Marilyn Bergner

The sickness impact profile : development and final revision of a health status measure.

The final development of the Sickness Impact Profile (SIP), a behaviorally based measure of health status, is presented. A large field trial on a random sample of prepaid group practice enrollees and smaller trials on samples of patients with hyperthyroidism, rheumatoid arthritis and hip replacements were undertaken to assess reliability and validity of the SIP and provide data for category and item analyses. Test-retest reliability (r = 0.92) and internal consistency (r = 0.94) were high. Convergent and discriminant validity was evaluated using the multitrait–multimethod technique. Clinical validity was assessed by determining the relationship between clinical measures of disease and the SIP scores. The relationship between the SIP and criterion measures were moderate to high and in the direction hypotheszed. A technique for describing and assessing similarities and differences among groups was developed using profile and pattern analysis. The final SIP contains 136 items in 12 categories. Overall, category, and dimension scores may be calculated.

The Sickness Impact Profile: Validation of a Health Status Measure

The Sickness Impact Profile (SIP), a measure of health status, is being developed as an outcome measure of health care. A preliminary study of the validity of the SIP was conducted on a sample of 278 subjects who were grouped into four subsamples differing in land and severity of sickness. Selfassessment of health status, clinician assessment of health status, and other measures of dysfunction were used as criteria. SIP scores discriminated among subsamples, and correlations between criterion measures and SIP scores provided evidence for the validity of the SIP. Differences among the correlations obtained for each criterion measure with SIP score are discussed in terms of the need for the development of criterion measures that can be expected to differentially relate to the constructs inherent in the SIP.

The sickness impact profile: conceptual formulation and methodology for the development of a health status measure.

The development of a health status measure, the Sickness Impact Profile (SIP), is described in terms of both its conceptualization and methodology. The need for a health status measure that is sensitive and appropriate, based on sickness-related behavior, and culturally unbiased, is discussed. A model of sickness behavior is presented as a guide for methodological development. The description of the initial developmental stage of the SIP includes detailed discussion and documentation of the collection, sorting and grouping of items that comprise the SIP, scaling of the items, scoring of the instrument, and testing and revision of the prototype instrument. Results of preliminary tests of reliability, validity, and administrative feasibility are presented. Subsequent steps in revision and finalization, now under way, are outlined.

The sickness impact profile. Development of an outcome measure of health care.

Dr. Betty Gilson is Associate Professor and Associate Dean, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington 98195. Dr. John Gilson is Director of Medical Education, Group Health Cooperative of Puget Sound, Seattle, Washington. Dr. Bergner is Assistant Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington. Dr. Bobbitt is Research Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington. Ms. Kressel is Senior Administrative Analyst, Health Policy Program, San Francisco, California. Dr. Pollard is a postdoctoral fellow, Department of Psychology, Northwestern University, Evanston, Illinois. Dr. Vesselagos address is: 2012 Tenth Avenue East, Seattle, Washington. This investigation was supported by the HMO Service of the Health Services and Mental Health Administration, Contract HSM 110-72-420. This paper was presented, in abbreviated form, at the American Public Health Association Annual Meeting, San Francisco, 1974. It was accepted for publication July 21, 1975. costly services. The proliferation of innovative organizational patterns for providing health services makes it necessary to obtain data demonstrating the relative benefits of available alternatives. Evaluators use three types of measures to assess health care services: measures of structure, measures of process, and measures of outcome. 1 2 Measures of structure or process assess factors that are presumably directly related to outcome. Measures of outcome are designed to assess the effects of the health care services on the population served. Often, structure or process measures are used because no adequate or efficient measure of outcome is available. While it has been assumed that these three types of evaluation measures are highly related and that structure and process measures can serve as proxies for outcome measures, the substitution will be legitimate only when the relationship between structure or process and outcome has been established. For example, one can assess the outcome of a program such as polio immunization by examining the number of immunizations administered (a process measure), since it has been demonstrated that such immunization leads to less polio (an outcome measure). On the other hand, since it is not known whether the number of clinician visits decreases illness, measuring numbers of visits does not provide knowledge of outcome.

Quality of life, health status, and clinical research.

Although interest is increasing in measurement of quality of life, health status, and functional status in clinical research, most often the primary focus of the research is traditional measures of mortality and morbidity. Quality-of-life assessments are usually added as an afterthought once the design, data collection, and analytic techniques have been specified. When nonmedical outcomes are considered, they are thought of as quality-of-life outcomes. Quality of life is not well conceptualized in the medical and health literature. In addition, clinical researchers are searching for a single best measure of quality of life. Lack of information about clinical significance and sensitivity and uncertainties about the advantages of different administration strategies are impediments to use of developed measures. These issues and problems are discussed and suggestions made about procedures and investigations that could provide guidance.

The Sickness Impact Profile: reliability of a health status measure.

