Occupational class inequalities in all-cause and cardiovascular mortality in Norwegian men and women: a population-based approach with 45 years follow-up.

OBJECTIVES: This study assessed associations of three theoretically different occupational class schemes with all-cause and cardiovascular mortality in Norwegian men and women. STUDY DESIGN: Pooled survey and register data from four Norwegian cohort studies. METHODS: We pooled survey data from four general population cohorts (N = 97,469) linked to national mortality registries with follow-up over 45 years. Survival was modelled using accelerated failure time models stratified by sex for three class schemes: The European Socio-Economic Classification (ESeC), The Oslo Register Data Class scheme (ORDC) and The International Socio-Economic Index (ISEI). Main analyses were adjusted for age, birth cohort, and study. Secondary analyses included smoking behaviour as a mediator. RESULTS: During median 27.6 years of observation, 37,488 participants had died (13,243 from cardiovascular disease). Hazard ratios for male all-cause mortality were lowest in the highest occupational class categories ORDC 2: 0.68 (0.65-0.72), ESeC 1: 0.76 (0.73-0.79) and ISEI 5th quintile: 0.80 (0.77-0.82) compared to working class reference categories. Female mortality risks were lowest for Cultural Lower Middle class ORDC 7: 0.84 (0.72-0.98), Small Employers and Self-employed ESeC4: 0.70 (0.50-0.97) and ISEI 5th quintile: 0.79 (0.70-0.90). Patterns for cardiovascular mortality were similar to all-cause mortality. Including smoking behaviour as a mediator attenuated associations, but overall mortality patterns according to occupational class remained unchanged. CONCLUSION: The results underline that mortality inequalities do not simply consist of higher risks in the most disadvantaged groups. The association of occupational class with mortality is found across different categories of occupational class schemes, illustrating their continued relevance for studying social determinants of health.

Measurement properties and normative data for the Norwegian SF-36: results from a general population survey.

BACKGROUND: The interpretation of the SF-36 in Norwegian populations largely uses normative data from 1996. This study presents data for the general population from 2002-2003 which has been used for comparative purposes but has not been assessed for measurement properties. METHODS: As part of the Norwegian Level of Living Survey 2002-2003, a postal survey was conducted comprising 9,164 members of the general population aged 16 years and over representative for Norway who received the Norwegian SF-36 version 1.2. The SF-36 was assessed against widely applied criteria including data completeness and assumptions relating to the construction and scoring of multi-item scales. Normative data are given for the eight SF-36 scales and the two summary scales (PCS, MCS) for eight age groups and gender. RESULTS: There were 5,396 (58.9%) respondents. Item levels of missing data ranged from 0.6 to 3.0% with scale scores computable for 97.5 to 99.8% of respondents. All item-total correlations were above 0.4 and were of a similar level with the exceptions of the easiest and most difficult physical function items and two general health items. Cronbach's alpha exceeded 0.8 for all scales. Under 5% of respondents scored at the floor for five scales. Role-physical had the highest floor effect (14.6%) and together with role-emotional had the highest ceiling effects (66.3-76.8%). With three exceptions for the eight age groups, females had lower scores than males across the eight health scales. The two youngest age groups (<30 years) had the highest scores for physical aspects of health; physical function, role-physical, bodily pain and general health. The age groups 40-49 and 60-69 years had the highest scores for role-emotional and mental health respectively. CONCLUSIONS: This SF-36 data meet necessary criteria for applications of normative data. The data is more recent, has more respondents including older people than the original Norwegian normative data from 1996, and can help the interpretation of SF-36 scores in applications that include clinical and health services research.

No change in the distribution of types and antibiotic resistance in clinical Staphylococcus aureus isolates from orthopaedic patients during a period of 12 years.

