Biomedical subjects

Elizabeth A Hahn

Publications and source records attributed to Elizabeth A Hahn.

At least 19 recordsLinked to original sources

PubMed2006

The impact of literacy on health-related quality of life measurement and outcomes in cancer outpatients.

BACKGROUND: Limited evidence exists regarding the relationship between literacy and health-related quality of life (HRQL). Research is needed to develop measurement techniques for low literacy populations and to evaluate potential literacy-related measurement bias. METHODS: A Talking Touchscreen (TT) was developed for an HRQL study. Low (n = 214) and high literacy (n = 201) adult cancer outpatients participated, 70% of whom were from racial/ethnic minorities. Patients completed three questionnaires by TT: FACT-G (cancer-specific), SF-36 (generic health status), and a standard gamble utility questionnaire. Measurement bias was evaluated using item response theory (IRT). Effects of literacy on HRQL were evaluated using regression models. RESULTS: Most (97%) patients rated the TT easy to use. In IRT analysis, 6/27 FACT-G and 12/31 SF-36 items demonstrated literacy bias; this was relatively balanced (10 items 'biased against' low literacy; 8 'biased against' high literacy). Mean literacy group differences were statistically and clinically non-significant for 9/14 HRQL outcomes. Adjustment for bias and/or covariates eliminated most remaining differences. CONCLUSIONS: The TT is valid and useful for HRQL assessment in low literacy populations. There appears to be no systematic literacy bias in reporting HRQL, and low literacy is not an independent risk factor for poorer HRQL.

Cancer Care Facilities↗

PubMed2006

The impact of converting to an electronic health record on organizational culture and quality improvement.

Implementing an information technology system can impact more than just quality of care and patient outcomes. The purpose of this 4-year, observational research project is to examine changes in organizational culture, quality improvement (QI) maturity, and quality of care following adoption of a single, electronic health record (EHR) system within an integrated healthcare network. The primary outcome measure, the Culture and Quality Questionnaire (CQQ), assesses the perceived culture of an organization and the degree of CQI maturity in seven quality management areas. Baseline surveys were distributed prior to conversion to the EHR. Subsequent data collection occurred at 12 months post "go live" and will occur at 24 and 36 months after the first hospital "go live". Secondary data were abstracted from routinely collected patient satisfaction measures and standard quality indicators. Contrary to expectation, our findings from the Baseline and 12-month follow-up data suggest that employees perceived the organizational culture as becoming more, rather than less, hierarchical. We also hypothesized that quality indicators would show improvement due to enhanced information flow and ease of information retrieval. This hypothesis was not supported by 1-year results. However, follow-up data from years two and three may provide different results.

Adult↗

PubMed2006

Application of robust statistical methods for sensitivity analysis of health-related quality of life outcomes.

BACKGROUND: Researchers often use conventional parametric procedures to test hypotheses of health-related quality of life (HRQL) mean equality across patient groups. However, these techniques are sensitive to the presence of skewed distributions and unequal group variances, which may characterize many HRQL measures. PURPOSE: To conduct a sensitivity analysis of conventional and robust approaches to test hypotheses of mean equality on HRQL measures for hematopoietic stem cell transplantation survivors and a healthy comparison group. METHODS: The methods applied were the conventional parametric procedure of least-squares analysis of variance applied to the raw scores, the conventional parametric procedure applied to transformed data, and a robust approximate degrees of freedom parametric procedure utilizing trimmed means and Winsorized variances. RESULTS: The choice of analysis method affected the conclusions about the null hypothesis of mean equality. More commonly observed, however, was a substantial difference in the value of the F-statistic and standard errors which was particularly evident in the measures with greater degrees of skewness and heterogeneity of variances. CONCLUSIONS: Robust statistical tests should be incorporated into sensitivity analyses when analyzing HRQL data.

Adult↗

PubMed2006

Item banks and their potential applications to health status assessment in diverse populations.

