Quality of Life Research

, Volume 14, Issue 1, pp 207–219 | Cite as

Responsiveness of generic health-related quality of life measures in stroke

  • A. Simon PickardEmail author
  • Jeffrey A. Johnson
  • David H. Feeny


Objective: To compare five preference-based generic measures of health-related quality of life (HRQOL) in terms of change scores, correlations among change scores, responsiveness, and quality adjusted life-years (QALYs) gained. Design: Observational longitudinal cohort study where clinical measures and self-assessed HRQOL measures were administered to stroke patients at baseline and at 6 months. Patients were categorized as ‘stable’, ‘some improvement’ and ‘large improvement’ using the Barthel Index, Modified Rankin Scale (MRS), and Center for Epidemiologic Studies Depression Scale (CES-D). For each group, paired t -tests and variants of effect size were used to compare the responsiveness of preference-based HRQOL summary scores, including the EQ-5D VAS and index-based score, SF-6D, and Health Utilities Index (HUI) Mark 2 (HUI2) and Mark 3 (HUI3) overall utility scores. Results: Ninety-eight of 124 (79%) patients completed the 6-month follow-up. Change scores of the EQ-Index, HUI2, and HUI3 were strongly correlated with changes in the Barthel Index and MRS, while the EQ-5D VAS had higher correlation with CES-D change scores than the other measures. The SF-6D, HUI3, and EQ-Index were generally more responsive than the HUI2 and EQ-5D Visual analogue scale (EQ-VAS). QALY estimates based on the EQ-5D index and HUI3 were twice as large as estimates based on the SF-6D and HUI2. Conclusions : The results of this study may assist in informing the selection of a preference-based generic HRQOL measure, although choice will also depend on study goals and context. We would caution against the generalization of the study results on responsiveness to conditions when more subtle change is expected.


Cerebrovascular disease Health-related quality of life Health status indicators Longitudinal studies 



