Measurement of health status in patients with chronic illness: comparison of the Nottingham health profile and the general health questionnaire

The results of two commonly used instruments for measuring health status were compared in patients with chronic illness. The Nottingham health profile (NHP) is a measure of perceived health, while the general health questionnaire (GHQ) is a measure of non-psychotic psychiatric disturbance. The questionnaires were completed by patients suffering either rheumatoid arthritis or migraine. The results provide evidence that, despite some specific problems in the measurement of pain and emotional reactions, the NHP and GHQ may be used to assess the impact of illness upon sufferers' lives, not only in severely disabling disorders such as rheumatoid arthritis, but in health problems such as migraine which have often been considered as relatively minor ailments.     

Importance of sensitivity to change as a criterion for selecting health status measures.

OBJECTIVE--To assess the sensitivity to change over time of four health status instruments in relation to patients with rheumatoid arthritis. DESIGN--Observational three month study of four self assessed instruments (arthritis impact measurement scales (AIMS), health assessment questionnaire (HAQ), Nottingham health profile (NHP), functional limitations profile (FLP)). SETTING--One rheumatology unit. PATIENTS--101 patients with definite or classic rheumatoid arthritis. MAIN MEASURES--Change scores for dimensions of instruments, as determined by effect size (mean change in score/baseline standard deviation of variable) and conventional rheumatological measures, at baseline and after three months. RESULTS--Change scores for comparable dimensions (mobility, activities of daily living, household, pain, mood or emotion, and social scales) of the instruments were compared among 30 patients who considered their health status to have improved over three months. For all dimensions of health status the magnitude of change varied considerably according to the instrument. Maximum range in effect size was for social scales (AIMS 0.06, NHP 0.24, FLP 0.60). No single instrument seemed consistently to show the most change over all dimensions. CONCLUSION--Selection of health status instruments for audit or evaluation may have a considerable impact on the pattern of results obtained, and the "responsiveness" of such scales should be as carefully examined as their reliability and acceptability when selecting outcome measures.     

Do patients with active chronic polyarthritis get "basic therapy"?

The determination of the adequacy of an individual therapeutical regimen is part of the process evaluation of medical care. To evaluate the adequacy of individual antirheumatic therapy, we developed a five step procedure: 1. Assessment of the patient's health status; 2. assessment of his/her former and current therapy; 3. determination of the adequate antirheumatic therapy following an explicit norm; 4. formal comparison of current and adequate treatment; 5. clinical evaluation of possible differences between norm and reality. Due to methodological reasons we concentrated on the current treatment of rheumatoid arthritis (rA) patients with remission inducing drugs (RIDs; e.g. Chloroquine, Gold). The study analyzed the RID treatment of 75 rA-sufferers; 25 patients were referred to our outpatient department for the first time in late 1986; 25 patients were recruited from a social-medical study covering employed but actually disabled members of a major health insurance (AOK) in Hannover; 25 subjects were derived from an ongoing population study ("prevalence and care of rheumatoid arthritis in Hannover"). Only 9 out of 49 (18%) patients with an active disease, formally in need of treatment, were currently treated with RIDs. Thus 40 out of 49 (82%) seemed to be under an inadequate treatment. From the clinical point of view this formal judgement was assumed to be false positive in 5 and false negative in 15 cases. In relation to the clinical judgements we found for the formal procedure a sensitivity of 0.70 with a specificity of 0.80 and an overall agreement of 73% (kappa 0.44).     

Health status reports in the care of patients with rheumatoid arthritis

We examined the use of formal health status reports every 3 months over 1 year in the clinical care of patients with rheumatoid arthritis (RA). The reports consisted of single-page, computer-generated summaries of scores derived from either the AIMS (Arthritis Impact Measurement Scales) or the MHAQ (Modified Health Assessment Questionnaire) health status questionnaires. A total of 1920 subjects from 27 community practice sites were randomly assigned to three study groups in each practice: intervention, attention placebo and control. Results showed that 55% of the physicians found the reports to be at least moderately useful as an aid to patient management, primarily for improving the doctor-patient relationship. However, no detectable differences among the three groups were seen in terms of medication compliance, number of physician visits, number of referrals, frequency of major medication changes, attitudes towards the physician, patient satisfaction or change in health status over 1 year. The failure to demonstrate objective benefits of health status reports in this study may be due to physician unfamiliarity with health status scores, failure to link the report with an office visit, the relative stability of clinical status in the subjects over 1 year and the relatively short time-frame of the study.     

