A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.

https://www.jstor.org/stable/pdf/3765916.pdf

The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.

Cross-sectional data from the Medical Outcomes Study (MOS) were analyzed to test the validity of the MOS 36-Item Short-Form Health Survey (SF-36) scales as measures of physical and mental health constructs. Results from traditional psychometric and clinical tests of validity were compared. Principal

The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.

Diagnostic Criteria of Nontuberculous Mycobacterial Lung Disease Key Laboratory Features of NTM Health Careand Hygiene-associated Disease Prevention Prophylaxis and Treatment of NTM Disease Introduction Methods Taxonomy Epidemiology Pathogenesis Host Defense and Immune Defects Pulmonary Disease Body Morphotype Tumor Necrosis Factor Inhibition Laboratory Procedures Collection, Digestion, Decontamination, and Staining of Specimens Respiratory Specimens Body Fluids, Abscesses, and Tissues Blood Specimen Processing Smear Microscopy Culture Techniques Incubation of NTM Cultures NTM Identification Antimicrobial Susceptibility Testing for NTM Molecular Typing Methods of NTM Clinical Presentations and Diagnostic Criteria Pulmonary Disease Cystic Fibrosis Hypersensitivity-like Disease Transplant Recipients Disseminated Disease Lymphatic Disease Skin, Soft Tissue, and Bone Disease

/pdf/an-official-ats-idsa-statement-diagnosis-treatment-and-1jy41yfwpp.pdf

An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases.

background We have little systematic information about the extent to which standard processes involved in health care — a key element of quality — are delivered in the United States. methods We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores. results Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence. conclusions The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.

/pdf/the-quality-of-health-care-delivered-to-adults-in-the-united-22gtu1x925.pdf

The quality of health care delivered to adults in the United States.

The widespread use of standardized health surveys is predicated on the largely untested assumption that scales constructed from those surveys will satisfy minimum psychometric requirements across diverse population groups. Data from the Medical Outcomes Study (MOS) were used to evaluate data completeness and quality, test scaling assumptions, and estimate internal-consistency reliability for the eight scales constructed from the MOS SF-36 Health Survey. Analyses were conducted among 3,445 patients and were replicated across 24 subgroups differing in sociodemographic characteristics, diagnosis, and disease severity. For each scale, item-completion rates were high across all groups (88% to 95%), but tended to be somewhat lower among the elderly, those with less than a high school education, and those in poverty. On average, surveys were complete enough to compute scales scores for more than 96% of the sample. Across patient groups, all scales passed tests for item-internal consistency (97% passed) and item-discriminant validity (92% passed). Reliability coefficients ranged from a low of 0.65 to a high of 0.94 across scales (median = 0.85) and varied somewhat across patient subgroups. Floor effects were negligible except for the two role disability scales. Noteworthy ceiling effects were observed for both role disability scales and the social functioning scale. These findings support the use of the SF-36 survey across the diverse populations studied and identify population groups in which use of standardized health status measures may or may not be problematic.

https://www.jstor.org/stable/pdfplus/3766189.pdf

The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups.

