Validity,reliability, and responsiveness of the Kansas City Cardiomyopathy Questionnaire in anemic heart failure patients

Background While generic health status measures quantify the impact of all patients’ diseases on their health-related quality of life, disease specific measures focus on only one of the many conditions that a patient may have. If a patient has two diseases with similar clinical manifestations, they may respond differently to a disease-specific instrument if one of their conditions improves while the other worsens or remains stable, thus undermining the instruments in that patient population. We sought empirical evidence of the reliability and validity (including responsiveness) of the Kansas City Cardiomyopathy Questionnaire (KCCQ), a disease-specific measure for heart failure (HF), among HF patients with and without anemia, a condition that has similar symptoms to HF. Methods This work used a prospective cohort study of 811 HF outpatients from 58 U.S. centers with a baseline assessment of anemia of whom 698 were followed for 3 months with serial health status measures. Results Among participants, 268 (33%) were anemic. The construct validity of the KCCQ was supported by showing similar correlations with the New York Heart Association (NYHA) classification in patients with and without anemia (P value for interaction = 0.38). The internal consistency (Cronbach’s alpha = 0.92 and 0.93 for anemic and non-anemic patients, respectively) and test–retest reliability (mean 3-month change scores in stable patients = −2.8 [SD = 1.4] and −0.5 [SD = 0.8], P = 0.14) were similar. Estimates of responsiveness were also similar. Conclusion This study provides empirical evidence that the psychometric properties of the KCCQ are similar in patients with or without anemia, a potentially confounding clinical condition in patients with heart failure.     

Readability estimates for commonly used health-related quality of life surveys

Purpose  To estimate readability of seven commonly used health-related quality of life instruments: SF-36, HUI, EQ-5D, QWB-SA, HALex, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and the NEI-VFQ-25. Methods  The Flesch–Kincaid (F–K) and Flesch Reading Ease (FRE) formulae were used to estimate readability for every item in each measure. Results  The percentage of items that require more than 5 years of formal schooling according to F–K was 50 for the EQ-5D, 53 for the SF-36, 80 for the VFQ-25, 85 for the QWB-SA, 100 for the HUI, HALex, and the MLHFQ. The percentage of items deemed harder than “easy” according to FRE was 50 for the SF-36, 67 for the EQ-5D, 79 for the QWB-SA, 80 for the VFQ-25, 100 for the HUI, HALex, and the MLHFQ. Conclusions  All seven surveys have a substantial number of items with high readability levels that may not be appropriate for the general population.     

Psychometric Properties of an Established Heart Disease Specific Health-related Quality of Life Questionnaire for Pacemaker Patients

Little is known about the HRQL of pacemaker patients due to the limited availability of disease-specific instruments. The aim of the Pacemaker Patients Quality of Life (PAPQoL) study was to determine the psychometric properties for the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) in patients before and after pacemaker implantation. Patients with a given indication for pacemaker therapy (N = 68) completed two self-administered HRQL instruments, the SF-36, a well-known and psychometrically sound health survey, and the MacNew, a reliable and valid heart-disease-specific HRQL instrument, before and one, three and six months after pacemaker implantation. We assessed disease severity with the New York Heart Association (NYHA) classification. Test–retest reliability, intra-class correlation, Cronbach’s α, validity coefficients, sensitivity analyses (effect sizes) and confirmatory factor analysis were carried out. The MacNew demonstrated adequate reliability (Cronbach’s α and ICCs > 0.80 on all scales), validity (correlations between similar SF-36 and MacNew subscales > 0.80), and responsiveness (all effect sizes ≥ 0.67) in pacemaker patients. The MacNew demonstrates adequate psychometric properties for evaluating HRQL in patients before and after pacemaker implantation.     

Psychometric properties of the Minnesota Living with Heart Failure—Brazilian version—in the elderly