In the context of an ethnically diverse, aging society, attention is increasingly turning to health-related quality of life measurement to evaluate healthcare and treatment options for chronic diseases. When evaluating and treating symptoms and concerns such as fatigue, pain, or physical function, reliable and accurate assessment is a priority. Modern psychometric methods have enabled us to move from long, static tests that provide inefficient and often inaccurate assessment of individual patients, to computerized adaptive tests (CATs) that can precisely measure individuals on health domains of interest. These modern methods, collectively referred to as item response theory (IRT), can produce calibrated "item banks" from larger pools of questions. From these banks, CATs can be conducted on individuals to produce their scores on selected domains. Item banks allow for comparison of patients across different question sets because the patient's score is expressed on a common scale. Other advantages of using item banks include flexibility in terms of the degree of precision desired; interval measurement properties under most circumstances; realistic capability for accurate individual assessment over time (using CAT); and measurement equivalence across different patient populations. This work summarizes the process used in the creation and evaluation of item banks and reviews their potential contributions and limitations regarding outcome assessment and patient care, particularly when they are applied across people of different cultural backgrounds.

Aged↗

PubMed2006

Evaluating linguistic equivalence of patient-reported outcomes in a cancer clinical trial.

BACKGROUND: In order to make meaningful cross-cultural or cross-linguistic comparisons of health-related quality of life (HRQL) or to pool international research data, it is essential to create unbiased measures that can detect clinically important differences. When HRQL scores differ between cultural/linguistic groups, it is important to determine whether this reflects real group differences, or is the result of systematic measurement variability. PURPOSE: To investigate the linguistic measurement equivalence of a cancer-specific HRQL questionnaire, and to conduct a sensitivity analysis of treatment differences in HRQL in a clinical trial. METHODS: Patients with newly diagnosed chronic myelogenous leukemia (n = 1049) completed serial HRQL assessments in an international Phase III trial. Two types of differential item functioning (uniform and non-uniform) were evaluated using item response theory and classical test theory approaches. A sensitivity analysis was conducted to compare HRQL between treatment arms using items without evidence of differential functioning. RESULTS: Among 27 items, nine (33%) did not exhibit any evidence of differential functioning in both linguistic comparisons (English versus French, English versus German). Although 18 items functioned differently, there was no evidence of systematic bias. In a sensitivity analysis, adjustment for differential functioning affected the magnitude, but not the direction or interpretation of clinical trial treatment arm differences. LIMITATIONS: Sufficient sample sizes were available for only three of the eight language groups. Identification of differential functioning in two-thirds of the items suggests that current psychometric methods may be too sensitive. CONCLUSIONS: Enhanced methodologies are needed to differentiate trivial from substantive differential item functioning. Systematic variability in HRQL across different groups can be evaluated for its effect upon clinical trial results; a practice recommended when data are pooled across cultural or linguistic groups to make conclusions about treatment effects.

Clinical Trials, Phase III as Topic↗

PubMed2005

Determinants of quality of life in patients with cancer.

BACKGROUND: Because health-related quality of life (QOL) is an important outcome in cancer management, the authors sought to better understand its determinants. To address this subject, they analyzed QOL, as measured with the Functional Assessment of Cancer Therapy-General questionnaire (FACT-G), Spanish Version 4, and depicted the complex relations among physical, psychological, social, and cultural factors, including spirituality. METHODS: A cross-sectional study design was used with a sample of 309 patients with cancer. The influence of several possible determinants was first studied by univariate regression analysis. Variables showing an association were included in a forward stepwise multivariate regression model. RESULTS: Five regression models were studied, for the FACT-G total score and its four subscales. Five variables explained 32.1% of the variance of the FACT-G total score: tumor stage, spiritual well-being, income, mood disorders, and mode of questionnaire administration. The type and relevance of the explanatory variables differed among the various dimensions of QOL. CONCLUSIONS: The authors underlined the entwining of biologic, psychosocial, and spiritual factors as determinants of the QOL of patients with cancer, thus supporting the multidimensional definition and modeling of the construct.

Adolescent↗

PubMed2005

Long-term health-related quality of life, growth, and spiritual well-being after hematopoietic stem-cell transplantation.