A symptom indicates disorder or disease and has been defined as a patient's perception of an abnormal physical, emotional, or cognitive state (1). Symptom assessment is a central task of the physician during the physicianpatient encounter because symptoms compel patients to seek health care and identify possibilities for specific diagnostic and therapeutic interventions. Health-related quality of life, in contrast, refers to general function and well-being but is less familiar to clinicians and is not assessed in routine patient care. This is interesting when we consider that symptoms have also been described as a change from normal function, sensation, or appearance (2) and that health-related quality of life is also used to measure change in function or well-being. Health-related quality-of-life measures designed for research purposes often include symptoms. For example, the widely used Short Form-36 Health Survey (3) includes items assessing pain, fatigue, and depressive symptoms. The Quality of Well-Being Scale includes symptomproblem complexes as one of its four domains, and symptoms contribute substantially to the derivation of the 0 to 1 preference score (4). For example, a burning or itching rash decreases the preference score by 0.240 compared with the 0.106 decrement associated with the inability to perform self-care activities. Disease-targeted measures often ask about many symptoms. For example, the Kidney Disease Quality of Life instrument includes 34 symptomproblem questions (5). Several studies suggest that symptoms and measures of functioning and well-being are empirically correlated (6). A recent analysis of a national sample of patients receiving care for HIV infection revealed a strong monotonic association between HIV-related symptoms and impaired functioning and well-being (7). Each additional symptom was associated with a mean (SD) decrease of approximately 1.5 10 points in physical and mental health-related quality-of-life summary scores. However, this previous study did not investigate whether some symptoms are more strongly associated with physical and mental health than other symptoms. Methods Study Design We evaluated a national probability sample of adults with known HIV infection who made at least one visit to a nonmilitary, nonprison medical provider other than an emergency department in early 1996. From all patients receiving care from 145 HIV providers in 28 metropolitan areas and 51 providers in 25 rural areas throughout the United States, a random sample was selected for face-to-face interviews. Of 4042 eligible participants sampled, 2864 (71%) were interviewed during the baseline study. Two follow-up surveys were conducted, the second between August 1997 and January 1998. Our study evaluated the 2267 patients who responded to both the baseline and second follow-up surveys. Deaths were confirmed by interviews with patient proxies or the patient's physician or were documented through the National Death Index. Further details of the study design were reported elsewhere (8, 9). Measures Symptoms Symptoms were selected for inclusion after review of previous research and symptom screens used in HIV clinical trials and incorporating expert judgments of HIV clinicians and community representatives. We constructed an index by summation across 13 symptoms in men and 14 symptoms in women. Symptoms assessed in both men and women included headache; fever, sweats, or chills; pain in the mouth, lips, or gums; white patches in the mouth; dry mouth; genital rashes or sores; nausea or loss of appetite; trouble with eyes; sinus infection, pain, or discharge; pain, numbness, or tingling of hands or feet; persistent cough, difficulty breathing, or difficulty catching one's breath for more than 1 week; diarrhea or loose or watery stools; and weight loss. Women were also asked about the presence of vaginal discharge. All patients were asked about the presence of symptoms since their previous follow-up interviews, an interval that averaged approximately 6 months. Total symptom scores in men and women were standardized by sex to a possible range of 0 to 14. Health-Related Quality of Life and Disability Days We evaluated two single global items assessing major components of health-related quality of life. We selected these measures to avoid the problem of direct inclusion of symptom items, which characterizes many health-related quality-of-life instruments. The questions were as follows: 1) Overall, how would you rate your current health? 2) Overall, how would you rate your quality of life? Both of these items used a response scale of 0 to 10, where 0 represents the worst possible score, 5 is halfway between worst and best, and 10 represents the best possible score. The response scale was adapted from the global ratings items included in the Consumer Assessment of Health Plans Study (10), and all responses were transformed to a scale of 0 to 100. We also assessed disability days, defined as a day in which at least half of the patient's time was spent in bed because of poor health. Each of these three items was administered by using a 4-week reporting period. Statistical Analyses The probability of selecting a respondent is a function of the likelihood of selecting a patient from a particular geographic area cared for by a particular HIV provider from among the total population of persons eligible for inclusion in the study. Analysis weights adjust for these sampling factors as well as for attrition due to nonresponse for causes other than death. Although it does not account for persons in the cohort who died during the follow-up interval, statistical weighting ensures that the cohort analyzed in our study represents as much as possible the larger population of HIV-infected patients in the United States (11). We adjusted standard errors for the differential weighting and complex sample design using linearization methods (12). We used randomly drawn donor responses within strata of respondents (hot deck imputation) to fill in the less than 5% of essential missing values (13). We used multiple linear regression to evaluate the independent associations of each symptom with perceived health, perceived quality of life, and disability days. All models were adjusted for the presence of other symptoms and sociodemographic characteristics, including age, sex, ethnicity, education, marital status, income, employment status, health insurance, risk group, stage of illness, region of the United States, and lowest reported CD4 lymphocyte count. Model fitting included the evaluation of all possible interactions; only interactions with a P value less than 0.05 were retained. We report significance tests of both linear terms with their corresponding interaction terms. All analyses were conducted by using Stata 5.0 software (Stata Corp., College Station, Texas). Role of the Funding Sources The funding sources had no role in the collection, analysis, or interpretation of the data or in the decision to submit the manuscript for publication. Results Of the 4042 eligible persons sampled, 2864 (71%) completed the baseline survey. Of those participating in the baseline survey, 2466 (86%) completed the first follow-up survey and 2267 (79%) completed the second follow-up survey. The characteristics of the 2267 persons interviewed for our study are described in Table 1. The 238 persons lost to follow-up because of confirmed death had poorer baseline health than survivors. Table 1. Characteristics of the Analytic Sample The associations of each of the 14 symptoms with perceived health, perceived quality of life, and disability days at second follow-up are shown in Table 2. Regression coefficients and 95% CIs are provided. Eight symptoms (headache; pain in mouth, lips, or gums; white patches in the mouth; dry mouth; nausea or loss of appetite; sinus infection, pain, or discharge; persistent cough, difficulty breathing, or difficulty catching one's breath; and weight loss > 2.25 kg) were associated with worse perceived health scores. Eight symptoms (pain in mouth, lips, or gums; white patches in the mouth; nausea or loss of appetite; trouble with eyes; pain, numbness, or tingling of hands or feet; persistent cough, difficulty breathing, or difficulty catching one's breath; diarrhea or loose or watery stools; and weight loss > 2.25 kg) were associated with worse perceived quality of life. Six symptoms (headache; fever, sweats, or chills; white patches in the mouth; nausea or loss of appetite; persistent cough, difficulty breathing, or difficulty catching one's breath; and weight loss of >2.25 kg) were associated with more disability days. On average, patients with sinus infection, pain, or discharge had higher perceived quality of life, although this was a suppression effect (the correlation was negative but the -coefficient was positive). At the second follow-up, an asymptomatic patient experienced an average quality-of-life score of 93, an average perceived health score of 82, and 0.33 disability day. Compared with the average asymptomatic respondent, among symptomatic patients white patches in the mouth were associated with 4% lower perceived health scores, 6% lower perceived quality-of-life scores, and 1.02 additional disability days. Nausea was associated with 5% lower perceived health scores, 8% lower perceived quality-of-life scores, and 1.03 additional disability days. Dyspnea was associated with 7% lower perceived health scores and 8% lower perceived quality-of-life scores. Weight loss was associated with 3% lower perceived health scores and 4% lower perceived quality-of-life scores. Both dyspnea and weight loss were associated with additional disability days. Table 2. Multivariable Associations of Symptoms with Perceived Health, Perceived Quality of Life, and Disability Days We tested for the presence of statistically significant interactions to assess the possibility that symptoms may be associated differently with healt

