Henk F. van Stel

Comparison of the SF-6D and the EQ-5D in patients with coronary heart disease

BackgroundThe SF-6D was derived from the SF-36. A single summary score is obtained allegedly preserving the descriptive richness and sensitivity to change of the SF-36 into utility measurement. We compared the SF-6D and EQ-5D on domain content, scoring distribution, pre-treatment and change scores.MethodsThe SF-6D and the EQ-5D were completed prior to intervention and 1, 3, 6 and 12 months post-intervention in a study enrolling 561 patients with symptomatic coronary stenosis. Patients were randomized to off-pump coronary artery bypass surgery (CABG), standard on-pump CABG, or percutaneous transluminal coronary angioplasty (PTCA). Baseline and change over time scores were compared using parametric and non-parametric tests.ResultsThe relative contribution of similar domains measuring daily functioning to the utility scores differed substantially. SF-6D focused more on social functioning, while EQ-5D gave more weight to physical functioning. Pain and mental health had similar contributions. The scoring range of the EQ-5D was twice the range of the SF-6D. Before treatment, EQ-5D and SF-6D mean scores appeared similar (0.64 versus 0.63, p = 0.09). Median scores, however, differed substantially (0.69 versus 0.60), a difference exceeding the minimal important difference of both instruments. Agreement was low, with an intra-class correlation of 0.45.Finally, we found large differences in measuring change over time. The SF-6D recorded greater intra-subject change in the PTCA-group. Only the EQ-5D recorded significant change in the CABG-groups. In the latter groups changes in SF-6D domains cancelled each other out.ConclusionAlthough both instruments appear to measure similar constructs, the EQ-5D and SF-6D are quite different. The low agreement and the differences in median values, scoring range and sensitivity to change after intervention show that the EQ-5D and SF-6D yield incomparable scores in patients with coronary heart disease.

The Impact of Severe Sepsis on Health-Related Quality of Life: A Long-Term Follow-Up Study

BACKGROUND:Severe sepsis is frequently complicated by organ failure and accompanied by high mortality. Patients surviving severe sepsis can have impaired health-related quality of life (HRQOL). The time course of changes in HRQOL in severe sepsis survivors after discharge from the intensive care unit (ICU) and during a general ward stay have not been studied. METHODS:We performed a long-term prospective study in a medical-surgical ICU. Patients with severe sepsis (n = 170) admitted for >48 h were included in the study. We used the Short-form 36 to evaluate the HRQOL of severe sepsis patients before ICU and hospital stay and at 3 and 6 mo after ICU discharge. Furthermore, we compared the results for ICU admission and 6 mo after ICU discharge with those of an age-matched general Dutch population. RESULTS:At 6 mo after ICU discharge, 95 patients could be evaluated (eight patients were lost to follow-up, 67 died). HRQOL showed a multidimensional decline during the ICU stay and gradual improvement over the 6 mo after ICU discharge for the social functioning, vitality, role-emotional, and mental health dimensions. However, 6 mo after ICU discharge, scores for the physical functioning, role-physical, and general health dimensions were still significantly lower than preadmission values. Physical and Mental Component Scores changed significantly over time. In particular, the Mental Component Score showed a small decline at ICU discharge but recovered rapidly, and at 6 mo after ICU discharge had improved to near normal values. In addition, Short-form 36 scores were lower than those in a matched general population in six of the eight dimensions, with the exception of social functioning and bodily pain. Interestingly, the preadmission HRQOL in surviving patients was already lower in three of the eight dimensions (role-physical, mental health, and vitality) when compared with the general population. CONCLUSIONS:Severe sepsis patients demonstrate a sharp decline of HRQOL during ICU stay and a gradual improvement during the 6 mo after ICU discharge. Recovery begins after ICU discharge to the general ward. Nevertheless, recovery is incomplete in the physical functioning, role-physical, and general health dimensions at 6 mo after ICU discharge compared with preadmission status.