Center for Epidemiologic Studies Depression Scale


EQ-5D visual analogue scale


health-related quality of life


Health Utilities Index


Modified Rankin Scale


quality-adjusted life years


Medical Outcomes Study (MOS) short-form health survey


standardized response mean


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Guyatt, GH, Feeny, DH, Patrick, DL 1993Measuring health-related quality of life.Ann Intern Med188622629Google Scholar
  2. Gold, MR, Siegel, JE, Russel, LB,  et al. 1996Cost-Effectiveness in Health and Medicine.Oxford University PressNew York, NYGoogle Scholar
  3. Pyne, JM, Sullivan, G, Kaplan, R, Keith Williams, D 2003Comparing the sensitivity of generic effectiveness measures with symptom improvement in persons with schizophrenia.Med Care41208217CrossRefPubMedGoogle Scholar
  4. Coons, SJ, Rao, S, Keininger, DL, Hays, RD 2000A comparative review of generic quality-of-life instruments.Pharmacoeconomics171335PubMedGoogle Scholar
  5. Ware, JE,Jr, Sherbourne, CD 1992The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.Med Care30473483PubMedGoogle Scholar
  6. Brooks, R 1996EuroQol: The current state of play.Health Policy375372CrossRefPubMedGoogle Scholar
  7. Feeny, DH, Torrance, G, Furlong, WJ 1996Chapter 26: Health Utilities Index.Spilker, B eds. Quality of Life and Pharmacoeconomics in Clinical Trials2Lippincott-Raven PublishersPhiladelphia239251Google Scholar
  8. Feeny, D, Furlong, W, Torrance, GW,  et al. 2002Multiattribute and single-attribute utility functions for the health utilities index mark 3 system.Med Care40113128CrossRefPubMedGoogle Scholar
  9. McHorney, CA 1998Methodological inquiries in health status assessment.Med Care36445448CrossRefPubMedGoogle Scholar
  10. Patrick, DL, Chiang, Y-P 2000Measurement health outcomes in treatment effectiveness evaluations: Conceptual and methodological challenges.Med Care381425Google Scholar
  11. Liang, MH 2000Longitudinal construct validity: Establishment of clinical meaning in patient evaluative instruments.Med Care388490Google Scholar
  12. Bessette, L, Sangha, O, Kuntz, KM,  et al. 1998Comparative responsiveness of generic versus disease-specific and weighted versus unweighted health status measures in carpal tunnel syndrome.Med Care36491502CrossRefPubMedGoogle Scholar
  13. Norman, GR, Stratford, P, Reghr, G 1997Methodological problems in the retrospective computation of responsiveness to change: The lesson of Cronbach.J Clin Epidemiol50869879CrossRefPubMedGoogle Scholar
  14. Kelly-Hayes, M, Wolf, PA, Kase, CS,  et al. 1989Time course of functional recovery after stroke: The Framingham Study.J Neurolog Rehab36570Google Scholar
  15. Lai, S-M, Duncan, PW 2001Stroke recovery profile and the modified rankin assessment.Neuroepidemiology202630CrossRefPubMedGoogle Scholar
  16. Dolan, P 1997Modeling valuations for EuroQol health states.Med Care3510951108CrossRefPubMedGoogle Scholar
  17. Brazier, J, Roberts, J, Deverill, M 2002The estimation of a preference-based measure of health from the SF-36.J Health Econ21271292CrossRefPubMedGoogle Scholar
  18. Ware, JE, Kosinski, M, Keller, SD 1994SF-36 Physical and Mental Health Summary Scales: A User’s Manual.The Health Institute, New England Medical CenterBoston, MAGoogle Scholar
  19. Juniper, EF, Guyatt, GH, Jaeschke, R 1996Chapter 6: How to develop and validate a new health-related quality of life instrumentSpilker, B eds. Quality of Life and Pharmacoeconomics in Clinical Trials2Lippincott-Raven PublishersPhiladelphia4956Google Scholar
  20. Hawthorne, G, Richardson, J, Atherton Day, N 2001A comparison of the assessment of quality of life (AQoL) with four other generic utility instruments.Ann Med33358370PubMedGoogle Scholar
  21. Locke BA, Putman P. Center for Epidemiological Studies Depression Scale (CES-D). Epidemiology and Psychpathology Research Branch, Division of Epidemiology and Services Branch, Public Health Service, National Institutes of Mental Health, 1971Google Scholar
