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Comparison of measures to assess outcomes in total hip replacement surgery
Abstract and Figures
To compare the performance of a disease specific and a general health questionnaire in assessing changes resulting from total hip replacement.
Two stage prospective study of patients undergoing total hip replacement surgery involving an assessment at a clinic before and six months after surgery. 60(32%) patients were followed up by post.
Outpatient departments at a specialist orthopaedic hospital and peripheral clinics within Oxfordshire.
188 patients admitted for unilateral total hip replacement between February and mid-August 1994.
Patients' self assessed scores with the 12 item Oxford hip score and SF-36 general health questionnaire together with surgeons' assessment with Charnley hip score obtained before and again at six months after surgery.
186 patients were followed up six months after total hip replacement; a subsample (n=60) by post. Of the 60 postal patients, 59(98.3%) fully completed the Oxford hip score compared with 44(73.3%) who fully completed the SF-36. For the followup sample as a whole, post operative changes in scores produced a large effect size of 2.75 on the Oxford hip score, compared with -1.89 physical function (SF-36), -2.13 pain (SF-36). With the exception of physical function and role (physical), postoperative SF-36 scores were shown to be similar to or better than those found by two population surveys on patients of comparable age. The responsiveness of a disease specific questionnaire, the Oxford hip score, and relevant sections of a general questionnaire, SF-36, were found to be similar as assessed by three different criteria.
A disease specific questionnaire, the Oxford hip score, and a general state of health questionnaire, SF-36, performed similarly in assessing outcomes of total hip replacement except that the disease specific questionnaire resulted in a higher completion rate and greater responsiveness in some sections. On the other hand the general health questionnaire drew attention to broader problems of physical function not considered by the Oxford hip score. The health questionnaires examined here offer a valid and practical means of monitoring outcomes of hip replacement surgery.
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... SF-36 is an 8-dimensional instrument for the assessment of health-related quality of life (HRQoL) [4]. Previous studies have suggested that there are limitations in the responsiveness of the SF-36 general health (GH) domain after orthopedic procedures such as total hip replacement [5][6][7], total knee replacement [7][8][9][10], and spine surgery procedures [11,12]. In contrast, other measures of general HRQoL, such as the EQ VAS, or the EQ-5D-3L index [13], have shown considerable improvements in patient-reported general health after the corresponding orthopedic procedures [14][15][16][17]. ...
... The limited responsiveness was observed for 10 years ( Figure S1). The findings of our study confirm previous reports of poor responsiveness of the GH domain after orthopedic surgery [5][6][7][8][9][10][11][12]. This raises the question whether or not orthopedic surgery improves patients' perceptions of GH. ...
... Our study evaluated two groups, with different mean ages, and for both groups the GH responsiveness was limited. Previous studies have reported limited GH responsiveness for several cohorts with different diagnoses, different mean ages and different proportions of women and men [5][6][7][8][9][10][11][12]. This suggest that an association between age, gender and limited responsiveness in GH for orthopedic surgery seems unlikely. ...
PurposeThe study evaluated perceptions of general health (GH) after surgical treatment of spinal stenosis and disk herniation. We used a large longitudinally collected data set to explore differences in responsiveness between the SF-36 GH domain, EQ VAS, EQ-5D index, and SF-6D index.Methods
Patients, surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017, were recruited from the national Swedish spine register. A total of 14,883 procedures were eligible for analysis. The responsiveness of the SF-36 GH domain to surgical treatment was evaluated with the standardized response mean (SRM) and effect size (ES). The internal consistency of the GH domain was evaluated, ceiling and floor effects were assessed, and the correlation between GH domain and EQ VAS was analyzed.ResultsThe SF-36 GH domain did not respond to surgical treatment of spinal stenosis and disk herniation. In contrast, EQ VAS, EQ-5D index, and SF-6D showed moderate to large responsiveness. There were pronounced ceiling effects in items 11a–c of the SF-36 GH domain. There was a negative effect size of change for item 11c. The internal consistency of the GH domain was satisfactory. There were marked differences in the correlations between EQ VAS and the GH domain preoperatively and postoperatively.Conclusions
The SF-36 GH domain should be used with caution when evaluating effects on GH perceptions after spine surgery procedures. The lack of responsiveness is most probably explained by ceiling effects for items 11a–c and a negative effect size of change for item 11c.
