close

Вход

Забыли?

вход по аккаунту

?

Investigation of quality of life mood pain disability and disease status in primary systemic vasculitis.

код для вставкиСкачать
Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 49, No. 6, December 15, 2003, pp 826 – 837
DOI 10.1002/art.11471
© 2003, American College of Rheumatology
ORIGINAL ARTICLE
Investigation of Quality of Life, Mood, Pain,
Disability, and Disease Status in Primary
Systemic Vasculitis
MARIA KOUTANTJI,1 EMMA HARROLD,1 SUZANNE E. LANE,2 SHIRLEY PEARCE,1
RICHARD A. WATTS,2 AND DAVID G. I. SCOTT2
Objective. To assess quality of life (QOL) and psychological adjustment in primary systemic vasculitis (PSV), and to
assess their relationship to disease-related measures.
Methods. Fifty-one PSV patients completed questionnaires assessing QOL (Short Form 36 [SF-36]), disability (Health
Assessment Questionnaire [HAQ]), and mood (Hospital Anxiety and Depression Scale [HADS]). Illness-related measures,
disease activity, and permanent damage scores (the Birmingham Vasculitis Damage Index [BVDI] modified, and the
Birmingham Vasculitis Activity Scale modified) were collected. Aspects of the HAQ’s psychometric properties were
evaluated.
Results. PSV patients’ SF-36 scores, except for mental health, were significantly lower than the norms, indicating poorer
QOL. Using the HADS, 43.2% of patients reported increased anxiety symptoms and 25.5% increased depressive symptoms. Patients with increased pain when compared with those with little or no pain had significantly impaired scores in
all SF-36 subscales, except for mental health; and they scored significantly worse on depression, fatigue, problems with
sleep, and symptom severity. Patients with neuropathic symptoms and those taking high levels of steroids had significantly impaired scores on some of the relevant measures. There were no significant correlations between the modified
BVDI scores with the SF-36 subscales or with the other self-report disease-related measures. The HAQ showed high
internal consistency and high concurrent and discriminant validity.
Conclusion. Many aspects of QOL are significantly impaired in PSV. Self-reported pain and disease symptoms, SF-36
scores, and depression and anxiety levels are significant indicators of the adverse impact of vasculitis on patients’ lives
that need to be assessed and managed.
KEY WORDS. Quality of life; Vasculitis; Pain; Mood.
INTRODUCTION
The primary systemic vasculitides (PSVs) are a group of
rare, life-threatening, chronic illnesses (1). They are characterized by inflammation of blood vessels, which can
Supported by the Arthritis Research Campaign, United
Kingdom.
1
Maria Koutantji, PhD, Emma Harrold, PhD, Shirley
Pearce, PhD: University of East Anglia, Norwich, United
Kingdom; 2Suzanne E. Lane, MB ChB, MRCP, Richard A.
Watts, BA, BM BCH, MA, DM, FRCP, David G. I. Scott, MB
ChB, MD, FRCP: Norfolk & Norwich University Hospital
NHS Trust, Norwich, United Kingdom.
Address correspondence to Maria Koutantji, PhD, Imperial College London, Department of Surgical Oncology and
Technology, 10th Floor QEQM Building, St. Mary’s Hospital,
Praed Street, London W2 1NY, UK. E-mail: M.Koutantji@
Imperial.ac.uk.
Submitted for publication October 3, 2001; accepted in
revised form November 7, 2002.
826
involve and cause damage to a many organ systems, including lungs, kidneys, and skin. This inflammation is
accompanied by severe and painful symptoms (2–5). The
medical treatment of the disease usually comprises highdose steroids and cyclosphosphamide for acute disease
episodes, followed by prolonged immunosuppression
(e.g., azathiopine, methotrexate), which in itself causes
additional symptoms.
It is likely that such a serious illness significantly impairs a patient’s quality of life (QOL), causes psychological
distress, and forces changes in the patient’s and family’s
way of life (6). However, the introduction of patient-reported QOL measures to vasculitis research has only just
started (7) because it is only recently that progress in
medical management has turned these previously fatal
illnesses to chronic ones. As a result, there is very little
published research assessing the impact of the disease on
QOL and psychological adjustment cross-sectionally or
longitudinally. Comparative studies with other systemic
Quality of Life in Vasculitides
diseases are scarce and limited in scope (8,9), as are comparisons between the specific vasculitides. However, there
are now studies in progress evaluating QOL and, to some
degree, psychological adjustment in these conditions.
Existing research in vasculitis has focused on evaluating
QOL using mainly generic instruments, such as the Short
Form 36 (SF-36). Hoffman et al’s (10) study is to our
knowledge the only relevant study published as a full
article where a disease-specific questionnaire was devised
with input from a patient focus group. The questionnaire
assessed the effects of Wegener’s granulomatosis (WG) on
the health, function, and income of 60 patients. The findings showed that patients experienced substantial medical
and functional morbidity, with 78% requiring long-term
immunosuppressive treatment. Daily activities were significantly reduced or constrained in 80% of these patients.
There was a negative impact of the disease on patients’
normal daily living, employment circumstances, and income and a variable impact on family and close relationships.
Boomsma et al (11) translated this questionnaire to
Dutch and assessed the impact of WG on 79 Dutch patients. They replicated Hoffman et al’s (10) main findings:
WG was associated with increased medical morbidity and
adverse effects on income and physical functioning. However, they reported lower impact of the disease on interpersonal relationships and attributed this finding to cultural and socioeconomic differences between The
Netherlands and the US.
A recent review on the socioeconomic impact of vasculitis suggests that its adverse negative effect is greater than
anticipated and recommends a full investigation (7).
The information from the following studies has been
extracted from work presented in conferences and published as abstracts, which allows limited scope for critical
appraisal of design and methods. Nevertheless, there are
consistent patterns in the reported findings, which are
relevant to the background and aims of this study. Exley et
al (12) used the SF-36 to assess QOL in patients (n ⫽ 30)
with active and inactive vasculitis and found impaired
levels of QOL. Herlyn et al (13) also used the SF-36 to
compare a group of patients with active PSV (n ⫽ 303)
with a group of patients in complete remission (n ⫽ 40)
and a healthy population (n ⫽ 350), assessing patients at
baseline and at 12 months followup. They found limited
QOL for both patient groups at both assessments. Raza et al
(14) investigated the relationship between vasculitis activity and damage by combining scores in the separate SF-36
subscales into scores for physical and mental components
in 83 patients with systemic necrotizing vasculitis. Their
patient group reported significantly lower SF-36 scores
than a healthy population. Interestingly, there were no
significant correlations between disease activity or damage
scores and physical or mental components of the SF-36.
