Is the physical functioning of older adults with diabetes associated with the processes and outcomes of care? Evidence from Translating Research Into Action for Diabetes (TRIAD).

AIMS: To examine the relationship between physical function limitations and diabetes self-management, processes of care and intermediate outcomes in adults ≥ 65 years of age with Type 2 diabetes. METHODS: We studied 1796 participants 65 years of age and older in managed care health plans enrolled in Translating Research into Action for Diabetes (TRIAD). Physical functioning was assessed at baseline with the Physical Component Summary of the Short Form-12 Health Survey. Diabetes self-management was assessed with follow-up surveys, and processes of care (eye examinations, urine microalbumin testing, foot examinations, etc.) and intermediate health outcomes (HbA(1c), blood pressure, LDL cholesterol) were assessed with medical chart reviews. Multivariate regression models were constructed to examine the associations between physical function limitations and outcomes. RESULTS: Frequency of eye examinations (odds ratio 0.69, 95% CI 0.49-0.99) was the only process of care that was worse for participants with physical function limitations (n = 573) compared with those without limitations (n = 618). Neither self-management nor intermediate outcomes differed by whether patients had or did not have physical function limitations. CONCLUSION: Limitations in physical functioning as assessed by the Short Form-12 were not associated with substantial difference in diabetes care in adults ≥ 65 years of age enrolled in managed care health plans.

Randomized testing of alternative survey formats using anonymous volunteers on the World Wide Web.

Consenting visitors to a health survey Web site were randomly assigned to a "matrix" presentation or an "expanded" presentation of survey response options. Among 4,208 visitors to the site over 3 months, 1,615 (38 percent) participated by giving consent and completing the survey. During a pre-trial period, when consent was not required, 914 of 1,667 visitors (55 percent) participated (odds ratio 1.9, P<0.0001). Mean response times were 5.07 minutes for the matrix format and 5.22 minutes for the expanded format (P=0.16). Neither health status scores nor alpha reliability coefficients were substantially influenced by the survey format, but health status scores varied with age and gender as expected from U.S. population norms. In conclusion, presenting response options in a matrix format may not substantially speed survey completion. This study demonstrates a method for rapidly evaluating interface design alternatives using anonymous Web volunteers who have provided informed consent.

Expectations regarding aging among older adults and physicians who care for older adults.

BACKGROUND: Understanding older adults' expectations regarding aging is important for both clinicians and policy-makers. OBJECTIVES: 1) To identify the content for a survey to measure expectations regarding aging; 2) to qualitatively compare older adults' and physicians' expectations regarding aging. SETTING: Three senior centers and one university-based internal medicine faculty practice. PARTICIPANTS: Forty-nine adults (mean age 78 years); 11 primary care clinicians (mean age 37 years). MEASUREMENTS: A facilitator conducted five focus groups of older adults and two of physicians using a standardized script designed to elicit expectations regarding aging. Qualitative analysis by two independent reviewers identified domains of expectations, with a 3rd reviewer used to resolve discrepancies. A corresponding coding scheme was applied to each line of the transcripts. Content and frequency of expectations regarding aging and beliefs regarding care seeking were examined and compared. RESULTS: Content analysis identified 26 domains of expectations regarding aging. Each of the seven most frequently mentioned domains of expectations was mentioned by at least 50% of participants. Of 760 unique statements coded, the most frequently described domains in both the older adult and physician groups were physical function, cognitive function, social function, pain, and sexual function. Older adults differed from physicians by describing five mental-health related domains: anxiety, emotional-well-being, happiness, sleep, and length of life/death. CONCLUSIONS: Using focus groups of older adults and physicians, we identified consistent content for a closed-ended patient-centered survey to measure expectations regarding aging. Further study should determine whether physicians address mental health aspects of aging valued by older persons.

Development of the 25-item National Eye Institute Visual Function Questionnaire.

