Disease activity and sleep quality in rheumatoid arthritis: a deeper look into the relationship.

Objectives: This study looks deeper into the relationship between rheumatoid arthritis (RA) disease activity and distinct dimensions of sleep quality. Methods: The Pittsburgh Sleep Quality Index (PSQI) was administered to a cohort of 147 RA patients. Health-related quality of life (HRQoL) and fatigue were measured with the SF-12 and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) instruments, respectively, whereas RA activity was determined with the Disease Activity Score 28 joints (DAS28). Ethical approval for the study and informed consent from the participants were obtained. Results: Most patients were females (78.2%), and the mean age of the entire sample was 63.7 years. Most participants (77.6%) were poor sleepers (i.e. PSQI ≥ 5) who suffered from fatigue more than good sleepers (FACIT-F: 21.6 vs. 39.3, p < 0.001). Overall sleep quality correlated, in the expected directions, with disease activity (Spearman's rho = 0.87, p < 0.001), physical health (-0.66, p < 0.001), mental health (-0.71, p < 0.001), and fatigue (0.87, p < 0.001). PSQI and its component scores differed across patient subgroups with increasing RA activity, even after adjusting for confounding variables. Conclusion: RA disease activity distinctly affects sleep quality, and given the already demonstrated importance of good sleep, this 'deeper look' might contribute to the effort to improve HRQoL in RA patients.

Are condition-specific utilities more valid than generic preference-based ones in asthma? Evidence from a study comparing EQ-5D-3L and SF-6D with AQL-5D.

BACKGROUND: Systematic discrepancies have been shown in utility values derived from different instruments. This study compares utilities from the condition-specific AQL-5D and the generic EQ-5D-3L and SF-6D in an asthmatic population with heterogeneous health-related quality of life (HRQoL), disease severity, and control status. METHODS: A consecutive sample of 104 patients diagnosed with asthma completed a survey containing the Greek versions of SF-36, EQ-5D-3L, and AQLQ(s). Treatment adequacy was assessed with the Asthma Control Questionnaire (ACQ), and asthma severity according to Global Initiative for Asthma 2016 guidelines. Association and agreement between instruments were assessed with Spearman's correlation and Bland-Altman plots. RESULTS: AQL-5D utilities exceeded (p < 0.001) those from EQ-5D-3L and SF-6D. There were weak-to-moderate correlations (<0.5) between most dimensions of AQL-5D, and those of EQ-5D-3L and SF-6D, and strong correlations between similar dimensions of EQ-5D-3L and SF-6D. Significant differences (p < 0.001) were observed throughout the visual analog scale (VAS), asthma severity and asthma control subgroups, with AQL-5D consistently higher than EQ-5D-3L and SF-6D. CONCLUSIONS: All instruments distinguished between differing degrees of asthma control, but only AQL-5D discriminated between asthma severity and HRQoL as well. Although the relatively small sample warrants caution in interpreting the subgroup results, this study contributes to the growing number of comparisons between condition-specific and generic preference-based instruments.

Children's and parents' perspectives of health-related quality of life in newly diagnosed adolescent idiopathic scoliosis.

The aim of this study is to compare child and parent perceptions of health-related quality of life in Adolescent Idiopathic Scoliosis. The scoliosis-specific SRS-22 and the generic KIDSCREEN-52 were administered to newly diagnosed patients and the latter also to a parent. Strong correlations (r > 0.5, p < 0.001) were revealed between conceptually similar dimensions of the instruments. Parents' assessments of their child's HRQoL were generally higher than the children/adolescents; however score differences were small and insignificant. The significance of parents' perceptions was also confirmed with OLS regressions. In conclusion, HRQoL is thoroughly investigated when both generic and disease-specific instruments are used.

Health-Related Quality of Life and Association With Arthropathy in Greek Patients with Hemophilia.

