Health Related Quality of Life: Health

status measures
- Quality of Life (QoL): Broad concept with many aspects that
measures peoples overall perception of their life.
- QoL includes both health-related and non health-related
aspects
- Non health-related aspects: economical, political, cultural,
- HRQoL is part of overall QoL
- HRQoL represents the functional effect of an illness and its
consequence therapy upon a patient, as perceived by the
patient
- In health related researches, QoL and HRQoL are used
interchangeably to indicate persons health

Importance of HRQoL
- In addition to physical functioning, the overall concept HRQoL
includes other aspects (domains) of health like psychological
and social functioning that are important to the patient
- HRQoL instruments can be used to detect undiagnosed or
undetected diseases such as depression.

HRQoL versus Utility Measures

Utility Measures:
- Such as SG & TTO
- Face to face interviews are conducted
- Because of using alternatives, they are termed PreferenceBased (or choice based) measures
- Respondents (subjects) are: general population, patients,
providers,
- Subjects are asked to imagine the health states described and
record their scores to reflect their preferences for various
scenarios
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HRQoL versus Utility Measures

HRQoL:
- Another technique to measure the effects of diseases and
treatments from a patients point of view.
- Non utility (non preference) measures
- Represents a patients estimation of his health at a point in time
- Conducted via survey (questionnaire)
- Respondents may be the patient, his relatives or caregivers, or
his health care providers, BUT the answers should be from the
patients standpoint.
- Include many scores for each patient based on different
domains of health (ex.: separate mental health score and
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physical health score for each respondent)

Assessment of HRQoL
A) General (Generic) Measures:
Focus on general health status
B) Disease-specific Measures:
Focus on specific aspects of the disease

General (Generic) Measures

- Could be used for comparison of different diseases conditions,
but may be not responsive to changes in health for every
disease
- Examples of General instruments:
Medical Outcomes Study Short-Form (MOS-SF). Includes (SF36, SF-12, SF-36 version 2)
Quality of Well-Being (QWB) Scale
Sickness Impact Profile

SF-36
- SF-36 is the most common used HRQoL generic instrument in
the USA
- Constructed to fill the gap between lengthy surveys and singleitem measures.
- Includes a self-evaluation of change in health during the past
year
- Standard version (4 weeks) and acute version (1 week)
- A newer version (version 2) and shorter version (SF-12) have
been developed.
- Ex.: SF-36 (Arabic version) and scoring (attached files)
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Disease-Specific Measures
- More responsive to changes in health
- Can not be used to compare different conditions.
- Sometimes it is so specific that comparisons between different
populations within the same disease are not possible (e.g.,
pediatric versus adult populations)

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Domains of health status

- Four essential dimensions (domains) should be included in all
HRQoL instruments:
Physical functioning
Psychological functioning
Social or role functioning
General health perceptions
- Less common indicated domains:
Economic, vocational, religious or spiritual status.

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Physical Functioning
- Indicates the observable limitations or disability experienced
over a defined period of time:
Can patients dress them selves?
Energy level
Confinement because of health problem
Bodily pain

Psychological (Mental) Functioning

- Psychological distress that can be a consequence of a disease
or a side effect of a treatment.
- Anxiety, depression, nervousness, moodiness, life satisfaction,
cognitive functioning.
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Social or Role Functioning

- The ability to develop, maintain, nurture social relationship
- Both the participation in social interactions and satisfaction by
these interactions
- The effect of health on ability to work, perform household duties
or complete schoolwork is covered by this concept
- Social or role functioning can be affected by physical or
psychological limitations

General Health Perception

- Elicits patients overall beliefs and evaluations about their health
- Relates to patients perceptions about their current health status
and their expectations for future health
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Assessing HRQoL instruments

- Decision makers are used to interpret objective data, such as
BP measurements, radiography results,
- patient-based assessment of pain, depression, anxiety are
subjective data.
- HRQoL instruments are required to be assessed for:
consistency (Reliability), precision (Validity) and
Responsevieness

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Reliability
- refers to the consistency of instrument
- Does the instrument produce the same score on multiple
administrations?
- Three types of reliability tests:
1. Test-retest reliability
- The same person completes HRQoL instrument then retakes
the same survey at later time. If his health status has not
changed, the scores should be similar for both times.
2. Internal consistency:
Measures the agreement between responses to questions within
the same domain, where it is logical to give the same answers.
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Reliability
3. Interrater reliability
-measures the agreement between two respondents when
assessing the health status of the same patient.
- Example: the mother and teacher of a kid with Attention Deficit
Hyperactivity Disorder (ADHD) are asked to complete the
survey. Then a comparison between the answers is done.
- Interrrater reliability is not commonly used as mostly patients
themselves are asked to fill the questionnaires.

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Validity
- Necessary to evaluate if the instrument actually measuring
what it is supposed to be measuring
- For an instrument to be valid, it must be reliable first
- Three common types for validity assessment
1. Content validity:
-whether the instrument offers an adequate representation of the
relevant variables of interest.
- Requires the existence of standard reference that might be wellaccepted theoretical definitions, existing accepted standards, or
interviews with those who have experience with the with the
problem under study (patients, caregivers, health care providers)
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Validity
2. Criterion validity:
- Demonstrates the relationship of HRQoL scores with external
evidence (criteria)
- Sometimes called predictive validity as the instrument scores
are used to predict health outcomes.
- Example:
High scores of HRQoL (indicting good health) and low use of
medical services
Low scores of HRQoL (poor health) predicts high mortality rate in
the coming year
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Validity
3. Construct validity:
- Evaluates both HRQoL instrument and the underlying theory.
- Convergent validity: ex.: scores of mental health of generic
instrument should correlate to those of disease specific
instrument for assessment of mental health
- Discriminant validity:
Ex.: a measure of physical functioning is not highly related to
mental functioning.
- known-group validity:
Ex.: higher level of anxiety in for first-time mothers than women
who gave birth to other children
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Responsiveness
- The ability of HRQoL instrument to detect changes in patients
health over time when his health status changes.

Other assessment issues

- HRQoL instruments must contain sufficient number of
questions to adequately measure the domains, but should be
short enough to be practical(not to be a burden on patient)
- The applicability of the domains to the research questions, the
ease of its use and the resources needed to obtain responses

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Pharmacoeconomics & HRQoL Measures

- HRQoL measures result in multiple scores per respondent
- It is possible that treatment A be more effective on some
dimensions of health
- Treatment B may be more effective on other dimensions
- Difficulty to use cost effectiveness ratios
- In some cases if Drug A cost is the same or lower than B and
show superior improvement on at least one dimension and not
worse on any other dimension, Drug A considered cost
effective
- In other cases, cost consequences tables may be presented
(costs in one column and scores of different domains are listed
other columns and no ratios are calculated)
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Preference-Based Classification Systems

- A hybrid of utility and HRQoL methods
- Utility score methods (SG, TTO) time and resource consuming
- HRQoL instruments do not calculate one utility score that can
be used to calculate pharmacoeconomics ratios
- An alternative option, preference-based classification systems:
Utility values (ranging from 0 to 1)
Less resource consuming instruments
- Most common preference-based systems:
EQ-5D, SF-6D, HUI3

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