OBJECTIVE: To develop and test the psychometric properties of a 25-item version of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). DESIGN: Prospective observational cohort study of persons with 1 of 5 chronic eye diseases or low vision who were scheduled for nonurgent visits in ophthalmology practices and a reference sample of persons without eye disease. SETTING: Eleven university-based ophthalmology practices and the NEI Clinical Center. PATIENTS: Eligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open-angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. Seven of the 12 sites also enrolled persons in a reference sample. Reference sample participants had no evidence of underlying eye disease but were scheduled for either screening eye examinations or correction of refractive error. All eligible persons had to be 21 years or older, English speaking, and cognitively able to give informed consent and participate in a health status interview. MEASUREMENTS AND MAIN RESULTS: To provide the data needed to create the NEI VFQ-25, all subjects completed an interview that included the 51-item NEI VFQ. Estimates of internal consistency indicate that the subscales of the NEI VFQ-25 are reliable. The validity of the NEI VFQ-25 is supported by high correlations between the short- and long-form versions of the measure, observed between-group differences in scores for persons with different eye diseases of varying severity, and the moderate-to-high correlations between the NEI VFQ-25 subscales that have the most to do with central vision and measured visual acuity. CONCLUSIONS: The reliability and validity of the NEI VFQ-25 are comparable to those of the 51-item NEI VFQ field test version of the survey. This shorter version will be more feasible in settings such as clinical trials where interview length is a critical consideration. In addition, preliminary analyses indicate that the psychometric properties of the NEI VFQ-25 are robust for the eye conditions studied; this suggests that the measure will provide reproducible and valid data when used across multiple conditions of varying severity.

Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study.

CONTEXT: Right heart catheterization (RHC) is commonly performed before high-risk noncardiac surgery, but the benefit of this strategy remains unproven. OBJECTIVE: To evaluate the relationship between use of perioperative RHC and postoperative cardiac complication rates in patients undergoing major noncardiac surgery. DESIGN: Prospective, observational cohort study. SETTING: Tertiary care teaching hospital in the United States. PATIENTS: Patients (n = 4059 aged >/=50 years) who underwent major elective noncardiac procedures with an expected length of stay of 2 or more days between July 18, 1989, and February 28, 1994. Two hundred twenty one patients had RHC and 3838 did not. MAIN OUTCOME MEASURE: Combined end point of major postoperative cardiac events, including myocardial infarction, unstable angina, cardiogenic pulmonary edema, ventricular fibrillation, documented ventricular tachycardia or primary cardiac arrest, and sustained complete heart block, classified by a reviewer blinded to preoperative data. RESULTS: Major cardiac events occurred in 171 patients (4.2%). Patients who underwent perioperative RHC had a 3-fold increase in incidence of major postoperative cardiac events (34 [15.4%] vs 137 [3.6%]; P<.001). In multivariate analyses, the adjusted odds ratios (ORs) for postoperative major cardiac and noncardiac events in patients undergoing RHC were 2.0 (95% confidence interval [CI], 1.3-3.2) and 2.1 (95% CI, 1.2-3.5), respectively. In a case-control analysis of a subset of 215 matched pairs of patients who did and did not undergo RHC, adjusted for propensity of RHC and type of procedure, patients who underwent perioperative RHC also had increased risk of postoperative congestive heart failure (OR, 2.9; 95% CI, 1.4-6.2) and major noncardiac events (OR, 2.2; 95% CI, 1.4-4.9). CONCLUSIONS: No evidence was found of reduction in complication rates associated with use of perioperative RHC in this population. Because of the morbidity and the high costs associated with RHC, the impact of this intervention in perioperative care should be evaluated in randomized trials.

The NEI-VFQ-25 in people with long-term type 1 diabetes mellitus: the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

