Self-perceived quality of life predicts mortality risk better than a multi-biomarker panel, but the combination of both does best

<p>Abstract</p> <p>Background</p> <p>Associations between measures of subjective health and mortality risk have previously been shown. We assessed the impact and comparative predictive performance of a multi-biomarker panel on this association.</p> <p>Methods</p> <p>Data from 4,261 individuals aged 20-79 years recruited for the population-based Study of Health in Pomerania was used. During an average 9.7 year follow-up, 456 deaths (10.7%) occurred. Subjective health was assessed by SF-12 derived physical (PCS-12) and mental component summaries (MCS-12), and a single-item self-rated health (SRH) question. We implemented Cox proportional-hazards regression models to investigate the association of subjective health with mortality and to assess the impact of a combination of 10 biomarkers on this association. Variable selection procedures were used to identify a parsimonious set of subjective health measures and biomarkers, whose predictive ability was compared using receiver operating characteristic (ROC) curves, C-statistics, and reclassification methods.</p> <p>Results</p> <p>In age- and gender-adjusted Cox models, poor SRH (hazard ratio (HR), 2.07; 95% CI, 1.34-3.20) and low PCS-12 scores (lowest vs. highest quartile: HR, 1.75; 95% CI, 1.31-2.33) were significantly associated with increased risk of all-cause mortality; an association independent of various covariates and biomarkers. Furthermore, selected subjective health measures yielded a significantly higher C-statistic (0.883) compared to the selected biomarker panel (0.872), whereas a combined assessment showed the highest C-statistic (0.887) with a highly significant integrated discrimination improvement of 1.5% (p < 0.01).</p> <p>Conclusion</p> <p>Adding biomarker information did not affect the association of subjective health measures with mortality, but significantly improved risk stratification. Thus, a combined assessment of self-reported subjective health and measured biomarkers may be useful to identify high-risk individuals for intensified monitoring.</p

Die präferenzbasierte Messung der gesundheitsbezogenen Lebensqualität: Vergleichende Analysen von sechs Instrumenten in drei Indikationen von Reha-Patienten und eine empirische Untersuchung zum Konzept qualitäts-adjustierter Lebensjahre