... On the PROMs side, few examples of systematic collection of patient-reported data have been available. 66 All professionals were aware of the previous key experience of PROMs integration into the English PESs, [67][68][69][70][71] with systematic benchmarking and public disclosure of data, 72 with a low awareness of the criticisms emerged also in UK. 13 Practitioners were familiar with the experience of international benchmarking of patient-reported indicators promoted by the OECD. 73 Despite this, the acceptability of integrating PROMs indicators into the PES was much lower than the PREMs ones. ...
In healthcare, the introduction of quality standards and indicators to assess performance triggered the development of multidimensional Performance Management Systems (PMSs). The concept of performance in healthcare has recently evolved and broadened its scope. One of the current challenges of PMSs is measuring and integrating the patient perspective into traditional measures. In the regional healthcare system of Tuscany (Italy), a PMS has been implemented and used since 2005. The PMS counts on the systematic involvement of clinicians and managers. Furthermore, the PMS also includes patients' perspective. Moreover, Tuscany has recently implemented the first regional permanent Patient-Reported Outcome and Experience Measures (PROMs and PREMs) Observatory in Italy. This paper presents the results of an action research aimed at analysing the integration of patient-reported outcome and experience indicators into a consolidated PMS. The study describes the process of identifying and discussing of patient-reported indicators with practitioners and categorising findings into three domains: design of patient-reported indicators, integration process into the PMS, and goal of adoption of the patient-related indicators. The paper also describes facilitators, challenges, and lessons learnt with respect to organisational, methodological, cultural, and responsibility-linked factors. The study discusses the ability to agree on how to transform patient data, especially PROMs, into effective performance indicators. The integration of patient-reported indicators into the PMS poses two main challenges: one in terms of sustainability of the performance system itself, and another regarding the attribution of the responsibility for patient outcomes between care settings and providers. This paper provides initial insights on how the integration of patient-reported indicators can make PMSs more inclusive and focussed on the patient-centred perspective.
... The maximum total score is 48, which corresponds to the lowest pain intensity and the least functional hip limitation in the last 4 weeks. The questionnaire is validated for patients receiving primary and revision THA (10,11). ...
Background and purpose:
To determine whether the Hip disability and Osteoarthritis Outcome Score-Physical function Short-form (HOOS-PS) is able to appropriately evaluate physical function in revision hip arthroplasty patients, this study assesses psychometric properties of the Dutch HOOS-PS in this patient population.
Patients and methods:
We assessed psychometric properties of the HOOS-PS following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria. Content validity, including comprehensibility, comprehensiveness, and relevance of the items, was assessed using cognitive debriefing interviews in hip revision patients (n = 8) and orthopedic surgeons specialized in revision surgery (n = 7). Construct validity, responsiveness, and interpretability (floor/ceiling effects) were assessed in revision hip arthroplasty patients (baseline n = 136, follow-up n = 67). We formulated hypotheses a priori to assess construct validity and responsiveness using the EuroQol 5-Dimensions Health Questionnaire, Numeric Rating scale for pain, and Oxford Hip Score as comparators. All questionnaires were measured at baseline and 1 year postoperatively.
Results:
We found insufficient content validity of the HOOS-PS, as relevance and comprehensibility of the items scored < 85% on the COSMIN criteria for revision hip arthroplasty patients. Construct validity was sufficient as all hypotheses were confirmed (≥ 75% COSMIN criteria). Interpretability was sufficient (< 15% COSMIN criteria) and responsiveness was insufficient (< 75% COSMIN criteria).
Interpretation:
The Dutch HOOS-PS is not able to sufficiently evaluate physical function in revision hip arthroplasty patients. Minor changes in the items are needed for the HOOS-PS to become sufficiently content valid, because the HOOS-PS lacks relevant items and comprehensiveness.
... It was first described by Bernhard von Langenbeck in 1874 and modified by Kocher, and since then, it has been known as "Kocher-Langenbeck (K-L) approach". 26 This approach does not disrupt the abductor mechanism, and many variations were described depending on the placement of the skin incision and the level at which the gluteus maximus muscle is dissected. [27][28][29] Approach details: Skin incision started about ten cm distal to the posterior superior iliac spine extending laterally and directed distally toward the greater trochanter about 15 cm coincident with the femoral shaft. ...