Health-related quality of life (HRQoL) is increasingly implicated in contemporary hemophilia management. This study focuses on the assessment of HRQoL in Greek patients with hemophilia and the comparison with normative data from the general population, as well as on the extent arthropathy may affect the patients' HRQoL. One hundred and nine adult patients completed the Greek social functioning (SF-36) and Haem-A-QoL questionnaires. Arthropathy was assessed by both the World Federation of Hemophilia clinical score and Pettersson radiological score. The most impaired domains of Haem-A-QoL were sports/leisure (SL) and physical health (PH; mean scores 61.2 and 42.2, respectively). The patients experienced statistically significant lower mean scores in all SF-36 domains than the normative sample, especially in role physical (RPH), bodily pain (BP), and general health (GH) subscales. Among Haem-A-QoL subscales, SL and PH were found strongly associated with severity of arthropathy using both orthopedic scores ( P < .001), and maintained the statistical significance after adjustment for age ( P < .05). A poor orthopedic status was also negatively associated with certain SF-36 subscales. However, none of these correlations remained after adjustment with age. Compared to normative data from Greece, patients with hemophilia showed deterioration in all HRQoL subscales, with a more pronounced effect in RPH, BP, and GH subscales. Health-related quality of life was strongly influenced by arthropathy, mainly in the physical aspects of HRQoL. The use of the disease-specific Haem-A-QoL tool can capture additional associations between HRQoL and hemophilic arthropathy.

Validity and reliability of the Greek version of the Diabetic Foot Ulcer Scale - Short Form (DFS-SF).

OBJECTIVE: Diabetic foot ulcer is a critical and costly complication of diabetes mellitus. The aim of this study was to assess the psychometric properties of the Greek version of the diabetic foot ulcer scale - short form (DFS-SF). DESIGN: A sample of patients with diabetic foot ulcer (N=110) was surveyed with the DFS-SF and various demographic and disease-related questions. The validated Greek SF-36 instrument was used as a "gold standard" for health-related quality of life comparisons. Hypothesized scale structure, internal consistency reliability (Cronbach's alpha) and various forms of construct validity (convergent, discriminative, concurrent and known--groups) were assessed. RESULTS: Multitrait scaling confirmed the scale structure of the DFS-SF, with 32 excellent item convergence (100%) and good discrimination (84.1%) rates. Cronbach's alphawas >0.70 for all scales. Spearman's correlations between similar DFS-SF and SF-36 scales ranged between 0.39-0.79 (p<0.001). Expected interscale correlations and known-groups comparisons supported construct validity. CONCLUSIONS: The observed psychometric properties of the Greek DFS-SF imply suitability for assessing health-related quality of life in patients with diabetic foot ulcer. Future studies should focus on generalizability of the results, as well as on specific issues such as longitudinal validity and responsiveness.

Establishing the Psychometric Properties of the ICOAP Questionnaire through Intra-Articular Treatment of Osteoarthritic Pain: Implementation for the Greek Version.

Objectives. In this prospective study, we intend to establish the psychometric properties of ICOAP for its use in studies involving the Hellenic population. Methods. SF-36 Health Survey was used as a standard against ICOAP scores from a sample of 89 patients (mean age: 71.07, 69 females) with hip and knee OA pain who underwent 2 treatment cycles of 4 intra-articular injections of sodium hyaluronate, separated by a 12-week medication-free time interval. Both questionnaires were filled twice with no missing data during follow-up. Results. ROC analysis accomplished ICOAP's criterion-related validation. Wilcoxon Signed-Rank Test and paired samples t-test endorsed ICOAP's responsiveness along with Effect Size values, standard response mean, and Relative Efficiency. Comparisons between the areas under curves (AUC) on ROC plots established external responsiveness. Cronbach's-alpha value favored ICOAP's internal consistency. This, along with intraclass correlation, results in both advocated reliability and content validity. Interitem discrimination was demonstrated by the ease of completion of ICOAP as well as the degree of familiarity with it. These findings inaugurated construct validity in collaboration with Spearman's and One-Way ANOVA results. Conclusions. ICOAP is a valid, reliable, and responsive QoL instrument and suitable for studies of osteoarthritic joint pain in the Greek setting.