Staphylococcus aureus (S. aureus) is the most common cause of bone and joint infections. However, limited information is available on the distribution of S. aureus geno- and phenotypes causing orthopaedic infections. The aim of this study was to identify the dominating types causing infections in orthopaedic patients, investigate if the characteristics of these types changed over time and examine if different types were more often associated with surgical site infection (SSI) than primary infection (non-SSI). All clinical S. aureus isolates collected from orthopaedic patients from 2000 through 2011 at Akershus University Hospital, Norway, were characterised by S. aureus protein A (spa) typing and tested for antibiotic resistance. A total of 548 patients with orthopaedic S. aureus infections were included, of which 326 (59 %) had SSI and 222 (41 %) had non-SSI. The median age was 62 years [range 2-97 years] and 54 % were male. Among the 242 unique spa types, t084 was the most common (7 %). Penicillin resistance was identified in 75 % of the isolates, whereas the resistances to the other antibiotics tested were <5 %. Three isolates (0.5 %) were resistant to methicillin. There was no significant difference in the distribution of geno- and phenotypes over time and there was no difference in types between SSI and non-SSI. In this large collection of S. aureus from orthopaedic patients, the S. aureus infections, regardless of origin, were heterogeneous, mainly resistant to penicillin, stable over time and consisted of similar types as previously found in both carrier and other patient populations.

Decisions to withhold or withdraw life-sustaining treatment in a Norwegian intensive care unit.

BACKGROUND: To withhold and withdraw treatment are important and difficult decisions made in the intensive care unit (ICU). The aim of this study was to investigate the incidence of withholding or withdrawing treatment, characteristics of the patients, and how these decision processes were handled and documented in a general ICU from 2007 to 2009 in a university hospital in Norway. METHODS: Patient characteristics and outcomes of treatment were prospectively registered. We retrospectively reviewed the medical records for information on limitations in treatment. RESULTS: In total, 1287 patients were admitted to the ICU. The ICU mortality was 208 (16%), and the hospital mortality was 341 (26%). In total, 301 patients (23%) had treatment withheld or withdrawn. Medical and unscheduled surgical patients with limitations in treatment had higher Simplified Acute Physiology Score II (P < 0.001) and were older (P < 0.001) than those without limitations in treatment. The most common main reason for withdrawing treatment was poor prognosis. According to the medical records, the patient was involved in the decision-making regarding withdrawal of treatment in only 2% of the cases, and the patient's relatives were involved in the decision-making in 77% of the cases. In 12% of the cases, type of treatment withdrawn was not documented. CONCLUSION: Withholding or withdrawing treatment in the ICU was common. Medical and unscheduled surgical patients with limitations in treatment were older and more severely ill than patients without limitations. There is a potential for better documentation of the processes regarding withholding or withdrawing life-sustaining intensive care treatment.

Quality of life in kidney donors.

Reports on quality of life of kidney donors include small populations with variable response rates. The aim was to evaluate quality of life in kidney donors in a large cross-sectional study. Through the Norwegian Renal Registry we contacted all 1984 kidney donors in the period 1963-2007 with a response rate of 76%. All received the Short-Form-36 (SF-36) survey form and a questionnaire specifically designed for kidney donors. SF-36 scores for a subgroup (n = 1414) of kidney donors were not inferior to a general population sample, adjusted for age, gender and education. When asked to reconsider, a majority stated that they still would have consented to donate. Risk factors for having doubts were graft loss in the recipient (OR 3.1, p < 0.001), medical problems after donation (OR 3.7, p < 0.001), unrelated donor (OR 2.2, p = 0.01) and less than 12 years since donation (OR 1.8, p = 0.04). Older age at donation was associated with lower risk (OR 0.98, p = 0.03). Compared with other donors, those expressing doubts had inferior SF-36 scores. Norwegian kidney donors are mostly first-degree relatives. They are fully reimbursed and offered life-long follow-up. All inhabitants are provided universal healthcare. This should be considered when extrapolating these results to other countries.

Survival over 12 years following acute stroke: initial treatment in a stroke unit vs general medical wards.