Femoral head fractures (FHFs) are considered a relatively uncommon injury; however, they carry a challenge to the trauma surgeon. Choosing the appropriate management option, either conservatively or surgically, if the latter was chosen, should it be open reduction and internal fixation or simple excision of the fragment, or acute total hip arthroplasty. Furthermore, selecting the best surgical approach through which surgical management could be performed depends on the fracture classification, the familiarity of the surgeon, and the presence of associated injuries. All approaches to the hip, including hip arthroscopy, had been proposed for the management of FHFs; however, the difference among approaches is related to the complexity of the approach, the need for special training or equipment, the effect of the approach on the functional outcomes as well as the rate of postoperative complications. This review discussed the possible surgical approaches used to manage FHFs, advantages, and disadvantages for each, and offered a guideline for selecting the most appropriate surgical approach.
... From the EuroQol EQ-5D-3L scores, the EQindex score was calculated (worst -0.543, best = 1.000). At day 0, day 120 and day 365, patients who had a knee PJI were asked to complete the Oxford knee score (OKS) [17] (worst = 0, best = 48) and patients with a hip PJI, the Oxford hip score (OHS) [18] (worst = 0, best = 48). Patients who had missed one follow-up time remained in the study and were invited for follow-up at later time points. ...
Background
There is currently no commonly accepted method of stratifying complexity of prosthetic joint infection (PJI). This study assesses a new classification, the Joint-Specific, Bone involvement, Anti-microbial options, Coverage of the soft tissues, Host status (JS-BACH) classification, for predicting clinical and patient reported outcomes in PJI.
Methods
Patients who received surgery for PJI at two centres in the UK between 2010 and 2015 were classified using JS-BACH as ‘uncomplicated’, ‘complex’ or ‘limited treatment options’. Patient reported outcomes were recorded at 365-days following the index operation and included the EuroQol EQ-5D-3L index score and the EQ-visual analogue score (VAS). Clinical outcome data were obtained from the most recent follow-up appointment.
Findings
220 patients met the inclusion criteria. At 365-days following the index operation, patients with ‘uncomplicated’ PJI reported similar EQ-index scores (0.730, SD:0.326) and EQ-VAS (79.4, SD:20.9) compared to the age-matched population. Scores for ‘uncomplicated’ PJI were significantly higher than patients classified as having ‘complex’ (EQ-index:0.515 SD:0.323, p = 0.012; EQ-VAS:68.4 SD:19.4, p = 0.042) and ‘limited treatment options’ PJI (EQ-index:0.333 SD:0.383, p < 0.001; EQ-VAS:60.2, SD:23.1, p = 0.005). The median time to final follow-up was 4.7 years (inter-quartile range 2.7–6.7 years) where there were 74 cases (33.6%) of confirmed recurrence. Using death as a competing risk, the Cox proportional-hazards ratio of recurrence for ‘complex’ versus ‘uncomplicated’ PJI was 23.7 (95% CI:3.23–174.0, p = 0.002) and having ‘limited options’ verses ‘uncomplicated’ PJI was 57.7 (95% CI:7.66–433.9, p < 0.001).
Interpretation
The JS-BACH classification can help predict likelihood of recurrence and quality of life following surgery for PJI. This will aid clinicians in sharing prognostic information with patients and help guide referral for specialist management of PJI.
... Moreover, they were chosen because of their relative brevity (12 questions), the inclusion of several relevant domains, and their validity in relation to other generic PROMs questionnaires and clinician-reported questionnaires. 57 58 The domains investigated by the OHS and the OKS are pain (ie, walking and standing up from a chair); motor skills (ie, ability to go up/downstairs and wear socks); and daily life activities (ie, ability to wash and dry themselves). ...
Introduction
Scholars, healthcare practitioners and policymakers have increasingly focused their attention on patient-centredness. Patient-reported metrics support patient-driven improvement actions in healthcare systems. Despite the great interest, patient-reported outcome measures (PROMs) are still not extensively collected in many countries and not integrated with the collection of patient-reported experience measures (PREMs). This protocol describes the methodology behind an innovative observatory implemented in Tuscany, Italy, aiming at continuously and longitudinally collecting PROMs and PREMs for elective hip and knee total replacement.
Methods and analysis
The Observatory is digital. Enrolled patients are invited via SMS or email to online questionnaires, which include the Oxford Hip Score or the Oxford Knee Score. Data are real-time reported to healthcare professionals and managers in a raw format, anonymised and aggregated on a web platform. The data will be used to investigate the relationship between the PROMs trend and patients’ characteristics, surgical procedure, hospital characteristics, and PREMs. Indicators using patient data will be computed, and they will integrate the healthcare performance evaluation system adopted in Tuscany.