Mapping chronic liver disease questionnaire scores onto SF-6D utility values in patients with primary sclerosing cholangitis.

PURPOSE: The chronic liver disease questionnaire (CLDQ) is a frequently used liver-specific quality of life instrument, but it does not provide information on preference-adjusted health status, which is essential for cost-utility analysis. We aimed to develop a mapping function deriving utilities from the CLDQ in primary sclerosing cholangitis (PSC). METHODS: Short form-6D (SF-6D) utilities were calculated from SF-36 data collected in a recent prospective study in which unselected patients with PSC also completed the CLDQ. Ordinary least squares (OLS), generalized linear, median, and kernel regression analyses were employed to devise a mapping function predicting utilities. This was validated in three random subsamples of the cohort and in a separate sample of PSC patients following liver transplantation. Adjusted R (2) and root-mean-square error (RMSE) as well as Pearson's r coefficients and mean absolute errors between predicted and observed values were used to determine model performance. RESULTS: Decompensated liver disease and fatigue, systemic symptoms, and emotional distress, assessed with the CLDQ, were related to worse SF-6D utilities. The final OLS prediction model explained 66.3 % of the variance in the derivation sample. Predicted and observed utilities were strongly correlated (r = 0.807, p < 0.001), but the mean absolute error (0.0604) and adjusted RMSE (10.6 %) were of intermediate size. Similar model characteristics were observed after employment of generalized linear and median regression models and at validation. CONCLUSIONS: A model has been constructed, showing good validity predicting SF-6D utilities from CLDQ scores at the group level in PSC. Further testing is required to externally validate the model.

Reengineering NHS Hospitals in Greece: Redistribution Leads to Rational Mergers.

The purpose of this study was to record and evaluate existing public hospital infrastructure of the National Health System (NHS), in terms of clinics and laboratories, as well as the healthcare workforce in each of these units and in every health region in Greece, in an attempt to optimize the allocation of these resources. An extensive analysis of raw data according to supply and performance indicators was performed to serve as a solid and objective scientific baseline for the proposed reengineering of the Greek public hospitals. Suggestions for "reshuffling" clinics and diagnostic laboratories, and their personnel, were made by using a best versus worst outcome indicator approach at a regional and national level. This study is expected to contribute to the academic debate about the gap between theory and evidence based decision-making in health policy.

The potential for a generally applicable mapping model between QLQ-C30 and SF-6D in patients with different cancers: a comparison of regression-based methods.

PURPOSE: To establish and compare generalized or "global" mapping relationships between QLQ-C30 and SF-6D, applicable across different cancer types. METHODS: Patients (N = 671) with breast, myeloma, colorectal, lymphoma, bone marrow, prostate, lung and gastroenteric cancer were randomly split into estimation (75%) and validation (25%) datasets. SF-6D was estimated from QLQ-C30 scores via ordinary least squares, generalized linear models and median (least-absolute deviations) regression approaches, and with Bayesian additive regression kernels. Predictive ability was assessed with root mean square error, mean absolute error and proportions of predictions with absolute errors >0.05 and >0.1, whereas explanatory power with adjusted R (2) or equivalent fit measures. Two external samples (breast and colorectal cancer) were used to further test the models. RESULTS: The QLQ-C30's global health item, the physical, emotional and social functioning scales, and the fatigue, pain and diarrhea symptom scales were significant predictors (p < 0.05 or better) in all models. Negligible deviations in models' performance were observed. All models overpredicted utilities for patients in worst health and underpredicted them for those in better health (p < 0.01 or better). Regarding external validation, performance was better in the colorectal cancer than in the breast cancer sample. CONCLUSIONS: This study has provided evidence to support the use of "global" mapping models to predict SF-6D utilities from QLQ-C30 in patients with different cancers. Testing with diverse patient samples is required to confirm the generalizability (or not) of mapping models across cancer conditions.

Psychometric properties of the Greek Haem-A-QoL for measuring quality of life in Greek haemophilia patients.