  22. Parikh, RM, Eden, DT, Price, TR, Robinson, RG 1988The sensitivity and specificity of the Center for Epidemiologic Studies Depression Scale in screening for post-stroke depression.Int J Psychiatry Med18169181PubMedGoogle Scholar
  23. Shinar, D, Gross, CR, Price, TR, Banko, M, Bolduc, PL, Robinson, RG 1986Screening for depression in stroke patients: The reliability and validity of the Center for Epidemiologic Studies Depression Scale.Stroke17241245PubMedGoogle Scholar
  24. Bamford, J, Sandercock, P, Dennis, M,  et al. 1991Classification and natural history of clinically identifiable subtypes of cerebral infarction.Lancet33715211526Google Scholar
  25. Van Swieten, JC, Koudstall, PJ, Visser, MC,  et al. 1988Interobserver agreement for the assessment of handicap in stroke patients.Stroke19604607PubMedGoogle Scholar
  26. Granger CV, Seltzer GB, Fishbein CF. Chapter 9: The completed stroke. In: Primary Care of the Functionally Disabled, Philadelphia: Lippincott-Raven Publishers, 1987; 191–209.Google Scholar
  27. Brott, T, Adams, HP, Olinger, CP,  et al. 1989Measurement of acute cerebral infarction: A clinical examination scale.Stroke20864870PubMedGoogle Scholar
  28. Sulter, G, Steen, C, De Keyser, J 1999Use of the Barthel Index and Modified Rankin Scale in acute stroke trials.Stroke3015381541PubMedGoogle Scholar
  29. Wallace, D, Duncan, PW, Lai, SM 2002Comparison of the responsiveness of the Barthel Index and the Motor Component of the Functional Independence Measure in stroke: The impact of using different methods for measuring responsiveness.J Clin Epid55922928CrossRefGoogle Scholar
  30. Radloff, LS, Locke, BZ 1986Chapter 9: The community mental health assessment survey and the CES-D scaleWeissman, MMMyers, JKRoss, CE eds. Community Surveys of Psychiatric DisordersRutgers University PressNew Jersey177189Google Scholar
  31. Hays, RD, Anderson, R, Revicki, D 1998Chapter 10: Assessing reliability and validity of measurement in clinical trialsStaquet, MJHays, RDFayers, PM eds. Quality of Life Assessments in Clinical TrialsOxford University PressOxford169182Google Scholar
  32. Kazis, LE, Anderson, JJ, Meenan, RF 1989Effect sizes for interpreting changes in health status.Med Care27S178S189PubMedGoogle Scholar
  33. Liang, MH, Larson, MG, Cullen, KE, Schwartz, JA 1985Comparative measurement efficiency and sensitivity of five health status instruments for arthritis research.Arthritis Rheum28542547PubMedGoogle Scholar
  34. Cohen, J. 1988Statistical Power Analysis for the Behavioral Sciences2Lawrence Erlbaum AssociatesHillsdale, NJ1974Google Scholar
  35. Curran, D, Fayers, PM, Molenberghs, G, Machin, D. 1998Chapter 14: Analysis of incomplete quality of life data in clinical trialsStaquet, MJHays, RDFayers, PM eds. Quality of Life Assessments in Clinical TrialsOxford University PressOxford249280Google Scholar
  36. Tengs, TO, Lin, TH 2003A meta-analysis of quality of life estimates for stroke.Pharmacoeconomics31191200Google Scholar
  37. de Vries, SO, Kuipers, WD, Hunink, MG 1998Intermittent claudication: Symptom severity versus health values.J Vasc Surg27422430PubMedGoogle Scholar
  38. Conner-Spady B, Suarez-Almazor M. A comparison of preference-based health status tools in patients with musculoskeletal disease. Proceedings of the 18th Plenary Meeting of the Euroqol Group, 6–7 September, 2001, Copenhagen DenmarkGoogle Scholar
  39. Hollingworth, W, Mackenzie, R, Todd, CJ, Dixon, AK 1995Measuring changes in quality of life following magnetic resonance imaging of the knee: SF-36, EuroQol or Rosser index?Qual Life Res4325334CrossRefPubMedGoogle Scholar
  40. Stavem, K 1999Reliability, validity and responsiveness of two multiattribute utility measures in patients with chronic obstructive pulmonary disease.Qual Life Res84554CrossRefPubMedGoogle Scholar
  41. Stavem, K 1998Quality of life in epilepsy: Comparison of four preference measures.Epilepsy Res29201209CrossRefPubMedGoogle Scholar
  42. Juniper, EF, Norman, GR, Cox, FM, Roberts, JN 2001Comparison of the standard gamble, rating scale, AQLQ and SF-36 for measuring quality of life in asthma.Eur Respir J183844CrossRefPubMedGoogle Scholar
