching the measurement of a more advanced health literacy dimension.