BACKGROUND: Heart failure (HF) has implications for the quality of life for any age range, more so for the elderly who simultaneously present other limitations imposed by multiple co-morbidities. Although there are several instruments to measure Health Related Quality of Life (HRQL), none is specific to the elderly with HF. Among disease-specific instruments, Minnesota Living with Heart Failure(LHFQ) has not been studied extensively among the elderly with respect to its psychometric properties. OBJECTIVE: The purpose of this study was to evaluate the convergent, divergent and discriminative validity of the Brazilian version of LHFQ applied to elderly HF patients. METHOD: One hundred and seventy (170) elderly were interviewed. LHFQ capacity to discriminate subjects among New York Heart Association (NYHA) Classes I, II and III/IV was analyzed. Convergent and divergent validity was evaluated through the correlation between the domains of LHFQ and the generic instrument, Medical Outcomes Study (MOS) 36-item Short-Form Health Survey (SF-36). RESULTS: The LHFQ total score and physical dimension sub-scale discriminated between the three sub-groups of NYHA Classes I, II and III/IV (P < .0001). The emotional dimension discriminated NYHA Classes I and III/IV (P = .0034). The physical and emotional dimensions of the LHFQ and SF-36 were significantly correlated (coefficients from .46 to .70 for physical dimension and from .31 to .65 for emotional dimension). However, contrary to expectations, the divergent validity was not totally confirmed as there was no difference in the magnitude of the correlations between the LHFQ emotional and physical dimensions and the SF-36 role physical, social functioning and role emotional. Thus, the results suggest that LHFQ seems to be a valid tool to measure HRQL in the elderly, but new studies remain necessary to gain a better understanding of its discriminative validity for more advanced NYHA functional classes and for its divergent validity.     

Italian translation of the Manchester-Oxford Foot Questionnaire, with re-assessment of reliability and validity

Purpose  To cross-culturally adapt and validate the Italian version of the Manchester-Oxford Foot Questionnaire (MOXFQ) in patients affected by hallux valgus. Methods  The MOXFQ was translated into Italian and culturally adapted following the forward and backward translation method. A sample of 172 patients with hallux valgus was asked to fill in the MOXFQ and the Short-Form 36 Health Survey (SF-36). Two-week retest was performed on a random sub-sample of 40 patients. Internal consistency and test–retest reliability were assessed using Cronbach’s alpha and intraclass correlation coefficient (ICC), respectively. Construct validity was assessed with the use of Spearman’s rank correlation coefficient, using a priori hypothesized correlations with SF-36 domains. Results  The internal consistency reliability was acceptable for all MOXFQ domains (Pain, Walking/standing and Social interaction) with Cronbachs’ alpha coefficients ranging from 0.72 to 0.83. The assessment of test–retest reliability reveals satisfactory values with ICCs ranging from 0.85 to 0.92. Construct validity was supported by the presence of all the hypothesized correlation, with the exception of Italian Walking/standing domain with the SF-36 Role-Physical domain (ρ = −0.29). Conclusions  The Italian version of MOXFQ is a valid and reliable instrument for evaluating foot pain and functional status in patients affected by hallux valgus.     

Evidence on the global measurement model of the Minnesota Living with Heart Failure Questionnaire

Purpose

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is the most widely used health-related quality of life measure in both clinical and research settings. Nevertheless, its measurement model has never been confirmed. This study aims to fill that gap with a large international sample.

Methods

Data from eight studies (3,847 patients with heart failure) from 21 countries were merged and analysed. Common variables included MLHFQ scores, functional capacity, cardiovascular risk factors and the socio-demographic characteristics of the patient. The measurement model of the MLHFQ was assessed by means of exploratory and confirmatory factor analyses (EFA-CFA). The reliability of MLHFQ scores was evaluated using Cronbach’s alpha coefficient and the MLHFQ’s ability to differentiate among known groups was assessed through severity levels.

Results

Findings from the EFA and CFA suggest that the MLHFQ total and domain-specific scores fall within a bifactor model. The physical and emotional scores were supported within the sample, as was the original total score. Furthermore, a third factor was revealed regarding social environment. The reliability coefficient reached 0.9 for almost all physical and total scores. All the MLHFQ mean scores showed the ability to differentiate among functional capacity groups, with most of the effect size coefficients reaching 0.8.

Conclusions

Beyond the suitable degree of reliability and validity displayed by the MLHFQ scores in the different country-specific versions, our results confirmed for the first time the unidimensionality of the most commonly used score in HF patients: the total MLHFQ score. Moreover, the social environment domain identified in this study can now be considered when assessing these patients’ HRQL, especially as a relevant outcome with regard to disease management.     

Quality of life in patients with heart failure: the perspective of primary health care

Objective

To measure and identify the dimensions and determinants of health-related quality of life (HRQoL) in patients with chronic heart failure.

Methods

We performed a cross-sectional study, in which HRQoL was measured with the short-form (SF)-36 and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in 544 clinically-stable patients with chronic heart failure managed by 97 primary care physicians.

Results

The mean age of the patients was 77.6 years (SD: 9.9) and was significantly higher in women. A total of 31.2% were in New York Heart Association (NYHA) grade III-IV and 88.6% had at least one chronic condition. In both questionnaires, physical dimensions scored worse than emotional dimensions. After adjustment was made for multiple regression, seven variables entered into one of the five models and explained between 22% and 36% of the variance.