Associations between demographic and disease-related variables and disability over the first five years of inflammatory polyarthritis: a longitudinal analysis using generalized estimating equations

OBJECTIVES: To investigate whether the relationship between demographic and disease-related variables and disability is constant during the first five years of inflammatory polyarthritis (IP) and to identify the contribution from involvement of specific joint areas to overall disability. METHODS: 684 patients referred to the Norfolk Arthritis Register were followed for five years using the Health Assessment Questionnaire (HAQ). The relationship between disability and demographic and clinical variables was analyzed using a multi-level modelling approach. RESULTS: Female gender, older age at symptom onset (> or = 64 years), joint involvement at six specific sites, joint tenderness and the number of deformed joints were all independently associated with disability (HAQ > or = 1.00). Similar results were obtained using a more stringent cut-off (HAQ > or = 1.50) or when analysis was restricted to the 325 patients who satisfied the 1987 ARA list criteria for rheumatoid arthritis. CONCLUSION: Disability, as measured by the HAQ, was associated with a large number of independent factors over the first five years of disease.     

The impact of a health education program targeting patients with high visit rates in a managed care organization

PURPOSE: To determine if a mailed health promotion program reduced outpatient visits while improving health status. DESIGN: Randomized controlled trial. SETTING: A midsized, group practice model, managed care organization in Ohio. SUBJECTS: Members invited (N = 3214) were high utilizers, 18 to 64 years old, with hypertension, diabetes, or arthritis (or all). A total of 886 members agreed to participate, and 593 members returned the initial questionnaires. The 593 members were randomized to the following groups: 99 into arthritis treatment and 100 into arthritis control, 94 into blood pressure treatment and 92 into blood pressure control, and 104 into diabetes treatment and 104 into diabetes control. MEASURES: Outpatient utilization, health status, and self-efficacy were followed over 30 months. INTERVENTIONS: Health risk appraisal questionnaires were mailed to treatment and control groups before randomization and at 1 year. The treatment group received three additional condition-specific (arthritis, diabetes, or hypertension) questionnaires and a health information handbook. The treatment group also received written health education materials and an individualized feedback letter after each returned questionnaire. The control group received condition-specific written health education materials and reimbursement for exercise equipment or fitness club membership after returning the 1-year end of the study questionnaire. RESULTS: Changes in visit rates were disease specific. Parameter estimates were calculated from a Poisson regression model. For intervention vs. controls, the arthritis group decreased visits 4.84 per 30 months (p < 0.00), the diabetes group had no significant change, and the hypertension group increased visits 2.89 per 30 months (p < 0.05), the overall health status improved significantly (-6.5 vs. 2.3, p < 0.01) for the arthritis group but showed no significant change for the other two groups, and coronary artery disease and cancer risk scores did not change significantly for any group individually. Overall self-efficacy for intervention group completers improved by -8.6 points (p < 0.03) for the arthritis group, and the other groups showed no significant change. CONCLUSIONS: This study demonstrated that in a population of 18 to 64 years with chronic conditions, mailed health promotion programs might only benefit people with certain conditions.     

Toward clinical applications of health status measures: sensitivity of scales to clinically important changes.

