Using the SF-36 and Euroqol on an elderly population

An important methodological issue in measuring health-related quality of life is whether instruments such as SF-36 and EQ can be used on an elderly population. This paper aims to test the completion, reliability and validity of the SF-36 and Euroqol on an elderly female population, and to compare them with the OPCS Disability Survey. Three hundred and eighty women aged 75 and over participated in a randomized controlled trial of the use of clodronate provided the sample. As part of the trial, patients were asked to complete the UK SF-36 and Euroqol, and the OPCS disability survey instrument administered by interview in a hospital clinic at baseline. A random subsample of respondents were retested six months later. The SF-36 achieved poorer levels of completion by dimension (68.1%–88.9%) than the OPCS (99.2%) and Euroqol (84%–93.5%) instruments. There were no major floor effects in the distribution of scores, except for the role dimensions of SF-36. Correlation between test-retest were significant for all instruments, but lower for the role dimensions and social functioning of SF-36, and these dimensions also had 95% Cls for the mean differences in excess of 10 points. There was substantial agreement between the three instruments, and evidence for their construct validity against age and recent use of health services. The sensitivities of the instruments were tested through hypothetical changes in health status. There was some evidence of greater sensitivity to lower levels of morbidity in the SF-36. Where brevity is required and the health changes are expected to be substantial, then EQ may be sufficient. For greater sensitivity SF-36 seems to have an advantage, however lower completion rates and problems with consistency suggest it requires adaptation. One solution would be to use interviewer administration. Another would be to change the SF-36 to make it more suitable for use in elderly people, although this may reduce its usefulness as a generic instrument.     

The relationship between physician cost and functional status in the elderly.

OBJECTIVE: To explore the relationship between functional status and physician cost (general practitioner/specialist) in an elderly population. DESIGN, SETTING AND PARTICIPANTS: A longitudinal study involving 328 patients aged 65 years or over admitted to medical and surgical wards of a Sydney metropolitan hospital over a 10-month period. MAIN OUTCOME MEASURES: Two predictive cost models were developed using multiple linear regression analyses. Nine predictors were modelled including functional status (Short Form 36; SF-36) and major diagnostic categories. These models were then applied to the Australian SF-36 norms to produce a profile of cost by level of functioning. RESULTS: After adjusting for potential confounders, five variables were found to be predictive of general practitioner cost at a 5% significance level. Females and age were positively associated, whereas case note mention of post-discharge services and high SF-36 vitality and role emotional scores were negatively predictive. For specialist cost, five variables were statistically significant. The SF-36 domains of physical functioning and mental health were positively associated. Higher vitality, role emotional scores and case note mention of post-discharge services were negatively associated. CONCLUSIONS: Cost models can be used to highlight the differences between general practitioner and specialist attendances, guide future physician care of the aged, and facilitate informed decision making.     

Mental quality of life: an indicator of unmet needs in patients with diabetes

This exploratory study investigates the quality of life needs of 173 individuals being treated for type 2 diabetes over a six month period of time. It samples patients whose primary care providers practice the most current model for delivering care, diabetes disease management. These physicians utilized a multidisciplinary diabetes education program to facilitate the patient-provider knowledge-based partnership essential in discase management. Patient quality of life changes were measured by the SF-36. A paired samples t-test showed significant diminishment in patients' mental quality of life indicating diminished overall emotional functioning, negatively impacting quality of life; possibly due to the effects of time. Multiple regression results also indicated that patients at risk for major depression and at risk for major depression superimposed on dysthymia experienced significantly diminished mental quality of life. These findings suggest that enhanced mental health assessment and mental health services provided by social workers in diabetes education programs and/or primary care settings would improve patient mental quality of life.     

Studies of hospital social stays in the frail elderly and their relationship to the intensity of social work intervention.