BACKGROUND AND OBJECTIVES: Health Related Quality of Life (HRQoL) is an important health outcome measure in haemophilia. The aim of this study was to assess the psychometric properties of the Greek version of Haem-A-QoL, a disease-specific questionnaire for haemophiliacs. METHODS: Haem-A-QoL and SF-36 were administered to 118 adult haemophilia patients. Hypothesized scale structure, internal consistency (Cronbach's α ), and test-retest reliability, as well as various types of construct validity were evaluated. RESULTS: Scale structure of Haem-A-QoL was confirmed, with good item convergence (87%) and discrimination (80.6%) rates. Cronbach's α was >0.70 for all but one dimension (dealing) and test-retest reliability was significantly high. The strength of Spearman's correlations between Haem-A-QoL and SF-36 scales ranged from 0.25 to 0.75 (P < 0.01). Multiple stepwise linear regression analysis revealed that all but one Haem-A-QoL dimensions were important predictors of SF-36 scales. Known-groups comparisons yielded consistent support of the instruments' construct validity and significant relationships were identified for age, educational level, haemophilia type, disease severity, and viral infections. CONCLUSION: Overall, the psychometric properties of the Greek version of Haem-A-QoL, resulting from this first time administration of the instrument to Greek adult haemophiliacs, confirmed it as a reliable and valid questionnaire for assessing haemophilia-specific HRQoL in Greece.

Do self-perceptions of emotional intelligence predict health-related quality of life? A case study in hospital managers in Greece.

The aim of this study was to examine HRQoL outcome and EI of managers of Health Organizations. We collected data from 120 general managers of Greek public hospitals who completed the Assessing Emotions Scale (AES) and the SF-36 Health Survey. The results showed that male managers generally exhibited better HRQoL and slightly worse EI than females, although differences were not significant throughout. The three EI factors of the AES addressing appraisal, optimism/regulation and utilization of emotions correlated from 0.18 to 0.39 with sub-dimensions of HRQoL mostly related to mental -rather than physical- aspects of health, and were also significant predictors of HRQoL. There was a noteworthy gender difference in the manner in which EI predicted HRQoL and this suggests more testing. Overall, this study might enrich the potential for EI studies in Greece as well as to contribute to the international literature.

EORTC QLQ-C30 and FACT-Lym for the assessment of health-related quality of life of newly diagnosed lymphoma patients undergoing chemotherapy.

PURPOSE: The aim of this study was to assess the validity of the European Organization for Research and Treatment of Cancer Quality of Life, Core 30 (EORTC QLQ-C30) and Functional Assessment of Chronic illness Therapy-Lymphoma (FACT-Lym) instruments (Greek version) in patients with lymphoma undergoing chemotherapy, as well as the comparative evaluation of the questionnaires themselves. METHOD: Health related quality of life (HRQoL) was assessed using the two previously mentioned instruments as well as the generic Short Form 36 (SF-36), which was used as a standard and its scores were compared to the corresponding norms of the Greek general population. The sample consisted of 80 newly diagnosed patients with lymphoma, who had completed their chemotherapy treatment. Reliability (Cronbach's a), central tendency and variability for the scales were assessed. Associations between the instruments' scales were examined via Spearman's correlations. RESULTS: Cronbach's a, was >0.70 for all the scales, with exception of the emotional well being scale of FACT-Lym and two functional scales of QLQ-C30. There is a significant correlation between similar scales of the questionnaires, and particularly strong (>0.50) between global, functional and physical subscales of the FACT-Lym and QLQ-C30 instruments. Also, five scales of the SF-36, showed significantly lower mean values compared to the corresponding Greek norms. CONCLUSIONS: The Greek versions of FACT-Lym and QLQ-C30 appear to be reliable and valid tools for assessing HRQoL in this category of patients. The two disease-specific QoL instruments complement each other and neither can be replaced by the other.

Investigating unmet health needs in primary health care services in a representative sample of the Greek population.