Grove et al (15) investigated the relationship between
SF-36 physical and mental functioning scores and disease
activity and damage scores in 91 PSV patients. They reported that overall physical functioning was significantly
impaired (no comparisons with norms or reference to cutoff points were reported in the abstract). Mental functioning was significantly impaired for patients with active
827
disease when compared with patients with inactive disease, and physical functioning only was significantly
lower for patients with high damage.
Currently there is no vasculitis-specific measure of
physical disability. The Health Assessment Questionnaire
(HAQ) has been used as a disability measure in 2 published studies (8,9) that included vasculitis patients in
their assessment of physical functioning in patients with
different rheumatic diseases.
In this study, we addressed generic and specific aspects
of QOL and psychological adjustment in a group of UK
vasculitis patients. Detailed evidence from a UK sample
allows assessment of 1) impact of vasculitis on QOL in a
UK context and 2) generalizability of previous findings. It
also enables the identification of key areas of disease impact, as indicated by the patients themselves, that could
benefit from future tailored medical or psychoeducational
interventions.
We conducted an exploratory survey of vasculitis patients from a prospective regional UK register aiming specifically to 1) evaluate the impact of the disease on PSV
patients’ QOL using the SF-36, assessing also neuropathic
and steroid treatment status, disability levels, pain, fatigue, and mood using the Hospital Anxiety and Depression Scale (HADS) (16); 2) compare levels of QOL between
the different PSV diagnostic groups; 3) assess internal consistency and concurrent and discriminant validity of the
HAQ as a measure of disability in PSV; and 4) evaluate the
relationship between the clinical marker of permanent
disease damage (modified Birmingham Vasculitis Activity
Score [BVDI]) with patients’ self-reported scores on the
above measures.
PATIENTS AND METHODS
Patients. Sixty-two patients diagnosed with PSV between 1988 and 1998 and resident within the county of
Norfolk, UK were identified from a prospective vasculitis
register. Patients were classified according to the following: WG by the 1990 American College of Rheumatology
(ACR) criteria (17); microscopic polyangiitis (MPA) by the
Chapel Hill Consensus Conference criteria (18); and
Churg-Strauss syndrome (CSS) by the 1990 ACR criteria
(19). Inclusion criteria were that the participants should
have a good understanding and use of the English language. Exclusion criteria were patients unwilling or unable to comply with the requirements of the protocol and
presence or history of severe psychiatric illness (e.g., psychosis).
Patients were contacted by the department of rheumatology and data for the study were collected via a postal
survey using self-report questionnaires. Questionnaires
were returned by 51 patients, achieving an 82% response
rate (WG: n ⫽ 31; MPA: n ⫽ 9; CSS: n ⫽ 11). Thirty
patients (59%) were male, 21 (41%) were female. Fortytwo (82%) were married or cohabiting and 9 (18%) were
single, widowed, or divorced. The characteristics of the
sample are presented in Table 1.
To evaluate the HAQ’s psychometric properties (i.e.,
discriminant validity), the 51 PSV patients were matched
Primary systemic
vasculitis
Age, years
Illness duration,
years
Rheumatoid
arthritis
n
Mean ⴞ SD
n
Mean ⴞ SD
51
51
63.06 ⫾ 10.13
4.19 ⫾ 2.89
51
51
63.12 ⫾ 10.01
3.63 ⫾ 2.23
Pain
60.3
67.78 ⫾ 27.97
76.9 ⫾ 24.0
⫺2.55‡
44.8
40.10 ⫾ 21.37
61.8 ⫾ 21.2
⫺6.98†
64.5
71.36 ⫾ 17.28
76.4 ⫾ 18.4
⫺1.87†
70.9
64.89 ⫾ 28.87
86.2 ⫾ 22.7
⫺6.23†
64.9
56.67 ⫾ 44.80
84.8 ⫾ 30.6
⫺5.92†
40.5
30.0 ⫾ 39.12
75.9 ⫾ 37.5
⫺8.32†
62.7
49.1 ⫾ 28.35
76.2 ⫾ 22.3
⫺8.08†
* Scores are the mean ⫾ SD. t-test compares this study sample and the norm sample.
† P ⬍ 0.001.
‡ P ⬍ 0.05.
Table 2. Age and duration of illness for vasculitis
patients and the matched rheumatoid arthritis patients
303
51
525
Clinical measures. Data on disease-related variables
had previously been collected for all participants by interview and hospital case note review by a rheumatologist
(SEL) using modified versions of the Birmingham Vasculitis Activity Score (BVAS) (20) and the BVDI (21). Patients
were classified by a clinician (RAW) who was independent
from those caring for the patients.
The BVAS (20) is a clinician-derived measure of disease
activity in 9 organs based on disease signs and symptoms.
The BVDI (21) is a clinician-derived measure of permanent
damage and irreversible damage to organs, a result of the
disease itself or from treatment.
These scores were intended for prospective use in the
clinic in the assessment of whether symptoms are due to
active vasculitis, chronic grumbling disease, permanent
damage, or comorbidity, e.g., infection. In this sample, the
BVAS and BVDI proforma were used to record clinical
findings, histology, and radiographic findings throughout
the disease course that could be attributed to vasculitis.
Severity of disease activity at time of patients’ first presentation to the clinic was recorded as the number of organ
systems affected by active disease at presentation using the
modified BVAS. Disease damage for near the time of ques-
Herlyn et al (ref 13)
This study
Norm 60–64 years
t- test
for sex, age, and disease duration to patients with rheumatoid arthritis (RA) from a database of 199 RA patients who
were participating at the same time in another trial. RA
patients were selected of the same sex and within 5 years
either side of the age of the PSV patient to be matched. The
RA patient with the closest disease duration was then
selected from this subset. Thirty-seven (72.5%) of the resulting RA sample were married or cohabiting and 14
(27.5%) were single, widowed, or divorced. The characteristics of the 2 samples are presented in Table 2.
Energy/vitality
2.52 ⫾ 1.80
2
Mental
health
46
Social
functioning
63.06 ⫾ 10.13
4.19 ⫾ 2.89
19.27 ⫾ 7.91
Role
emotional
66
3.42
19
Role
physical
51
51
51
Physical
functioning
Mean score
ⴞ SD
n
Median
score
Source
Age, years
Illness duration, years
Modified Birmingham
Vasculitis Activity
Score at presentation
Modified Birmingham
Vasculitis Damage
Index near study
recruitment
n
Table 3. Short Form 36 subscale scores obtained in this study, a tertiary referral center, and norms taken from the Oxford Healthy Life Survey*
Table 1. Descriptive statistics (median, mean, standard
deviation) for age, duration of illness, and clinical
markers’ scores for the vasculitis patients in this study
46.6
46.27 ⫾ 22.89
68.1 ⫾ 21.9
⫺6.78†
Koutantji et al
General health
perception
828
Quality of Life in Vasculitides
829
Figure 1. Short Form-36 (SF-36) subscale scored obtained in this study, a tertiary referral center (reference 13), and norms taken from the Oxford Healthy Life Survey, 1991–1992.
tionnaire completion was measured as the number of organ systems damaged by disease using the modified BVDI.