BACKGROUND: Few studies have assessed the influence of the organization of stroke care on long-term survival. AIMS OF THE STUDY: To compare survival over 12 years after stroke between subjects treated in an acute stroke unit (SU) and those treated in general medical wards (GMW). METHODS: In total, 550 subjects ≥60 years of age with acute stroke were prospectively allocated according to date of birth (day of the month) to treatment in a SU with relatively short length of stay or GMWs. We assessed survival through a link to the register of Statistics Norway. Groups were compared using Kaplan-Meier analysis on an intention-to-treat basis. RESULTS: Of the 550 eligible subjects, 271 were allocated to a SU and 279 to GMWs. There still was no difference in mortality over 12 years between the groups (P = 0.15, log-rank test) CONCLUSIONS: An acute SU offering early treatment and rehabilitation did not offer better long-term mortality after stroke in patients ≥60 years old than initial treatment in GMWs.

Agreement of a child's respiratory symptom diary with parental reports and peak expiratory flow.

OBJECTIVE: To assess the agreement of a self-completed diary to monitor respiratory symptoms in children aged 6-12 years with parental symptom reports and fluctuations in lung function. DESIGN: We created a text- and symbol-based questionnaire for daily completion by children at school. Using a screening questionnaire completed by the parents, we selected 101 children with lower respiratory symptoms in the last year or doctor-diagnosed asthma to complete the diary. We assessed the agreement with a parent-completed daily symptom diary and measurements of peak expiratory flow (PEF) over 5 weeks, estimating % agreement and the kappa statistic (kappa) for pairwise comparisons. RESULTS: Simple agreement between PEF variability, parent-reported and child-reported symptoms was moderate to high. Using kappa, agreement between children's and parents' reports of respiratory symptoms was only fair to moderate, and agreement with lung function measurements was poor for both parent- and child-reported symptoms. CONCLUSION: Agreement between children's and parents' reports on day-to-day respiratory symptoms was fair to moderate. The children's symptom diary agreed poorly with lung function measurements, but was neither worse nor better than the parent-completed diary.

Prognostic merit of N-terminal-proBNP and N-terminal-proANP in mechanically ventilated critically ill patients.

BACKGROUND: Amino-terminal fragments of type-A and type-B natriuretic peptide prohormones (NT-proBNP, NT-proANP) are powerful prognostic markers in patients with cardiac disease, and NT-proBNP has been demonstrated to predict outcome in severe sepsis and septic shock. We assessed the prognostic value of NT-proBNP and NT-proANP in a consecutive series of mechanically ventilated intensive care patients and compared their prognostic merit. METHODS: Seventy unselected patients admitted to the intensive care unit (ICU) were included in the study 48 h after start of controlled mechanical ventilation. Venous blood was obtained on inclusion and assayed for NT-proBNP and NT-pro ANP. Univariate and multivariate logistic regression analysis was used to assess the association of NT-proBNP and NT-proANP levels with 30-day mortality. Established risk factors and possible confounders were used as covariates. Discrimination of different prognostic models was assessed calculating the area under the receiver-operating characteristics curve (ROC-AUC). RESULTS: NT-proBNP and NT-proANP levels were higher in non-survivors (n=25) than in 30-day survivors (n=45). Log NT-proBNP [odds ratio (OR) 2.34, 95% CI 1.17-4.66], and log NT-proANP (OR 2.44, 95% CI 1.12-5.30) were independently predictive of increased mortality. A prior diagnosis of chronic obstructive lung disease was predictive of decreased mortality (OR 0.29, 95% CI 0.08-1.00). The relative prognostic values, evaluated by the ROC-AUCs of NT-proBNP (AUC 0.74, 95% CI 0.61-0.86) and NT-proANP (AUC 0.73, 95% CI 0.61-0.86), were nearly identical. CONCLUSIONS: High NT-proANP and NT-proBNP levels associated with decreased short-term survival in unselected, mechanically ventilated ICU patients. NT-proANP performed equally well as a prognostic indicator as NT-proBNP, and may represent a clinically useful alternative to NT-proBNP.

Derivation and validation of a simple risk score for predicting 1-year mortality in stroke.

