Q J Med 2004; 97: 519-524
QJM vol. 97 no. 8 © Association of Physicians 2004; all rights reserved.
Assessment of individual quality of life using the SEIQoL-DW in older medical patients
From the 1Department of Medicine and Therapeutics, University of Aberdeen, and Departments of 2Medicine for the Elderly and 3Neuropsychology, Woodend Hospital, Grampian University Hospitals Trust, Aberdeen, UK
Received 22 October 2003 and in revised form 12 March 2004
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Summary |
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Background: Many hospital admissions aim to optimize quality of life (QoL). However, the standard medical clerking does not systematically record QoL items.
Aim: To examine whether the current disease-based clerking could be supplemented in older people with QoL information.
Design: Survey of non-elective admissions aged 
65 years.
Methods: Participants (n = 60) were interviewed on day 3–5 of their admission. QoL was measured using the SEIQoL-DW and the SF36 (version 2). Cognitive and physical function were also assessed. Aspects of feasibility and acceptability were explored, and the potential clinical benefits of the information investigated.
Results: Mean patient age was 81 years; 36 (60%) were female. Forty-five completed the SEIQoL-DW, (mean time 37.7 min), of whom 17 experienced practical difficulties drawing the cue levels, and 25 had difficulty manipulating the direct weighting device of the SEIQoL-DW. However, the assessment process was judged as acceptable, and elicited more subjective information than was recorded in medical and nursing notes. Doctors considered the individual QoL information potentially useful for planning discharge and follow-up.
Discussion: The SEIQoL-DW is probably too time-consuming for standard medical clerking. However, as it was judged acceptable by patients, and according to medical staff, gives potentially valuable information, there may be circumstances in which its use is worthwhile.
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Introduction |
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The National Service Framework for Older People1 sets out standards for the care of older people. The second standard, Person-Centered Care, aims to ensure that older people are treated as individuals and receive care which meets their individual needs. The rationale for this standard is to listen to older people in order to respect their dignity and privacy, and this also entails accepting differences in culture and religion. All older people are to receive assessments which match their individual circumstances, and it is recognized that some may benefit from fuller and more detailed assessments in specialist areas. One area of assessment which might help health professionals to understand more fully the needs of older patients is in the assessment of quality of life.
The term ‘quality of life’ (QoL) is increasingly used in clinical medicine and medical research, but is rarely defined, and this has led to confusion when measurement of QoL has been attempted.2,3 As McDowell and Newell4 have pointed out, some authors regard multiple-item health status questionnaires such as the SF-365 as providing a direct measure of QoL, and tend to use the terms ‘quality of life’ and ‘general health status’ interchangeably. However, others favour the theoretical approach of Calman,6 which states that QoL is the gap between an individual's hopes/expectations and their present actual experience. Standardized batteries of questions covering a number of fixed domains (such as the SF-36) predominantly assess experiences, but have limited ability to assess individual expectations. Thus only one of the two pieces of information required to calculate the ‘gap’ is estimated and the QoL, as defined by Calman, cannot be determined.
One of the QoL scales which is based on the Calman approach is the Schedule for the Evaluation of Individual Quality of Life,7 now available in a shorter format, as the SEIQoL-DW.8–11 In the SEIQoL-DW, the individual begins by nominating the five main QoL domains that he/she considers of most importance, and the resulting scale should be uniquely relevant to that individual.
Currently, the medical ‘clerking’ which forms the basis of the standard medical case record is symptom/disease-based and has been influenced very little by the concept of QoL. However, as acute diseases have declined in the West, the consequent increase in chronic diseases has highlighted the fact that a simple disease-based classification is often inadequate for planning medical therapy or rehabilitation, particularly in older people.
Our study therefore set out to examine whether disease-based clerking needs to be routinely supplemented in older people, by the use of, for example, the SEIQoL-DW.