  43. Bosch, JL, Hunink, MG 2000Comparison of the Health Utilities Index Mark 3 (HUI3) and the EuroQol EQ-5D in patients treated for intermittent claudication.Qual Life Res9591601CrossRefPubMedGoogle Scholar
  44. Anderson, C, Laubscher, S, Burns, R 1996Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients.Stroke2718121816PubMedGoogle Scholar
  45. Duncan, PW, Samsa, GP, Weinberger, M,  et al. 1997Health status of individuals with mild stroke.Stroke28740745PubMedGoogle Scholar
  46. Hobart, JC, Williams, LS, Moran, K,  et al. 2002Quality of life measurement after stroke: Uses and abuses of the SF-36.Stroke3313481356CrossRefPubMedGoogle Scholar
  47. Dorman, PJ, Slattery, JM, Farrell, B,  et al. 1997A randomized comparison of the EuroQol and SF-36 after strokeBr Med J315461Google Scholar
  48. Dorman, PJ, Slattery, JM, Farrell, B,  et al. 1998Qualitative comparison of the reliability of health status assessments with the EuroQol and SF-36 questionnaires after stroke.Stroke296368PubMedGoogle Scholar
  49. Mathias, SD, Bates, MM, Pasta, DJ,  et al. 1997Use of the Health Utilities Index with stroke patients and their caregivers.Stroke2818881894PubMedGoogle Scholar
  50. Grootendorst, P, Feeny, D, Furlong, W 2000Health Utilities Index Mark 3: Evidence of construct validity for stroke and arthritis in a population health survey.Med Care38290299CrossRefPubMedGoogle Scholar
  51. Norman, GR, Sridhar, FG, Guyatt, GH, Walter, SD 2001Relation of distribution- and anchor-based approaches in interpretation of changes in health-related quality of life.Med Care3910391047CrossRefPubMedGoogle Scholar
  52. Samsa, GP, Edelman, D, Rothman, ML,  et al. 1999Determining clinically important differences in health status measures.Pharmacoeconomics15141155PubMedGoogle Scholar
  53. Drummond, M 2001Introducing economic and quality of life measurements into clinical studies.Ann Med33344349PubMedGoogle Scholar
  54. Walters SJ, Brazier JE. What is the relationship between the minimally clinically important difference and health state utility values? The case of the SF-6D’. Health and Quality of Life Outcomes 2003; 1: 4.Google Scholar
  55. Brazier, JE, Harper, R, Munro, J,  et al. 1999Generic and condition-specific outcome measures for people with osteoarthritis of the knee.Rheumatology38870877CrossRefPubMedGoogle Scholar
  56. Harper, R, Brazier, JE, Waterhouse, JC,  et al. 1997Comparison of outcome measures for patients with chronic obstructive pulmonary disease (COPD) in an outpatient setting.Thorax52879887PubMedGoogle Scholar
  57. Jenkinson, C, Stradling, J, Petersen, S 1997Comparison of three measures of quality of life outcome in the evaluation of continuous positive airways pressure therapy for sleep apnoea.J Sleep Res6199204CrossRefPubMedGoogle Scholar
  58. Guyatt, GH, Norman, GR, Juniper, EF, Griffith, LE 2002A critical look at transition ratings.J Clin Epidemiol55900908CrossRefPubMedGoogle Scholar
  59. Husted, JA, Cook, RJ, Farewell, VT,  et al. 2000Methods for assessing responsiveness: A critical review and recommendations.J Clin Epidemiol53459468CrossRefPubMedGoogle Scholar
  60. Wyrwich, KW, Wolinsky, FD 2000Identifying meaningful intra-individual change standards for health-related quality of life measures.J Eval Clin Pract63949CrossRefPubMedGoogle Scholar
  61. Sprangers, MAG, Schwartz, CE 1999Integrating response shift into health-related quality of life research: A theoretical model.Soc Sci Med4815071515CrossRefPubMedGoogle Scholar

Copyright information

© Springer 2005

Authors and Affiliations

  • A. Simon Pickard
    • 1
    Email author
  • Jeffrey A. Johnson
    • 2
    • 3
  • David H. Feeny
    • 2
    • 3
    • 4
    • 5
  1. 1.College of PharmacyUniversity of Illinois at ChicagoChicagoUSA
  2. 2.Department of Public Health Sciences, Faculty of Medicine and DentistryUniversity of AlbertaUSA
  3. 3.Institute of Health EconomicsUSA
  4. 4.Faculty of Pharmacy and Pharmaceutical SciencesUniversity of AlbertaEdmonton
  5. 5.Health Utilities Inc.DundasCanada

Personalised recommendations