PURPOSE: To examine health-related quality of life (HRQOL) and growth, and spiritual well-being in adult survivors of hematopoietic stem-cell transplantation (HSCT) for a malignant disease. METHODS: HSCT survivors (n = 662) were recruited through the International Bone Marrow Transplant Registry/Autologous Blood and Marrow Transplant Registry and were drawn from 40 transplantation centers. HSCT survivors completed a telephone interview and a set of questionnaires a mean of 7.0 years post-HSCT (range, 1.8 to 22.6 years). Study measures included a variety of standardized measures of HRQOL and growth and spiritual well-being. An age- and sex-matched healthy comparison (HC) group (n = 158) was recruited using a peer nomination method. The HC group completed a parallel telephone interview and set of questionnaires. RESULTS: Multivariate analysis of variance analyses found the HSCT survivor group reported poorer status relative to the HC group for all HRQOL outcome clusters including physical health, physical functioning, social functioning, psychological adjustment, and dyadic adjustment. In contrast, the HSCT survivor group reported more psychological and interpersonal growth. Mean effect size for the 24 outcome indices examined was 0.36 standard deviations, an effect size often considered clinically meaningful or important. The largest group differences were found for measures of general health, physical function and well-being, depression, cognitive function, and fatigue. CONCLUSION: The experience of HSCT for a malignant disease has a wide-ranging, longstanding, and profound impact on adult recipients. Relative to healthy controls, HSCT survivors reported poorer physical, psychological, and social functioning but, conversely, more psychological and interpersonal growth, differences that appeared to persist many years after HSCT.

Adult↗

PubMed2005

Frequency and predictors of retinal detachment after pediatric cataract surgery without primary intraocular lens implantation.

PURPOSE: To determine the frequency and to identify predictors of retinal detachment after pediatric cataract surgery without primary intraocular lens implantation. METHODS: Retrospective review at an eye hospital identified 1017 eyes among 579 patients who underwent limbal-approach surgery without primary IOL implantation at age < or =16 years for cataract unassociated with other ocular abnormalities aside from microcornea. Patients had a minimum of 2 years postoperative follow-up. The outcome measure was the presence or absence of postcataract surgery retinal detachment, and analyses were performed on patients' eyes with adjustment for intrasubject correlation. RESULTS: Mean postcataract surgery follow-up was 6.8 +/- 3.6 years (range, 2.0 to 18.3 years). Retinal detachment developed in 33 (3.2%) of the 1017 patients' eyes and was diagnosed at a mean of 6.8 +/- 4.4 years postcataract surgery (range, 0.4 to 14.8 years). Multivariable Cox proportional hazards regression analysis with adjustment for intrasubject correlation identified an aphakic refractive error more myopic than the age-adjusted aphakic norm [hazard ratio (HR), 5.9; 95% confidence interval (CI), 1.9 to 18.0; P = 0.002] and postcataract surgery wound dehiscence (HR, 15.4; 95% CI, 2.2 to 108.5; P = 0.006) as predictors of retinal detachment; a primary posterior capsulotomy/anterior vitrectomy procedure was not predictive of retinal detachment. CONCLUSIONS: Retinal detachment is infrequent following pediatric cataract surgery without primary IOL implantation, at least with short-term follow-up. A postoperative aphakic refractive error more myopic (less hyperopic) than the age-adjusted aphakic norm is predictive of this complication.

Adolescent↗

PubMed2005

Cross-cultural evaluation of health status using item response theory: FACT-B comparisons between Austrian and U.S. patients with breast cancer.

To make meaningful cross-cultural comparisons of health-related quality of life (HRQOL) or to pool international research data, it is essential to create culturally unbiased measures that detect clinically important differences between patients. We evaluated the measurement properties of the Functional Assessment of Cancer Therapy-Breast (FACT-B) in 111 Austrian and 144 U.S. patients with breast cancer using item response theory (IRT) methods. A small number of items were identified as displaying statistically significant differential item functioning (DIF), suggesting possible measurement bias. The majority of the items functioned similarly between the two cultural groups. U.S. patients reported lower (worse) physical function and well-being compared with Austrian patients, higher (better) social/family well-being and similar emotional well-being, before and after adjustment for DIF. IRT and related measurement models provide useful methods for assessing cross-cultural equivalence and determining which items can be pooled across languages before analyzing HRQOL data. Determination of clinically significant cross-cultural differences will require additional investigation.

Austria↗

PubMed2004

The talking touchscreen: a new approach to outcomes assessment in low literacy.

PURPOSE: Cancer patients who are deficient in literacy skills are particularly vulnerable to experiencing different outcomes due to disparities in care or barriers to care. Outcomes measurement in low literacy patients may provide new insight into problems previously undetected due to the challenges of completing paper-and-pencil forms. DESCRIPTION OF STUDY: A multimedia program was developed to provide a quality of life assessment platform that would be acceptable to patients with varying literacy skills and computer experience. One item at a time is presented on the computer touchscreen, accompanied by a recorded reading of the question. Various colors, fonts and graphic images are used to enhance visibility, and a small picture icon appears near each text element allowing patients to replay the sound as many times as they wish. Evaluation questions are presented to assess patient burden and preferences. RESULTS: An ethnically diverse group of 126 cancer patients with a range of literacy skills and computer experience reported that the 'talking touchscreen' (TT) was easy to use, and commented on the usefulness of the multimedia approach. CLINICAL IMPLICATIONS: The TT is a practical, user-friendly data acquisition method that provides greater opportunities to measure self-reported outcomes in patients with a range of literacy skills.