Quality of life before intensive care unit admission is a predictor of survival

IntroductionPredicting whether a critically ill patient will survive intensive care treatment remains difficult. The advantages of a validated strategy to identify those patients who will not benefit from intensive care unit (ICU) treatment are evident. Providing critical care treatment to patients who will ultimately die in the ICU is accompanied by an enormous emotional and physical burden for both patients and their relatives. The purpose of the present study was to examine whether health-related quality of life (HRQOL) before admission to the ICU can be used as a predictor of mortality.MethodsWe conducted a prospective cohort study in a university-affiliated teaching hospital. Patients admitted to the ICU for longer than 48 hours were included. Close relatives completed the Short-form 36 (SF-36) within the first 48 hours of admission to assess pre-admission HRQOL of the patient. Mortality was evaluated from ICU admittance until 6 months after ICU discharge. Logistic regression and receiver operating characteristic analyses were used to assess the predictive value for mortality using five models: the first question of the SF-36 on general health (model A); HRQOL measured using the physical component score (PCS) and mental component score (MCS) of the SF-36 (model B); the Acute Physiology and Chronic Health Evaluation (APACHE) II score (an accepted mortality prediction model in ICU patients; model C); general health and APACHE II score (model D); and PCS, MCS and APACHE II score (model E). Classification tables were used to assess the sensitivity, specificity, positive and negative predictive values, and likelihood ratios.ResultsA total of 451 patients were included within 48 hours of admission to the ICU. At 6 months of follow up, 159 patients had died and 40 patients were lost to follow up. When the general health item was used as an estimate of HRQOL, area under the curve for model A (0.719) was comparable to that of model C (0.721) and slightly better than that of model D (0.760). When PCS and MCS were used, the area under the curve for model B (0.736) was comparable to that of model C (0.721) and slightly better than that of model E (0.768). When using the general health item, the sensitivity and specificity in model D (sensitivity 0.52 and specificity 0.81) were similar to those in model A (0.45 and 0.80). Similar results were found when using the MCS and PCS.ConclusionThis study shows that the pre-admission HRQOL measured with either the one-item general health question or the complete SF-36 is as good at predicting survival/mortality in ICU patients as the APACHE II score. The value of these measures in clinical practice is limited, although it seems sensible to incorporate assessment of HRQOL into the many variables considered when deciding whether a patient should be admitted to the ICU.

Clustering of health-related behaviors, health outcomes and demographics in Dutch adolescents: A cross-sectional study

BackgroundRecent studies show several health-related behaviors to cluster in adolescents. This has important implications for public health. Interrelated behaviors have been shown to be most effectively targeted by multimodal interventions addressing wider-ranging improvements in lifestyle instead of via separate interventions targeting individual behaviors. However, few previous studies have taken into account a broad, multi-disciplinary range of health-related behaviors and connected these behavioral patterns to health-related outcomes. This paper presents an analysis of the clustering of a broad range of health-related behaviors with relevant demographic factors and several health-related outcomes in adolescents.MethodsSelf-report questionnaire data were collected from a sample of 2,690 Dutch high school adolescents. Behavioral patterns were deducted via Principal Components Analysis. Subsequently a Two-Step Cluster Analysis was used to identify groups of adolescents with similar behavioral patterns and health-related outcomes.ResultsFour distinct behavioral patterns describe the analyzed individual behaviors: 1- risk-prone behavior, 2- bully behavior, 3- problematic screen time use, and 4- sedentary behavior. Subsequent cluster analysis identified four clusters of adolescents. Multi-problem behavior was associated with problematic physical and psychosocial health outcomes, as opposed to those exerting relatively few unhealthy behaviors. These associations were relatively independent of demographics such as ethnicity, gender and socio-economic status.ConclusionsThe results show that health-related behaviors tend to cluster, indicating that specific behavioral patterns underlie individual health behaviors. In addition, specific patterns of health-related behaviors were associated with specific health outcomes and demographic factors. In general, unhealthy behavior on account of multiple health-related behaviors was associated with both poor psychosocial and physical health. These findings have significant meaning for future public health programs, which should be more tailored with use of such knowledge on behavioral clustering via e.g. Transfer Learning.