While the validity and reliability of many newer health status instruments have been reported, few data are available regarding the sensitivity of these instruments to clinically discernible changes in patient status. We studied this feature of the Sickness Impact Profile (SIP) in a group of patients with rheumatoid arthritis, comparing it with more traditional measures of functional status (the American Rheumatism Association (ARA) functional classification and a patient self-rating scale). Four different approaches were devised to measure "sensitivity to clinical change." These involved comparisons of functional score changes with clinical changes in patient status which were independently agreed upon by both clinician and patient, and also comparisons with several clinical disease severity indicators. When applied to groups of patients, the SIP and the patient self-rating scale were modestly superior to the ARA scale, but neither the SIP nor the self-rating scale was clearly superior to the other. For considering individual patients, all of the scales were relatively insensitive, and predictive accuracy for clinically estimated change was low. New strategies for assessing sensitivity to small changes should be developed and applied to health status and functional scales. Attention to this characteristic should allow refinement of existing scales and may enhance their clinical usefulness.     

Community-based lifestyle interventions: changing behaviour and improving health

OBJECTIVE: To explore the association between change in physical activity levels and fruit and vegetable consumption and changes in self-reported overall health and mental health, of residents living in deprived English communities. DESIGN: Household survey conducted in 2002 and repeated in 2004. SETTING: Thirty-nine deprived UK communities in areas participating in the New Deal for Communities (NDCs), a major government funded community development initiative. PARTICIPANTS: Ten thousand four hundred and nineteen residents in NDC areas and neighbouring comparator areas. MAIN RESULTS: Overall levels of physical activity and fruit and vegetable consumption are low but a large positive change in diet or levels of physical activity is associated with a significant change in mental health (2.86 and 2.71, respectively: P < 0.01). Smaller, but also statistically significant, changes were found in physical health (0.07 and 0.05, P < 0.01). Specific dimensions of mental health which showed a large change in association with lifestyle change were those associated with 'peacefulness' and 'happiness'. CONCLUSIONS: These findings suggest that, for residents of these neighbourhoods, positive lifestyle changes such as increasing physical activity levels and increase in fruit and vegetable consumption are associated with positive changes in mental health. WHAT THIS PAPER ADDS: What is already known? Mental health, a key area of health inequality is related to physical health, and associated with education, employment, environment and community issues. There is known to be a relationship between improved lifestyle (increased physical activity levels and better diet) and better health. What does this study add? This study shows that over two years, measurable changes in lifestyle were associated with improvements in both mental health and self-reported overall health. The association of lifestyle changes with overall health, although statistically significant, were less significant than those with mental health over the same period, suggesting those wanting to measure the impact of community activity on health will be more likely to see a measurable short-term impact on mental, rather than overall self-reported health.     

Disease activity and severity in patients with rheumatoid arthritis: relations to socioeconomic inequality

The aim of this study was to investigate possible differences in measures on disease process, joint damage, health status and self-efficacy between patients with rheumatoid arthritis (RA) living in an affluent and in a less affluent area in the same city. We analyzed data collected on patients enrolled in a community-based register of patients with RA in Oslo, Norway. 246 patients were examined by questionnaire in 1994 and 133 patients were examined clinically in 1997. Measures on disease process, joint damage, health status and self-efficacy were compared between patients from two residential areas. There was no significant difference regarding joint counts, patients' or investigator's evaluation of disease severity, blood test results and number of joint replacements. Significant differences were observed for disability and for various dimensions of health measured by the arthritis impact measurement scales and the short form-36: patients in the less affluent area reported poorer health status. Patients in this area also showed significantly lower scores on the arthritis self-efficacy scale. Patients with RA in two socioeconomically different areas in Oslo thus were found to be equal regarding disease process and joint damage measures. However, in the measures reflecting physical and psychosocial health status, patients in the less affluent area seemed to be more seriously ill. They also showed less confidence in their ability to influence the disease. Even in a welfare society with universal access to health care the impact of a well-defined chronic disease seems to be closely linked to the patient's socioeconomic situation.     

Analysis of quality of life among patients with bronchial asthma or rheumatoid arthritis

AIMS: The authors have analysed the quality of life of 228 asthmatic patients and of 81 patients suffering from rheumatoid arthritis with a general and a disease specific instrument. RESULTS: Their results indicate that the subjects experience a lower level of quality of life. Despite the availability the valid clinical tests they can not predict how the patients feel, what is their health status like. CONCLUSIONS: In every day clinical practice it is necessary to quantify the patients quality of life especially in chronically ill patients. To do so it is important to use reliable instruments which are easy to use. They have found strong correlation between the Euro-QoL and the disease specific instruments both in asthma and rheumatoid arthritis, so they could conclude that the Euro-QoL questionnaire is an easy and reliable instrument in daily practice to assess the quality of life of asthmatics and patients suffering from rheumatoid arthritis.     

