Health Surveys Can Be Used to Measure Health or Health Status

In Crossing the Quality Chasm: A New Health Arrangement for the 21st Century, the Plant of Medicine proposes half dozen specific aims to better the quality of care in the Us.¹ These specific aims are to provide care that is safe, effective, timely, efficient, equitable, and patient centered. Of these goals, patient-centered care has received the to the lowest degree attending from both the scientific community and practicing clinicians. Patient-centered care gives patients opportunities to exist "involved in medical decision making," and guides care providers "in attending to their patients' concrete and emotional needs, and maintaining or improving their quality of life."¹

To promote patient-centered care, clinicians should measure out the health status of their patients with the use of standardized surveys, and then employ this information to assistance in clinical decision-making. There take been pregnant advances in wellness status surveys, and these measures are increasingly existence used as primary outcomes in clinical trials. Yet formal health status measures are rarely, if ever, used in clinical do. The reasons for this credible gap between research and clinical practice are circuitous but likely include a lack of understanding of the definition of health status, a lack of familiarity with wellness status surveys, a perception that these measures are "soft," and most importantly, a lack of credence that health status measures may exist useful in clinical practice.

Health Status: Definition and Measurement

Health status is the impact of disease on patient office every bit reported past the patient. More specifically, health status tin can be divers every bit the range of manifestation of affliction in a given patient including symptoms, functional limitation, and quality of life, in which quality of life is the discrepancy between actual and desired role (Effigy 1). An of import betoken here is that clinicians are traditionally focused on the diagnosis of disease and evaluation of symptoms, whereas patients are focused on the complete range of health status. Furthermore, patient report is essential considering information technology has been shown that clinicians do not accurately estimate the wellness status of patients. There is ofttimes a large discrepancy between medico-rated and patient-rated symptom burden and functional limitation,^2,iii and traditional clinical testing is of express help because there is generally poor correlation between test results (eg, the severity of coronary affliction on coronary angiography) and patient-reported health status.⁴ Therefore, for care to become more than patient-centered, nosotros need to employ standardized patient surveys to measure the complete spectrum of wellness status.

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Figure i. The range of wellness condition: symptoms, function, and quality of life. Figure adapted from Spertus et al (Am Heart J. 2002;143:636–642) and Wilson and Cleary (JAMA. 1995;273:59–65).

Health condition surveys have been developed over the last several decades largely through work done in the social sciences.⁵ This includes a meaning torso of basic science work in the field of psychometrics, analogous to the bones laboratory piece of work done to develop diagnostic tests similar serum troponin. Every bit a result of this work, nosotros tin accurately measure the health status of our patients past use of standardized surveys that are inexpensive, like shooting fish in a barrel to administrate, and provide information that cannot be determined accurately in any other way. These include general surveys such equally the Short-Class 36 (SF-36), which measures overall physical and mental health status without disease-specific questions,^{half dozen} and condition-specific surveys similar the Seattle Angina Questionnaire (SAQ).^7,viii The SAQ was specifically developed for utilize in patients with coronary avenue disease (CAD) and measures angina frequency, angina stability, physical limitation, quality of life, and treatment satisfaction related to angina.

An important barrier to the acceptance and utilise of surveys like the SF-36 and SAQ by clinicians is the perception that health status measures are soft, or not as scientific equally physiological measures like practice treadmill testing (ETT). Instruments such as the SF-36 and SAQ, nevertheless, were developed with the use of sound psychometric principles and take been subjected to extensive validity and reliability testing.^{half-dozen–eight} In fact, the SAQ is more reproducible than either ETT or medico interpretation of coronary angiography.^8,9 If the usefulness of whatsoever diagnostic test or clinical measure hinges on its validity and reliability, so nowadays health condition surveys vest forth side more traditional clinical measures and physiological tests.

Health Status and Clinical Practice

Health status measurement directly promotes patient-centered care, only can also support several other quality care aims equally outlined past the Institute of Medicine. For case, the commitment of effective intendance includes, "applying evidence-based medicine to avoid both the underuse of effective care and overuse of ineffective intendance that is more than likely to impairment than help the patient."¹ Past accurately measuring the symptom burden, part, and quality of life of our patients, we can make more informed clinical decisions about the use of therapies for which the primary goal is to improve health status. For example, a patient with CAD who indicates that their current angina frequency, concrete limitation, and quality of life on the SAQ are not a problem for them (eg, scores of ≥75 on these scales) likely does non need up-titration of antianginal medications, and would be unlikely to derive a health status benefit from percutaneous coronary intervention. On the other hand, a patient'due south low scores on these scales indicate that at that place are pregnant symptom, functional, and/or quality of life deficits that need to be addressed.

In this event of Apportionment, Spertus et al¹⁰ demonstrate that patient-reported wellness status, every bit measured past the SAQ, is independently predictive of subsequent mortality and hospitalization in outpatients with CAD. They plant significant associations betwixt SAQ scores and both mortality and subsequent hospitalization for acute coronary syndromes, even after aligning for traditional clinical run a risk factors. In other words, patient-reported wellness status has incremental value in the identification of patients at elevated risk for adverse upshot.