CONTEXT: Numerous models have been presented for the prognosis in acute stroke; however they have been criticized for being difficult to use, and few have been validated in independent samples. OBJECTIVES: To develop simple risk score models for 1-year mortality in acute stroke in patients > 60 years old and validate the models. DESIGN: From a cohort of 2321 consecutive patients > 60 years of age with acute stroke in one hospital, we randomly selected 800 patients for chart review. Among 737 patients with validated acute stroke, we randomly split the sample into (1) a derivation (60%; n = 442) and (2) a validation sample (40%; n=295). We used logistic regression to develop three models with 2-4 covariates and a corresponding risk score from the derivation sample. The models were validated using area under the receiver operating curves. RESULTS: Three risk score models for 1-year mortality after stroke were developed using combinations of age, Canadian Neurological Scale score (CNSscore) (< or = 3.5 = 0, >3.5 = 1), Charlson comorbidity index and stroke type (ischemic = 0, hemorrhagic = 1). Both 2-variable (Age - 60 + (30*CNSscore)), 3-variable (Age - 60 + (30*CNSscore) + 4*Charlson)) and 4-variable (Age - 60 + (25*CNSscore) + (5*Charlson) + (18*Stroke type)) models reliably predicted the outcome with an area under the receiver operating curve ranging 0.71 to 0.72. CONCLUSIONS: Simple models incorporating two to four covariates reliably predicted 1-year mortality. Such models can be used to stratify prognosis in clinical practice, research or intervention trials.

Associations of timing of surgery with postoperative length of stay, complications, and functional outcomes 3-6 years after operative fixation of closed ankle fractures.

AIMS: To evaluate the associations of timing of surgery with postoperative length of stay (LOS), complications, and functional outcomes 3-6 years after open reduction and internal fixation (ORIF) in closed ankle fractures. PATIENTS AND METHODS: Historical cohort study by chart review of 1011 patients for postoperative LOS and complications; 959 individuals were invited to participate in a postal survey with functional outcomes questionnaires. Complications were classified as perioperative, early, or late. The associations with time from trauma to surgery (<8h, 8h to 6days, >6days) were assessed with (1) postoperative LOS using multivariable random-effects negative binomial regression, (2) complications using multivariable binary and multinomial logistic regression, and (3) three different functional outcomes using multivariable linear regression. RESULTS: The mean patient age was 51.4 (range 18-94) years, 556 (55%) were female, and 567 individuals (59%) responded to the questionnaire. There were no statistically significant associations between time to surgery and either postoperative LOS or complications after adjusting for several patient and fracture characteristics. Patients operated on >6days after the trauma had significantly worse scores on the Olerud and Molander Ankle Score (OMAS) (p=0.039) and somewhat worse, but non-significant, scores on the Lower Extremity Functional Scale (LEFS; p=0.573) and the Self-Reported Foot and Ankle Score (SEFAS) scale (p=0.161) than those operated on <8h after trauma. CONCLUSION: In ankle-fracture surgery, there was no apparent association between timing of surgery and postoperative LOS or complications. A delay of surgery for 8h to 6days resulted in similar functional outcomes after 3-6 years suggesting there may be a safe window of time for surgery of up to 6days after trauma that can be used to plan and perform the final ORIF.

The association of body mass index with complications and functional outcomes after surgery for closed ankle fractures.

AIMS: This study assessed the association of classes of body mass index in kg/m2 (classified as normal weight 18.5 kg/m2 to 24.9 kg/m2, overweight 25.0 kg/m2 to 29.9 kg/m2, and obese ≥ 30.0 kg/m2) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures. PATIENTS AND METHODS: We performed a historical cohort study with chart review of 1011 patients who were treated for ankle fractures by open reduction and internal fixation in two hospitals, with a follow-up postal survey of 959 of the patients using three functional outcome scores. RESULTS: Obese patients had more severe overall complications and higher odds of any complication than the normal weight group, with adjusted odds ratio 1.67 (95% confidence interval (CI) 1.08 to 2.59; p = 0.021) and 1.71 (95% CI 1.10 to 2.65; p = 0.016), respectively. In total 479 patients (54.6%) responded to the questionnaire. Obese patients had worse scores on the Olerud and Molander Ankle Score (p < 0.001), Self-Reported Foot and Ankle Questionnaire (p = 0.003) and Lower Extremity Functional Scale (p = 0.01) than those with normal weight. In contrast, overweight patients did not have worse functional scores than those with normal weight. CONCLUSION: Obese patients had more complications, more severe complications, and worse functional outcomes three to six years after ankle surgery compared with those with normal weight. Cite this article: Bone Joint J 2017;99-B:1389-98.