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Methods |
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Following approval from the local research ethics committee, patients were selected consecutively on days 3–5 of an acute medical admission to a Medicine for the Elderly service. All patients, who were able to give informed consent, were interviewed using, the SEIQoL-DW (see Figure 1 for details of the three-stage process). The SF-36 was used to provide complementary information about the differences between individuals and to express person scores relative to the population norm.5 The Mini Mental State Examination (MMSE)12 and the Controlled Oral Word Association (COWA)13 were applied to assess cognitive and executive function. A nurse working with the patient also assessed the patient's level of physical dependency using the Barthel Index.14
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The potential clinical benefits of the QoL information obtained were investigated in a subset of patients by asking medical staff, Juniors (Senior House Officers) and Seniors (Specialist Registrars/Consultant Geriatricians), whether they felt the information generated would have been relevant to the care of the patient. We asked them to consider the three areas of treatment in hospital, of discharge, and follow up, using five-point Likert scales. In order to control for potential bias, this procedure was repeated in half the sample by a Specialist Registrar unfamiliar with the patient, using only the discharge letter as a source of information regarding the patient's condition.
Medical and nursing notes were reviewed for 19 patients, to determine whether they recorded the information identified by the patient in the SEIQoL-DW.
Total SEIQoL-DW and SF-36 scores were calculated following the appropriate scoring methods,15,16 and data entered into SPSS. The internal consistency of the eight SF-36 dimensions was measured using Cronbach's alpha (
).17 The validity of the SEIQoL-DW was explored by correlating the single index scores with the eight dimensions of the SF-36 plus the mental and physical component summary scores. The extreme points on the Likert scale (strongly agree and strongly disagree) were rarely selected by either grade of doctor. Therefore for purposes of analysis, the ratings were categorized into disagree, no opinion, or agree.
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Results |
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Study population
The study population was drawn from a cohort of patients admitted non-electively to an assessment ward in a Department of Medicine for the elderly. One hundred and twelve patients were potentially available for the study, but after discussion with medical and nursing staff, 41 were excluded because of severe illness (17 patients) or marked cognitive impairment (24 patients). We then invited 71 patients to take part in the study, of whom 11 declined, giving a final study population of 60.
The mean age of the 60 patients was 81 years (range 65–95 years) and 36 (60%) were female, with the majority of patients either widowed (32, 53%) or married (16, 27%). Only two (3%) were living in residential care, with a majority (38, 63%) living alone.
Time taken to complete the scales
The mean time taken to complete the SEIQoL-DW was 37.7 minutes (range 15–105 minutes) and for the SF-36, 33.6 minutes (range 8–100 minutes).
Cognitive and physical function
Forty-eight of the 60 patients (80%) were able to complete an MMSE, and 36 of the 60 (60%) the COWA. Of those who completed the MMSE, 25 of the 48 (56%) were graded as cognitively able (score of 24) and 24 of 36 patients (66%) were graded as average or above average for the COWA. Interestingly, eight (16%) of those who scored <24 on the MMSE were graded as average or above average on the COWA. Therefore 33 (55%) of the subjects studied scored an MMSE of 24 or greater, or COWA at average or above average levels. For the Barthel Index, seven (11.7%) had high levels of physical dependency (score <10), 24 (40%) were moderately impaired (score 10–15) and 29 (48.3%) were reasonably independent (score 16–20).
Individual quality of life assessment using the SEIQoL-DW
The SEIQoL-DW was fully completed in 45 (75%) of the 60 patients (Table 1). The main reasons for non-completion were confusion (5), distress (3), fatigue (2) and blindness (2). Twelve (33.3%) patients experienced difficulties in identifying five areas of their life which were important to them, and so were shown the ‘pick list’, while three (6.7%) could not provide five areas despite prompting. Seventeen (37.8%) patients were unable to draw cue levels. Twenty-five (55.6%) were unable to manipulate the direct weighting device due to lack of dexterity, impaired vision, fatigue, or limited cognitive ability. In the remainder, the investigator reported that the majority of patients needed a little assistance with this device.
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Internal consistency of the SF-36 and the validity of the SEIQoL-DW
The internal consistencies of the SF-36 domains are detailed in Table 2. The Cronbach's
‘group-comparison’ criterion of 0.7 was attained for all dimensions except general health and social function. The ‘individual-comparison’ criterion of 0.9 was attained for physical function and role emotion. The results for this study are comparable with those achieved from a sample of cognitively normal older adults, and with the 1998 US general population (Table 2). Table 3 shows that the SEIQoL-DW scores achieved significant correlation with vitality, social function and the mental component summary scores of the SF-36.
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Doctors’ opinions of the SEIQoL-DW information
In the majority of cases, both the SHOs (39, 65%) and their senior colleagues (31, 52.6%) agreed that the SEIQoL-DW information would be useful for planning the patients’ discharge, and for managing the patients’ problem following discharge (SHOs 61.6% and senior colleagues 50%). However, they rarely reported the data as being useful for managing patient care while in hospital (SHOs 17.5%, senior colleagues 10%). A similar pattern of responses was obtained from a Specialist Registrar who was unfamiliar with the patients.