The elderly frequently suffer long lengths of hospital stay (LOS). These long stays are often associated with long social care stays which occur when patients no longer require acute care and are awaiting post-discharge services. In this study, actual acute care LOS and social care LOS were studied specifically in hospitalized frail elderly. Our data demonstrate that frail elderly receiving only acute care do not suffer markedly prolonged total LOS (TLOS). However, in hospitalized frail elderly patients who experience acute care and social care stays, social care LOS accounts for over half of all hospital days. When patients were grouped and studied according to the type of post-discharge services being sought by the health care team, significant differences in acute LOS and social care LOS were noted. Subgroups of patients were also identified among the various groups which differed significantly in their LOS parameters. Patients who required more than one discharge plan during the course of hospitalization experienced the longest hospital stays of all groups, and spent almost 70% of these days receiving non-acute social care. In a study of the relationship between the intensity of social work intervention and social care LOS in the frail elderly, a statistically significant relationship was noted between the timing and frequency of social work intervention and the actual length of social care stays. Early and frequent social work interventions were associated with significantly shorter social care LOS. We conclude that the study of TLOS should include acute LOS and social care LOS to obtain a reliable measure of the course and cost of hospital care for the frail elderly. The study of social care subgroups may facilitate future investigations to define the social care problems which contribute most to TLOS, and the patient populations which should be most heavily targeted for early and intensive social work intervention.     

Elderly people with cognitive impairment: costing possible changes in the balance of care

The objective of this paper is to investigate the service needs and support costs of elderly people with cognitive impairment on hospital and community health services, primary health care, social services, and informal carers in England. It examines the resource consequences of major changes in the provision of care, exploring the implications for both cost and effectiveness. The study was designed to provide a secondary analysis of the OPCS disability surveys in order to estimate the balance of care, and current provision of services. It also estimates of costs of present provision and potential policy options. Results show large scale improvements in the provision of care for people living in private households and local authority homes require significant increases in funding, but reductions in the provision of long-stay hospital beds can significantly reduce the cost burden to the public purse. Given the increasing demand pressure on health and social care expenditure, it seems unlikely that large scale improvements in the care supplied to elderly people with cognitive impairment can be achieved without some change in the balance of care. The cost of implementing improvements in care for the 200000 people living in private households and the 45000 people in local authority homes could be offset by reducing the provision of costly long stay hospital provision with alternative institutional care such as NHS nursing homes.     

Quality of Life of Primary Caregivers of Elderly with Cerebrovascular Disease or Diabetes Hospitalized for Acute Care: Assessment of Well-Being and Functioning Using the SF-36 Health Questionnaire

OBJECTIVE: To use the Short Form 36 (SF-36) to determine the extent to which health-related quality of life (HRQOL) is decreased among primary caregivers of patients with cerebrovascular accident (CVA) or diabetes mellitus (DM) compared to normal Taiwanese population and to identify the determinants of this decrease. METHODS: Data from a cross-sectional survey of 187 primary caregivers who had responsibility for inpatients with a medically verified diagnosis of CVA or DM were compared to those of randomly selected residents. Data were collected by face-to-face interviews with trained interviewers. RESULTS: The age- and gender-adjusted mean differences of caregivers on primarily mental scales of SF-36 were significantly negative compared to general population, as much as a 3-12 points reduction on this 100-point scale. While the age- and gender-adjusted mean differences on physical functioning and bodily pain scales were significantly positive, as much as a 3-6 points increase. Effects of caregiving on the perceived social life of the caregiver and disability of inpatients in eating and getting in/out of bed were associated with the SF-36 Physical Component Scale (PCS) score while female gender, type of caregiver, care conflicts, degree of care demand of daily living, and effects of caregivering on perceived social life of caregivers were negatively associated with the SF-36 Mental Component Scale (MCS) score. CONCLUSIONS: Primary caregivers of CVA or DM hospitalized elderly have poorer mental but better physical well-being than the population norm. Both caregiver and inpatient factors contribute to caregivers' HRQOL.     

Behavioural disabilities in psychogeriatric patients and residents of old people''s homes.