Associations of Symptoms and Health-Related Quality of Life

Medical Outcomes Study HIV Health Survey

The Veterans Health Administration (VHA) sees ≈17,000 human immunodeficiency virus (HIV)-infected patients each year, which makes it the largest provider of HIV care in the United States HIV causes chronic progressive disease that leads to early death Newer combination antiretroviral treatments ar

Quality Enhancement Research Initiative for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Differences in Symptom Expression in Older HIV-positive Patients

In 2001, the very influential Institute of Medicine report Crossing the Quality Chasm led to a new emphasis on quality in health care [1]. Shortly thereafter, studies showing that care often did not meet professional standards heightened concerns and increased efforts to develop widely accepted quality standards for routine use [2–4]. Calls to measure the quality of care for patients infected with human immunodeficiency virus (HIV) soon followed [5]. The foundation for thinking about health care quality was laid out many years ago by a physician named Avedis Donabedian [6]. The key elements were the structure of care, including the physical and human environment and administrative systems; the process of care, or what is done for the patient; and the outcomes of care. Despite the increasing emphasis on outcomes (especially at the health care system level), outcomes are notoriously difficult to use for the individual level, because it is so difficult to define the unimprovable outcome in the individual case. The structure of care is outside of the providerpatient interaction. Therefore, process of

Samuel A. Bozzette

Papers

Associations of Symptoms and Health-Related Quality of Life

Medical Outcomes Study HIV Health Survey

Quality Enhancement Research Initiative for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Differences in Symptom Expression in Older HIV-positive Patients

Quality of Care for Patients Infected with HIV