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Aspects of health-related quality of life: Associations with psychological and biological factors, and use as patient reported outcome in routine health care
Linköping University, Department of Social and Welfare Studies, Health, Activity, Care. Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Health-related quality of life (HRQoL) is increasingly recognised as an important patient-reported outcome in health care research. However, the use is still restricted and several questions remain about the value and feasibility of using measures of HRQoL in routine health care. The general aims of the thesis were therefore to increase the understanding of these issues by studying 1) associations of HRQoL with psychological and biological factors, 2) comorbidity adjustments of HRQoL measurement results, and 3) the patient-perceived value and feasibility regarding the use of measures of HRQoL as patient-reported outcome in routine health care.

Methods Three different data sets were used; baseline data (questionnaire, anthropometric, and biological) from the ongoing Life conditions, Stress, and Health Study (n=1007, papers I and II), data from a population survey from the County Council of Östergötland in combination with data from two national Swedish registries, the National Inpatient Register and the Causes of Death Register (n=6086, paper III), and data (questionnaire) from the multicentre Swedish Health Promoting Hospitals Network Health outcome assessment project (n=463, paper IV). The HRQoL measures used were the SF-36 and the EQ-5D. Statistical methods include variance, correlation and regression analyses.

Results Psychological resources (Self-esteem, Sense of Coherence, and Perceived Control) as well as psychological risk factors (depressive mood) were found to relate independently to HRQoL (SF-36) in the expected directions (positive relations for resources and negative relations for risk factors), but with fewer sex differences than expected (Paper I). Low HRQoL (SF-36) was found to relate to higher levels of inflammatory biological factors (C-reactive protein, Interleukin-6, and MatrixMetalloProteinase-9), and, especially regarding Interleukin-6, many association remained significant, though attenuated, after adjustment for factors of known importance to HRQoL (age, sex, disease, lifestyle and psychological factors) (Paper II). A new comorbidity index, the Health-related Quality of Life Comorbidity Index (HRQL-CI), explicitly developed for use in HRQoL outcomes studies, showed higher explanatory power (higher R2 values) than the commonly used Charlson Comorbidity Index (CCI) regarding impact of comorbidity on HRQoL (SF-36 and EQ-5D). However, regarding mortality the CCI discriminated better between those who died within a year from answering the HRQoL questionnaires, died within ten years, or who were still alive after ten years. This result is in line with the CCI’s original purpose as a mortality predictor. Using morbidity data from mandatory, highly valid national health data bases was found to be useful in a large study of this kind, where using data from medical records might be impractical. (Paper III). Using measures of HRQoL as patient-reported outcome measures in routine health care was regarded as valuable by the majority of the patients in the Health outcome assessment project. A new concept was introduced, respondent satisfaction, and the respondent satisfaction summary score was in most cases equal, i.e. SF-36 and EQ-5D were found to be quite similar regarding the cognitive response process (understanding and responding to the items in the EQ-5D and the SF-36) and patient-perceived content validity (if EQ-5D and SF-36 gave patients the ability to describe their health in a comprehensive way) (Paper IV).

Conclusions The four papers investigated different aspects of HRQoL that are important for the implementation of the use of measures of HRQoL within the health care system. In conclusion, 1) the use of measures of HRQoL to identify patients with low HRQoL for further health promoting interventions might be supported on a psychological (psychological resources are related to better HRQoL) and biological basis (low HRQoL being an important sign of increased biological vulnerability), 2) a comorbidity index specifically aimed to adjust for comorbidity in patient HRQoL outcomes studies was found to be valid in a normal population (that might serve as a reference population in future studies), and 3) patients perceived the use of measures of HRQoL to be valuable and feasible in routine health care, and questionnaire length and ease of response were not found to be crucial arguments in the choice between SF-36 and EQ-5D. Hence, in their own way, they all and together, contribute to removing obstacles in the implementation process of using patient-reported outcome measures in the health care system for quality improvement.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. , 80 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1295
National Category
Other Medical Sciences not elsewhere specified
Identifiers
URN: urn:nbn:se:liu:diva-74758ISBN: 978-91-7519-958-0 (print)OAI: oai:DiVA.org:liu-74758DiVA: diva2:492046
Public defence
2012-03-16, K2, Kåkenhus, Campus Norrköping, Linköpings universitet, Norrköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-02-07 Created: 2012-02-07 Last updated: 2012-03-23Bibliographically approved
List of papers
1. Psychological factors related to physical, social,and mental dimensions of the SF-36: a populationbasedstudy of middle-aged women and men
Open this publication in new window or tab >>Psychological factors related to physical, social,and mental dimensions of the SF-36: a populationbasedstudy of middle-aged women and men
2010 (English)In: patient related outcome measures, Vol. 1, 153-162 p.Article in journal (Refereed) Published
Abstract [en]