Conclusions

HRQoL in patients with chronic heart failure is impaired across all domains. Being female and being in NYHA functional class III-IV, as well as other factors such as depression, osteoarticular disease, hospital admission, body mass index and age, were associated with poorer self-perceived HRQoL.     

Do the unlabeled response categories of the Minnesota Living with Heart Failure Questionnaire satisfy the monotonicity assumption of simple-summated scoring?

Quality of Life Research - Half of the 21-item Minnesota Living with Heart Failure Questionnaire (MLHFQ) response categories are labeled (0?=?No, 1?=?Very little,...     

Mapping the Minnesota Living with Heart Failure Questionnaire (MLHFQ) onto the Assessment of Quality of Life 8D (AQoL-8D) utility scores

Quality of Life Research - The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is a widely used condition-specific measure of quality of life (QoL) in patients with heart failure. To use...     

Impact of family income and sickle cell disease on the health-related quality of life of children

Purpose  The objective of this study was to determine the impact of family income and sickle cell disease on the health-related quality of life (HRQL) of children. Methods  This was a cross-sectional study of children with and without sickle cell disease. Participants completed the PedsQL™ generic core scales parent-proxy or child self-report questionnaire during a routine clinic visit. HRQL was the primary outcome measured. Family income and sickle cell disease were the primary independent variables of interest. Results  A total of 104 children with sickle cell disease and 74 without disease participated in the study. After adjusting for family income, patient age, and the presence of co-morbidities, children with severe sickle cell disease had increased odds of worse overall HRQL (parent-proxy HRQL report odds ratio [OR] 4.0) and physical HRQL (parent-proxy report OR 5.67, child self-report OR 3.33) compared to children without sickle cell disease. Conclusions  Children with sickle cell disease have significantly impaired HRQL, even after considering the potential detrimental effect of family income on HRQL. Targeted interventions to improve these children’s HRQL are warranted.     

Psychometric performance of the brazilian version of the Mini-cuestionario de calidad de vida en la hipertensión arterial (MINICHAL)

This study aimed to evaluate the feasibility, acceptability, ceiling and floor effects, reliability, and convergent construct validity of the Brazilian version of the Mini Cuestionario de Calidad de Vida en la Hipertensión Arterial (MINICHAL). The study included 200 hypertensive outpatients in a university hospital and a primary healthcare unit. The MINICHAL was applied in 3.0 (± 1.0) minutes with 100% of the items answered. A "ceiling effect" was observed in both dimensions and in the total score, as well as evidence of measurement stability (ICC=0.74). The convergent validity was confirmed by significant positive correlations between similar dimensions of the MINICHAL and the SF-36, and significant negative correlations with the Minnesota Living with Heart Failure Questionnaire - MLHFQ, however, correlations between dissimilar constructs were also observed. It was concluded that the Brazilian version of the MINICHAL presents evidence of reliability and validity when applied to hypertensive outpatients.     

A Study of the Construct Validity of the Health Utilities Index Mark 3 (HUI3) in Patients with Schizophrenia

This study assessed the construct validity of the Health Utilities Index Mark 3 (HUI3) in patients with schizophrenia. Patients with schizophrenia recruited from a tertiary mental hospital in Singapore completed the HUI3, the Short-Form 36 Health Survey (SF-36) and the Schizophrenia Quality of Life Scale (SQLS). Patients were assessed for presence and absence of 22 common psychiatric symptoms. Construct validity was assessed using 6 a priori hypotheses. Two hundred and two patients (mean age: 37.8 years, female: 52%) completed the survey. As hypothesized, overall HUI3 utility scores were correlated with SF-36 measures (Spearman’s rho: 0.19 to 0.51), SQLS scales (Spearman’s rho: −0.56 to −0.36), and the number of psychiatric symptoms (Spearman’s rho: −0.49). The HUI3 emotion attribute was moderately correlated with SF-36 mental health (Spearman’s rho: 0.45) and SQLS psychosocial scales (Spearman’s rho: −0.43), and HUI3 pain attribute was strongly correlated with SF-36 bodily pain scale (Spearman’s rho: 0.58). The mean HUI3 overall, emotion, cognition, and speech scores for patients with schizophrenia were 0.07, 0.09, 0.04 and 0.04 points lower than respective age-, sex- and ethnicity-adjusted population norms (p<0.001 for all, ANCOVA). This study provides evidence for the construct validity of the HUI3 in patients with schizophrenia.     