Patient self-report measures. The measures of psychological state, QOL, physical functioning, fatigue, and
symptoms were collected from self-completed questionnaires.
The HADS (16) was used to assess depression and anxiety levels and has been developed specifically for use in
patients with physical health conditions. The measure has
been clinically validated in cross-sectional and longitudinal studies (22).
The SF-36 UK version (23), a generic measure of health
status, was used to assess certain aspects of patients’ QOL
that may be affected by illness. The dimensions comprising the measure are physical function, role limitation due
to physical and emotional problems, social functioning,
mental health, energy and vitality levels, pain, and perceptions of general health. The measure has been assessed
for validity and reliability in its application to the general
population and patient groups in the UK and US (23).
The HAQ (24) was used to measure levels of physical
functioning and disability. This is one of the most frequently used measures of physical functioning in randomized clinical trials of RA (25) and has recently been used to
assess physical disability in other rheumatic conditions,
including the vasculitides (8,9).
Pain, fatigue, symptom severity, and sleep levels were
measured using a 101-point visual analog scale (VAS)
(26,27).
Statistical analyses. Data were analyzed using SPSS
software (Chicago, IL). The distributions of the response
variables were checked for normality and transformations
were performed as appropriate. When the pattern of the
results observed using the transformed scores was similar
to the results obtained from the raw data analysis, the raw
data analysis is presented; if different, we report the results obtained using the transformed scores. Nonparametric tests were used as appropriate where the normality
assumptions could not be met. The data were analyzed
using Mann-Whitney U tests, t-tests, one-way analysis of
variance (one-way ANOVA), and correlations (Pearson r or
Spearman rho). Internal consistency of the HAQ was evaluated using Cronbach’s ␣ and correlations between HAQ
scores and SF-36 physical disability scores were calculated to assess concurrent validity. Discriminant validity
of the HAQ was also assessed comparing scores between
the vasculitis sample and a matched sample of RA patients
using Wilcoxon’s signed rank test.
RESULTS
Quality of life. SF-36 scores in this patient cohort appear to be lower than those obtained from patients with
vasculitis attending a tertiary referral center from the Herlyn et al study (13), and lower than those in a normal
population of similar age (Table 3 and Figure 1). Low
SF-36 scores indicate poor QOL.
Because there were no standard deviations available for
830
Koutantji et al
Table 4. Comparisons between vasculitis diagnostic groups for age, symptom severity, disease status scores, fatigue, sleep,
pain, functional disability, and mood
Wegener’s
granulomatosis
(n ⴝ 22–31)
Churg-Strauss
syndrome
(n ⴝ 7–11)
Microscopic
polyangiitis
(n ⴝ 5–9)
ANOVA F
value
Age, years
Disease duration, years
Modified BVAS
Modified BVDI
59.97 ⫾ 9.84
4.24 ⫾ 2.94
21.84 ⫾ 8.29
2.14 ⫾ 1.33
67.00 ⫾ 7.27
4.83 ⫾ 2.58
17.09 ⫾ 6.27
3.91 ⫾ 2.39
68.89 ⫾ 10.78
3.25 ⫾ 3.14
13.11 ⫾ 3.06
1.86 ⫾ 1.46
4.25†
0.74
5.68‡
5.19†
Symptom severity (VAS)
15.45 ⫾ 17.01
38.57 ⫾ 25.93
72.00 ⫾ 27.75
16.35§
Fatigue (VAS)
Fatigue with age, creatinine, and
hemoglobin as covariates
Sleep (VAS)
Pain this week (VAS)
Pain today (VAS)
Functional disability (HAQ)
HAQ (square root)
Anxiety (HADS)
Depression (HADS)
35.32 ⫾ 23.31
60.57 ⫾ 29.70
70.00 ⫾ 36.74
4.82†
4.42†
33.59 ⫾ 33.77
24.42 ⫾ 31.32
18.77 ⫾ 28.26
0.53 ⫾ 0.78
0.50 ⫾ 0.53
6.90 ⫾ 3.49
5.94 ⫾ 3.77
46.25 ⫾ 25.60
19.91 ⫾ 20.57
14.63 ⫾ 16.29
1.26 ⫾ 1.12
0.95 ⫾ 0.64
7.55 ⫾ 3.27
6.91 ⫾ 4.23
44.00 ⫾ 40.37
27.50 ⫾ 33.27
27.50 ⫾ 33.27
1.13 ⫾ 1.02
0.91 ⫾ 0.58
6.78 ⫾ 3.49
6.67 ⫾ 3.94
0.53
0.16
0.54
3.81†
3.39†
0.17
0.31
Post hoc Scheffé test
locating significant
differences
WG–MPA†
—
WG–MPA†
WG–CSS†
CSS–MPA†
WG–CSS†
WG–MPA§
CSS–MPA†
WG–MPA†
WG–CSS¶
WG–MPA#
—
—
—
WG–CSS**
WG–CSS††
—
—
* Scores are the mean ⫾ SD. ANOVA ⫽ one-way analysis of variance; WG ⫽ Wegener’s granulomatosis; MPA ⫽ microscopic polyangiitis; BVAS ⫽
Birmingham Vasculitis Activity Score; BVDI ⫽ Birmingham Vasculitis Damage Index; CSS ⫽ Churg-Strauss syndrome; VAS ⫽ 101-point visual analog
scale; HAQ ⫽ Health Assessment Questionnaire; HADS ⫽ Hospital Anxiety and Depression Scale.
† P ⬍ 0.05.
‡ P ⬍ 0.01.
§ P ⬍ 0.001.
¶ P ⫽ 0.088.
# P ⫽ 0.078.
** P ⫽ 0.079.
†† P ⫽ 0.09.
the Herlyn et al (13) study that would allow comparisons
between all 3 groups, statistical comparisons were only
conducted between patients who participated in this study
and available norms for each SF-36 subscale using t-tests.
The results showed that vasculitis patients in this study
were significantly impaired in all aspects of QOL when
compared with the normal population, except for mental
health (see Table 3).