Background: Measures of health-related quality of life (HRQoL) are increasingly used as patient-reported outcome measures in routine health care. Research on determinants and correlates of HRQoL has, therefore, grown in importance. Earlier studies have generally been patient-based and few of them have examined differences between women and men. The aim of this study was to explore the relationship between psychological factors and physical, social, and mental dimensions of HRQoL, as measured by the Medical Outcome Study Short Form-36 Health Survey (SF-36), in a normal population and to see if observed relations were the same for women and men.

Methods: Relations between scale scores for the eight scales of SF-36 and scale scores for Self-esteem, Sense of Coherence, Perceived Control, Depressed Mood (CES-D), and Cynicism were assessed through partial correlation and multiple linear regression analyses on a sample of 505 women and 502 men (aged 45–69 years), stratified for sex and adjusted for effects of age, presence of disease, back pain, lifestyle, and social support.

Results: All psychological factors tested, except Cynicism, were significantly correlated to all scales of the SF-36 for women and men (Pearson product-moment partial correlation coefficient, |r| = 0.11–0.63 and |r| = 0.11–0.60, respectively). The addition of psychological factors into regression models resulted in significant total explained variance (R2) changes in all scales of the SF-36 for both sexes. Any discrepancies between women and men pertained more to the strength of relationships rather than the significance of different psychological factors.

Conclusion: In this population-based study, psychological factors showed significant correlation, for women and men alike, with the physical and social scales of SF-36, as well as the mental scales. These findings suggest that assessments of HRQoL are not merely a measure of absolute function but are also dependent on people’s perception of their ability.

Place, publisher, year, edition, pages
Dove Medical Press Limited, 2010
Keyword
Health-related quality of life, patient-reported outcome measures, population
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-66496 (URN)10.2147/PROM.S13209 (DOI)
Projects
LSH-studien
Available from: 2011-03-17 Created: 2011-03-17 Last updated: 2014-11-13Bibliographically approved
2. Associations between SF-36 and inflammatory biomarkers CRP, CXCL8, IL-1β, IL-6, IL-10, and MMP-9 in a normal middle-aged Swedish population
Open this publication in new window or tab >>Associations between SF-36 and inflammatory biomarkers CRP, CXCL8, IL-1β, IL-6, IL-10, and MMP-9 in a normal middle-aged Swedish population
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective: To evaluate associations between health-related quality of life, HRQoL, and inflammatory biomarkers in a normal population, and investigate whether associations could be explained by the presence of disease, lifestyle and/or psychological factors.

Methods: A randomly selected sample of a middle-aged Swedish population (n=961; aged 45-70 years, 50% women) was investigated. Self-reported data on HRQoL (SF-36), presence of disease, lifestyle and psychological factors, and plasma levels of biomarkers of inflammation: C-reactive protein (CRP), CXCL8, interleukin (IL)-1β, 6, and 10, and matrix metalloproteinase-9, were analyzed using correlation and regression analyses.

Results: After adjustment for sex and age, significant negative associations were seen for all scales of the SF-36 to plasma levels of IL-6 and CRP (except the Mental Health scale for CRP), and to a lesser extent to MMP-9, while only a few significant associations were noted for the other biomarkers. Associations with IL-6 were attenuated but generally remained significant after full adjustment (for age, sex, presence of disease, lifestyle and psychological factors) in regression analyses, while associations with CRP for many scales became nonsignificant after control for lifestyle factors.