Hintergrund: In jüngster Zeit werden zunehmend präferenzbasierte Verfahren zur Messung der gesundheitsbezogenen Lebensqualität („health-related quality of life“, HRQoL) entwickelt, validiert und in gesundheitsökonomische Analysen einbezogen. Gegenwärtig stehen in deutscher Übersetzung sechs präferenzbasierte Instrumente zur Verfügung: der EuroQol-Fragebogen (EQ-5D), der 15D-Fragebogen (15D), der Health Utilities Index 2 und 3 (HUI 2, HUI 3), die Short-Form-6-Dimensions (SF-6D) und die Quality of Well-being Scale - self-administered (QWB-SA). In diesen Verfahren werden die verschiedenen Einzelaspekte der gesundheitsbezogenen Lebensqualität zu einer eindimensionalen Maßzahl, einem Indexwert, zusammengefasst. Dieser Indexwert kann mit Angaben zur Lebenszeit verknüpft werden und im Rahmen gesundheitsökonomischer Kosten-Nutzwert-Analysen („cost-utility analysis“, CUA), in Form von qualitäts-adjustierten Lebensjahren („quality adjusted life years“, QALYs) den Kosten einer medizinischen Technologie gegenübergestellt werden. Der Gebrauch von QALYs ist international weit verbreitet und wird von einer Vielzahl von Bewertungsinstitutionen, u.a. vom National Institute for Health and Clinical Excellence (NICE) in England und Wales, explizit gefordert. Aktuelle Studien zeigen jedoch, dass die Gültigkeit des QALY-Konzeptes hinterfragt werden sollte. Ziel: Das primäre Ziel dieser Arbeit ist die detaillierte Beschreibung, Anwendung und ver-gleichende empirische Untersuchung der psychometrischen Güte der oben genannten präfe-renzbasierten Messinstrumente in drei Reha-Kollektiven der Indikationsgebiete muskulo-skelettale Krankheiten, Herz-Kreislaufkrankheiten und Psychosomatik. Darüber hinaus werden unter Rückgriff auf die Prospect Theory drei direkte Verfahren zur Messung der gesund-heitsbezogenen Lebensqualität, das Standard-Gamble-, das Time-Trade-Off- und das Rating-Scale-Verfahren, am Beispiel Tinnitus empirisch untersucht. Methoden: Die Daten, die dieser Arbeit zugrunde liegen, stammen aus zwei Projekten. Das Projekt „Methodische Aspekte der nutzentheoretischen Lebensqualitätsmessung“ wurde in der zweiten Förderphase des „Norddeutschen Verbunds für Rehabilitationsforschung“ (NVRF) von 2001 bis 2005 durchgeführt (Förderkennzeichen: 01GD0106). Im Rahmen dieses Projektes erfolgte die Erhebung der präferenzbasierten Messinstrumente in den drei Indikations-gruppen zu Beginn und am Ende der Rehabilitation. Das Projekt „Die Bewertung von Gesundheit am Beispiel Tinnitus“ wurde im Rahmen des Graduiertenkollegs „Bedarfsgerechte und kostengünstige Gesundheitsversorgung“, gefördert durch die Deutsche Forschungsgemeinschaft (DFG), durchgeführt. In zwei gleichgroßen Gruppen (Personen mit einer Tinnitus-Erkrankung und Person aus der Allgemeinbevölkerung), parallelisiert nach Alter und Geschlecht, wurden mit den genannten direkten nutzentheoretischen Erhebungsmethoden Nutzwerte für die Erkrankung Tinnitus ermittelt. Zur Datenexploration wurden Methoden der de-skriptiven Statistik verwendet. Vergleichende Analysen erfolgten anhand der deskriptiven Kennwerte, Anzahl fehlender Werte, Häufigkeitsverteilungen und Korrelationskoeffizienten. Multivariate statistische Verfahren, wie z.B. die Varianzanalyse und Faktorenanalyse wurden durchgeführt. Ergebnisse: Beim Vergleich der deskriptiven Kennwerte zeigten sich Unterschiede zwischen den analysierten Instrumenten. In den drei untersuchten Indikationsgruppen wies der 15D die durchschnittlich höchsten Indexwerte aus und der QWB-SA die niedrigsten. In den drei untersuchten Gruppen erreichte kein Patient den niedrigsten möglichen Indexwert (Bodeneffekt). Deckeneffekte wurden insbesondere für den EQ-5D in allen drei beobachtet. Der 15D und der SF-6D wiesen höhere Kennwerte der Änderungssensitivität als der EQ-5D, HUI 2, HUI 3 und QWB-SA aus. Die Ergebnisse zur Bewertung von Gesundheit am Beispiel des Tinnitus zeigten, dass die Bewertung von Gesundheitszuständen vom eigenen aktuellen Gesundheitszu-stand und von der individuellen Risikoeinstellung abhängig ist. Tinnitus-Patienten wiesen dem Krankheitsbild Tinnitus höhere Nutzwerte zu als Nicht-Betroffene. Darüber hinaus zeigten sich Tinnitus-Betroffene als risikoavers im Vergleich zu Nicht-Betroffenen, die einer risikobehafteten medizinischen Behandlungsmaßnahme eher zustimmten. Ein Zusammenhang zwischen der Risikoeinstellung einer Person und der Nutzwertbewertung konnte statistisch nachgewiesen werden. Diskussion: Die Ergebnisse weisen darauf hin, dass die Indexwerte der sechs präferenzbasierten Messinstrumente nur bedingt vergleichbar sind, was bei der Planung einer Studie berück-sichtigt werden muss. Aus den vorliegenden Ergebnissen zur nutzentheoretischen Bewertung des Tinnitus kann geschlossen werden, dass zukünftige Studien die individuelle Risikoeinstellung berücksichtigen sollten, um die ermittelten Nutzwerte entsprechend adjustieren zu können.There are different instruments available in German language to measure health-related quality of life for use in health-economic studies. Yet, virtually no information is available regarding the applicability and the methodological quality of preference-based instruments in rehabilitation research. In our study we evaluate the applicability and methodological properties of preference-based quality of life measures as applied in rehabilitation research. The set of questionnaires included validated German language versions of the SF-36, QWBSA, EQ-5D, Health Utilities Index (HUI) and 15D. The results show that all instruments appear to be highly acceptable for rehabilitation patients. If small changes are expected in evaluative studies, application of SF-6D or 15D should be recommended. Comparisons of distributions and mean index scores in this sample demonstrate that results obtained with different preference-based measures are not equivalent