OBJECTIVES: To examine the association of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) overall and specific scale scores with visual acuity, diabetic retinopathy, and other characteristics, in a cohort of persons with type 1 diabetes. DESIGN: Population-based cohort study. SETTING: An 11-county area in southern Wisconsin. PARTICIPANTS: Six hundred two persons with diabetes whose conditions were diagnosed when they were younger than 30 years and who were currently taking insulin participated in baseline, 4-year, 10-year, and 14-year follow-up examinations. MAIN OUTCOME MEASURES: An interview that consisted of the 25-item NEI-VFQ was completed. Visual acuity was measured by the Early Treatment of Diabetic Retinopathy Study (ETDRS) protocol and the presence and severity of retinopathy and macular edema were detected by masked grading of stereoscopic color fundus photographs using the modified Airlie House classification and the ETDRS retinopathy severity scheme. RESULTS: Univariate analyses revealed that the total NEI-VFQ-25 score was lower in persons who were older, had a longer duration of diabetes, higher glycosylated hemoglobin, were in renal failure, had a history of cardiovascular disease, hypertension, or amputation of a lower limb, had poorer visual acuity, more severe diabetic retinopathy, macular edema, glaucoma, cataract, abnormalities in tactile sensation or temperature sensitivity, smoked more total pack-years, led a more sedentary lifestyle, and had poor peak expiratory flow. In multivariate analyses, while controlling for the physical and mental component scores from the Medical Outcomes Survey 36-Item Short-Form Health Survey as measures of comorbidity, lower total NEI-VFQ-25 scores were independently associated with poorer visual acuity, more severe retinopathy, older age, history of loss of tactile sensation, and more total pack-years of cigarettes smoked. CONCLUSIONS: In this cross-sectional study, the 25-item NEI-VFQ seems to be strongly associated with vision, independent of severity of retinopathy and other complications associated with type 1 diabetes. It may be a useful measure of health-related quality of life as it relates to vision in epidemiological studies and clinical trials in persons with diabetes.

Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery.

BACKGROUND: Major surgical procedures are performed with increasing frequency in elderly persons, but the impact of age on resource use and outcomes is uncertain. OBJECTIVE: To evaluate the influence of age on perioperative cardiac and noncardiac complications and length of stay in patients undergoing noncardiac surgery. DESIGN: Prospective cohort study. SETTING: Urban academic medical center. PATIENTS: Consecutive sample of 4315 patients 50 years of age or older who underwent nonemergent major noncardiac procedures. MEASUREMENTS: Major perioperative complications (cardiac and noncardiac), in-hospital mortality, and length of stay. RESULTS: Major perioperative complications occurred in 4.3% (44 of 1015) of patients 59 years of age or younger, 5.7% (93 of 1646) of patients 60 to 69 years of age, 9.6% (129 of 1341) of patients 70 to 79 years of age, and 12.5% (39 of 313) of patients 80 years of age or older (P < 0.001). In-hospital mortality was significantly higher in patients 80 years of age or older than in those younger than 80 years of age (0.7% vs. 2.6%, respectively). Multivariate analyses indicated an increased odds ratio for perioperative complications or in-hospital mortality in patients 70 to 79 years of age (1.8 [95% CI, 1.2 to 2.7]) and those 80 years of age or older (OR, 2.1 [CI, 1.2 to 3.6]) compared with patients 50 to 59 years of age. Patients 80 years of age or older stayed an average of 1 day more in the hospital, after adjustment for other clinical data (P = 0.001). CONCLUSIONS: Elderly patients had a higher rate of major perioperative complications and mortality after noncardiac surgery and a longer length of stay, but even in patients 80 years of age or older, mortality was low.

Correlates of attributing new disability to old age. Study of Osteoporotic Fractures Research Group.

OBJECTIVES: To describe women who attribute new disability to old age and to identify demographic, medical, behavioral, and psychosocial characteristics that correlate with attributing new disability to old age. DESIGN: Prospective cohort study with 4-year follow-up. SETTING: Four geographic regions of the United States. PARTICIPANTS: 9704 women aged > or = 67 years participating in the Study of Osteoporotic Fractures. Of these, 657 who reported no disability at baseline but at follow-up reported difficulty carrying out 1 or more of 13 functional activities were eligible for our analysis. MEASUREMENTS: All women reporting difficulty in any functional activity at follow-up were asked "What is the main condition that causes you to have difficulty or prevents you from (doing the activity)?" and were shown a card listing 14 medical conditions as well as the option "old age," from which they could choose only one response. Women attributing difficulty or inability in 1 or more functional activities to old age were classified as attributing new disability to old age. We examined the relationship between attributing new disability to old age and the following characteristics measured at baseline: age, level of education, medical comorbidity, cognitive function, body mass index (BMI), gait speed, grip strength, visual acuity, physical activity level, smoking status, social network level, and depressed mood. RESULTS: Overall, 13.5% of women attributed new disability to old age. Age was a strong independent correlate of attributing new disability to old age: compared with women age 67 to 69, the odds of attributing new disability to old age for women age 70 to 79 was 3.6 times as large (95% confidence interval [CI] = 1.6-8.3), and for women age 80 or over was 5.5 times as large (95% CI = 2.1-14.7). The only other characteristic that remained an independent correlate of attributing new disability to old age was grip strength; for each decile decrease in grip strength, a woman's odds of attributing new disability to old age increased by 9% (odds ratio [OR] = 1.09, 95% CI = 1.01-1.19). CONCLUSIONS: Despite great advances in geriatric medicine, old age is still perceived as a causal agent in functional decline, especially among our oldest patients. Further study is needed to determine whether, how often, and under what circumstances older adults who attribute new disability to old age have medical conditions amenable to interventions that could preserve their functioning and improve their quality of life.