Conclusions: Poor HRQoL was related to low grade inflammation in a normal population. The results suggest a possible pathway for earlier observed effects of HRQoL on mortality risk and indicate that low HRQoL is a sign of increased biological vulnerability. The data further indicate that IL-6, CRP, and MMP-9 are more informative markers than CXCL8, IL-1β, and IL-10 for these relationships, but also that they may not convey exactly the same information.

Keyword
CRP; health-related quality of life; interleukin; MMP-9; population; SF-36
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75137 (URN)
Available from: 2012-02-17 Created: 2012-02-17 Last updated: 2012-02-17Bibliographically approved
3. Impact of comorbidity on health-related quality of life: a population-based study using the Charlson Comorbidity Index and the new Health-Related Quality of Life Comorbidity Index, with data from the Swedish National Inpatient Register
Open this publication in new window or tab >>Impact of comorbidity on health-related quality of life: a population-based study using the Charlson Comorbidity Index and the new Health-Related Quality of Life Comorbidity Index, with data from the Swedish National Inpatient Register
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objectives: To investigate the impact of comorbidity on general health-related quality of life (HRQoL) in a Swedish normal population using the Charlson Comorbidity Index (CCI), designed for mortality outcomes, and the new Health-Related Quality of Life Comorbidity Index (HRQL-CI, with physical and psychosocial subindexes) designed for HRQoL outcomes, and comorbidity analyses based on data from the Swedish national inpatient register.

Study design and setting:L In 1999, 6083 women (54%) and men aged 20-74 (mean 46, SD 15) responded to a public health survey in the county of Östergötland, Sweden, including measures of general HRQoL (the SF-36 and the EQ-5D).

Results: During 1987-1999, 478 (15 %) and 664 (21 %)/418 (13 %) persons had been registered with ≥1 hospital admission ICD-code included in the CCI and the HRQL-CI physical/psychosocial dimensions, respectively. Both indices discriminated between persons with different degrees of comorbidity regarding their HRQoL. The HRQL-CI received somewhat higher R2 values (e.g. SF-36 scales Physical Functioning 0.161 vs 0.067 and Mental Health 0.026 vs 0.004).

Conclusions: The new HRQL-CI, created on the basis of self-reports, proved to be a valid measure of comorbidity in a Swedish normal population using national register data.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75138 (URN)
Available from: 2012-02-17 Created: 2012-02-17 Last updated: 2012-02-17Bibliographically approved
4. Respondent satisfaction regarding SF-36 and EQ-5D, and patients' perspectives concerning health outcome assessment within routine health care
Open this publication in new window or tab >>Respondent satisfaction regarding SF-36 and EQ-5D, and patients' perspectives concerning health outcome assessment within routine health care
2007 (English)In: Quality of Life Research, ISSN 0962-9343, E-ISSN 1573-2649, Vol. 16, no 10, 1647-1654 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To investigate respondent satisfaction regarding SF-36 and EQ-5D and patients' perspectives concerning health outcome assessment within routine health care. Methods: Eighteen Swedish hospitals participated in the study which included 30 patient intervention groups (e.g. education groups for patients with ischemic heart disease or chronic obstructive pulmonary disease). Patients responded to SF-36 and EQ-5D before and after ordinary interventions (n = 463), and then completed an evaluation form. Results: Regarding respondent satisfaction, most patients found both questionnaires easy to understand (70% vs. 75% for SF-36 and EQ-5D respectively), easy to respond to (54% vs. 60%), and that they gave the ability of describing their health in a comprehensive way (68% for both). Health outcome assessment in routine health care was perceived as valuable by 57% of the patients, while 4% disapproved. Most patients (68%) considered both questionnaires equally suitable, 25% preferred SF-36 and 8% EQ-5D. Among those who were more satisfied with a short questionnaire (EQ-5D), several still preferred a longer and more comprehensive questionnaire (SF-36). Conclusion: Health outcome assessment within routine health care seems to be acceptable, and even appreciated, by patients. Questionnaire length and ease of response were not found to be crucial arguments in choosing between SF-36 and EQ-5D. © 2007 Springer Science+Business Media B.V.

Keyword
outcome assessment, SF-36, EQ-5D, patient perspective, respondent satisfaction
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-39617 (URN)10.1007/s11136-007-9263-8 (DOI)50285 (Local ID)50285 (Archive number)50285 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2017-12-13

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