Effectiveness and Outcomes in Health Care Proceedings of an Invitational Conference (1990) / Chapter Skim
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17 Assessing Health-Related Quality of Life Outcomes
17 Assessing Health-Related Quality of Life Outcomes
Pages 137-151
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From page 137... ...
methods for interpreting observed changes in measures. Before reviewing these issues, however, I would like to identify two challenges to our reliance on outcomes assessment for controlling health care costs.
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From page 138... ...
Rationing, capping reimbursement, and other methods of cost containment may produce outcomes in the lower left quadrant, that is, worse quality of life and lower costs. The upper left quadrant (higher cost, worse quality of life)
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From page 139... ...
Specific dimensions of opportunity, perception, functional status, impairment, and survival fall along this continuum. See Table 2 for a more comprehensive description of the concepts and dimensions of health-related quality of life.
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From page 140... ...
140 EFFECTIVENESS AND OUTCOMES IN HEALTH CARE TABLE 2 Concepts and Domains of Health-Related Quality of Life Concept and Domain Opportunity Social or cultural handicap Individual resilience Health perceptions Satisfaction with health function General health perceptions Functional status Social Limitations in usual roles Integration Contact Intimacy Psychological Affective Cognitive Physical Activity restrictions Fitness Impairment Subjective complaints S 1gns Self-reported disease Psychological measures Tissue alterations Diagnoses Death and duration of life Definition/Indic ator Disadvantage because of health Capacity for health; ability to withstand stress; reserve Physical, psychological, social Self-rating of health; health concern, worry Acute or chronic limitations in social roles of student, worker, parent, household member Participation in the community Interaction with others Perceived feelings of closeness; sexual Psychological attitudes and behaviors, including distress and general wellbeing or happiness Alertness, disorientation; problems in reasoning Acute or chronic limitation in physical activity, mobility, self-care, sleep, communication Performance of activity with vigor and without excessive fatigue Reports of physical and psychological symptoms, sensations, pain, health problems, or feelings not directly observable Physical examination: observable evidence of defect or abnormality Patient listing of medical conditions or impairments Laboratory data, records, and their clinical interpretation Pathological evidence Clinical judgments after "all the evidence" Mortality; survival; longevity SOURCE: Patrick and Erickson (5~.
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From page 141... ...
. prove .ers, or community Statistical: items weighted equally or from frequency of response 141 Strength Represents net impact May not be responsive Single instrument Effects on different outcomes possible Can select relevant outcomes Multiple comparisons possible Broadly applicable Summarize range of concepts May detect unanticipated effects More acceptable to respondents May be more responsive Interval scale Patient view incorporated Self-weighting samples More familiar techniques Appears easier to use Weakness Effects on different outcomes not possible May not be responsive Length often problem Cannot relate different outcomes to common scale Need to identify major outcome May not be responsive enough May not have focus of patient interest Length often problem Effects may be difficult to interpret Comparisons across conditions and populations not possible Difficulty obtaining weights May not differ from statistical weights that are easier to obtain May be influenced by prevalence SOURCE: Guyatt et al.
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From page 142... ...
Measures developed originally at The RAND Corporation the 108-item Health Insurance Study battery and the 20- to 40-item Medical Outcomes Study short-form generic measures cover a wide spectrum of health concepts for use in general populations (15~. All these generic measures have been tested extensively with different patient populations.
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From page 143... ...
Disease-specific measures are those designed to assess specific diagnostic groups or patient populations, often with the goal of measuring responsiveness or "clinically important" changes. These are changes that clinicians and patients think are discernible and important, have been detected with an intervention of known efficacy, or are related to well-established physiological measures (such as grip strength for arthritis patients or spirometry for those with chronic obstructive lung disease)
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From page 144... ...
The ARA classification, for example, may detect large changes, such as those following hip replacement, but not smaller changes following drug therapy judged successful by other criteria. The popularity of disease-specific measures arises primarily from the need of clinical trials and practitioners to use scales that are most responsive to clinical changes that occur over time.
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From page 145... ...
These omissions may not seriously compromise the usefulness of short-form measures in relatively well populations, but outcomes assessment in specific populations such as older persons, mentally ill persons, and institutionalized persons may require longform assessments. Responsiveness, how well short-form measures detect subtle changes in behavioral and subjective health status, also requires testing and comparison with clinical measures.
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From page 146... ...
Changes in disease-specific measures may be easier to interpret because they are more specific or more closely associated with changes in clinical measures of disease activity such as blood pressure or joint inflammation. Clinician or patient assessments of improvement, which are common measures of change or effects, may be more closely associated with changes in diseasespecific measures than with those in generic health status measures (27~.
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From page 147... ...
Figure 1 also indicates that the causal relationships among concepts can be reversed; for example, functional limitations and perceived health can be viewed as influencing impairment or physiological measures of chronic disease (29~. Reversing the causal chain permits testing of the variable course of chronic disease, whereby impairments may become permanent and lead to changes in behavior and perceptions that, in turn, influence symptoms or level of impairment.
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From page 148... ...
dimensions will be important for determining the association between specific disease states or disorders and their behavioral, perceptual, and social consequences. Increasing our understanding of these relationships will help us realize the potential of health-related quality of life measures for identifying the intervention strategies that address the most important concerns of patients, their families, clinicians, and society in general.
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From page 149... ...
Policy research tends to rely on available national data, and currently these data provide limited information about health status. The Effectiveness Initiative will be successful only if it motivates data collection and methods that incorporate a broad spectrum of health outcomes (such as death, impairment, functional status, and perceptions)
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From page 150... ...
Assessment of Function in Routine Clinical Practice: Description of the COOP Chart Method and Preliminary Findings. Journal of Chronic Diseases 40 Supplement 1:SSS-63S, 1987.
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From page 151... ...
73? Profile Demure Change?
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