Aerobic exercise in adolescents with obesity: preliminary evaluation of a modular training program and the modified shuttle test

BackgroundIncreasing activity levels in adolescents with obesity requires the development of exercise programs that are both attractive to adolescents and easily reproducible. The aim of this study was to develop a modular aerobic training program for adolescents with severe obesity, with a focus on variety, individual targets and acquiring physical skills. We report here the effects on aerobic fitness from a pilot study. Furthermore, we examined the feasibility of the modified shuttle test (MST) as an outcome parameter for aerobic fitness in adolescents with severe obesity.MethodsFifteen adolescents from an inpatient body weight management program participated in the aerobic training study (age 14.7 ± 2.1 yrs, body mass index 37.4 ± 3.5). The subjects trained three days per week for 12 weeks, with each session lasting 30–60 minutes. The modular training program consisted of indoor, outdoor and swimming activities. Feasibility of the MST was studied by assessing construct validity, test-retest reliability and sensitivity to change.ResultsComparing pretraining and end of training period showed large clinically relevant and significant improvements for all aerobic indices: e.g. VO2 peak 17.5%, effect size (ES) 2.4; Wmax 8%, ES 0.8. In addition, a significant improvement was found for the efficiency of the cardiovascular system as assessed by the oxygen pulse (15.8%, ES 1.6).Construct validity, test-retest reliability and sensitivity to change of the MST were very good. MST was significantly correlated with VO2 peak (r = 0.79) and Wmax (r = 0.84) but not with anthropometric measures. The MST walking distance improved significantly by 32.5%, ES 2.5. The attendance rate at the exercise sessions was excellent.ConclusionThis modular, varied aerobic training program has clinically relevant effects on aerobic performance in adolescents with severe obesity. The added value of our aerobic training program for body weight management programs for adolescents with severe obesity should be studied with a randomized trial. This study further demonstrated that the MST is a reliable, sensitive and easy to administer outcome measure for aerobic fitness in adolescent body weight management trials.

Nonlinear exercise training in advanced chronic obstructive pulmonary disease is superior to traditional exercise training. A randomized trial.

RATIONALE The optimal exercise training intensity and strategy for individualized exercise training in chronic obstructive pulmonary disease (COPD) is not clear. OBJECTIVES This study compares the effects of nonlinear periodized exercise (NLPE) training used in athletes to traditional endurance and progressive resistance (EPR) training in patients with severe COPD. METHODS A total of 110 patients with severe COPD (FEV1 32% predicted) were randomized to EPR or NLPE. Exercise training was performed three times per week for 10 weeks. The primary outcomes were cycling endurance time and health-related quality of life using the Chronic Respiratory Questionnaire. The difference in change between EPR and NLPE was assessed using linear mixed-effects modeling. MEASUREMENTS AND MAIN RESULTS NLPE resulted in significantly greater improvements in cycling endurance time compared with EPR. The difference in change was +300.6 seconds (95% confidence interval [CI] = 197.2-404.2 s; P < 0.001). NLPE also resulted in significantly greater improvements in all domains of the Chronic Respiratory Questionnaire compared with EPR, ranging from +0.48 (95% CI = 0.19-0.78) for the domain, emotions, to +0.96 (95% CI = 0.57-1.35) for dyspnea. CONCLUSIONS NLPE results in greater improvements in cycle endurance and health-related quality of life in patients with severe COPD than traditional training methods. Clinical trial registered with www.trialregister.nl (The Netherlands Trial Register; NTR 1045).

Adjusting weighted kappa for severity of mistriage decreases reported reliability of emergency department triage systems: a comparative study

OBJECTIVE Mistriage can have serious consequences for patients with urgent complaints. We therefore reviewed the assessment of triage-reliability, and propose an alternative weighted kappa that accounts for severity of mistriage. STUDY DESIGN AND SETTING A systematic literature search was performed in three online databases and a search engine. An alternative kappa weighting scheme was developed (triage-weighted kappa), and kappas of previous conducted reliability studies were recalculated. RESULTS Kappa is the most frequently used statistic in triage-reliability studies (n=33). More than half of the studies did not report the type of kappa that was used. Linear and quadratically weighted kappa values do not reflect the seriousness of mistriage. Several studies reported almost perfect agreement, whereas percentages of mistriage ranged between 11.1% and 43.4%. In all studies, triage-weighted kappa was lower than reported kappas with a mean difference of 0.17 (range: 0.04-0.32). CONCLUSION No existing studies on reliability of triage systems account for mistriage. Using triage-weighted kappa, which reflects severity of mistriage, shows that the reliability of triage systems is lower than reported.