Unmet health care needs are determined as the difference between the services judged necessary and the services actually received, and stem from barriers related to accessibility, availability and acceptability. This study aims to examine the prevalence of unmet needs and to identify the socioeconomic and health status factors that are associated with unmet needs. A cross-sectional study was conducted in Greece in 2010 and involved data from 1,000 consenting subjects (>18 years old). Multiple binary logistic regression analysis was applied to investigate the predictors of unmet needs and to determine the relation between the socio-demographic characteristics and the accessibility, availability and acceptability barriers. Ninety nine participants (9.9%) reported unmet health needs during the 12 months prior to the research. The most frequently self-reported reasons were cost and lack of time. Youth, parenthood, physician consultations, and poor mental health increased the likelihood of unmet needs. Women were less likely to report accessibility and availability than acceptability barriers. Educational differences were evident and individuals with primary and secondary education were associated with significantly more accessibility and availability barriers compared with those with tertiary education. Unmet health needs pose a significant challenge to the health care system, especially given the difficult current financial situation in Greece. It is believed that unmet health needs will continue to increase, which will widen inequalities in health and health care access.

Investigating demographic, work-related and job satisfaction variables as predictors of motivation in Greek nurses.

AIM: To investigate whether demographic variables and work-related factors predict work motivation in Greek nurses. BACKGROUND: Nurses' motivation is crucial for an effective health-care system. Herzberg's and Maslow's motivation theories constitute the framework of this study. METHOD: The sample consisted of 200 nurses from every sector and registration level in a University Hospital in Greece. The response rate was 76%. INSTRUMENTS: A previously developed and validated questionnaire addressing four work-related motivators (job attributes, remuneration, co-workers and achievements) on a five-point Likert scale. RESULTS: Most participants were women, married, between 36 years and 45 years old and higher education graduates. The highest mean score was recorded for 'achievements' (mean 4.07, SD 0.72), which emerged as the most important motivator. Job satisfaction, work sector and age were statistically significantly related to motivational factors. CONCLUSIONS: Nurses placed emphasis on motivators not strictly relating to economic rewards, but which can be seen as intrinsic and could lead to self-actualization. IMPLICATIONS FOR NURSING MANAGEMENT: The constantly changing health sector requires that human resources and job context be a priority for health administrators. By promoting nurses' satisfaction and efficacy, an improvement in service quality is expected.

Reforming reimbursement of public hospitals in Greece during the economic crisis: Implementation of a DRG system.

OBJECTIVES: Until recently, in-patient NHS hospital care in Greece was reimbursed via an anachronistic and under-priced retrospective per diem system, which has been held primarily responsible for continuous budget deficits. The purpose of this paper is to present the efforts of the Ministry of Health (MoH) to implement a new DRG-based payment system. METHODS: As in many countries, the decision was to adopt a patient classification from abroad and to refine it for use in Greece with national data. Pricing was achieved with a combination of activity-based costing with data from selected Greek hospitals, and "imported" cost weights. Data collection, IT support and monitoring are provided via ESY.net, a web-based facility developed and implemented by the MoH. RESULTS: After an initial pilot testing of the classification in 20 hospitals, complete DRG reimbursement data was reported by 113 hospitals (85% of total) for the fourth quarter of 2011. The recorded monthly increase in patient discharges billed with the new system and in revenue implies increasing adaptability by the hospitals. However, the unfavorable inlier vs. outlier distribution of discharges and revenue observed in some health regions signifies the need for corrective actions. CONCLUSIONS: The importance of this reimbursement reform is discussed in light of the current crisis faced by the Greek economy. There is yet much to be done and many projects are currently in progress to support this effort; however the first cost containment results are encouraging.

Public procurement of health technologies in Greece in an era of economic crisis.