Ethics and dissemination
The data protection officers of local healthcare organisations and the regional privacy office framed the initiative referring to the national and regional guidelines that regulate patient surveys. The findings will be reported both in real time and for publication in peer-reviewed journals.
Introduction:
Prosthesis loosening is an alteration of the function and position of a total hip prosthesis with reference to the initial surgical moment. The main mechanism unanimously accepted for aseptic prosthetic losses at the level of the cup is represented by the biological mechanism.
Material and method:
Experimental and virtual, interdisciplinary tools, techniques and methods were used to determine the behavior of the hip replacement prosthesis with the morcellated graft and the reconstruction net. Performing an orthopedic assembly with a morcellated bone graft and reconstruction net. An assembly was performed on a hip joint taken from an animal (cow). The biological material and the components of the prosthesis were prepared similarly to the revision prosthesis intervention. Experimental testing of orthopedic assembly with morcellated bone graft and reconstruction net. This assembly was tested on a universal machine to determine the maximum force at which it yields. This was 1790 Kgf, i.e. 17559 N. Virtual experimental testing of the hip joint with orthopedic revision assembly with a morcellated bone graft and reconstruction net for normal gait loading. The orthopedic assembly with the morcellated graft and the reconstruction net was reconstructed in the virtual environment. Normal load was used. Results maps were obtained.
Conclusions:
Analyzing the results from the two tests, experimental and virtual, and important conclusions were drawn regarding this orthopedic assembly.
Background:
The supercapsular percutaneously assisted total hip (SuperPATH) approach was designed to be a less-invasive surgical approach to THA. This approach may have advantages, including less pain, more rapid mobilization, and shorter hospital length of stay. However, few published studies have compared the SuperPATH technique to existing standard approaches in a randomized, controlled manner.
Questions/purposes:
In this study, we asked: (1) Do patients with SuperPATH demonstrate improved early function, using the timed up and go (TUG) and timed stair climbing (TSC) tests as instruments for assessment during the first 100 days postoperatively? (2) Are patient-reported outcomes, in the form of Oxford Hip Scores, better for the SuperPATH group during the first 3 months postoperatively? (3) Are opioid consumption and pain score in the first month postoperatively different between patients undergoing SuperPATH and patients undergoing a standard posterior approach? (4) Are patients with SuperPATH able to discontinue using mobility aids and return to work more quickly?
Methods:
Between February 2017 and May 2019, 46% (46 of 101) of patients were recruited among 101 patients who met our inclusion criteria. Those 46 patients were randomized into two groups on the day of surgery; 54% (25 of 46) were assigned to the study group (SuperPATH approach) and 46% (21 of 46) were assigned to the control group (posterior approach). The SuperPATH technique uses the plane between the gluteus medius and the external rotators while preserving the piriformis and the superior aspect of the capsule. A percutaneous accessory portal is required for acetabular reaming and cup insertion. The posterior approach involves releasing short rotators and partially releasing the quadratus femoris while retaining the gluteus maximus's insertion site. The two groups did not differ in BMI, gender, American Society of Anesthesiologists class, surgical side, or diagnosis. The length of stay, component position, and blood loss were similar between the groups, but the operative time was longer in the SuperPATH group than in the group with the posterior approach. One patient from the control group was lost to follow-up and was excluded. Three patients in the study group had complications. The TUG and TSC tests are timed tasks for the patient. In the TUG test, patients stand from sitting, walk 3 meters and turn, walk back, and sit down. The TSC test measures the time taken to ascend and descend 10 steps. Patients were followed for 24 months for any complications.