Incidence and risk factors for removal of an internal fixation following surgery for ankle fracture: A retrospective cohort study of 997 patients.

BACKGROUND: Implant removal in ankle fractures treated by open reduction and fixation is often based on diffuse complaints. This study determined the incidence of implant removal and identified risk factors for two principal causes for removal: complaints and surgical site infection (SSI). METHODS: Retrospective cohort study involving 997 patients operated on 2009-2011 with follow-up through to 2013. The incidence of implant removal was analysed using competing risk analysis. Risk factors for implant removal were assessed using cause-specific hazard ratios (HRs) from a Cox regression analysis. RESULTS: The mean age at surgery was 51.6 years, 550 (55%) of the patients were female, and 170 patients (17%) had implant removal: 144 due to complaints and 26 due to infection. Multivariable HRs for implant removal due to complaints were 0.70 for male sex (p=0.047), 0.79 for each 10-year increase in age (p<0.001), 0.70 for treatment with a syndesmosis screw (p=0.038), and 1.09 for each 15-min increase in operation duration (p=0.007). HRs for hardware removal due to infection were 1.42 for each 10-year increase in age (p=0.006) and 3.15 for current smoking (p=0.005). CONCLUSION: In total 17% of patients had implant removal after open reduction and fixation; the majority because of subjective complaints. The risk factors for implant removal were different for removal due to complaints than for those removed due to infection. This information may be used to inform patients about the risk and risk factors for future implant removal.

Patterns of finasteride use in the male populations of four Nordic countries: A cross-national drug utilization study.

Objective Finasteride 5 mg is a drug used to treat prostate hyperplasia. Little is known about its pattern of usage. This cross-national analysis of individual-level data from Denmark, Finland, Norway and Sweden was undertaken to appraise its usage and describe cross-national differences. Materials and methods Individual-level data from nationwide prescription registers in Denmark (1995-2009), Finland (1997-2010), Norway (2004-2009) and Sweden (July 2005-2011) were used to examine cross-national finasteride utilization patterns in the adult male population (≥15 years). The study presents period prevalences, incidence rates, waiting time distributions and Lorenz curves. Results During the study period, 295,620 men had at least one prescription redemption of finasteride 5 mg, and there were approximately 3 million dispensing events of finasteride prescriptions in the four Nordic countries. Different patterns of finasteride use were observed among the four Nordic countries. The period prevalence was markedly higher in Finland and Sweden than in Denmark and Norway. In 2009, period prevalences were 18.2/1000 males in Finland and 12.0/1000 males in Sweden compared to 6.7/1000 males in Norway and 4.9/1000 males in Denmark. Incidence rates of finasteride use for Finland, Norway and Sweden were about three times that for Denmark in 2008-2009. Long-term use of finasteride was found in all four Nordic countries with a high ratio between prevalent and incident users. Conclusion Despite resemblances regarding political systems and healthcare services in the Nordic countries, differences in finasteride utilization were found across Denmark, Finland, Norway and Sweden.

Comparison of traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis.

OBJECTIVES: To compare traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis. DESIGN: A three-armed single blind randomised controlled study. SETTING: In an outpatient specialist clinic, we recruited 65 patients with symptoms of sinusitis >3 months and signs of sinusitis on computed tomography (CT). INTERVENTIONS: We randomised patients to one of three study arms: (1) 2-4 weeks of medication with antibiotics, corticosteroids, 0.9% sodium chloride solution, and local decongestants (n=21), (2) 10 treatments with traditional Chinese acupuncture (n=25), or (3) 10 treatments with minimal acupuncture at non-acupoints (n=19). OUTCOME MEASURES: Change in sinus soft tissue swelling on CT, symptoms of sinusitis, and health-related quality of life (HRQoL), using the two component summary scales of the Short Form 36 and a rating scale. RESULTS: In the conventional treatment group, sinus soft tissue swelling was reduced over 4 weeks (p=0.04), and HRQoL improved over 12 weeks (p=0.01-0.05). Pairwise comparisons of changes in total symptom score between the groups showed signs of a difference between conventional medication and sham over 4 weeks (p=0.06). CONCLUSION: Sinus soft tissue swelling was reduced in the conventional treatment group over 4 weeks, and HRQoL improved over 12 weeks. Only a non-significant difference in symptom score change over 4 and 12 weeks was shown between conventional medication and traditional Chinese acupuncture.