Job maintenance by supported employment: an overview of the "supported employment plus" trial

The number of days of absence from work associated with mental illness has risen dramatically in the past 10 years in Germany. Companies are challenged by this issue and seek help for the physical and mental health of their employees. Supported Employment concepts such as the Individual Placement and Support (IPS) model have been designed to bring jobless persons with mental disorders back to work. In the randomized, controlled SEplus trial, a modified IPS-approach is tested concerning its ability to shorten times of sick leave of persons with mental distress or a mental disorder and to prevent them from losing their job. The trial is outlined in this study protocol

Aspects of sustainability: cooperation, job satisfaction, and burnout among Swiss psychiatrists

PURPOSE: Greater sustainability in mental health services is frequently demanded but seldom analyzed. Levels of cooperation, job satisfaction, and burnout are indicators of social sustainability in this field and are of particular importance to medical staff. Because registered psychiatrists play a central role, we assessed the status quo and interactions between these three factors among registered psychiatrists in Switzerland. METHOD: A postal survey with three standardized questionnaires about cooperation, job satisfaction, and burnout was conducted among all registered psychiatrists in the German-speaking part of Switzerland (n = 1485). Addresses were provided by the Swiss Medical Association. RESULTS: Response rate was 23.7% (n = 352), yielding a largely male sample (62.8%; n = 218) aged 55.5 ± 8.7 years old. Quantity (47 ± 56.2 contacts over 3 months) and duration (91.1 ± 101.6 min per week) of cooperation was found to be diverse depending on the stakeholder. Quality of cooperation was greatest in general practitioners (81.5%) while it was worst in community mental health providers (54.9%). Overall job satisfaction was assessed rather high (3.7 ± 0.8), and burnout rates were below crucial values (Emotional Exhaustion, 2.9 ± 0.8; Depersonalization, 1.9 ± 0.5). Both were positively influenced by cooperation. The strongest correlation was found between job satisfaction and burnout, and both had significant inverse relationships in all dimensions. CONCLUSION: To foster sustainability in outpatient mental health care regarding cooperation, job satisfaction, and burnout, personal aspects such and age or years of registration, organizational aspects, such as networking and practice setting, as wells as supportive aspects such as psychotherapy, and self-help groups, must be considered. Quality of cooperation should be reinforced in particular. Because Integrated and Managed Care models cover several of these factors, the models should be more strongly embedded in health care systems

Age- and gender-specific mortality risk profiles for depressive outpatients with major chronic medical diseases

BACKGROUND: As leading causes of death, chronic medical diseases, particularly common cardiovascular diseases, are associated with depression. The combination of depression and chronic medical disease in turn is linked with poorer health and premature death. Despite numerous studies on mortality in people with depression and chronic medical disease, the effects of age and gender were not consistently considered. To appropriately estimate mortality in the clinical setting, we aimed to analyse age- and gender-specific mortality profiles in outpatients with depression and chronic medical disease by considering depression severity. METHODS: We examined data from N=327,018 outpatients with depression aged 18 years and older (mean=60 years), which we obtained from German electronic health-insurance claims data covering the years 2007-2010. We considered major chronic medical disease groups: cardiovascular diseases, diabetes, diseases of the respiratory system and cancer. To analyse both adjusted mortality risk and rates over one year in a comprehensive manner, we calculated General Estimation Equation (GEE) Poisson models for binary data. RESULTS: The mortality risk increased with age and was higher for males. Especially patients below 60 years of age with cancer or diabetes had an increased mortality risk, but not patients with cardiovascular disease. Mortality was comparably increased in patients with severe depression, diabetes or respiratory disease. LIMITATIONS: We did not have data from a control group without depression. CONCLUSIONS: Notably, not cardiovascular diseases but cancer and, to a lesser extent, diabetes, both in younger patients, respiratory diseases and severity of depression require particular attention in outpatient care to reduce mortality

Hell Is Other People? Gender and Interactions with Strangers in the Workplace Influence a Person's Risk of Depression