Novel information obtained from the SEIQoL-DW
Areas seen as important to patients, but not identified in the notes, included the following: finances, religion, social activities, neighbours, pets, sex and love. The QoL areas which were mentioned more frequently in the notes were those which could be deemed as of more importance to medical and nursing staff for the routine care of the patient, for example, family, health and home.
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Discussion |
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This is the first study to assess the potential utility of a formal assessment of QoL as part of the routine medical clerking of older patients admitted acutely to hospital. Although it has highlighted a number of difficulties in administration, it does show the potential usefulness of the information in the assessment of person-centred care for rehabilitation and discharge planning purposes.
Difficulties were observed during the practical tasks in the SEIQoL-DW. In particular, impaired vision, lack of dexterity and, fatigue and confusion appeared to make Stages Two and Three especially troublesome, and all patients required some level of hands-on assistance from the administrator to complete the direct weighting procedure. However, patients were usually able to complete Stage One, with over 85% eliciting at least four areas important to their QoL. Completion rates might be improved by simplifying the practical aspects of the assessment. For example, the bar chart could be replaced by a more simple visual analogue scale on which the patient could mark rather than having to draw a bar. In addition, we would recommend that adaptations to the direct weighting device be carried out to make it easier to manipulate.
Patients judged that both the SEIQoL-DW and the SF-36 were acceptable assessments to be carried out within the hospital. In addition, each assessment elicited substantially more subjective information regarding the patients’ lives than was recorded in their routine medical and nursing notes. The SEIQoL-DW in particular provided new information on areas of life that the patients considered to be important including their financial situation, their support network (e.g. neighbours), their hobbies, social life, religious beliefs and pets. Medical staff clearly viewed the information elicited during the SEIQoL-DW as being relevant for planning the patients’ discharges and any potential follow up.
For many of the patients, the SF-36 and the SEIQoL-DW proved to be time-consuming assessments. Patients were keen to talk about the important areas of their lives and to elaborate on the brief answers in the SF-36. Medical and nursing staff under time pressures could potentially find it extremely difficult to administer either of these assessments routinely in all patients. However, further exploration needs to be carried out to assess whether a shortened and more easily administered assessment might be beneficial to both the patient and the clinician carrying out the assessment. In more complex cases, assessment should be matched to individual circumstances. If rehabilitation and discharge planning are to be effective, it may well be that the cost of the time for a full assessment of QoL in a patient is justified by the benefits of the information gleaned. Further studies are required.
The dimensions of the SF-36 were shown to have acceptable internal consistency, suggesting that it is a reliable instrument for use in this population. Our attempts to assess the validity of the SEIQoL-DW were tentative, and need further exploration. However, it would appear that the SEIQoL-DW index score is most closely associated with the psychological and social aspects of the SF-36, perhaps indicating that the SEIQoL-DW is measuring QoL on a subjective level. This finding represents a small step towards validating the SEIQoL-DW as an individualized QoL measure in the acute medical situation.
Conclusions
Even when severely ill or cognitively impaired patients are excluded, practical problems in administering the SF-36 and SEIQoL-DW would limit their use as part of the routine medical clerking of all patients at the time of an acute admission. However, both were judged as being acceptable to patients and, according to their doctors, the information elicited by the SEIQoL-DW should be useful for planning patient discharge and follow-up. We would therefore consider the SEIQoL-DW to be a viable tool for eliciting information in select groups of patients—perhaps those with complex rehabilitation needs or requiring residential or nursing care. The SEIQoL-DW could be used to facilitate both of these processes by informing the professionals involved about the QoL areas that are most important to the patient. We would hope that QoL could be restored or even improved by such information.
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Acknowledgments |
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We would like to thank Dr Saskia Teunisse at the University of Aberdeen, Department of Psychology, for her support and advice regarding the administration and interpretation of the SEIQoL-DW. The project was funded by the Chief Scientist Office of the Scottish Executive Health Department.
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Footnotes |
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Address correspondence to Professor D.G. Seymour, Department of Medicine for the Elderly, Woodend Hospital, Eday Road, Aberdeen AB15 6XS. e-mail: d.g.seymour{at}abdn.ac.uk
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References |
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