However, the scores for depression and anxiety obtained
with the HADS present a different picture. HADS scores of
8 –10 indicate possible, scores of 11–14 indicate probable,
and scores of 15–21 indicate extreme cases of depression
and anxiety (16). Of the 51 patients who completed the
depression subscale, 11.8% scored as possible, 9.8%
scored as probable, and 3.9% scored as extreme cases of
depression. Of the 50 patients who completed the anxiety
subscale, 27.5% scored as possible, 15.7% scored as probable cases, and nobody scored as an extreme case of anxiety. Overall in this sample, 25.5% of patients presented
with depressive symptoms and 43% with anxiety symptoms to a variable degree, indicating that these diseases are
associated not only with physical morbidity but also with
significant psychological distress for a considerable number of patients.
In this study, PSV patients’ mean HAQ score was 0.79 (SD
0.94), although the 3 subgroups scored differently, with significant differences found between the WG and CSS groups
(Table 4). Fries et al (28) reported mean HAQ scores in a
sample of 331 community-based RA patients being 0.80.
Differences between PSV diagnostic groups on pain and
disability levels and aspects of QOL. One-way ANOVA
was conducted to assess differences between diagnostic
groups on patient-reported levels of pain, functional disability (HAQ), symptom severity, sleep, fatigue (101-point
VAS), and QOL (SF-36). Post-hoc Scheffé tests were used
to locate pairs of diagnostic groups that were significantly
different from each other (Table 4).
The diagnostic groups differed significantly in terms of
age (F[2,50] ⫽ 4.25, P ⬍ 0.05): Those with WG were significantly younger than those with MPA. The groups did
not differ significantly in terms of disease duration. There
was a significant main effect for diagnosis on HAQ score
(F[2,48] ⫽ 3.39, P ⬍ 0.05). A difference approaching significance (exact P ⫽ 0.077) was located between the groups
diagnosed with WG and those with CSS. Patients with a
diagnosis of WG indicated lower levels of functional disability than patients with CSS, as shown by lower HAQ
scores. There was a significant main effect for diagnosis on
symptom severity (F[2,33] ⫽ 16.35, P ⬍ 0.001). The 3
diagnostic groups were significantly different from each
other. MPA patients had the highest symptom severity
scores, followed by CSS patients and then WG patients.
There was a significant main effect for diagnosis on
Quality of Life in Vasculitides
831
Table 5. Short Form-36 subscale scores for vasculitis diagnostic groups*
Wegener’s
granulomatosis
(n ⴝ 22–31)
Churg-Strauss
syndrome
(n ⴝ 7–11)
Microscopic
Polyangitis
(n ⴝ 5–9)
ANOVA F
value
Post hoc
Scheffé test
Physical functioning
56.77 ⫾ 26.57
38.18 ⫾ 27.68
34.38 ⫾ 28.47
3.32†
Role physical
Role emotional
Social function
Pain
Mental health
Energy/vitality
General health perception
30.00 ⫾ 40.15
56.67 ⫾ 44.76
67.78 ⫾ 22.67
67.78 ⫾ 25.50
70.53 ⫾ 15.17
42.26 ⫾ 22.80
48.57 ⫾ 24.27
31.82 ⫾ 40.45
45.45 ⫾ 45.39
62.63 ⫾ 37.93
68.69 ⫾ 27.13
75.27 ⫾ 22.19
38.64 ⫾ 16.29
36.50 ⫾ 19.67
27.78 ⫾ 38.41
70.37 ⫾ 45.47
58.02 ⫾ 36.76
66.67 ⫾ 38.89
69.33 ⫾ 18.76
34.44 ⫾ 22.70
49.88 ⫾ 20.15
0.03
0.76
0.43
0.01
0.37
0.49
1.17
WG–CSS‡
WG–MPA§
—
—
—
—
—
—
—
SF-36 Subscales
* Scores are the mean ⫾ SD. ANOVA ⫽ one-way analysis of variance; WG ⫽ Wegener’s granulomatosis; CSS ⫽ Churg-Strauss syndrome; MPA ⫽
microscopic polyangiitis.
† P ⬍ 0.05.
‡ P ⫽ 0.16.
§ P ⫽ 0.13.
fatigue (F[2,33] ⫽ 4.82, P ⬍ 0.05). Age, creatinine, and
hemoglobin levels (the last 2 were used as indicators of
renal function), were entered in the analysis as covariates
to evaluate their possible effects on fatigue. The main
effect of diagnosis remained significant (F[2,30] ⫽ 4.42,
P ⬍ 0.05) and none of the covariates were significant. In
this analysis, differences were located between WG and
both MPA (P ⫽ 0.078) and CSS groups (P ⫽ 0.088), with
WG patients reporting lower levels of fatigue than the
other 2 groups.
The 3 groups did not differ significantly in terms of
reported QOL on any of the subscales of the SF-36, except
for physical functioning (F[2,48] ⫽ 3.32, P ⬍ 0.05). The
difference was located between WG and MPA patients,
with WG patients reporting higher levels of physical functioning without limitations due to health. There were no
significant main effects of diagnosis on levels of anxiety
and depression (HADS), pain, or impact on sleep in the
previous week (using a 101-point VAS) (Table 5).
Differences on QOL in PSV according to level of pain,
neuropathic symptoms, and steroid treatment. We were
particularly interested in evaluating the impact of levels of
pain as part of the experience of living with vasculitis on
patients’ QOL. Pain can be a result of inflammation and
damage caused by the disease itself or procedures and
treatment-related side effects. We operationally divided
the whole sample into 2 groups (little or no pain versus
moderate to severe pain) on the basis of the amount of pain
experienced over the past week (101-point VAS) using a
median split (median ⫽ 10).
Patients with pain when compared with those with little
or no pain, using Mann-Whitney U tests, had significantly
impaired scores in all aspects of QOL (SF-36), except for
mental health (Tables 6 and 7 and Figure 2). They also
scored significantly higher on scores of depression
(HADS), on symptoms of fatigue, problems with sleep, and
perceived symptom severity using 101-point VAS scores
(associated P levels ranged from ⬍0.001 to 0.04). The 2
Table 6. Short Form-36 subscale scores for vasculitis patients according to levels of pain
experienced*
Pain this week
(>10 VAS)
Little or no pain
this week
(<10 VAS)
Subscale
n
Mean
n
Mean
Mann-Whitney
U score
Physical function
Role physical
Role emotional
Social function
Pain
Mental health
Energy/vitality
General health perception
22
21
21
21
21
22
22
22
36.14 ⫾ 26.23
15.48 ⫾ 30.08
42.86 ⫾ 44.90
50.79 ⫾ 28.45
42.86 ⫾ 23.12
67.45 ⫾ 18.53
29.09 ⫾ 19.43
35.59 ⫾ 20.92
27
28
28
28
28
27
28
25
60.37 ⫾ 25.90
40.18 ⫾ 42.68
69.05 ⫾ 41.50
74.60 ⫾ 25.28
85.32 ⫾ 13.54
74.81 ⫾ 16.07
48.75 ⫾ 19.37
55.32 ⫾ 21.21
153.5†
195.5‡
199.5‡
150.5†
38.5§
211.0
143.0†
140.5†
* Scores are the mean ⫾ SD. Mann-Whitney U values refer to comparisons between groups. VAS ⫽ visual
analog scale.