Design and analysis of a Web-based guideline tutorial system that emphasizes clinical trial evidence.

OBJECTIVE: To describe a Web-based guideline tutorial system and evaluate its features. METHODS: A Web-based tutorial system called SAGE (Self-study Acceleration with Graphic Evidence) was constructed to teach knowledge important for care after myocardial infarction. SAGE features a pretest, followed by an overview that coordinates studying resources for a set of learning objectives. Resources include pretest answers, guideline passages, and graphical presentations of clinical trial results. Data on the use of SAGE was obtained from 79 residents participating in a larger trial. Linear regression was used to correlate the amount learned with resource-use, and resource-use with user characteristics. RESULTS: On average, users accessed less than half of the guideline passages and very little of the graphic evidence. Greater use of guideline passages was correlated with greater immediate learning, but use of graphic evidence was not. CONCLUSIONS: Further research is needed to motivate more thorough self-study and to integrate clinical trial evidence with guideline-based education.

Self-study from web-based and printed guideline materials. A randomized, controlled trial among resident physicians.

BACKGROUND: On-line physician education is increasing, but its efficacy in comparison with existing self-study methods is unknown. OBJECTIVE: To compare knowledge, learning efficiency, and learner satisfaction produced by self-study of World Wide Web-based and print-based guidelines for care after acute myocardial infarction. DESIGN: Randomized, controlled trial. SETTING: 12 family medicine and internal medicine residency programs at four universities. PARTICIPANTS: 162 residents. INTERVENTIONS: In proctored sessions, participants were randomly assigned to study from printed materials or from SAGE (Self-Study Acceleration with Graphic Evidence), a Web-based tutorial system. Both methods used identical self-assessment questions and answers and guideline text, but SAGE featured hyperlinks to specific guideline passages and graphic evidence animations. MEASUREMENTS: Scores on multiple-choice knowledge tests, score gain per unit of study time, and ratings on a learner satisfaction scale. RESULTS: Immediate post-test scores on a 20-point scale were similar in the SAGE and control groups (median score, 15.0 compared with 14.5; P>0.2), but SAGE users spent less time studying (median, 27.0 compared with 38.5 minutes; P<0.001) and therefore had greater learning efficiency (median score gain, 8.6 compared with 6.7 points per hour; P = 0.04). On a scale of 5 to 20, SAGE users were more satisfied with learning (median rating, 17.0 compared with 15.0; P<0.001). After 4 to 6 months, knowledge had decreased to the same extent in the SAGE and control groups (median score, 12.0 compared with 11.0; P = 0.12). CONCLUSIONS: On-line tutorials may produce greater learning efficiency and satisfaction than print materials do, but one self-study exposure may be insufficient for long-term knowledge retention. Further research is needed to identify instructional features that motivate greater final learning and retention.