A patient-based questionnaire to assess outcomes of foot surgery: Validation in the context of surgery for hallux valgus

Background: A patient-based outcome measure with good measurement properties is urgently needed for use in clinical trials of foot surgery. Methods: We evaluated an existing foot pain and disability questionnaire (the Manchester Foot Pain and Disability Questionnaire) for its suitability as an outcome measure in the context of hallux valgus corrective surgery. Interviews with patients led to initial changes, resulting in 20 candidate questionnaire items with five response categories each. These were tested in a prospective study of 100 patients (representing 138 foot operations) undergoing hallux valgus corrective surgery. Analysis of underlying factor structure, dimensionality, internal reliability, construct validity and responsiveness of the questionnaire items in relation to (i) SF-36 general health survey and (ii) American Orthopaedic Foot & Ankle Society (AOFAS) hallux clinical scale resulted in a final 16 item questionnaire (the ‘Manchester-Oxford Foot Questionnaire’ (MOXFQ)), consisting of three domains/scales: ‘Walking/standing’ (seven items), ‘Pain’ (five items) and ‘Social interaction’ (four items) each having good measurement properties. All three domains were unidimensional. Conclusions: The new 16-item MOXFQ has good measurement properties in the context of outcomes assessment of surgery for hallux valgus. Future studies should assess the MOXFQ in the context of surgery for other foot and ankle conditions.     

Comparing a disease-specific and a generic health-related quality of life instrument in subjects with asthma from the general population

Background  

Few epidemiologic studies have assessed health-related quality of life (HRQL) of asthma patients from a general population and it is unclear which instrument is best suitable for this purpose. We investigated the validity of the Asthma Quality of Life Questionnaire (AQLQ) and the SF-36 completed by individuals with asthma from the population-based SAPALDIA (Swiss study on air pollution and lung diseases in adults) cohort.     

Greater Years of Maternal Schooling and Higher Scores on Academic Achievement Tests are Independently Associated with Improved Management of Child Diarrhea by Rural Guatemalan Mothers

Appropriate home management can alleviate many of the consequences of diarrhea including malnutrition, impaired development, growth faltering, and mortality. Maternal cognitive ability, years of schooling, and acquired academic skills are hypothesized to improve child health by improving maternal child care practices, such as illness management. Using information collected longitudinally in 1996–1999 from 466 rural Guatemalan women with children <36 months, we examined the independent associations between maternal years of schooling, academic skills, and scores on the Raven’s Progressive Matrices and an illness management index (IMI). Women scoring in the lowest and middle tertiles of academic skills scored lower on the IMI compared to women in the highest tertile (−0.24 [95% CI: −0.54, 0.07]; −0.30 [95% CI: −0.54, −0.06], respectively) independent of sociodemographic factors, schooling, and Raven’s scores. Among mothers with less than 1 year of schooling, scoring in the lowest tertile on the Raven’s Progressive Matrices compared to the highest was significantly associated with scoring one point lower on the IMI (−1.18 [95% CI: −2.20, −0.17]). Greater academic skills were independently associated with maternal care during episodes of infant diarrhea. Schooling of young girls and/or community based programs that provide women with academic skills such as literacy, numeracy and knowledge could potentially improve mothers’ care giving practices.     

Health related quality of life in 10-year-old schoolchildren

Objective  The purpose of this study was to investigate the health related quality of life (HRQL) in a total cohort of general school children. Methods  The study population consisted of the children starting 4th grade (age 9–10) in Finnish primary schools in autumn 2004 (n = 1,346) and their parents in a city of 175,000 inhabitants. Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0) was used for assessment of HRQL. The response rate was 81% for the children (n = 1,091). Most children had parents who participated (n = 999). Results  The children reported highest HRQL mean values in physical (85.00, SD 10.95) and social (84.71, SD 14.28), and lowest in school (78.89, SD 14.53) and emotional (75.43, SD 15.67), functioning scales. Girls reported significantly lower emotional (t = −2.43, P = 0.02) functioning than boys. Child self reports show lower social (t = −2.57, P = 0.01) and school (t = −3.44, P = 0.0006) functioning, and higher emotional (t = 5.82, P < 0.0001) and physical (t = 4.79, P < 0.0001) functioning than their parent-proxy assessments. Conclusions  Interventions aiming at supporting the emotional and school functioning of the school children are recommended. Parents may overestimate the social and school functioning and underestimate the physical and emotional functioning compared to their children’s own perceptions.     