A comparison was made of the behavioural disabilities of two groups of elderly institutionalised people, one in psychogeriatric hospital wards and the other in residential homes. The results indicated that despite considerable overlap, there is evidence of significantly greater disability in the hospital population, particularly as regards incontinence, confusion, communication difficulties, and need for supervision. Comparison with previous data suggests that there is an increasing number of elderly people with such problems in the care of social services departments. This trend, if supported and continued, is likely to reduce further the distinction between old people in hospital and those in social services homes, with important implications for future planning of the care and management of the elderly.     

Gender differences in the utilization of health care services

BACKGROUND: Studies have shown that women use more health care services than men. We used important independent variables, such as patient sociodemographics and health status, to investigate gender differences in the use and costs of these services. METHODS: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of health care services and associated charges were monitored for 1 year of care. Self-reported health status was measured using the Medical Outcomes Study Short Form-36 (SF-36). We controlled for health status, sociodemographic information, and primary care physician specialty in the statistical analyses. RESULTS: Women had significantly lower self-reported health status and lower mean education and income than men. Women had a significantly higher mean number of visits to their primary care clinic and diagnostic services than men. Mean charges for primary care, specialty care, emergency treatment, diagnostic services, and annual total charges were all significantly higher for women than men; however, there were no differences for mean hospitalizations or hospital charges. After controlling for health status, sociodemographics, and clinic assignment, women still had higher medical charges for all categories of charges except hospitalizations. CONCLUSIONS: Women have higher medical care service utilization and higher associated charges than men. Although the appropriateness of these differences was not determined, these findings have implications for health care.     

Development of a modified Winchester disability scale--the elderly at risk rating scale.

OBJECTIVE: To show that the elderly at risk rating scale (EARRS) satisfies the requirements of an assessment tool for routine health checks in people over 75 and would also be suitable as a method of collecting epidemiological data on the needs of the elderly in a locality. DESIGN: Development and validation of a questionnaire based on a modification of the Winchester rating scale, by a series of prospective, comparative studies before the use of the instrument in a community survey. SETTING: Elderly care day hospital and the community. SUBJECTS: Elderly patients referred to an elderly care day hospital; population survey of subjects over 75 living at home. MAIN OUTCOME MEASURES: Reliability of responses using the kappa statistic; comparison of the scale with the Barthel index of daily living. RESULTS: EARRS has satisfactory validity and reliability when repeated by the same observer or a different observer, with a mean weighted kappa score above 0.80 in both instances. As a measure of disability in the community, it is better than the Barthel score in that it avoids the ceiling effect. The score is correlated with age, social situation, and receipt of support services, and individual questions scale appropriately to adverse outcomes. CONCLUSION: The EARRS satisfies the requirements of an assessment tool for health checks in the elderly, It is suitable for both population surveys and routine practice in primary care, has proved popular with practice nurses, and is easy to complete.     

Effective partnership working: a case study of hospital discharge

The process of discharging patients from hospital provides a critical indicator of the state of partnership working between health and social care agencies. In many ways, hospital discharge can be seen to epitomise the challenges which beset partnership working. For patients who have care needs which continue following their discharge from hospital, how well health and social care partners are able to coordinate their policies and practice is critical. Where arrangements work well, patients should experience a seamless transition; where things go wrong, patients are all too often caught in the middle of contested debate between health and social care authorities over who is responsible for what. In 2002, growing concerns over the numbers of mainly elderly people who were experiencing delays in being discharged from hospital led to the announcement that a system of 'cross-charging' would be introduced to target delayed discharges which were the responsibility of local authority social services departments. The government's proposals were widely criticised and were the focus of much antagonism. The intervention of the Change Agent Team (an agency with responsibility for providing practical support to tackle delayed discharges) marked a turning point in the presentation of the policy and in supporting local implementation efforts. This paper examines partnership working between health and social care by exploring the specific issues which this case study of hospital discharge provides. The analysis highlights the importance of understanding the dynamics of partnership working on the ground. It also underlines the need for a new relationship between central government and local agencies when old-style models of command and control are no longer fit for purpose. A new approach is required that addresses the complex and multiple relationships which characterise the new partnership agenda.     