A pragmatic defence of health status measures

A family of instruments has been developed over the last twenty five years in order to measure the individual's subjective view of his health. The instruments vary in how broadly they define health. A wide range of critiques have challenged both the validity of these measures and their uses. This paper argues that disproportionate attention has been given to one form of health status measure--the so-called utility-based measures. The ensuing controversies have distracted from the substantial progress achieved in the application of health status measures. This paper identifies the major areas of progress and argues that any serious critique needs to engage with this now sizeable body of applied knowledge.     

Congress on Medical Education and Licensure: … Chicago,Feb. 7–9

The number of veterans obtaining healthcare services at Huntington Veteran's Administration Medical Center (HVAMC) had significantly increased over the five-year span from fiscal year 2000 through fiscal year 2004. The authors' purpose in this study was to determine changes in outpatient satisfaction levels at HVAMC over that five-year period. The authors assessed the following specific measures of patient satisfaction: courtesy, access, patient preferences, coordination of care, education and information, emotional support, overall quality, pharmacy services, and overall satisfaction. Of the 17,000 patients meeting the criteria, 630 were randomly selected; 195 patients completed surveys, resulting in a 31% response rate. Results demonstrated an overall significantly higher level of patient satisfaction than five years previously. On the basis of these results, the medical center administration can probably conclude that any process improvements made over the five-year period have been successful.     

Overall outpatient satisfaction and its components: perceived changes at the Huntington VA Medical Center over five years

The number of veterans obtaining healthcare services at Huntington Veteran's Administration Medical Center (HVAMC) had significantly increased over the five-year span from fiscal year 2000 through fiscal year 2004. The authors' purpose in this study was to determine changes in outpatient satisfaction levels at HVAMC over that five-year period. The authors assessed the following specific measures of patient satisfaction: courtesy, access, patient preferences, coordination of care, education and information, emotional support, overall quality, pharmacy services, and overall satisfaction. Of the 17,000 patients meeting the criteria, 630 were randomly selected; 195 patients completed surveys, resulting in a 31% response rate. Results demonstrated an overall significantly higher level of patient satisfaction than five years previously. On the basis of these results, the medical center administration can probably conclude that any process he improvements made over the five-year period have been successful.     

The health-related quality of life of patients with epilepsy compared with angina pectoris, rheumatoid arthritis, asthma and chronic obstructive pulmonary disease

The objective of this study was to compare the health-related quality of life (HRQL) of patients with epilepsy with populations suffering from different chronic diseases, using the short form 36 (SF-36) health profile measure. The populations to be compared were adult patients drawn from hospital based registers, with confirmed epilepsy (n = 397), angina pectoris (n = 785), rheumatoid arthritis (n = 1030), asthma (n = 117) and chronic obstructive pulmonary disease (COPD) (n = 221). Health-related quality of life scores were compared using analysis of covariance (ANCOVA) for predicting mean scores adjusted for age, gender, education and comorbidity. Patients with epilepsy on average scored highest on all scales, reflecting that in our sample the majority had well-controlled epilepsy. Our results indicate that the HRQL of a representative sample of patients with epilepsy is good, when compared with other chronic disorders, although reduced in several dimensions compared with a general reference population. Patients with rheumatoid arthritis (RA) and COPD scored lowest on the physical function scales, while rheumatoid arthritis patients reported most pain. This revised version was published online in June 2006 with corrections to the Cover Date.     