† P ⱕ 0.01.
‡ P ⬍ 0.05.
§ P ⬍ 0.001.
832
Koutantji et al
Table 7. Mood, disability, and disease-related symptom scores for the vasculitis patients according to levels of
pain experienced*
Pain this week
(>10 VAS)
HADs-depression
HADs-anxiety
HAQ
Symptom severity in the last month (VAS)
Problem of sleep (VAS)
Problem of fatigue (VAS)
Little or no pain this week
(<10 VAS)
n
Mean
n
Mean
Mann-Whitney
U score
22
22
21
16
16
16
7.59 ⫾ 3.97
7.91 ⫾ 3.61
1.15 ⫾ 1.08
41.25 ⫾ 28.66
53.69 ⫾ 33.57
57.75 ⫾ 31.25
28
27
28
17
18
17
5.18 ⫾ 3.15
6.33 ⫾ 3.14
0.51 ⫾ 0.73
16.47 ⫾ 24.64
25.55 ⫾ 26.34
33.35 ⫾ 23.99
177†
224
190.5‡
61†
75.5‡
75‡
* Scores are the mean ⫾ SD. Mann-Whitney U values refer to comparisons between groups. VAS ⫽ 101-point visual analog scale; HADS ⫽ Hospital
Anxiety and Depression Scale; HAQ ⫽ Health Assessment Questionnaire.
† P ⱕ 0.01.
‡ P ⬍ 0.05.
groups did not differ in age, duration of illness, BVAS
score, or BVDI score.
The impact of permanent neuropathic symptoms
(present at interview versus absent) and steroid treatment
(collected from medical notes) on relevant QOL and selfreport measures was also investigated using Mann-Whitney U tests. Patients with neuropathic symptoms had significantly impaired scores on symptom severity (101-point
VAS), disability (HAQ), and SF-36 physical functioning
(P ⬍ 0.05) (Table 8). Steroid treatment (⬍10 mg prednisolone versus ⱖ10 mg prednisolone) when used as a
grouping factor showed that patients on higher dose had
significantly impaired scores for pain this week (101-point
VAS), depression (HADS), SF-36 social function, SF-36
energy and vitality, and SF-36 pain (P ⬍ 0.05; Table 9).
Assessment of aspects of validity of the HAQ as a disability measure for PSV. Internal consistency, a test of the
homogeneity of the scale, was assessed with calculation of
Cronbach’s ␣ values for the HAQ overall and for each
subscale against the overall score. Cronbach’s ␣ values
ranged from 0.91 to 0.93 (Table 10), these are considered to
be high (29), indicating high internal consistency of the
measure when used with PSV patients.
Concurrent validity was evaluated by correlating the
HAQ total score with the SF-36 physical functioning subscale score. There was a significant negative correlation
between the 2 measures (␳ ⫽ – 0.80, P ⬍ 0.01) which
indicate that high HAQ scores are associated with low
SF-36 physical functioning scores (Table 11), a strong
correlation in the expected direction, which provides
Figure 2. Short Form-36 (SF-36) subscale scores for the primary systemic vasculitis patients according to
levels of pain experienced (little or no pain group versus moderate to severe pain group).
Quality of Life in Vasculitides
833
Table 8. Significant differences observed on quality of life measures according to
neuropathy status*
SF-36 physical functioning
HAQ
Symptom severity in the last month
(101-point VAS)
Neuropathy
present
(n ⴝ 12)
No
neuropathy
(n ⴝ 38)
Mann-Whitney
U score
31.36 ⫾ 24.81
1.31 ⫾ 1.46
42.86 ⫾ 20.38
54.21 ⫾ 27.89
0.13 ⫾ 0.57
24.81 ⫾ 29.81
112†
122†
46†
* Scores are the mean ⫾ SD. Mann-Whitney U values refer to comparisons between groups. SF-36 ⫽ short
form 36; HAQ ⫽ Health Assessment Questionnaire; VAS ⫽ visual analog scale.
† P ⬍ 0.05.
support for concurrent validity of the HAQ used in this
population.
Discriminant validity was assessed as the degree to
which the HAQ was able to distinguish between 2 patient
groups (30). Wilcoxon’s signed rank tests were performed
on the HAQ subscales to compare disability levels for PSV
patients and a matched sample of RA patients. One of the
study rheumatologists predicted a priori that RA patients
would be more disabled overall. One of the psychologists
also predicted that for the 2 component dimensions of the
HAQ, the RA patients would be more disabled in fine
motor skills (i.e., gripping, dressing and grooming) and
that there would be no difference in global disability (i.e.,
walking and activities) between the 2 patient groups.
The matched pairs of patients were compared for pain
this week, pain today, and HAQ scores using t-tests. There
were significant differences between the pairs on each of
these scores, these differences were maintained under
square root transformations (Table 12). RA patients reported significantly higher levels of pain this week and
pain today than the PSV patients. The RA patients reported significantly higher levels of disability on the HAQ
than PSV patients according to the prediction.
The 2 groups were also compared using Wilcoxon’s
signed rank test on the subscale scores of the HAQ. There
were statistically significant differences between the 2 patient groups on all subscales except for walking and activities (Table 13). RA patients reported levels of impairment
to physical functioning that were significantly greater than
those reported by the PSV patients. The exceptions were
the walking and the activities subscales, where no signif-
icant differences were found; RA patients still reported
slightly greater, although comparable, levels of impairment on walking and activities to those of the PSV patients; this finding also supports the relevant prediction.
The relationships between the clinical marker of permanent disease damage (modified BVDI) and self-report
measures of QOL. No significant correlations were found
between the modified BVDI scores with any of the SF-36
subscales or with the other self-report disease-related measures (Table 14). However, there were significant positive
correlations between the HAQ total scores and scores on
pain, symptom severity, problems of fatigue, and sleep
(Table 14), where high HAQ scores were associated with
high scores on the above variables. There were also significant negative correlations between scores on pain this
week, pain today, symptom severity, fatigue, and sleep
with all SF-36 subscales’ scores, except for scores on
symptom severity and sleep with SF-36 role reduced due
to emotional problems, and symptom severity scores with
SF-36 mental health scores (Table 14). High scores on the
above variables were associated with low SF-36 scores,
which indicate poorer QOL.