The results of training of informal caregivers on the quality of life of the ederly with a déficit in self-care

The elderly population in Brazil has been growing apace, and this demographic transition has increasingly led to a situation where the elderly are dependent upon their relatives. However, the development of a training program could contribute to an improvement in the services provided by these caregivers, enhancing quality of life for the elderly. The aim of this study is to evaluate the effect of a Training Program for Informal Caregivers on the quality of life of elderly people with a deficit in self-care. Home visits were initially made to 15 elderly patients and the SF-36 questionnaire was applied. A multi-professional training program for the caregivers of these elderly people was then developed. The SF-36 questionnaire was again applied after 2 months of the training program to verify its effectiveness on the quality of life of the elderly people. On average a significant increase of scores related to "mental health" and a significant decrease in "limitations of physical aspects" was detected. The training of informal groups of caregivers by professionals from the healthcare area should be encouraged in order to promote awareness, exchange experiences and discuss the best inherent strategies for care.     

Los problemas de salud también explican la utilización de servicios sociales en atención domiciliaria

ObjectiveTo identify which social and health variables are associated with receiving social services in patients included in home care programmes with the implementation of the Dependence Law.DesignCross-sectional study.Setting72 primary health care teams in Catalonia.PatientsPatients over 64 years old with chronic diseases in home care programmes in Catalonia.MeasurementsHealth status variables: Charlson, Barthel, Pfeiffer, Braden and Gijon, data from their carer (Zarit), self perception of health (SF-12), health professional visits, as well as: emergency visits, temporary admissions, and final results such as death or definitive admission in a nursing home or a hospital.ResultsA total of 1068 patients were included, 46.8% of the patients received some kind of social service, public or private. We observed that the variables related to receive some kind of social services are: high dependence (Barthel test), pressure sores and home care rehabilitation. Barthel test is highly associated with having social problems (Gijon test), living without an informal carer, more than 2 GP visits and having additional private health care.ConclusionsTo be more fair, the evaluation of the provisions of the Dependence Law should also consider the health status of the patient. With the implementation of this law we can observe difficulties in access to social services for middle class patients. These patients do not have access to public social assistance and cannot pay for a private one. Social services are still an alternative to family care.     

HMOS' continuum of care. How HMOs target their services to meet the needs of the elderly

As healthcare organizations begin to expand their services to serve the elderly, they can learn from the experience of managed care providers. Kaiser Permanente in San Diego, a health maintenance organization (HMO) integrates healthcare providers with more traditional hospital services such as discharge planning and placement coordination, as well as social services, care management, and rehabilitation. Having all these services in the same office facilitates good patient care and planning. When a patient goes into hospice, home care, or a skilled nursing facility, one of four physicians takes on sole responsibility for his or her treatment and continuity of care. Group Health Cooperative of Puget Sound, Seattle, is a consumer-governed HMO. Group Health makes decisions based on data about enrollees plus input from medical staff and senior groups. It emphasizes putting the right services with the right consumer using subgroupings based on functional status: healthy, moderately frail, and frail. Seniors Plus, a social HMO in Minneapolis, integrates acute and long-term care. Providers determine who needs functional assessment and care management by looking first at the diagnosis, then the severity of impairment and comorbidity, other medical problems such as depression and falling that indicate a need, and finally limitations in function and ability to perform activities of daily living.     