We suggest that interactions with strangers at work influence the likelihood of depressive disorders, as they serve as an environmental stressor, which are a necessary condition for the onset of depression according to diathesis-stress models of depression. We examined a large dataset (N = 76,563 in K = 196 occupations) from the German pension insurance program and the Occupational Information Network dataset on occupational characteristics. We used a multilevel framework with individuals and occupations as levels of analysis. We found that occupational environments influence employees’ risks of depression. In line with the quotation that ‘hell is other people’ frequent conflictual contacts were related to greater likelihoods of depression in both males and females (OR = 1.14, p<.05). However, interactions with the public were related to greater likelihoods of depression for males but lower likelihoods of depression for females (ORintercation = 1.21, p<.01). We theorize that some occupations may involve interpersonal experiences with negative emotional tones that make functional coping difficult and increase the risk of depression. In other occupations, these experiences have neutral tones and allow for functional coping strategies. Functional strategies are more often found in women than in men.ISSN:1932-620

Development and testing of the insulin treatment experience questionnaire (ITEQ)

OBJECTIVES: To develop and psychometrically evaluate a domain-specific questionnaire to assess subtle but clinically relevant differences in treatment experiences and satisfaction over a wide range of currently available insulin therapy regimens. The study focussed on patients with type 2 diabetes mellitus and placed particular attention on the impact of different forms of insulin therapy on diabetes self-management. METHODS: The development of the Insulin Treatment Experience Questionnaire (ITEQ) was conducted in three steps: (i) a qualitative phase to generate relevant items and identify relevant domains; (ii) a pilot study to reduce the number of generated items; and (iii) a validation study to assess major psychometric properties of the final ITEQ version. RESULTS: The final version of the questionnaire comprised 28 items with the subscales &#039;leisure activities&#039; (four items), &#039;psychological barriers&#039; (two items), &#039;handling&#039; (five items), &#039;diabetes control&#039; (six items), &#039;dependence&#039; (five items), &#039;weight control&#039; (three items), &#039;sleep&#039; (two items), and one further item assessing general treatment satisfaction. The subscales&#039; internal consistencies (Cronbach&#039;s alpha) ranged from 0.52 to 0.83. Motivated by the homogenous structure of inter-scale-correlations (range 0.10-0.46), a summary composite score was calculated (alpha = 0.86). Construct validity showed statistically significant correlations with other scales (ITEQ vs the Problem Areas in Diabetes [PAID] questionnaire total score -0.60, ITEQ vs the Diabetes Treatment Satisfaction Questionnaire [DTSQ] total score 0.52). CONCLUSION: The newly developed ITEQ displayed satisfactory to good psychometric properties, thereby allowing the assessment of everyday life experience and treatment satisfaction in patients with insulin-treated type 2 diabetes. Additional research is needed to assess test-retest reliability and sensitivity to change

Cost of illness for bipolar disorder: a systematic review of the economic burden

OBJECTIVES: Recent reviews lack important information on the high cost-of-illness worldwide for bipolar disorder (BD). Therefore, the present study systematically analyzed those costs, their driving components, and the methodological quality with which the few existing cost-of-illness investigations have been performed. METHODS: In June 2012, we conducted a systematic literature review of electronic databases to identify relevant cost-of-illness studies published since 2000. Their methodological quality was assessed. Costs were standardized by first extrapolating them to 2009 using country-specific gross domestic product inflators and then converting them into US dollars via purchasing power parities (PPP). RESULTS: The main characteristics of 22 studies were evaluated. Ignoring outliers, costs per capita ranged from 8,000 to 14,000 USD-PPP for overall direct healthcare, from 4,000 to 5,000 USD-PPP for direct mental healthcare, and from 2,500 to 5,000 USD-PPP for direct BD-related care. Indirect costs ranged from 2,000 to 11,000 USD-PPP. Inpatient care was the main cost driver in three studies; drug costs, in two studies. Methodological quality was deemed satisfactory. CONCLUSIONS: The cost variance was great between studies. This was likely due to differences in methodology rather than healthcare systems, thereby making such comparisons difficult. The results showed that BD has a substantial economic burden on society. To gain more evidence, international standardized checklists are needed when undertaking cost-of-illness studies