Adult↗

PubMed2004

High-risk human papillomavirus detection: a split-sample comparison of hybrid capture and chromogenic in situ hybridization.

The American Society for Colposcopy and Cervical Pathology (ASCCP) has proposed high-risk human papillomavirus (HPV) testing as the "preferred" triage for women with atypical squamous cells of undetermined significance. We studied 401 atypical squamous cells of undetermined significance liquid-based cervicovaginal cytology split samples for HPV by chromogenic in situ hybridization (CISH) and by Hybrid Capture (HC) II (Digene, Gaithersburg, MD); 202 underwent HC II followed by CISH, and 199 underwent CISH followed by HC II. Of 401 vials, 101 (25.2%) were positive for HPV by 1 or more methods. HC II labeled 83 of 401 (20.7%) samples as positive, while 38 of 401 (9.5%) were positive by CISH. Positive attributes of CISH include the provision of a cytomorphologic link in assessing HPV positivity and comparative ease of use in laboratories without trained molecular diagnosticians. Greater efficacy and quantitative design are advantages of HC II. Comparing data by sequence of testing showed a lower likelihood of positive test results on the second ancillary test than on the first ancillary test, regardless of age or testing method (odds ratio, second/first = 0.58; P = .003). This finding suggests that liquid-based cervicovaginal cytology samples are not homogeneous throughout. Correlative studies with histology and polymerase chain reaction may clarify predictive values for both methods.

Adolescent↗

PubMed2003

Quality of life in patients with newly diagnosed chronic phase chronic myeloid leukemia on imatinib versus interferon alfa plus low-dose cytarabine: results from the IRIS Study.

PURPOSE: Quality of life (QOL) outcomes in patients with chronic myeloid leukemia (CML) were evaluated in an international phase III study. PATIENTS AND METHODS: Newly diagnosed patients with chronic phase CML were randomly assigned to imatinib or interferon alfa plus subcutaneous low-dose cytarabine (IFN+LDAC). Cross-over to the other treatment was permitted because of intolerance or lack of efficacy. Patients completed cancer-specific QOL (Functional Assessment of Cancer Therapy-Biologic Response Modifiers) and utility (Euro QoL-5D) questionnaires at baseline and during treatment (n = 1,049). The primary QOL end point was the Trial Outcome Index (TOI; a measure of physical function and well-being). Secondary end points included social and family well-being (SFWB), emotional well-being (EWB), and the utility score. Primary analyses were intention to treat with secondary analyses accounting for cross-over. RESULTS: Patients receiving IFN+LDAC experienced a large decline in the TOI, whereas those receiving imatinib maintained their baseline level. Treatment differences at each visit were significant (P <.001) and clinically relevant in favor of imatinib. Mean SFWB, EWB, and utility scores were also significantly better for those patients taking imatinib. Patients who crossed over to imatinib experienced a large increase in TOI; significant (P <.001) differences were observed between patients who did and did not cross over in favor of imatinib. CONCLUSION: Imatinib offers clear QOL advantages compared with IFN+LDAC as first-line treatment of chronic phase CML. In addition, patients who cross over to imatinib from IFN+LDAC experience a significant improvement in QOL compared with patients who continue to take IFN+LDAC.

Adolescent↗

PubMed2003

Upstaging of atypical ductal hyperplasia after vacuum-assisted 11-gauge stereotactic core needle biopsy.