Modifiable risk factors predict functional decline among older women: a prospectively validated clinical prediction tool. The Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To identify modifiable predictors of functional decline among community-residing older women and to derive and validate a clinical prediction tool for functional decline based only on modifiable predictors. DESIGN: A prospective cohort study. SETTING: Four geographic areas of the United States. PARTICIPANTS: Community-residing women older than age 65 recruited from population-based listings between 1986 and 1988 (n = 6632). MEASUREMENTS: Modifiable predictors were considered to be those that a clinician seeing an older patient for the first time could reasonably expect to change over a 4-year period: benzodiazepine use, depression, low exercise level, low social functioning, body-mass index, poor visual acuity, low bone mineral density, slow gait, and weak grip. Known predictors of functional decline unlikely to be amenable to intervention included age, education, medical comorbidity, cognitive function, smoking history, and presence of previous spine fracture. All variables were measured at baseline; only modifiable predictors were candidates for the prediction tool. Functional decline was defined as loss of ability over the 4-year interval to perform one or more of five vigorous or eight basic daily activities. RESULTS: Slow gait, short-acting benzodiazepine use, depression, low exercise level, and obesity were significant modifiable predictors of functional decline in both vigorous and basic activities. Weak grip predicted functional decline in vigorous activities, whereas long-acting benzodiazepine use and poor visual acuity predicted functional decline in basic activities. A prediction rule based on these eight modifiable predictors classified women in the derivation set into three risk groups for decline in vigorous activities (12%, 25%, and 39% risk) and two risk groups for decline in basic activities (2% and 10% risk). In the validation set, the probabilities of functional decline were nearly identical. CONCLUSIONS: A substantial portion of the variation of functional decline can be attributed to risk factors amenable to intervention over the short term. Using eight modifiable predictors that can be identified in a single office visit, clinicians can identify older women at risk for functional decline.

Influence of age-related maculopathy on visual functioning and health-related quality of life.

PURPOSE: To describe the influence of age-related maculopathy on visual functioning and health-related quality of life. METHODS: A prospective, cross-sectional, observational cohort sample of 201 persons with various stages of age-related maculopathy was recruited from the Massachusetts Eye and Ear Infirmary as part of a longitudinal study of age-related macular degeneration. Persons were considered to have age-related maculopathy if one or more of the following clinical characteristics were present: drusen, retinal pigment epithelial changes, geographic atrophy, or evidence of exudative disease. Median corrected visual acuity for this sample was 20/25 in the better eye, with all subjects having 20/200 or better visual acuity in at least one eye at baseline. All participants underwent a comprehensive ophthalmologic examination with a dilated pupil. In addition to the usual clinical data collection, severity of age-related maculopathy was graded by an ophthalmologist who used standard clinical criteria and was masked to the participants' descriptions of visual functioning and health-related quality of life. All participants completed an interview that included the Activities of Daily Vision Scale, a survey designed to assess difficulties with routine daily activities that require vision, and the Short Form-36 Health Survey, a generic measure of multidimensional health-related quality of life. RESULTS: Severity of age-related maculopathy was associated with poorer scores of the Activities of Daily Vision Scale. This association was most significant for near vision and driving activities. In this sample, the SF-36 Health Survey scales were not significantly correlated with severity of age-related maculopathy. CONCLUSIONS: Reported visual functioning is significantly associated with the clinical severity of age-related maculopathy. However, once visual acuity is taken into consideration, clinical grading of age-related maculopathy did not explain a significant portion of the variation in visual functioning. The lack of significant correlation between severity of age-related maculopathy and the SF-36 Health Survey may have resulted from the small number of participants in our sample with severe bilateral age-related maculopathy.

Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.

BACKGROUND: Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications. METHODS AND RESULTS: We studied 4315 patients aged > or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital. The main outcome measures were major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL. Rates of major cardiac complication with 0, 1, 2, or > or = 3 of these factors were 0.5%, 1.3%, 4%, and 9%, respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and 11%, respectively, among 1422 patients in the validation cohort. Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes. CONCLUSIONS: In stable patients undergoing nonurgent major noncardiac surgery, this index can identify patients at higher risk for complications. This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies, as well as low-risk patients in whom additional evaluation is unlikely to be helpful.

Age-related differences in management of heart disease: a study of cardiac medication use in an older cohort. Pacemaker Selection in the Elderly (PASE) Investigators.