团体认知行为疗法对老年慢性阻塞性肺疾病患者的干预效果研究

目的探讨团体认知行为疗法对老年慢性阻塞性肺疾病(COPD)患者焦虑、抑郁、自我效能及生活质量的干预效果.方法采用方便抽样的方法,选取2017年9月至2018年9月山西省某三级甲等医院呼吸与危重症医学科收治的276例老年COPD患者为研究对象,按入院时间将患者分为实验组(n=132)和对照组(n=144),对照组接受常规护理和健康教育,实验组在常规护理基础上增加团体认知行为干预,在干预前、干预后、干预后1个月使用抑郁自评量表、焦虑自评量表、一般自我效能量表、生活质量量表评价干预效果.结果干预前两组患者焦虑自评量表、抑郁自评量表、一般自我效能量表及生活质量量表评分差异均无统计学意义(P>0.05);干预后、干预后1个月两组患者焦虑自评量表、抑郁自评量表、生活质量量表、一般自我效能量表评分均优于干预前,且差异均具有统计学意义(P<0.05).结论团体认知行为疗法可缓解老年COPD患者的焦虑、抑郁症状,提升自我效能感,改善其生活质量.本研究为老年COPD患者心理护理方法的改进提供了科学依据,同时为其他慢病人群的护理管理和健康教育提供参考.     

Is the short form 36 (SF-36) suitable for routine health outcomes assessment in health care for older people? Evidence from preliminary work in community based health services in England.

STUDY OBJECTIVE: To examine the short form 36 (SF-36) health status measure when used to assess older people's views of the outcome of community based health care. DESIGN: Completion of a structured questionnaire, before and after intervention alongside in-depth interviews with a subsample of the interviewees. SETTING: Community based continence and mental health services in two health authorities in the North West Health Region. PATIENTS: Forty seven older people newly referred to mental health services or continence services between December 1992 and April 1993 participated. MAIN RESULTS: The SF-36 showed minimal change over time for both patient groups. The more detailed in-depth interviews showed that people experienced positive changes and derived value from contact with services in a number of important ways. For many reasons these benefits were not reflected in their SF-36 scores. CONCLUSIONS: The SF-36 is not likely to be the "measure of choice" for this type of evaluation, particularly where it involves older patient groups who have high levels of comorbidity. The content of the SF-36 and its lack of detail for individual assessment of change means it masks rather than illuminates patients' views of outcome.     

Health outcomes by self-report: validity of the SF-36 among Australian hospital patients

This paper examines the performance of the SF-36 as a self-reported outcome measure in a diverse sample of Australian hospital in-patients. The data derive from the Care Continuum and Health Outcomes Project with a total of 2088 randomly selected patients, yielding a response rate of 80%. Distributions, completion rates and, in particular, correlates of measures were used to investigate the validity of the SF-36 according to clinical and psychometric criteria. Physical functioning, bodily pain, role limitations- physical, general health and vitality scales better represented physical than mental health, with the relative strength decreasing in that order; while mental health, role limitations-emotional and social functioning scales better represented mental health, with the relative strength decreasing in order. A cultural dimension was a strong independent correlate of all scales. While the SF-36 performed satisfactorily, there were weaknesses: the social functioning scale was too narrow to cover social health, both role limitations scales had crude response categories and particular subgroups, the frail elderly and those with complex health conditions, required measures with finer gradings for scales such as physical functioning and bodily pain. Further testing is needed to develop self-reports for use in hospital outcomes measurement which is already proposed in Australia.     

Inappropriate use of emergency ambulance services and the implications for primary health care in Japan