The impact of socio-economic factors on functional status decline among community-dwelling older adults in China

The purpose of this paper is to examine the impact of baseline socio-economic factors on functional status decline over a period of 3 years among a sample of Chinese older men and women, using the China Health and Nutrition Surveys of 1997 and 2000. In addition, the study tries to determine whether risk differentials by these socio-economic factors can be explained by other demographic, health-related and nutritional risk factors. The eligible study population was defined as women and men aged 55 years and over who at baseline were free from any form of disablement in activities of daily living (ADLs) or instrumental activities of daily living (IADL) tasks. Among subjects with complete data at followed-up (N = 976), the overall incidence proportions of any functional status decline, IADL only and ADL declines were 25.8%, 18.9% and 6.9%, respectively. Our study found that education is strongly and inversely associated with incidence of combined functional status decline and IADL only but not with the onset of ADL disability. Similarly, household income per capita was inversely associated with functional status decline and IADL disability incidence, with a clear dose-response relationship, even after adjustment for age and gender. However, multivariate analysis demonstrated that the latter association was highly confounded by other demographic factors, especially urban-rural area of residence. Using a combined measure of socio-economic status that includes years of education and household income per capita, the age and gender-adjusted odds ratio for functional status decline and belonging to lower SES class as compared to middle, upper middle and upper classes was 3.82 (95% CI: 2.15, 6.77) and 2.77 (95% CI: 1.52, 5.03) after further adjustment for urban-rural area of residence and living arrangements. Hence, there are wide socio-economic disparities in the functional health of older adults in China, although such disparities are more seen for IADL decline and are almost exclusively attributed to differentials in educational attainment. Finally, nutritional and health-related risk factors do not seem to act as intermediate factors in this association and hence further research should try to uncover other mechanisms by which SES affects changes in functional health among older adults in China.     

Willingness to accept risk in the treatment of rheumatic disease.

STUDY OBJECTIVE--The aim was to assess patients willingness to accept mortal risk in the drug treatment of chronic rheumatic disease. DESIGN--A non-random sample of consecutive patients were interviewed with a standardised survey instrument. SETTING--The study took place in the Royal National Hospital for Rheumatic Diseases, Bath, UK. PATIENTS--100 consecutive in- and out-patients aged 65 or less were interviewed, 50 with rheumatoid arthritis and 50 with ankylosing spondylitis. Mean age was 48 years with mean disease duration of 14 years. The rheumatoid arthritis group was mainly female (84%), v 26% in the ankylosing spondylitis group. MEASUREMENTS AND MAIN RESULTS--Risk preferences were elicited using the method of standard gamble in the context of a hypothetical new drug. Patients indicated the maximum percentage probability of mortality they regarded as acceptable to achieve four different levels of benefit: total cure (20.7%), relief of pain (16.9%), relief of stiffness (13.1%), return to normal functioning (14.5%). Rheumatoid arthritis patients displayed a higher (p less than 0.05) willingness to accept risk than ankylosing spondylitis patients for all gambles except relief of stiffness. Analysis of variance indicated that willingness to accept risk decreases with the duration of disease and increases with reductions in self assessed health status. CONCLUSIONS--Evaluative methods such as standard gamble can elicit useful risk-benefit preference data from patients to assist those who manage clinical risks.     

合肥市某机构近5年职工健康体检结果分析及健康干预对策

目的通过对合肥市某机构近5年来职工健康体检状况的综合分析,探寻危害职工健康的主要因素,为实施相应的健康干预对策提供依据。方法收集近5年职工体检报告,分析体检指标年度变化趋势和异常指标在不同年龄职工分布情况。结果 5年来职工相关指标异常由高到低依次为:高血脂16.49%、脂肪肝12.07%、高胆固醇7.66%、高尿酸6.77%、高血糖4.57%、心电图异常4.42%。高血脂、脂肪肝、高血糖检出率呈逐年上升趋势;除心电图异常外,高血脂、脂肪肝、高胆固醇、高尿酸、高血糖以35岁以上职工检出率最高。结论慢性生活方式疾病危险因素是影响职工当前和未来健康的主要危害因素,加强健康生活方式指导,改变不良的生活方式行为,是提高职工身心健康水平的方法和主要干预对策。     

The short-term effect of patient health status assessment in a health maintenance organization