BACKGROUND: Previous studies have suggested suboptimal use of cardiac medications for secondary prevention after myocardial infarction (MI) and atrial fibrillation (AF), especially among older people. OBJECTIVE: To determine whether patients older than 75 years are less likely than those aged 65 to 74 to be prescribed medications with evidence-based indications, including angiotensin-converting enzyme (ACE) inhibitors for left ventricular dysfunction (LVD) and/or diabetes mellitus (DM), aspirin and/or beta-blockers for those with a history of MI, and warfarin for chronic AF. DESIGN: A retrospective cohort study. SETTING: Twenty-nine hospitals, predominantly tertiary-care institutions. PARTICIPANTS: A total of 407 patients randomized to ventricular or dual-chamber pacing from February 26, 1993, to September 30, 1994, in the Pacemaker Selection in the Elderly (PASE) trial. MEASUREMENTS: A review of the patient's medical history and a physical exam at study enrollment, three follow-up timepoints, and a study closeout. RESULTS: Patients older than 75 years with LVD and/or DM were less likely to be prescribed ACE inhibitors (OR = .56 (0.31-1.00)); patients older than 75 with a history of MI were less likely to be taking aspirin (OR = .43 (0.19-.95)), and patients older than 75 with AF were less likely to be prescribed warfarin (OR = .18 (0.05-.61)). Patients older than 75 years of age with any or all of the conditions studied were less likely to be prescribed indicated medications than those ages 65 to 74 (OR = .35 (0.18-.70)), after controlling for between-group differences in comorbidity, gender, and number of noncardiac medications. CONCLUSION: Older age is a significant independent negative correlate of evidence-based cardiac medication use in this cohort. Causes for this finding need to be explored.

Psychometric properties of the National Eye Institute Visual Function Questionnaire (NEI-VFQ). NEI-VFQ Field Test Investigators.

OBJECTIVE: To test the reliability and validity of the 51-item Field Test Version of the National Eye Institute Visual Function Questionnaire (NEI-VFQ) across 5 common chronic eye conditions. DESIGN: Prospective observational cohort study of persons with 1 of 5 chronic eye diseases who were scheduled for nonurgent visits in ophthalmology practices or had low vision from any cause, and a reference sample of persons without eye disease. SETTING: Six university-based ophthalmology practices and the National Eye Institute Clinical Center, Bethesda, Md. PATIENTS: Eligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open-angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. Each of the 7 sites also enrolled persons in a reference sample. Reference sample participants had no evidence of underlying eye disease but were scheduled for either screening eye examinations or correction of refractive error. All eligible persons had to be aged 21 years or older, English speaking, and cognitively able to give informed consent and participate in a health status interview. MEASUREMENTS AND MAIN RESULTS: To provide the data needed to assess the reliability and validity of the 51-item NEI-VFQ, all subjects completed an interview that consisted of the 51-item NEI-VFQ, the Medical Outcomes Study 36-Item Short-Form Health Survey, and at least 1 measure of vision-targeted functional status. Estimates of internal consistency and test-retest reproducibility indicate that the 51-item NEI-VFQ is reliable. Tests of association with other scales and clinical variables support the construct validity of the survey. CONCLUSIONS: In this cross-sectional study, the 51-item NEI-VFQ seems to be reliable and valid and should be a useful tool for group-level comparisons of vision-targeted, health-related quality of life in clinical research. Additionally, the psychometric properties of the NEI-VFQ were not influenced by the type or severity of the underlying eye disease, suggesting that the measure will provide reproducible and valid data when used across multiple eye conditions.

The Glaucoma Symptom Scale. A brief index of glaucoma-specific symptoms.

OBJECTIVE: To develop a brief symptom survey specific for persons with glaucoma, the Glaucoma Symptom Scale (GSS). DESIGN: Cross-sectional study of symptoms, functional impairment, and vision-targeted health-related quality of life among persons with glaucoma. PATIENTS: A sample of 147 persons with glaucoma among a broad range of treatment categories from 4 tertiary care glaucoma centers and 44 persons without eye disease enrolled from the same 4 centers. MAIN OUTCOME MEASURES: Participants completed a modified version of the Ocular Hypertension Treatment Study 10-item symptom checklist. Participants also completed 2 vision-specific measures, the National Eye Institute Visual Function Questionnaire and the VF-14. Participants underwent a clinical evaluation, including ocular and medical history, dilated ophthalmic examination, and Humphrey 24-2 automated visual field testing. RESULTS: The GSS has 2 underlying domains that demonstrate sufficient internal consistency reliability for between-group comparisons. The GSS discriminates well between persons with and without glaucoma. Additionally, tests of association with clinical markers of glaucoma severity support the clinical validity of the measure and tests of association with established vision-targeted measures provide evidence of construct validity. CONCLUSION: The simplicity, brevity, and psychometric properties of the GSS support its use in clinical practice and research to quantify symptoms in patients with glaucoma and to assist in investigations concerning the effect of glaucoma and treatments.