Results:
The TUG time at 100 days was 8.9 ± 2.6 seconds in the SuperPATH group and 8.7 ± 2.2 seconds in the posterior group (mean difference -0.2 seconds [95% CI -1.8 to 1.4]; p = 0.98); results were similar at other timepoints. The TSC time at 100 days was 11.6 ± 4.7 seconds in the SuperPATH group and 10.8 ± 3.6 seconds in the posterior group (mean difference -0.7 seconds [95% CI -3.5 to 2.1]; p = 0.88), and there were no differences between the two groups at all timepoints. The Oxford Hip Score showed no difference at any point postoperatively. At 6 weeks, it was 36 ± 5.9 points in the SuperPATH group and 38 ± 8.6 in the posterior group (mean difference 1.7 points [95% CI -2.7 to 6.1]; p = 0.51). At 3 months, it was 42± 6.7 points in the SuperPATH group and 41 ± 10.2 points in the posterior group (mean difference 0.7 points [95% CI -6.2 to 4.9]; p = 0.34). Patients' pain scores did not show any differences at all tested timepoints (mean difference 1 [95% CI -0.2 to 2.2]; p = 0.102). Total opioid consumption in the posterior group was higher in the first 2 weeks than that in the SuperPATH group (mean difference 6 [95% CI 2.3 to 9.9]; p = 0.001), but there was no difference in either group by week 4 (mean difference 0.4 [95% CI -0.5 to 1.4]; p = 0.36). There was no difference in return to work between the SuperPATH group and the posterior approach group (mean difference 6 days [95% CI -29 to 41]; p = 0.74). Discontinuation of mobility aids was similar between the two groups (mean difference 0.9 days [95% CI -25 to 27]; p = 0.94).
Conclusion:
The SuperPATH approach had no clinical advantages over the posterior approach, resulted in more complications, and only showed a short-term reduction in pain. The results of our small randomized controlled trial can be used to calculate future sample sizes, but our data suggest that any differences favoring the SuperPATH approach are likely to be small and transient. This approach should not be used routinely in clinical practice until an adequately powered trial shows clinically important differences in patient-relevant endpoints. The improved postoperative recovery is likely multifactorial and not dependent on the invasiveness of the approach.
Level of evidence:
Level II, therapeutic study.
Introduction:
Among the health needs related to an aging society, the increase in the number of hip replacement surgeries stands out.
Objective:
The study aimed to examine the socio-demographic data of patients operated in the private and state health care with total hip arthroplasty in different approaches, and to compare their quality of life before and after surgery.
Data and methods:
Patients were selected by simple convenience sampling technique at the Department of Orthopedics, Clinical Centre of the University of Pécs and at the Da Vinci Private Clinic in Pécs. Patients completed a complex questionnaire before the surgery and 6 weeks later. We evaluated socio-demographic data, disease and surgical conditions. Two international questionnaires were also completed (SF-36, Oxford Hip Score).
Results:
The research involved 164 persons, 75 persons of the state care, 89 persons of the private care. The proportion of villagers was significantly higher in the state care (p = 0.014), while mainly metropolitans were found in the private care. The proportion of primary (p<0.001) and secondary education (p = 0.042) was significantly higher for state care patients, while higher education was prevalent among patients treated in the private sector (p<0.001). In the state care the proportion of pensioners (p = 0.005), in the private care the proportion of intellectual workers and contractors was significantly higher (p<0.001). Both groups' quality of life showed significant improvement (p<0.001).
Conclusion:
Patients in the two groups significantly differed in socio-demographic characteristics, but both showed significant improvements in the quality of life 6 weeks after surgery. Orv Hetil. 2022; 163(26): 1037-1046.
Objective:
To determine the reproducibility, criterion-related validity, and minimal clinically important difference (MCID) of the stair negotiation test (SNT) after total hip arthroplasty (THA).
Methods:
Sixty patients who underwent THA were included in this study. They performed the SNT and rated their difficulty in stair negotiation (question 7 of the Oxford Hip Score [OHSQ7]) before and 6 months after surgery. The SNT determined the time taken by a patient to ascend, turn around, and descend the stairs (15 cm × 4 steps) and was measured twice each time. As a measure of reproducibility, the intraclass correlation coefficient (ICC1,1) was calculated using the preoperative SNT. As an index of criterion-related validity, Spearman's rank correlation coefficient was used to evaluate the relationship between the better score of two trials in the preoperative SNT and the OHSQ7. The MCID of the SNT was calculated using the distribution-based method and the anchor-based method. The change in the OHSQ7 between before and after surgery was used as an anchor in the latter method.
Results:
The ICC1,1 of the SNT was 0.97. The SNT was significantly correlated with the OHSQ7 (r = 0.40, p < .05). Moreover, the anchor-based MCID of the SNT was 1.98 seconds.
Conclusion:
The SNT is an objective assessable test of stair negotiation ability in post-THA patients that has good reproducibility and moderate criterion-related validity. Changes in the SNT beyond the MCID (1.98 seconds) represent clinically important changes in stair negotiation ability.