DISCUSSION
In this study we evaluated the impact of PSV on patients’
QOL, psychological adjustment, and physical functioning.
The results of the assessment of QOL using the SF-36
showed that this vasculitis group demonstrated impaired
Table 9. Significant differences observed on quality of life measures according to steroid
treatment status*
Pain this week (101-point VAS)
HADS depression
SF-36 social function
SF-36 energy/vitality
SF-36 pain
<10 mg
prednisolone
(n ⴝ 42)
> 10 mg
prednisolone
(n ⴝ 8)
Mann-Whitney
U score
18.55 ⫾ 23.18
6⫾3
69.05 ⫾ 27.39
43.26 ⫾ 27.39
71.69 ⫾ 25.17
52.13 ⫾ 41.56
9⫾5
43.06 ⫾ 28.13
43.06 ⫾ 28.13
47.22 ⫾ 34.50
81.5†
96.5†
76†
84†
94†
* Scores are the mean ⫾ SD. Mann-Whitney U values refer to comparisons between groups. VAS ⫽ visual
analog scale; HADS ⫽ Hospital Anxiety and Depression Scale; SF-36 ⫽ Short Form 36.
† P ⬍ 0.05.
834
Koutantji et al
Table 10. Cronbach’s ␣ coefficients for HAQ subscales
and HAQ overall score as indicators of internal
consistency*
HAQ subscales
Cronbach’s ␣
Dressing and grooming
Rising
Eating
Walking
Hygiene
Reach
Grip
Activities
HAQ overall score
0.91
0.92
0.93
0.92
0.91
0.91
0.93
0.92
0.93
* HAQ ⫽ Health Assessment Questionnaire.
levels on all aspects of QOL, except for mental health,
when compared with normative data. In addition, this
group had lower QOL scores than a German vasculitis
group (13). These results support previous findings in PSV
when the SF-36 was used to assess QOL from work currently published as abstracts (e.g., 12–15); and they support findings from 2 published studies that used a vasculitis-specific assessment of QOL (10,11). The SF-36 results
from this study showed that patients reported significantly
impaired levels of physical and social functioning, energy
and vitality, and role limitation due to physical and emotional problems; they also reported increased levels of
pain and lower perceptions of general health when compared with the norms. Given the severity of the illness
itself, the unpredictability of its course, and the significant
side effects of its treatment, the observed low levels of
QOL correspond well with the clinical features of the
illness and clinical experience.
However, no statistically significant differences were
observed in this study between the vasculitis group and
normative data for the SF-36 mental health subscale. Using
the HADS, however, we found that 25.5% of the whole
vasculitis sample reported high depressive symptoms and
43.2% reported high anxiety symptoms to a variable degree. Prevalence levels obtained with the HADS in a
healthy population (22) were 5% for depression (cut off 8),
and 7% for anxiety (cut off 10). In a study investigating
mood levels in cancer patients (31) using the HADS, 8.7%
of patients scored within the range for possible clinical
disorder for depression, and 27% did so for anxiety. In this
study, we observed 5.1 times the depressive symptoms
and 6.17 times the anxiety symptoms reported in the
healthy population (22), and obtained 2.93 times the incidence of depressive symptoms and 1.6 times the incidence
of anxiety symptoms when compared with the cancer patients’ mood levels (31). Although the generalizability of
these results needs to be assessed, they indicate that psychological distress is high in this disease group, and this is
likely to be a major issue for many patients. It is reasonable
to suggest that psychological distress should be assessed
and addressed as part of the disease management efforts.
Our findings also indicate that there might be a discrepancy in levels of psychological distress obtained by the
SF-36 mental health subscale and the HADS. This requires
further investigation to determine the most psychometrically sound way to evaluate distress in this population.
As part of the aims of this study, we also investigated
differences in QOL and psychological adjustment between
the 3 different diagnostic subgroups of PSV. Despite the
small power for the MPA and CSS groups, statistically
significant differences were observed for some of the outcome variables, providing some preliminary information
on areas of differentiation between the diagnoses that
could guide future research.
Patients with moderate to severe pain showed significantly impaired scores in all aspects of QOL as assessed by
the SF-36, except for mental health, although they still
scored lower than the little or no pain group in this subscale. Furthermore, patients with pain reported significantly higher depression scores and higher anxiety scores
(using the HADS), although not significantly so. They also
scored significantly higher on symptom severity over the
past month, levels of fatigue, and problems with sleep.
These findings suggest that pain, whatever its cause, is a
major determinant of QOL in a similar way in PSV as in
most other diseases. It is reasonable to suggest that appropriate and adequate pain management should be a high
priority of clinicians treating PSV patients, given its significant association with impaired levels of QOL in a range
of dimensions. Patients with neuropathic symptoms and
patients on higher levels of steroid treatment had significantly impaired scores on some, but not as many, of the
relevant measures. Presence of neuropathy was associated
with impaired scores on SF-36 physical functioning, disability (HAQ), and symptom severity; treatment with
higher steroid dose was associated with significantly
higher levels of pain, depression (HADS), and impaired
levels of SF-36 scores for social function and energy and
vitality.
In addition to the disability subscale of the SF-36, we
Table 11. Spearman’s rho correlation coefficients between the Health Assessment Questionnaire (HAQ) scores and Short
Form-36 subscale scores
HAQ
* P ⬍ 0.001.
† P ⬍ 0.01.
‡ P ⬍ 0.05.
Physical
functioning
n ⴝ 48
Role
physical
n ⴝ 48
Role
emotional
n ⴝ 48
Social
functioning
n ⴝ 48
Mental
health
n ⴝ 48
Energy
n ⴝ 49
Pain
n ⴝ 48
Health
perception
n ⴝ 46
⫺0.80*
⫺0.37†
⫺0.18
⫺0.50*
⫺0.37†
⫺0.36‡
⫺0.43†
⫺0.49†
Quality of Life in Vasculitides
835
Table 12. Pain and functional disability measures for the vasculitis patients and the matched rheumatoid arthritis patients*
Primary systemic
vasculitis
Pain this week (VAS)
Pain today (VAS)
Pain today (square root transformation)
HAQ
HAQ (square root transformation)
Rheumatoid arthritis
n
Mean
n
Mean
49
49
49
49
49
24.40 ⫾ 29.27
19.65 ⫾ 26.91
3.07 ⫾ 3.23
0.79 ⫾ 0.94
0.67 ⫾ 0.59
49
49
49
49
49
45.71 ⫾ 24.81
38.24 ⫾ 26.08
5.71 ⫾ 2.40
1.46 ⫾ 0.97
1.09 ⫾ 0.50
t
⫺3.42†
⫺3.04‡
⫺4.19†
⫺3.26‡
⫺3.48†
* Scores are the mean ⫾ SD. VAS ⫽ 101-point visual analog scale; HAQ ⫽ Health Assessment Questionnaire.