BACKGROUND: Nonpalpable mammographic abnormalities are frequently evaluated by means of a stereotactic core needle biopsy. This technique is a very sensitive indicator of invasive cancer, but is less reliable to discriminate between ductal carcinoma in situ and atypical ductal hyperplasia (ADH). The objective of this study was to determine the correlation of the 11-gauge vacuum-assisted core needle biopsy to open biopsy when a diagnosis of ADH is obtained. HYPOTHESIS: The use of 11-gauge vacuum-assisted stereotactic core needle biopsy does not conclusively diagnose ADH. DESIGN: Retrospective analysis. SETTING: University-affiliated teaching hospital. PATIENTS: Mammographic findings were evaluated with an 11-gauge vacuum-assisted stereotactic core biopsy in 1750 patients. Seventy-seven patients were diagnosed as having ADH; of these, 65 underwent excisional biopsy. MAIN OUTCOME MEASURES: Pathological upstaging rate. RESULTS: Of the 65 patients who underwent excisional breast biopsy, 11 (17%) had their condition upstaged to a breast cancer diagnosis. These patients had presented at a later age than those who retained a benign diagnosis after excisional biopsy. The number of cores taken did not correlate with diagnostic accuracy. CONCLUSIONS: Of the 65 patients who underwent open biopsy for ADH in this series, only 83% had an accurate diagnosis. A diagnosis of ADH by stereotactic core needle biopsy should be followed by an open excisional biopsy.

Adult↗

PubMed2003

Phase I/II trial of vinorelbine and divided-dose carboplatin in advanced non-small cell lung cancer.

Vinorelbine administered in a doublet with cisplatin has become a standard treatment in patients with advanced non-small cell lung cancer (NSCLC). However, carboplatin appears to provide comparable efficacy with a better nonhematologic safety profile than cisplatin. Herein we report the results of a phase I/II trial of weekly vinorelbine and divided-dose carboplatin in patients with stage IIIB/IV NSCLC, Eastern Cooperative Oncology Group performance status < or = 2, and adequate bone marrow. Patients received vinorelbine starting at 20 mg/m(2) (to 25 mg/m(2)) and carboplatin area under the curve (AUC) 2.5 in divided-doses, both given on Days 1 and 8 every 21-day cycle for up to 6 cycles or until disease progression. Dose-limiting toxicity was defined for Cycles 1 and 2. Tumor response and toxicity were assessed using standard criteria. Twenty-one patients with a mean age of 67 years (range, 43-79) and stage IIIB/IV (8/13) disease were enrolled. All but 1 patient were chemotherapy-nai;ve; the majority (n = 20) had good performance status (< or = 1). Seventy-nine courses (median, 4) were administered. The vinorelbine/carboplatin doublet was well tolerated, with 7 courses interrupted or delayed because of toxicity. Toxicities were generally mild and evenly divided between hematologic (i.e., neutropenia) and nonhematologic (i.e., fatigue). No growth factor support was required for hematologic toxicity. There was only one case of grade 2 alopecia, and no cases of > or = grade 2 neurotoxicity. There were 5 (24%) partial responses, and 9 (43%) patients had stable disease. Weekly vinorelbine 25 mg/m(2) and divided-dose carboplatin AUC 2.5 is a well tolerated regimen with activity in advanced NSCLC patients. Further evaluation of this regimen in combination with novel targeted biologic therapy is warranted.

Adenocarcinoma↗

PubMed2003

Health outcomes assessment in vulnerable populations: measurement challenges and recommendations.

With growing recognition that some population subgroups are particularly vulnerable to receiving suboptimal health care and achieving poor health outcomes, innovative techniques are required for collecting and evaluating health outcomes data. Research is also needed to better understand the causal pathways linking vulnerability with health outcomes. This article focuses on patients with a chronic illness (cancer) who also have low literacy and/or poor English language skills. We summarize the association among literacy, language, ethnicity, and health outcomes; describe innovative technologies to enhance communication; and discuss the advantages of using psychometric measurement models in health outcomes assessment. Results from our ongoing research projects are presented, including the development of an audiovisual computer-based testing platform for self-administration of questionnaires. Such innovative multimedia technologies allow patients with limited or even no reading ability to participate in outcomes assessment and have the potential to be incorporated into a clinical setting with minimal burden on staff and patients. Appropriate methods are also needed to evaluate measurement equivalence across diverse patient groups, that is, the extent to which items in a questionnaire perform similarly across groups. Item response theory measurement models provide a strategy for differentiating between measurement bias and real differences that may exist between groups. Recommendations for clinical practice and research are offered specifically to address medically underserved and vulnerable populations.

Activities of Daily Living↗

PubMed2003

Quality of life on imatinib.