This study was designed to test the short-term effects of health assessment on the process of care and patient satisfaction. The 29 Chart physicians used the Dartmouth COOP Charts to measure their adult patients' health status during a single clinical encounter; the 27 control clinicians used no measure of health status. We compared the change between baseline and post-intervention information for a sample of all study clinicians' patients. Most of the patients were female (67%), well educated (70% had at least a college education) and young (approximately 90% were aged 59 years or younger). We found that the ordering of tests and procedures for women was increased by exposure to the COOP Charts (52% vs. 35%; p<0.01); the effect in men was not as significant (37% vs. 23%: p=0.06). Although women reported no change in satisfaction with care, men claimed that the clinician helped in the management of pain (p=0.02). We conclude that the use of health status measures during a single clinical encounter in an HMO changes clinician test ordering behaviour and may improve the help male patients receive for pain conditions. The long-term impact of these management changes is not known.This grant was supported by the henry J. Kaiser Family Foundation.     

Adalimumab for Rheumatoid Arthritis

Third-party payors and national health systems require evidence that new medications for rheumatoid arthritis are cost effective. To determine cost effectiveness, one must consider the cost of a given therapy versus the long-term cost of the disease, with and without therapy. The direct and indirect costs of rheumatoid arthritis over the course of the disease, including the considerable costs related to hospitalization and disability, have been quantified. Resource utilization and treatment costs are high for patients with rheumatoid arthritis, and there is a strong link between functional disability and direct cost of care.Traditional disease-modifying antirheumatic drugs (DMARDs) [such as methotrexate and gold] have limited long-term effects in improving lives and avoiding costs for patients with rheumatoid arthritis. Tumor necrosis factor (TNF) antagonists, the newest class of rheumatoid arthritis drug therapies, significantly improve patient outcomes, including reducing the signs and symptoms of rheumatoid arthritis, improving physical function and health-related quality of life, and inhibiting radiographie damage. Failing to treat rheumatoid arthritis effectively is very costly; effective treatment includes early, aggressive therapy. As a result, the National Health Service in the UK, other societal decision-makers, and third-party payors have recommended the use of TNF antagonists, in many instances, for the treatment of rheumatoid arthritis.The TNF antagonists — infliximab, etanercept, and the most recently approved, adalimumab — address the limitations of traditional DMARDs, thus setting a new therapeutic standard for rheumatoid arthritis. Data from three key studies (Anti-TNF Research Program of the Monoclonal Antibody Adalimumab in Rheumatoid Arthritis, DE019 and DE011) indicate that adalimumab provides a rapid, sustainable, predictable, and significantly greater reduction in the signs and symptoms of rheumatoid arthritis than traditional DMARDs. Adalimumab yields significantly less structural joint damage as measured by the total Sharp scores and scores on its two major components: joint erosions and joint space narrowing. It also improves physical function (as measured by the Health Assessment Questionnaire Disability Index) and health utility (as measured by the Health Utilities Index Mark 3).In conclusion, rheumatoid arthritis and other musculoskeletal diseases are costly, but an upfront investment in highly effective therapies may provide long-term cost savings compared with traditional therapies. The immediate, out-of-pocket costs of TNF antagonists are greater than traditional DMARDs, but with the potential to significantly improve response rates, inhibit structural joint damage, and improve disability and health utility, TNF antagonists have the potential to be more cost effective over the long run. TNF antagonists can be valuable for patients in need and therefore appropriate for reimbursement by national health systems and third-party payors.     

Decentralized didactic training for physician assistants: academic performances across training sites

Decentralized training for the didactic portion of allied health programs has been assessed for its ability to increase the likelihood that graduates will practice in underserved areas. The question still remains whether these distant sites provide an education that is comparable to that offered at the main campuses. Exams and final grades for all classes over the course of five years at MEDEX Northwest in Seattle were compared to determine whether there was any major discrepancy between the main training location and the decentralized sites. With the exception of three individual cases, overall academic performances in all training sites were comparable. This suggests that programs employing some of the curricular and administrative controls in place at MEDEX Northwest can achieve a parity in education across their various training sites.