† P ⱕ 0.001.
‡ P ⬍ 0.01.
used the HAQ to assess physical functioning and evaluated its psychometric properties when used in PSV. Overall, there was evidence of high internal consistency and
concurrent and discriminant validity of the HAQ as a
measure of functional disability in PSV. Future research
should assess its reliability.
The HAQ scores were significantly correlated with patient-reported illness symptoms (pain today and pain this
week, fatigue, sleep, and symptom severity) and with the
SF-36 subscale scores (physical functioning, social functioning, energy and vitality, pain, mental health, and general health perception), suggesting that these were the
areas of difficulty for patients experiencing adverse effects
on their physical functioning. The exception was SF-36
scores for impact on role due to emotional problems,
where no significant correlation with the HAQ was observed.
However, the scores derived from the modified BVDI
clinical measure were weakly and not significantly correlated with patient reports of illness symptoms or with QOL
scores. Studies of QOL in other chronic rheumatic illnesses have shown that patients’ mood is significantly
related to the way they perceive their illness and not to
markers of disease activity or damage (32,33). It seems that
self-report measures provide better information for the
experience of living with a systemic illness than disease
markers, and simple VAS illness-related measures (e.g., for
pain, sleep, fatigue) could easily be incorporated in clinical assessment to capture this.
Pincus et al (9) described a modified version of the HAQ
(the Multidimensional Health Assessment Questionnaire
[MDHAQ]) and suggested it may be suitable for use with a
range of rheumatic diseases in addition to RA. Their findings using the MDHAQ, and the results of this study,
render some support for this. Future research should assess validity and reliability of different methods of assessing disability and psychological distress in PSV.
On the basis of the preliminary findings from this study
and previous cross-sectional research that needs to be
published in full, it seems that many aspects of QOL are
significantly impaired in PSV. Additional longitudinal research is essential to establish causal pathways and assess
the impact of the disease over time. Future psychological
work could 1) investigate how patients and their caretakers think and cope with their illness, and how these affect
their QOL; and 2) design, implement, and evaluate psychoeducational interventions that aim to address their
psychosocial needs. Although a clinical marker of disease
damage serves as an indicator of physical status of vasculitis, it is not necessarily related to measures of QOL or
Table 13. Comparison of the vasculitis patients and the matched rheumatoid arthritis
patients on subscales of the HAQ*
Primary systemic
vasculitis
Rheumatoid
arthritis
HAQ subscale
n
Mean ⴞ SD
n
Mean ⴞ SD
Wilcoxon’s signed
rank test (z score)
Dressing and grooming
Rising
Eating
Walking
Hygiene
Reach
Grip
Activities
HAQ overall score
51
51
51
51
49
50
50
50
49
0.84 ⫾ 1.22
0.47 ⫾ 0.83
0.39 ⫾ 0.80
1.02 ⫾ 1.26
0.65 ⫾ 1.19
0.94 ⫾ 1.19
0.84 ⫾ 1.28
1.22 ⫾ 1.33
0.79 ⫾ 0.94
51
51
51
51
49
50
50
50
49
1.53 ⫾ 1.24
1.25 ⫾ 1.63
1.14 ⫾ 1.02
1.18 ⫾ 1.24
1.51 ⫾ 1.30
1.68 ⫾ 1.32
1.67 ⫾ 1.30
1.29 ⫾ 1.17
1.41 ⫾ 0.98
⫺2.34†
⫺3.41‡
⫺3.69‡
⫺0.62
⫺3.09§
⫺2.83§
⫺2.91§
⫺0.36
⫺3.16§
* HAQ ⫽ Health Assessment Questionnaire.
† P ⬍ 0.05.
‡ P ⱕ 0.001.
§ P ⬍ 0.01.
836
Koutantji et al
Table 14. Spearman rho correlation coefficients between HAQ scores and modified BVDI scores, and scores of pain, symptom
severity, problems of fatigue, and sleep*
Modified BVDI
Pain this week (VAS)
Pain today (VAS)
Symptom severity in the
last month (VAS)
Problem of fatigue (VAS)
Problem of sleep (VAS)
SF-36
pain
SF-36
mental
health
SF-36
energy
vitality
SF-36
general
health
perception
⫺0.26
⫺0.46†
⫺0.45†
⫺0.48†
⫺0.25
⫺0.87§
⫺0.82§
⫺0.33¶
⫺0.14
⫺0.45†
⫺0.38†
⫺0.28
⫺0.28
⫺0.54§
⫺0.51§
⫺0.52†
⫺0.25
⫺0.44†
⫺0.43†
⫺0.57§
⫺0.39‡
⫺0.55*†
⫺0.37‡
⫺0.50†
⫺0.40‡
⫺0.63§
⫺0.68§
⫺0.56§
⫺0.32¶
⫺0.63§
HAQ
SF-36
physical
function
SF-36
role
physical
SF-36
role
emotional
SF-36
social
function
0.15
0.42†
0.47†
0.63§
⫺0.15
⫺0.46†
⫺0.46†
⫺0.69§
⫺0.04
⫺0.45†
⫺0.41†
⫺0.40‡
⫺0.14
⫺0.34‡
⫺0.29‡
⫺0.18
0.45†
0.60§
⫺0.53†
⫺0.55†
⫺0.44†
⫺0.41‡
⫺0.41‡
⫺0.26
* HAQ ⫽ Health Assessment Questionnaire; BVDI ⫽ Birmingham Vasculitis Damage Index; SF-36 ⫽ short form-36; VAS ⫽ 101-point visual analog
scale.
† P ⱕ 0.01.
‡ P ⬍ 0.05.
§ P ⬍ 0.001.
¶ P ⬍ 0.07.
physical and emotional functioning. Self-reported pain
and disability, presence of neuropathy, treatment with
steroids, depression and anxiety scores, scores on the SF36, and self-report measures of disease symptoms are significant indicators of the impact of vasculitis on the patient’s life and need to be assessed and addressed in
overall patient management.
ACKNOWLEDGMENTS
We would like to thank all participants and staff involved
in the study for their time, and Dr. R. Luqmani for his
helpful comments on a conference presentation of this
work.
REFERENCES
1. Watts R, Scott D. Classification and epidemiology of the vasculitides. Bailliere’s Clin Rheumatol 1997;11:191–218.
2. Chakravarty K. Vasculitis by organ system. Bailliere’s Clin
Rheumatol 1997;11:357–93.