We aimed to assess individual differences in complaints in patients just before total hip replacement (THR) and the importance attached to the relief of each of them. In a pilot study, using open-ended interviews, we identified 16 main complaints, four of which (night pain, unequal leg length and discomfort during sexual and recreational activities) were not included in any of the six hip-rating scales in general use. Each of the 16 complaints was then assessed in 72 patients and rated for severity and the relative importance of relief. From this we calculated a severity-importance rating for each complaint and a patient-specific score for all complaints. The 72 patients had a mean age of 64 years (17 to 92) and 51% were men. The most important reasons for wanting a THR were day pain and walking difficulty, but the complaints mentioned above and not included in standard hip scores were also important. Greater attention to the individual requirements of patients might improve evaluation of the outcome of orthopaedic treatments.
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.
1. The results have been reported of total hip replacement by a low-friction technique using high-density polyethylene for the acetabular component in 379 primary interventions, performed between November 1962 and December 1965 and followed for between four and seven years.
2. Apart from failures due to infection, the rate of which in the era under review was 3·8 per cent, late failures from mechanical causes were unusual after total hip replacement by this technique. When the socket was cemented in position, which is now routine, the late mechanical failure from all causes was only 1·3 per cent in 210 cases.
3. As regards the quality of the results and their maintenance over the years, the results were so good (Table X) that it was unnecessary to distinguish an intermediate class of "improvement" between success and failure.
4. As regards relief of pain and ability to walk, the average final rating, on a scale numbered 1 to 6, was 5·9 for both, indicating 90 per cent of patients in Grade 6 (excellent) and only 10 per cent in Grade 5 (good).
5. The average recovery of movement was not as spectacular and was influenced considerably by the pre-operative range, but in all cases that range was improved on. Even starting with the stiffest of hips about one patient in four regained a right angle of flexion movement. There was no tendency to lose movement with the passage of time.
6. As regards late infection (2·2 per cent out of a total of 3·8 per cent), the various findings tend to exonerate cement as a cause.
7. The mechanical details of the technique became stabilised in the period 1959 to 1962 in the Teflon era, and with the exception of improved methods of reattachment of the greater trochanter, they are identical with our current practice in 1971.
Survival analysis is a powerful tool for analysing the results of total joint replacement, but it has major drawbacks when the failure rates are very low. We have reviewed 35 recent survival analyses of joint replacements to assess the magnitude of these problems and make recommendations as to how they may be avoided.
Reliability, the ratio of the variance attributable to true differences among subjects to the total variance, is an important attribute of psychometric measures. However, it is possible for instruments to be reliable, but unresponsive to change; conversely, they may show poor reliability but excellent responsiveness. This is especially true for instruments in which items are tailored to the individual respondent. Therefore, we suggest a new index of responsiveness to assess the usefulness of instruments designed to measure change over time. This statistic, which relates the minimal clinically important difference to the variability in stable subjects, has direct sample size implications. Responsiveness should join reliability and validity as necessary requirements for instruments designed primarily to measure change over time.
In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.
An Anglicized version of the SF-36, a recently developed generic health status measure, was tested among people aged 65 years and over in hospital outpatient and general practice settings as both a self-completed and interview-administered instrument. The SF-36 was quick to complete, with 84% completed in 10 minutes or less (median time 8 minutes), while the distribution of scores provided further evidence of its sensitivity and validity. As an interview-administered instrument the SF-36 was acceptable among all age groups, although 32% of outpatients and 10% of general-practice patients, consisting predominantly of people aged 75 years and over with poor physical or mental health scores, felt unable to self-complete the questionnaire. In addition, 26% of respondents missed out at least one of the 36 statements, with missing items being significantly related to older age and self-completion. Missing responses were mainly concentrated on a small number of questions whose emphases on work or vigorous activities meant that they were frequently regarded as not applicable by elderly people. Suggested modifications to these questions for elderly respondents are given. With these changes the SF-36 is regarded as suitable for use as a self-completed questionnaire among the younger age group of elderly people, although some asisstance may often be required by people aged 75 years and over and especially those with poor physical or mental health.
A multidimensional index that measures the health status of individuals with arthritis has been developed. The Arthritis Impact Measurement Scales (AIMS) are a combination of previously studies and newly created health status scales which assess physical, emotional, and social well-being. The self-administered AIMS questionnaire has been pilot tested in a mixed arthritis population. Results indicate that the instrument is practical and that it generates scalable, reliable, and valid measures of both aggregated and disaggregated health status. The AIMS approach to health status measurement should prove useful for evaluating the outcomes of arthritis treatments and programs.