Imatinib (Gleevec), a highly effective specific tyrosine kinase inhibitor, demonstrates a better side effect profile than interferon-alpha (IFN), which impairs patients' quality of life (QoL). This phase III international study evaluated QoL outcomes in 1,106 newly diagnosed patients with chronic-phase chronic myeloid leukemia (CML) who were randomized to receive either imatinib 400 mg daily or IFN up to 5 MU/m(2)/d with cytarabine (Ara-C) 20 mg/m(2)/d added for 10 days every month (IFN + LDAC). Crossover to the other treatment arm was permitted due to a lack of efficacy or treatment intolerance. QoL was assessed with the Functional Assessment of Cancer Therapy-Biologic Response Modifiers (FACT-BRM) at baseline, monthly for 6 months and then at months 9, 12, and 18. The Trial Outcome Index (TOI; a composite endpoint of physical/functional/treatment-specific subscales) was the primary endpoint. Secondary endpoints measured were social/family well-being (SFWB) and emotional well-being (EWB). QoL was analyzed for the first 18 months of treatment using mixed effects growth curve models. The primary analyses were intention-to-treat (ITT); secondary analyses incorporated crossover as a time-dependent covariate. A total of 1,049 patients completed at least one QoL assessment. Two hundred sixty-one patients (50%) crossed over from IFN to imatinib and 11 (2%) crossed over from imatinib to IFN. There was a significant decline in TOI scores for the IFN treatment arm compared with preservation of baseline TOI scores in the imatinib arm (P <.001, ITT). Mean social/family and EWB scores were 22.8 and 19.5, respectively, for imatinib and 21.6 and 17.6, respectively, for IFN (P <.001, ITT). After crossing over from IFN to imatinib, patients experienced a significant (P <.001) increase in TOI scores. Imatinib offers clear QoL advantages over IFN as first-line treatment of chronic-phase CML. In addition, patients who crossed over to imatinib reported higher QoL than those who remained on IFN. Semin Hematol 40(suppl 2):31-36.

Adolescent↗

PubMed2003

The effects of continuing medical education credits on physician response rates to a mailed questionnaire.

This study investigated whether the opportunity to obtain Continuing Medical Education (CME) credit together with a five-dollar bill increased response rates and questionnaire completion rates in a physician survey involving mailed questionnaires. One thousand, three hundred and fourteen cardiologists, family practitioners, general internists (non-surgeons) and 264 vascular surgeons randomly identified from the American Medical Association database participated. After two, of up to four, questionnaire mailings, the opportunity to obtain CME credit and a five-dollar bill were included with questionnaire mailings. Among non-surgeons, 26.5% responded to pre-incentive mailings and 30.2% of those initially unresponsive replied after the interventions. Among surgeons, 39% responded to pre-incentive mailings and 32.7% of those initially unresponsive replied after the interventions. In conclusion, the opportunity to receive CME credit combined with a small monetary incentive is an effective motivation for physicians participating in a study involving mailed questionnaires.

Adult↗

PubMed2002

Meaningful change in cancer-specific quality of life scores: differences between improvement and worsening.

INTRODUCTION: There has been increased recent attention to the clinical meaningfulness of group change scores on health-related quality of life (HRQL) questionnaires. It has been assumed that improvements and declines of comparable magnitude have the same meaning or value. METHOD: We assessed 308 cancer patients with the Functional Assessment of Cancer Therapy (FACT) and a Global Rating of Change. Patients were classified into five levels of change in HRQL and its dimensions based upon their responses to retrospective ratings of change after 2 months: sizably worse, minimally worse, no change, minimally better, and sizably better. Raw score and standardized score changes on the FACT-G subscales and total score were then compared across different categories of patient-rated change. RESULTS: The relationship between actual FACT change scores and retrospective ratings of change was modest but usually statistically significant (r: 0.07 to 0.35). Change scores associated with each retrospective rating category were evaluated to determine estimates of meaningful difference. Patients who reported global worsening of HRQL dimensions had considerably larger change scores than those reporting comparable global improvements. Although related to a ceiling effect, this remained true even after removing cases that began near the ceiling of the questionnaire. DISCUSSION: Relatively small gains in HRQL have significant value. Comparable declines may be less meaningful, perhaps due to patients' tendency to minimize personal negative evaluations about one's condition. This has important implications for the interpretation of the meaningfulness of change scores in HRQL questionnaires. Factors such as adaptation to disease, response shift, dispositional optimism and the need for signs of clinical improvement may be contributing to the results and should be investigated in future studies.

Adaptation, Psychological↗