3. Valente RM, Conn DL. Polyarteritis: polyarteritis nodosa and
microscopic polyangitis. In: Klippel JH, Dieppe PA, editors.
Rheumatology. 2nd ed. London: Mosby; 1998.
4. Hoffman GS. Wegener’s granulomatosis. In: Klippel J, Dieppe
P, editors. Rheumatology. 2nd ed. London: Mosby; 1998.
5. Guillem LP Churg J. Chrug-Strauss syndrome. In: Klippel J,
Dieppe P, editors. Rheumatology. 2nd edition. London:
Mosby; 1998.
6. Koutantji M, Pearce S, Harrold E. Psychological aspects of
vasculitis. Rheumatology 2000;39:1173–9.
7. Cotch MF. The socioeconomic impact of vasculitis. Curr Opin
Rheumatol 2000;12:20 –3.
8. Abu-Shakra M, Smythe H, Lewtas J, Badley E, Weber D, Keystone E. Outcome of polyarteritis nodosa and Churg-Strauss
syndrome. Arthritis Rheum 1994;12:1798 –1803.
9. Pincus T, Swearingen C, Wolfe F. Toward a multidimensional
health assessment questionnaire (MDHAQ): assessment of advanced activities of daily living and psychological status in
the patient-friendly health assessment questionnaire format.
Arthritis Rheum 1999;42:2220 –30.
10. Hoffman GS, Drucker Y, Cotch MF, Locker GA, Easley K,
Kwoh K. Wegener’s granulomatosis (WG): patient-reported
effects of disease on health, function and income. Arthritis
Rheum 1998;41:2257– 62.
11. Boomsma MM, Stegeman CA, Cohen Tervaert JW. Comparison of Dutch and US patients’ perceptions of the effects of
Wegener’s granulomatosis on health, function, income and
interpersonal relationships: comment on the article by Hoffman et al. Arthritis Rheum 1999;42:2495– 6.
12. Exley AR, Moots RM, Carruthers D, Bacon P. Short-form-36 in
vasculitis. Clin Exp Immunol 1995;63 Suppl 1:101.
13. Herlyn K, Reinhold-Keller E, Zeidler A, Raspe H, Gutfleisch J,
Peter HH, et al. Health-related quality of life in primary systemic vasculitides. Arthritis Rheum 1998;41 Suppl 9:S122.
14. Raza K, Wilson A, Carruthers DM, Reay C, Amft N, Bacon PA.
Impaired SF36 in patients with primary systemic necrotizing
vascultis (1oSNV): influence on factors besides disease activity and damage. Arthritis Rheum 1999;42 Suppl 9:S315.
15. Grove ML, Wilson A, Raza K, Carruthers DM, Bacon PA.
Patients with damage from primary systemic vasculitis experience impaired physical health as measured by the SF36.
Rheumatology 2001;40 Suppl:125.
16. Zigmond AS, Snaith RP. The hospital anxiety and depression
scale. Acta Psychiatr Scand 1983;67:361–70.
17. Leavitt RY, Fauci AS, Bloch DA, Michel BA, Hunder GG,
Arend WP, et al. The American College of Rheumatology 1990
criteria for the classification of Wegener’s granulomatosis.
Arthritis Rheum 1990;33:1101–7.
18. Jennette J, Falk R, Andrassy K, Bacon PA, Churg J, Gross WL,
et al. Nomenclature of systemic vaculitides: proposal of an
international consensus conference. Arthritis Rheum 1994;
37:187–92.
19. Masi AT, Hunder GG, Lie JT, Michel BA, Bloch DA, Arend
WP, et al. The American College of Rheumatology 1990 criteria for the classification of Churg Strauss syndrome (allergic
granulomatosis and angiitis). Arthritis Rheum 1990;33:1094 –
100.
20. Luqmani RA, Bacon PA, Moots RJ, Janssen BA, Pall A, Emery
P, et al. Birmingham Vasculitis Activity Score (BVAS) in
systemic necrotising vasculitis. QJM 1994;87:671– 8.
21. Exley AR, Bacon PA, Luqmani R, Kitas GD, Gordon C, Savage
CO, et al. Development and initial validation of the vasculitis
damage index (VDI) for the standardized clinical assessment
of damage in the systemic vasculitides. Arthritis Rheum 1997;
40:371– 80.
22. Herrmann C. International experiences with the hospital anxiety and depression scale: a review of validation data and
clinical results. J Psychosom Res 1997;42:17– 41.
23. Jenkinson C, Wright L, Coulter A. Quality of life measurement
in health care: a review of measures and population norms for
the UK SF-36. Oxford: Health Services Research Unit; 1996.
24. Fries J, Spitz P, Young D. The dimensions of health outcomes:
Quality of Life in Vasculitides
25.
26.
27.
28.
29.
the Health Assessment Questionnaire disability and pain
scales. J Rheumatol 1982;9:789 –93.
Fransen J, Stucki G. Current use of health status instruments
in randomised controlled trials on patients with rheumatoid
arthritis. Dis Manage Health Outcomes 1998;3:271–7.
Jensen MP, Karoly P, Braver S. The measurement of clinical
pain intensity: a comparison of six methods. Pain 1986;27:
117–26.
Jensen MP, Karoly P. Self-report scales and procedures for
assessing pain in adults. In: Turk CD, Melzack R, editors.
Handbook of pain assessment. London: The Guildford Press;
1992. p. 135–51.
Fries JF, Spitz PW, Kraines RG, Holman HR. Measurement of
patient outcome in arthritis. Arthritis Rheum 1980;23:137– 45.
Bowling A. Measuring disease. Philadelphia: Open University Press; 1995.
837
30. Horne R, Weinman J, Hankins M. The beliefs about medicines
questionnaire: the development and evaluation of a new
method for assessing the cognitive representation of medication. Psychol Health 1999;14:1–24.
31. Moorey S, Greer S, Watson M, Gorman C, Rowden L, Tunmore R, et al. The factor structure and factor stability of the
Hospital Anxiety and Depression Scale in patients with cancer. Br J Psychiatry 1991;158:255–9.
32. Burckhardt C, Archenholtz B, Mannerkorpi K, Bjelle A. Quality of life of Swedish women with fibromyalgia syndrome,
rheumatoid arthritis or systemic lupus erythematosus. J Musculoskel Pain 1993;1:199 –207.
33. Drent M, Wirnsberger R, Breteler M, Kock L, Vries J, Wouters
E. Quality of life and depressive symptoms in patients suffering from sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 1998;
15:59 – 66.
Документ
Категория
Без категории
Просмотров
0
Размер файла
337 Кб
Теги
statue, pain, investigation, disability, systemic, vasculitis, primary, disease, moody, life, quality
1/--страниц
Пожаловаться на содержимое документа