The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style.

OBJECTIVES: The impact of urinary incontinence (UI) on health-related quality of life (QoL) is significant yet variable, but little is known about patient-defined content areas regarding the influence of UI on QoL and whether patient-specific factors correlate with specific content areas of UI-related QoL. In order to identify the most valid content areas for a new UI-related QoL questionnaire, our primary goal was to determine the content areas of greatest concern regarding UI-related QoL among older persons with urge incontinence. The second goal was to examine the possible role of patients' explanatory style as a mediator of UI impact on health-related QoL. Data on the questionnaire will be presented elsewhere. DESIGN: Focus groups comprising urge-incontinent persons were used to obtain verbatim descriptions of the impact of UI on QoL. SETTING: A university-affiliated tertiary hospital. PARTICIPANTS: Community-dwelling women (n = 25) and men (n = 5) more than 60 years of age, with urge incontinence, recruited from newspaper, newsletter, and radio advertisements. MEASUREMENTS: Qualitative content analysis of focus group transcripts was used to determine QoL items. These were compared with previously described UI-related QoL items obtained from the literature. Subjects' statements regarding causes of UI were evaluated for predominant explanatory style. RESULTS: Thirty-two UI-related QoL items were identified, more than half of which were not described previously. Compared with expert-defined UI-related QoL items from the literature, patient-defined items focused more on coping with embarrassment and interference from UI than on prevention of actual activity performance. Explanatory statements were made frequently by patients talking about their UI. Although positive style explanatory statements were most common, they did not correlate with any QoL items. By contrast, there was a significant correlation between negative explanatory style and six specific UI-related QoL items. CONCLUSIONS: Focus groups of older persons with urge incontinence suggest that experts and patients view the impact of urge UI on QoL differently. Whereas experts focus more on functional impact, patients more often cite the impact of UI on their emotional well-being and on the interruption of activities. In addition, the association between negative explanatory style and specific UI-related QoL items suggests that explanatory style may be an important mediator of patients' perceptions of UI-related QoL.

Quality of life and clinical outcomes in elderly patients treated with ventricular pacing as compared with dual-chamber pacing. Pacemaker Selection in the Elderly Investigators.

BACKGROUND: Standard clinical practice permits the use of either single-chamber ventricular pacemakers or dual-chamber pacemakers for most patients who require cardiac pacing. Ventricular pacemakers are less expensive, but dual-chamber pacemakers are believed to be more physiologic. However, it is not known whether either type of pacemaker results in superior clinical outcomes. METHODS: The Pacemaker Selection in the Elderly study was a 30-month, single-blind, randomized, controlled comparison of ventricular pacing and dual-chamber pacing in 407 patients 65 years of age or older in 29 centers. Patients received a dual-chamber pacemaker that had been randomly programmed to either ventricular pacing or dual-chamber pacing. The primary end point was health-related quality of life as measured by the 36-item Medical Outcomes Study Short-Form General Health Survey. RESULT: The average age of the patients was 76 years (range, 65 to 96), and 60 percent were men. Quality of life improved significantly after pacemaker implantation (P<0.001), but there were no differences between the two pacing modes in either the quality of life or prespecified clinical outcomes (including cardiovascular events or death). However, 53 patients assigned to ventricular pacing (26 percent) were crossed over to dual-chamber pacing because of symptoms related to the pacemaker syndrome. Patients with sinus-node dysfunction, but not those with atrioventricular block, had moderately better quality of life and cardiovascular functional status with dual-chamber pacing than with ventricular pacing. Trends of borderline statistical significance in clinical end points favoring dual-chamber pacing were observed in patients with sinus-node dysfunction, but not in those with atrioventricular block. CONCLUSION: The implantation of a permanent pacemaker improves health-related quality of life. However, the quality-of-life benefits associated with dual-chamber pacing as compared with ventricular pacing are observed principally in the subgroup of patients with sinus-node dysfunction.