Measuring health-related quality of life in children from different perspectives using the Pediatric Quality of Life Inventory™ (PedsQL™) and teachers’ ratings

Background  Health-related quality of life (HRQL) is a concept being increasingly used in paediatric health care. Since health professionals have to rely on both child and adult reports of the child’s condition, more information as to which factors moderate the correspondence between these reports would be useful. Aim and methods  This study attempted to identify the cross-informant variance (CIV) in child, parent and teacher reports about the child’s HRQL in a large sample of elementary school children. We used the Austrian-German version of the generic core Pediatric Quality of Life Inventory™ (PedsQL™) for children and parents as well as a short HRQL rating scale derived from PedsQL™ for teachers. We identified the CIV with the use of intraclass correlation and paired score differences in 620 triple assessments, compared them to results of other PedsQL™ studies and tried to identify the factors having an impact on CIV and on the self-reported HRQL of children whose proxy ratings demonstrated a large CIV. Results  On the whole, our results indicated low to medium agreement between children and parents, similar to results of other PedsQL™ studies in schoolchildren. The only variable that was found explaining child-parent variance was the child’s gender, with girls deviating more from their parents than boys. Child-teacher and parent-teacher CIV seemed to be primarily an effect of the child’s school performance and the teacher-parent relationship. Children whose proxy ratings differed by more than ± 15 scores showed significantly lower self-reported HRQL in some areas as compared to children whose proxy ratings showed less CIV. Conclusion  Our results underline that it is more difficult to get concordant HRQL ratings of schoolchildren as compared to children with chronic disease.     

Dietary factors in relation to daily activity energy expenditure and mortality among older adults

Objectives  To examine the association between dietary factors to daily activity energy expenditure (DAEE) and mortality among older adults. Design and setting  A sub-study of Health, Aging, and Body Composition study. Participants  298 older participants (aged 70–82 years) in the Health, Aging, and Body Composition Energy Expenditure sub-study. Measurements  Dietary factors, DAEE, and all-cause mortality were measured in 298 older participants. Dietary factors include dietary intake assessed by the Block Food Frequency Questionnaire (FFQ), Healthy Eating Index (HEI), and self-reported appetite and enjoyment of eating. DAEE was assessed using doubly labeled water. All-cause mortality was evaluated over a 9 year period. Results  Participants in the highest tertile of DAEE were more likely to be men and to report having a ‘good’ appetite; BMI among men, proportion married, IL-6 and CRP levels and energy intake were also higher. Fewer black participants were in the ‘good’ HEI category. Participants in the ‘good’ HEI category had higher cognitive scores and a higher education level. Participants who reported improvement in their appetite as well as participants who reported a ‘good’ appetite were at lower risk for mortality (HR (95% CI): 0.42 (0.24–0.74) and 0.50 (0.26–0.88), respectively) even after adjusting for DAEE, demographic, nutritional and health indices. Conclusions  We showed an association between DAEE and appetite and mortality among well-functioning, community-dwelling older adults. These findings may have some practical use for the health providers. Inclusion of a question regarding appetite of an elderly patient may provide important information regarding risk for health deterioration and mortality.     

Responsiveness of the Adult Attention-Deficit/Hyperactivity Disorder Quality of Life Scale (AAQoL)

Aims This study examined responsiveness of the Adult Attention-Deficit/Hyperactivity Disorder Quality of Life Scale (AAQoL), which was developed to assess health-related quality of life (HRQL) among adults with attention-deficit/hyperactivity disorder (ADHD). Methods Adults with ADHD completed the AAQoL, Conners’ Adult ADHD Rating Scale (CAARS), SF-36, and Endicott Work Productivity Scale (EWPS) at baseline and week 8 of a randomized, placebo-controlled trial of atomoxetine. Clinicians rated symptom severity and improvement (CGI-ADHD-S, CGI-ADHD-I). Responsiveness was examined through effect sizes and association with change in the measures listed previously (Spearman correlations, GLMs). Results Analyses included 328 patients (58.8% male; mean age = 36.9 years). All AAQoL scales reflected significant improvement from baseline to week 8 (P < 0.0001). AAQoL change scores were significantly correlated with change in the CGI-ADHD-S (r = −0.37 to −0.50), EWPS (r = −0.43 to −0.63), and CAARS (r = −0.35 to −0.62) (all P < 0.001). AAQoL change scores significantly discriminated among patients with various levels of symptom improvement. AAQoL effect sizes (−0.67 to −1.11) were larger than effect sizes for the SF-36 (0.15 to −0.39). Conclusions The AAQoL was responsive to change in symptoms of ADHD, and it appears to be a useful outcome measure for treatments of ADHD in adults.