Both cardiovascular and non-cardiovascular comorbidity are related to health status in well-controlled type 2 diabetes patients: a cross-sectional analysis

BackgroundType 2 diabetes patients have a decreased health-related quality of life compared to healthy persons, especially regarding physical functioning and well-being. Health-related quality of life is even lower in type 2 diabetes patients when other diseases co-exist. In contrast to earlier studies, we assessed the associations between the number and type of comorbidities and health status in well-controlled type 2 diabetes patients, in whom treatment goals for HbA1c, blood pressure and cholesterol had been reached. Approximately one in five type 2 diabetes patients belongs to this group.MethodsCross-sectional analysis was performed in 2086 well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg, total cholesterol ≤5.2 mmol/l and not using insulin) type 2 diabetes patients in general practice. Both number and type (cardiovascular and non-cardiovascular) of comorbidities were determined for each patient. Health status was assessed with the questionnaires Short Form-36 (SF-36) and EuroQol (EQ). The SF-36 generates eight dimensions of health and a Physical and Mental Component Score (PCS and MCS), scale: 0–100. The EQ consists of two parts: EQ-5D and EQ Visual Analogue Scale. Multivariable linear regression analysis was used to assess if number and type of comorbidities were associated with health status.ResultsWell-controlled type 2 diabetes patients with comorbidities had a much lower health status, with a decrease ranging from -1.5 for the MCS to -26.3 for role limitations due to physical problems, compared to those without. Health status decreased when the number of comorbidities increased, except for mental health, role limitations due to emotional problems, MCS and both EQ measures. In patients with both cardiovascular and non-cardiovascular comorbidity, physical functioning, role limitations due to physical problems and PCS were significantly lower than in patients with only cardiovascular comorbidity. Physical functioning was also lower compared to patients with only non-cardiovascular comorbidity.ConclusionsEven acceptable values of HbA1c, blood pressure and cholesterol in type 2 diabetes patients are not necessarily related with a good health status. We have shown that comorbidities have a large impact on health status. Physicians may take into account patient’s health status and integrate the impact of comorbidities into diabetes care.

DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative Treatment. A MULTICENTER RANDOMISED CLINICAL TRIAL

BackgroundPersisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses.Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management.We, therefore, constructed a randomised clinical trial comparing these two treatment strategies.Methods/designThe DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used.The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-up will be three years.DiscussionConsidering the high incidence and the multicenter design of this study, it may be assumed that the number of patients needed for this study (n = 214), may be gathered within one and a half year.Depending on the expertise and available equipment, we prefer to perform a laparoscopic resection on patients randomised for elective surgery. Should this be impossible, an open technique may be used as this also reflects the current situation.Trial Registration(Trial register number: NTR1478)

Health-related quality of life in critically ill patients: How to score and what is the clinical impact?

Purpose of reviewTraditionally, the assessment of critical care has focused largely on mortality. However, in the last few years, there is more attention on the quality of survival. Health-related quality of life (HRQOL) is an important issue for both patients and family. The purpose of this review is to describe HRQOL scoring in critically ill patients and to discuss the clinical impact on HRQOL. Recent findingsStudies on the effect of critical illness on HRQOL show contradicting results. Several studies found that HRQOL at the time of discharge from hospital was impaired and that a gradual improvement occurred during follow-up, in some cases to preadmission hospital levels. Others show a full recovery to preadmission HRQOL. SummaryIn this article, we reviewed the methods and description of measurement instruments used in critically ill patients. The most recently used instruments to measure HRQOL, how to score HRQOL before ICU admission and the impact of critical illness on HRQOL are discussed. Assessment of HRQOL can improve the answers given by critical care physicians and nurses about the prospects of their patients. To get insights in these issues regarding the impact of ICU treatment, we should incorporate not only short-term outcomes, for example length of stay and mortality, but also HRQOL.