Accuracy of infrared ear thermometry in adult patients.

OBJECTIVE: To assess (1) the agreement between infrared ear thermometry and core reference temperature (in the pulmonary artery). (2) the agreement between measurements in the right and left ears, and (3) the screening validity of infrared tympanic thermometry in detecting rectal fever. DESIGN: Temperatures were measured in both ears with an infrared thermometer, in one group of patients by simultaneous measurements with thermistors inserted in the pulmonary artery, esophagus, and rectum, and in the other group with a rectal glass-mercury thermometer. SETTING: An intensive care unit and a department of internal medicine in a secondary care hospital. PATIENTS AND PARTICIPANTS: Two samples: 16 adult patients admitted to the intensive care unit and 103 consecutive patients admitted to the department of medicine. MEASUREMENTS: The major outcome measures were (a) the agreement between infrared ear thermometry and thermistor pulmonary artery temperature and (b) the sensitivity and specificity for detecting fever, using rectal measurement as reference. RESULTS: Both rectal and esophageal thermistor measurements showed better agreement with the pulmonary artery reference temperature than single ear tympanic thermometry. The sensitivity and specificity of ear thermometry for detecting fever (> or = 38.0 degrees C rectal reference) were 0.58 and 0.94, respectively. Double ear thermometry had a sensitivity of 0.61 and a specificity of 0.95, when using the mean value. CONCLUSIONS: Both rectal and esophageal thermistor measurements showed better agreement with pulmonary artery temperature than single ear themometry. Using the mean of two ear measurements improves the agreement and screening validity for detecting fever by rectal temperature. If temperature measurements are critical, esophageal measurements achieve excellent agreement with pulmonary artery temperatures.

Survival of unselected stroke patients in a stroke unit compared with conventional care.

BACKGROUND: Recent meta-analyses have reported a beneficial effect of stroke units compared with traditional care, both on patient survival and on dependency after one year. AIM: To determine whether these results can be reproduced outside a clinical trial setting. SETTING: A medium-sized general hospital. METHODS: From 1993 to 1998, all patients aged >60 years with suspected acute stroke were allocated either to a stroke unit or general medical wards according to date of birth (day of the month). Patients were identified retrospectively, using a discharge diagnosis of ICD-9 codes 431, 434 and 436. We assessed 30-day and 1-year survival. RESULTS: In the stroke unit, 926/1128 patients survived at 30 days, vs. 905/1141 in the general medical wards (p=0.08). Beyond the first 30 days, there was no difference in survival (p=0.27). Under Cox regression analysis, there was a 20% reduction in mortality in the stroke unit after 30 days compared with the general medical wards (RR 0.80, p=0.02) after adjusting for age, gender, stroke type and season of the year. DISCUSSION: In this, the largest single-centre study to evaluate the survival benefit of a stroke unit, survival at 30 days was increased, although not significantly so. Survival at one year was unchanged.

Association of willingness to pay with severity of chronic obstructive pulmonary disease, health status and other preference measures.

SETTING: Willingness to pay (WTP) is a method frequently used to measure the benefits of health interventions in monetary terms. OBJECTIVE: To assess the construct validity of the WTP method in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Fifty-nine COPD patients (34 men, mean age 57 years) were asked about their maximum WTP for a theoretical cure for COPD. In addition, they reported utility scores using standard gamble, time trade-off, a multi-attribute utility instrument, and a rating scale. They also responded to the Short Form 36 (SF-36) questionnaire, dyspnea measures and had comprehensive pulmonary function tests. RESULTS: The participants reported a median WTP of Norwegian kroner 200 000 (US $24 096) for a theoretical cure for COPD without side-effects. The associations of WTP with utility scores, dimensions of health status, dyspnea measures and lung function tests were low. CONCLUSION: The findings of this study question the validity of the WTP method in patients with chronic obstructive pulmonary disease.