Public procurement is generally an important sector of the economy and, in most countries, is controlled by the introduction of regulatory and policy mechanisms. In the Greek healthcare sector, recent legislation redefined centralized procurement through the reestablishment of a state Health Procurement Committee (EPY), with an aim to formulate a plan to reduce procurement costs of medical devices and pharmaceuticals, improve payment time, make uniform medical requests, transfer redundant materials from one hospital to another and improve management of expired products. The efforts described in this paper began in early 2010, under the co-ordination of the Ministry of Health (MoH) and with the collaboration of senior staff from the International Monetary Fund (IMF), the European Commission (EC) and the European Central Bank (ECB). The procurement practices and policies set forth by EPY and the first measurable outcomes, in terms of cost savings, resulting from these policies are presented. The importance of these measures is discussed in light of the worst economic crisis faced by Greece since the restoration of democracy in 1974, as a result of both the world financial crisis and uncontrolled government spending.

Longitudinal predictive ability of mapping models: examining post-intervention EQ-5D utilities derived from baseline MHAQ data in rheumatoid arthritis patients.

OBJECTIVES: The purpose of this methodological study was to to provide insight into the under-addressed issue of the longitudinal predictive ability of mapping models. Post-intervention predicted and reported utilities were compared, and the effect of disease severity on the observed differences was examined. METHODS: A cohort of 120 rheumatoid arthritis (RA) patients (60.0% female, mean age 59.0) embarking on therapy with biological agents completed the Modified Health Assessment Questionnaire (MHAQ) and the EQ-5D at baseline, and at 3, 6 and 12 months post-intervention. OLS regression produced a mapping equation to estimate post-intervention EQ-5D utilities from baseline MHAQ data. Predicted and reported utilities were compared with t test, and the prediction error was modeled, using fixed effects, in terms of covariates such as age, gender, time, disease duration, treatment, RF, DAS28 score, predicted and reported EQ-5D. RESULTS: The OLS model (RMSE = 0.207, R(2) = 45.2%) consistently underestimated future utilities, with a mean prediction error of 6.5%. Mean absolute differences between reported and predicted EQ-5D utilities at 3, 6 and 12 months exceeded the typically reported MID of the EQ-5D (0.03). According to the fixed-effects model, time, lower predicted EQ-5D and higher DAS28 scores had a significant impact on prediction errors, which appeared increasingly negative for lower reported EQ-5D scores, i.e., predicted utilities tended to be lower than reported ones in more severe health states. CONCLUSIONS: This study builds upon existing research having demonstrated the potential usefulness of mapping disease-specific instruments onto utility measures. The specific issue of longitudinal validity is addressed, as mapping models derived from baseline patients need to be validated on post-therapy samples. The underestimation of post-treatment utilities in the present study, at least in more severe patients, warrants further research before it is prudent to conduct cost-utility analyses in the context of RA by means of the MHAQ alone.

Reliability and validity of the Greek QLQ-C30 and QLQ-MY20 for measuring quality of life in patients with multiple myeloma.

OBJECTIVES: The aim of this study was to assess the psychometric properties of the Greek EORTC QLQ-C30 and QLQ-MY20 instruments. METHOD: A sample of myeloma patients (N = 89) from two tertiary hospitals were surveyed with the QLQ-C30, QLQ-MY20 and various demographic and disease related questions. The previously validated Greek SF-36 instrument was used as a "gold standard" for health-related quality of life (HRQoL) comparisons. Hypothesized scale structure, internal consistency reliability (Cronbach's alpha) and various forms of construct validity (convergent, discriminative, concurrent and known-groups) were assessed. RESULTS: Multitrait scaling confirmed scale structure of the QLQ-C30 and QLQ-MY20, with good item convergence (96% and 72%) and discrimination (78% and 58%) rates. Cronbach's α was >0.70 for all but one scale (cognitive functioning). Spearman's correlations between similar QLQ-C30 and SF-36 scales ranged between 0.35-0.80 (P < 0.001). Expected interscale correlations and known-groups comparisons supported construct validity. QLQ-MY20 scales showed comparatively lower correlations with QLQ-C30 functional scales, and higher correlations with conceptually related symptom scales. CONCLUSIONS: The observed psychometric properties of the two instruments imply suitability for assessing myeloma HRQoL in Greece. Future studies should focus on generalizability of the results, as well as on specific issues such as longitudinal validity and responsiveness.