This commodity joins other studies that have demonstrated that health status independently predicts mortality in patients with and without cardiovascular disease.^11–15 Thus, contrary to its perception every bit a soft measure, it seems that quantitative assessment of health status can predict hard outcomes. Furthermore, in the study past Spertus et al,¹⁰ the magnitude of health status as a hazard factor in patients with CAD compares favorably to established risk variables like diabetes and left ventricular hypertrophy.¹⁶

The results of this study further support adding health status measurement to our present clinical armamentarium. The use of wellness status data in clinical practice can provide a manner for patients to participate further in their care, in this instance by providing information useful in their risk stratification. A patient with high SAQ scores has a significantly better prognosis than a patient with similar coronary anatomy and comorbid weather condition who has lower SAQ scores. Conversely, a patient with low SAQ scores is at elevated take chances for subsequent mortality and hospitalization for ACS, above and beyond their traditional demographic, cardiac, and comorbid factors.

The study past Spertus et al^x has several limitations that deserve attention. Firstly, potential selection bias from missing assessments is a business organization for almost all studies with survey-based data. In this instance, nineteen% of the surveys were missing, and the authors employed multiple imputation methods to try to address this issue. Missing assessments are the Achilles heel of health condition research, but newer statistical techniques may assist to overcome this problem.¹⁷

Secondly, wellness condition should be measured longitudinally whenever possible. Although this study demonstrates the value of a single health status measurement in the prediction of outcomes, it is important to know whether serial measurement would requite a more authentic picture show of the health status of a patient, and whether changes in health status (eg, declines from i measurement to the next) would provide a more robust prediction of outcomes than a single 'snapshot' measurement.

Finally, although the written report past Spertus et al¹⁰ helps farther define a clinical role for health status measures, it does not prove that the standardized measurement of the health status and the improved knowledge of prognosis will interpret into better outcomes for our patients. This is an important focus for time to come enquiry in this field.

Future Directions

The field of health condition research has made tremendous advances, but researchers need to continue to strive to run into several important challenges (Figure 2), such as:

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Figure ii. Wellness status research: by, present, and future.

	(1) Developing surveys that are designed for rapid administration, scoring, and interpretation in clinical practice (ie, filled out past patients in the waiting room, with results immediately bachelor to clinicians).
	(two) Providing meliorate clinical interpretation of survey results. Although many health status surveys are "valid and reliable," nigh produce results that exercise not have obvious clinical pregnant or advise an obvious clinical response. For example, SAQ scores past themselves do non hateful much unless they are converted to categories similar '"astringent," "moderate," "mild," or "no significant" physical limitation due to angina.
	(3) Conducting studies with longitudinal measurement of wellness status, and use newer statistical techniques to deal with response bias from missing surveys.
	(four) About importantly, conducting studies that are specifically designed to evaluate whether health status measures can, when used in clinical practice, improve patient outcomes, including mortality, hospitalization, and quality of life. For these studies to exist successful, health condition must exist modifiable and the survey results must exist actionable (ie, the survey results demand to exist linked to specific clinical actions to improve patient intendance). Fortunately, some of the determinants of wellness condition in patients with CAD seem to be practiced targets for intervention. For example, angina and depressive symptoms are prevalent in CAD patients, are strongly associated with worse quality of life, and can be modified with appropriate recognition and handling.16,18–twenty

Information technology is useful to describe an illustration between health condition and blood pressure. Start, neither tin be inferred from observation without formal measurement. Second, health condition measurement is as reproducible, if not more and so, than blood pressure measurement. Finally, health status is an independent predictor of result on par with claret force per unit area. Future research is needed to prove that standardized measurement of health status tin can guide clinical decisions in means that will meliorate patient outcomes, just as the treatment of high blood pressure improves outcomes.

In the meantime, consideration should still be given to the use of health status surveys in clinical practice. On the basis of the existing evidence, including the study by Spertus et al,¹⁰ these surveys tin can accurately measure the health condition of our patients, thereby providing a improve agreement of the impact of disease and medical intervention on their lives; aid with clinical decisions near treatments such as antianginal therapy and percutaneous coronary intervention, which are specifically intended to improve symptom control, functional condition, and quality of life; and improve our assessment of patient prognosis. Hopefully, the future will meet standardized health status measurement used as a vital clinical instrument that complements our electric current clinical toolbox and directly improves the quality of care we provide through the promotion of patient-centered care.

The opinions expressed in this editorial are not necessarily those of the editors or of the American Centre Association.

Footnotes

Correspondence to John S. Rumsfeld, Doctor PhD, Cardiology (111B), Denver VA Medical Middle, 1055 Clermont St, Denver, CO 80220. E-mail [e-mail protected]

References

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Source: https://www.ahajournals.org/doi/10.1161/01.CIR.0000020805.31531.48

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