The number and per-capita emergency transports by public ambulancesand the percentage of transports of patients with non-emergencyconditions has been increasing in Japan, especially in urbanareas. Public ambulance services are, of course, essential fortransporting patients with crucial health problems. However,inappropriate ambulance use by patients who do not need emergencytreatment, but who need primary health care, means that thesepatients cannot get suitable health care, and diminishes theeffectiveness and efficiency of emergency medical-care servicesystems. The purposes of this study were to identify the factorsrelating to usage of public ambulance services in urban areas,to determine how to make these services more effective and moreefficient, and to discuss how to provide primary health-careservices so as to reduce the inappropriate use of public ambulanceservices. We investigated the accessibility of primary health-careservices, the characteristics of public ambulance service utilization,and the potential needs of the elderly for emergency-care servicesin two Tokyo wards: Edogawa andSetagaya. There were less healthresources, such as clinics, hospital beds and physicians, percapita in Edogawa than in Setagaya. Both the percentage of ambulancetransports of patients suffering from mild problems and thepercentage of ambulance transports on Sundays were higher inEdogawa than in Setagaya. Our survey showed that the percentagesof the elderly who would call for ambulances for each of threespecific health problems (fever, chest pain and ankle sprain)were all higher in Edogawa than in Setagaya. In both wards,elderly people living with their children and/or grandchildrenwere more likely to choose different health resources accordingto the specific problem being experienced than were elderlypeople living with other aged persons but without young people.The insufficient development of primary healthcare resourcesand systems increased the inappropriate use of high-cost emergencyambulance services by the elderly living in urban areas, wherefamily support is weakening. Health systems therefore need tobe reoriented so as to enhance accessibility to primary healthcareservices.     

In-house referral: a primary care alternative to immediate secondary care referral?

BACKGROUND: Methods are needed to ensure that those patients referred from primary to secondary care are those most likely to benefit. In-house referral is the referral of a patient by a general practitioner to another general practitioner within the same practice for a second opinion on the need for secondary care referral. OBJECTIVE: To describe whether in-house referral is practical and acceptable to patients, and the health outcomes for patients. METHODS: Practices were randomized into an intervention or a control group. In intervention practices, patients with certain conditions who were about to be referred to secondary care were referred in-house. If the second clinician agreed referral was appropriate the patient was referred on to secondary care. In control practices patients were referred in the usual fashion. Patient satisfaction and health status was measured at the time of referral, 6 months and one year. RESULTS: Eight intervention and seven control practices took part. For the 177 patients referred in-house, 109 (61%) were judged to need referral on to secondary care. For patient satisfaction, the only difference between the groups studied was that at 12 months patients who had been referred in-house reported themselves as being more satisfied than those referred directly to hospital. For health status, the only difference found was that at the time of referral, patients who had been referred in-house and judged to need hospital referral reported themselves as being less able on the 'Physical function' subscale of the SF-36 than patients who were referred in-house and judged to not need hospital referral. CONCLUSION: In-house referral is acceptable to patients and provides a straightforward method of addressing uncertainty over the need for referral from primary to secondary care.     

Comorbidity assessments based on patient report: results from the Veterans Health Study

The objective of the study was to develop a self-reported measure of patients' comorbid illnesses that could be readily administered in ambulatory care settings and that would improve assessment of their health-related quality of life and utilization of health services. Data were analyzed from the Veterans Health Study, an observational study of health outcomes in patients receiving Veterans Administration (VA) ambulatory care. Patients who received ambulatory care services in 4 VA outpatient clinics in the greater Boston area between August 1993 and March 1996 were eligible for inclusion. Among the 4137 patients recruited, 2425 participated in the Veterans Health Study, representing a response rate of 59%. Participants were mailed a health-related quality of life questionnaire, the Medical Outcomes Study Short Form Health Survey (SF-36). They were also scheduled for an in-person interview at which time they completed a medical history questionnaire. We developed a comorbidity index (CI) that included 30 self-reported medical conditions (physical CI) and 6 self-reported mental conditions (mental CI). The physical CI and the mental CI were significantly associated with all SF-36 scales and explained 24% and 36%, respectively, of the variance in the physical component summary and the mental component summary of the SF-36. Both indexes were also significant predictors of future outpatient visits and mortality. The CI is an independent predictor of health status, outpatient visits, and mortality. Its use appears to be a practical approach to case-mix adjustment to account for differences in comorbid illnesses in observational studies of the quality of healthcare. It can be administered to large patient populations at relatively low cost. This method may be particularly valuable for clinicians and researchers interested in population-based studies, case-mix adjustment, and clinical trials.