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QoL Lecture final.ppt

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QoL Lecture final.ppt

  1. 1. Reasons of offering Treatment • Our interventions increase longevity, prevent future morbidity, or make patients feel better. • The first two of these three endpoints are relatively easy to measure. • In the last 20 years, however, clinicians have recognized the importance of direct measurement of how people are feeling, and how they are able to function in daily activities. Investigators have developed increasingly sophisticated methods of making these measurements.
  2. 2. Health Related QoL • Refers to a person or group's perceived physical and mental health over time. • To measure the effects of chronic illness in their patients to better understand how an illness interferes with a person's day-to-day life. • To measure the effects of numerous disorders, short- and long-term disabilities, and diseases in different populations.
  3. 3. What is Health-Related Quality of Life? • Health-related quality of life represents the functional effects of an illness and its consequent therapy upon a patient, as perceived by the patient DOMAINS • Physical • Psychological • Social
  4. 4. Knowledge defined as “coded information in the brain” - but 100 billion neurons, synapses in the brain - and the working of the brain only partially known - and we have evolutionary learning and hidden knowledge (interaction brain and environment over time) - hence always limited knowledge - hence behaviour is always systematic and random
  5. 5. Knowledge and science create value and reduce cost • Uncured diseases ranked by cost to society: – Heart disease – Cancer – Alzheimer´s – Diabetes – Arthritis – Depression – Stroke – Osteoporosis • The expected benefits from investment in medical science are enormous and will remain so
  6. 6. Quality of Life: Cancer Survival Rates • Acute Lymphatic Leukaemia – 1964-66: 4 % – 1994-96 89% • Breast Cancer – 1964-66 65% – 1994-96 84% • Prostate Cancer – 1964-66 45% – 1994-96 72% • Testicle Cancer – 1964-66 49% – 1994-96 95% • Lung Cancer women men – 1964-66 11% 8% – 1994-96 10% 10%
  7. 7. Why is HRQoL Important? • One of the aims of treating patients must be to enable them to feel better and to function better in their day-to- day activities. • The importance of incorporating health- related quality of life into their routine clinical practice and into clinical studies.
  8. 8. Reasons of offering Treatment We believe our interventions: • increase longevity • prevent future morbidity • make patients feel better. • The first two of these three endpoints are relatively easy to measure. • Investigators have developed increasingly sophisticated methods of direct measurement of how people are feeling, and how they are able to function in daily activities.
  9. 9. Measuring HRQL • Investigators measure HRQL using questionnaires that typically include questions about how patients are feeling or what they are experiencing associated with response options such as yes-no, or seven-point scales • Investigators aggregate responses to these questions into domains or dimensions (such as physical or emotional function) that yield an overall score.
  10. 10. Clinical Scenario • You are a physician following a 35 year-old man who has had active Crohn's disease for 8 years. • The symptoms were severe enough to require resectional surgery four years ago, and despite treatment with sulphasalazine and metronidazole, the patient has had active disease requiring oral steroids for the last two years. • Repeated attempts to decrease the prednisone have failed, and the patient has required doses of greater than 15 mg. per day to control symptoms. • You are impressed by both the methodology and results of a recent report documenting that such patients benefit from oral methotrexate and suggest to the patient that he consider this medication. When you explain some of the risks of methotrexate, particularly potential liver toxicity, the patient is hesitant. How much better, he asks, am I likely to feel while taking this medication?
  11. 11. • Users' Map for an Article about HRQL Are the recommendations valid? » Primary Guides 1. Have the investigators measured aspects of patients' lives that patients consider important? 2. Did the HRQL instruments work in the way they are supposed to? » Secondary Guides 3. Are there important aspects of HRQL that have been omitted? 4. If there were tradeoffs between quality and quantity of life, or an economic evaluation, have they used the right measures? What are the results? What was the magnitude of effect on HRQL? Will the results help me in caring for my patients? • 1. Will the information from the study help me inform my patients? • 2. Did the study design simulate clinical practice?
  12. 12. Measuring HRQoL • Health status, functional status, and quality of life are three concepts often used interchangeably to refer to the same domain of "health” • The health domain ranges from negatively valued aspects of life, including death, to the more positively valued aspects such as role function or happiness