Health status, dyspnea, lung function and exercise capacity in patients with chronic obstructive pulmonary disease.

SETTING: A secondary hospital outside Oslo. OBJECTIVE: To assess relationships between health status and measures of dyspnea, lung function and exercise capacity in patients with chronic obstructive pulmonary disease (COPD), to identify dimensions where lung-specific instruments associate and discriminate better than general measures. DESIGN: We assessed health status in 59 out-patients with COPD, using the following instruments: Short Form 36 (SF-36)-a general health status measure, Respiratory Quality of Life Questionnaire (RQLQ)-a lung-specific measure, the Karnofsky performance scale, and a rating scale. All patients rated their dyspnea and had spirometry and exercise capacity measured. RESULTS: Mean (SD) patient age was 57.3 (9.7) years, FEV1 47% (15%) of predicted, 6 minute walk distance 503 m (122 m). Dyspnea was the strongest predictor for health status. Both SF-36 and RQLQ had dimensions associating well with dyspnea and exercise capacity. The associations with FEV1 ranged from none to moderate. CONCLUSION: All RQLQ scales had a moderate to substantial association with indices of dyspnea and exercise capacity, while the SF-36 associated well only in dimensions related to physical health. The general measure has a broader scope and complements the lung-specific measure. These findings support the construct validity of both the SF-36 and the RQLQ, and justify using a general measure to supplement a lung-specific measure.

Quality of life in epilepsy: comparison of four preference measures.

Several specific and general measures are available for the assessment of overall health related quality of life in epilepsy. Few of the commonly used measures provide utility weights for use in cost-utility analyses. This study compares four methods for measuring utility weights: time trade-off (TTO), standard gamble (SG), 15D, end the EuroQol visual analog scale. All patients aged 18-67 years with a diagnosis of epilepsy, who had been admitted to or attended the outpatient clinic at a large county hospital 1987-1994, received a comprehensive questionnaire. From 397 respondents, 82 patients were randomly selected. Most of the 57 patients completing the study generally had well-controlled epilepsy, but were still on anti-epileptic medication. Mean age was 44 years. Fourty-one percent were male and 59% female. The resulting utility weights differed considerably between the measures, both with regard to central tendency and dispersion. Median utility scores: EuroQol visual analog scale 0.75, 15D 0.90, TTO 0.98, SG 0.99. There was a good association between the EuroQol rating scale and the 15D, and a moderate association between SG and TTO. These preference instruments measure different aspects of health-related quality of life and thus yield different results. Caution should be taken when interpreting cost-utility studies, as results will depend on the choice of utility instrument.

Properties of the 15D and EQ-5D utility measures in a community sample of people with epilepsy.

To perform economic evaluation studies in epilepsy using utilities, such as cost-utility analyses, it is necessary to have reliable and valid instruments for eliciting people's preferences. The objective of this study was to assess the reliability and validity of two multiattribute utility measures in a community sample of 397 people with epilepsy. We assessed the test-retest reliability of individual questionnaire items and aggregate scores. Additionally, construct validity was assessed by correlating items of the EQ-5D with items of the 15D health status questionnaire, and discriminant validity was assessed by comparing scores for known groups. The test-retest reliabilities for the individual items of the 15D (weighted kappa 0.59-0.90, except mobility with only 0.28) and the EQ-5D (weighted kappa 0.49-0.86) were acceptable. For the composite utility scores the test-retest reliability was better (intraclass correlation coefficient 0.93 for both 15D and the EQ-5D). Spearman's rank correlations between EQ-5D single item scores and corresponding 15D single item scores were high (rho 0.34-0.79) and generally higher than the associations between non-corresponding items. Some EQ-5D and 15D items discriminated well between patients according to seizure status, psychiatric comorbidity and working status; less well after antiepileptic drug use and neurologic comorbidity. Both the EQ-5D and 15D were reliable instruments and showed properties supporting the construct validity of both measures.