This report describes the results of research conducted on the reliability of the Sickness Impact Profile (SIP). The SIP is a questionnaire instrument designed to measure sickness-related behavioral dysfunction and is being developed for use as an outcome measure in the evaluation of health care. The test-retest reliability of the SIP in terms of several reliability measures was investigated using different interviewers, forms, administration procedures, and a variety of subjects who differed in terms of type and severity of dysfunction. The results provided evidence for the feasibility of collecting reliable data using the SIP under these various conditions. In addition, subject variability in relation to reliability is discussed.

National Outcomes of Cataract Extraction: Increased Risk of Retinal Complications Associated with Nd.-YAG Laser Capsulotomy

PURPOSE The authors studied 57,103 randomly selected Medicare beneficiaries who underwent extracapsular cataract extraction in 1986 or 1987 to determine the possible association between performance of neodymium (Nd):YAG laser capsulotomy and the risk of subsequent retinal break or detachment. METHODS Cases of cataract surgery were identified from Medicare claims submitted in 1986 and 1987 and were followed through the end of 1988. Episodes of cataract surgery, posterior capsulotomy, and retinal complications were ascertained based on procedure and diagnosis codes listed in physician bills and hospital discharge records. Lifetable and Coxs proportional hazards models were used to analyze the risk of retinal detachment or break in patients undergoing and not undergoing capsulotomy during the period of observation. RESULTS Of the 57,103 persons identified as having undergone extracapsular cataract extraction in 1986 or 1987, 13,709 subsequently underwent Nd:YAG laser capsulotomy between 1986 and 1988. A total of 337 persons had aphakic or pseudophakic retinal detachments between 1986 and 1988 and an additional 194 underwent repair of a retinal break. Proportional hazards modeling shows a 3.9-fold increase in the risk of retinal break or detachment among those who underwent capsulotomy (95% confidence interval: 2.89 to 5.25). Younger patient age, male sex, and white race also were associated with increased risk of retinal complications after extracapsular cataract extraction. CONCLUSION The authors conclude that there is a statistically significant increase in the risk of retinal detachment or break in those patients who undergo capsulotomy after cataract extraction. Therefore, capsulotomy should be deferred until the patients impairment caused by capsular opacification warrants the increased risk of retinal complications associated with performance of capsulotomy.

Measurement of Health Status

According to a now classic article by Moriyama,1 until the early 1960s, death rates provided the only relevant and sensitive measure of the health of populations. But by the mid 1960s, death rates, whether population-specific or general, no longer seemed sensitive to the changes that were taking place in health and health care in the United States. Further, Moriyama argued that death rates were unlikely to change materially except if major medical breakthroughs to increase life expectancy occurred. At about the same time, more reliance was being placed on measures of morbidity-which had been refined by the early 1960s-to assess health status. The National

National Outcomes of Cataract Extraction: Retinal Detachment and Endophthalmids after Outpatient Cataract Surgery

Background: A near-total shift to cataract extraction on an outpatient basis occurred as a result of an administrative ruling by the Health Care Financing Administration. No national study has been conducted to assess the possible effects of that decision on clinical outcomes of surgery. The authors compared the rates of retinal detachment (RD) repair and hospitalization for endophthalmitis after extracapsular cataract extraction (ECCE) (including phacoemulsification) in 1986 and 1987 with those following inpatient cataract extraction in 1984. Methods: Using the 5% random sample of Medicare beneficiaries, we analyzed the claims of all individuals 66 years of age or older who underwent ECCE by nuclear expression or phacoemulsification in 1986 and 1987. A total of 57,103 patients were identified and followed to the end of 1988. Cumulative probability of RD repair and hospitalization for endophthalmitis was calculated by standard lifetable methods. These findings were compared with the cumulative probability of the same complications in a cohort of 330,000 patients who underwent cataract extraction on an inpatient basis in 1984. Results: In the 1986-to-1987 cohort, the cumulative probability of RD within 3 years after cataract surgery was 0.81% and the cumulative probability of endophthalmitis within 1 year was 0.08%. The rate of RD is similar to that which we previously reported for 330,000 patients who underwent inpatient surgery in 1984, but the rate of endophthalmitis is significantly lower in the 1986-to-1987 outpatient cohort (0.08% versus 0.12%; z = 2.42; P = 0.01). Conclusions: The shift to outpatient cataract surgery was accompanied by no significant increase in the probability of RD repair and possibly a significant decrease in the rate of hospitalization for endophthalmitis.

The prevalence of pain in four cancers

Although pain is widely recognized as a major problem in cancer patients, most studies have concentrated on pain among those with advanced or terminal cancer in specialized treatment settings. The study reported here gives a more complete picture of the problem of pain among cancer patients by providing data generalizable to those in early as well as late stages of the disease, and receiving care in the community as well as specialized treatment centers. Having included measures of several distinct features of pain, this study also provides a more complete understanding of the cancer patients day‐today pain problem than earlier investigations. The findings presented here indicate that serious pain may occur in all cancer stages, and often represents an ongoing medical problem. The data suggest that many patients may benefit from earlier and more aggressive use of available antipain treatment methods.