  13. 13. Measuring HRQoL • Health-related quality-of-life questionnaires are either administered by trained interviewers or self-administered. • The former method is resource intensive but ensures compliance, decreases errors, and decreases missing items. • The latter approach is much less expensive but increases the number of missing subjects and increases missing responses. • A compromise between the two approaches is to have instruments completed with supervision.
  14. 14. What makes a Good HRQL Instrument • The goals of HRQL measures include differentiating between people who have a better HRQL and those who have a worse HRQL (a discriminative instrument) as well as measuring how much the HRQL has changed (an evaluative instrument)
  15. 15. Types of HRQL Measures Generic Instruments • Health Profiles • Two basic approaches characterize the measurement of HRQL: generic instruments (including single indicators, health profiles, and utility measures) and specific instruments • Health profiles are instruments that attempt to measure all important aspects of HRQL.
  16. 16. Example of Health Profile • The Sickness Impact Profile is an example of a health profile and includes a physical dimension (with categories of ambulation, mobility, as well as body care and movement); a psychosocial dimension (with categories including social interaction, alertness behavior, communication, and emotional behavior); and five independent categories including eating, work, home management, sleep and rest, as well as recreations and pastimes.
  17. 17. Generic Instrument • Utility Measures • The other type of generic instrument, utility measures of quality of life, are derived from economic and decision theory; they reflect the preferences of patients for treatment process and outcome. • They can be used in cost–utility analyses that combine duration and quality of life. In utility measures, HRQL is summarized as a single number along a continuum that usually extends from death (0.0) to full health (1.0) • Utility scores reflect both the health status and the value of that health status to the patient.
  18. 18. Specific Instruments • The second basic approach to quality-of- life measurement focuses on aspects of health status that are specific to the area of primary interest. • The instrument may be specific to the disease (such as heart failure or asthma), to a population of patients (such as the frail elderly), to a certain function (such as sleep or sexual function), or to a problem (such as pain).
  19. 19. Choosing the Appropriate HRQL Measure Health Status Surveys • The choice of an HRQL measure depends on the purpose of the study • Generic measures may be particularly useful for surveys that attempt to document the range of disability in a general population or a patient group
  20. 20. Instruments (contd) • Clinical Trials • Initially, when studying a new therapy (such as a new drug), investigators rely on disease-specific measures. • Disease-specific measures are clinically sensible in that patients and clinicians intuitively find the items directly relevant; their increased potential for responsiveness is particularly compelling in the clinical trial setting
  21. 21. Using instruments • A number of specific measures can be used together in a battery to obtain a comprehensive picture of the impact of different interventions on HRQL. • A variety of instruments, including measures of well-being, physical function, emotional function, sleep, sexual function, and side effects, were used to show that antihypertensive agents have a differential impact on many aspects of HRQL
  22. 22. Evaluating QoL STUDY DESIGNS • Cross-Sectional (Non-Randomised Longitudinal) Study: describes the predictors of QoL (Specialty vs PHC) • Randomized Study of a Clinical Intervention: measure reflects the nature of disease • Cost effectiveness & Cost-benefit Analysis (measuring QALYs)
  23. 23. Selecting an Assessment Instrument Instruments used vary according to: • The identity of the respondent (clinician, patient, relative) • The setting of the evaluation • The type of questionnaire used (short form, interview, survey) • The General approach to the evaluation
  24. 24. Selecting an Assessment Instrument • General Instruments are used in general population to assess a wide range of domains applicable to a variety of health states, conditions & disease (Gen. Health Surveys) • Disease Specific Instruments focus on the domains most relevant to the disease and on the characteristics of the patients in whom the condition is most prevalent (Clinical trials/specific therapeutic interventions)
  25. 25. Indicators of QoL • Functional ability • Health Status • Symptoms and Somatic State • Psychosocial Well-being • Social support & life satisfaction • Morale • Independence • Control over life • Coping & adjustment abilities
  26. 26. Types of QoL Measures • Generic • Dimension-specific • Disease – specific • Item- specific
  27. 27. HRQ Instruments • Sickness Impact Profile • Nottingham Health Profile • McMaster Health Index Questionnaire • WHOQOL Assessment • DALYs: Disability Adjusted Life Years • The Quality of Well being Scale
  28. 28. Thanks You

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