Biomedical subjects

Jack A Clark

Publications and source records attributed to Jack A Clark.

At least 19 recordsLinked to original sources

PubMed2006

Confidence and uncertainty long after initial treatment for early prostate cancer: survivors' views of cancer control and the treatment decisions they made.

PURPOSE: The many years most men diagnosed with early prostate cancer live after diagnosis allow evolving assessments of their cancer control and their treatment choices, but little is known of these outcomes or the factors that influence them. PATIENTS AND METHODS: We surveyed an established, prospective cohort that had initiated treatment for early prostate cancer 4 to 8 years previously. We assessed perceived cancer control, quality of treatment decisions, and other domains of quality of life, along with treatment-related urinary, bowel, and sexual dysfunction. RESULTS: Most men reported high confidence in cancer control and their treatment decisions, but many reported misgivings about one or both. The diagnostic, treatment, and quality-of-life factors associated with these two outcomes were distinct. Perceived cancer control was lower among those with adverse medical factors: higher pretreatment Gleason scores, subsequent rises in prostate-specific antigen (PSA), and secondary androgen ablation therapy. Confidence in treatment decisions was unrelated to these factors and was higher in men who opted for radical prostatectomy or brachytherapy, reported close attention to current PSA, had high masculine self-esteem and little distress from sexual dysfunction, and were married. CONCLUSION: Although perceptions of cancer control and the quality of their treatment decisions are linked, men can distinguish between these two outcomes. They incorporate objective indicators of high risk and adverse outcomes when assessing their cancer control; confidence in treatment decisions represents a more complex psychosocial adjustment to the persistent uncertainty that originates with their diagnosis.

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PubMed2006

Bringing prostate cancer quality of life research back to the bedside: translating numbers into a format that patients can understand.

PURPOSE: Although measuring quality of life of patients with prostate cancer serves important research goals, its primary clinical purpose is informing patients. Sophisticated quality of life measures produce purely numerical results that patients have difficulty understanding. We present an approach that preserves the methodological strengths of validated multi-item measures but provides more accessible information for clinical use. MATERIALS AND METHODS: Using validated indexes measuring urinary, bowel and sexual function we surveyed patients with clinically localized prostate cancer before treatment and at intervals thereafter. Based on patient responses to parallel distress measures we defined 3 levels of function, including normal-no abnormal symptom, intermediate-any abnormal symptom but none severely abnormal and poor-any severely abnormal symptom. We then translated patient survey results into these levels. To assess measurement properties we compared average symptom distress scores in patients at each symptom level. RESULTS: Levels of function and patient distress scores correlated strongly. Large and approximately equal differences in distress scores separated patients at successive levels in all symptom indexes (effect size greater than 1.2, p < 0.0001). Using these categories we created tables showing 24-month outcomes in 417 previously reported patients by pretreatment symptom level and treatment, providing a tool for patients to determine posttreatment outcomes in similar patients. CONCLUSIONS: Using symptom indexes to define levels of function produces a quality of life metric that is valid, defines quantitative intervals, is transparent and may be more useful to patients. This approach provides methodologically sound outcome information to patients attempting to choose a prostate cancer treatment.

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PubMed2005

The value of the marginalia as an adjunct to structured questionnaires: experiences of men after prostate cancer surgery.

In both research and clinical settings, men who survive prostate cancer emphasize the need for more open communication about the challenges they face. They explain that symptomatic dysfunction associated with treatment is grounded in complex social situations and relationships. Yet, structured quality of life questionnaires preclude expressions of the elaborate accounts they often evoke. We explore this in the case of prostate cancer. Seventy-one patients who had undergone radical prostatectomy at a mid-Atlantic University Medical Center, a Veterans Affairs medical center affiliated with the same university, or were US members of an international prostate cancer support group completed a survey protocol including assessments of urinary morbidity, psychosocial adjustment to illness (PAIS), and health status (SF-36). At the conclusion, a single open-ended item was offered; 48 offered an extended response. The open-ended item was recorded and analyzed qualitatively. Data were summarized according to four main themes: (1) quality of patient-physician communication; (2) change in sexual identity; (3) fear of cancer; and (4) the humiliation of urinary incontinence. Future research on outcomes of treatment and clinical inquiry must focus on methods that systematically capture patients' experiences.

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PubMed2005

Quality of life in prostate cancer.

Little more than a decade ago, measurements of health-related quality of life (HRQOL) of prostate cancer patients began to enter the medical literature. Initially controversial and of little apparent relevance to clinical care, HRQOL has grown in importance in prostate cancer to the point that providing it in treatment discussions is now considered a core element of clinical care. The United States (US) Food and Drug Administration has used it to make approval decisions for prostate cancer drugs, and Europeans have endorsed its central role in prostate cancer as well [Altwein J, Ekman P, Barry M, et al. How is quality of life in prostate cancer patients influenced by modern treatment? The Wallenberg symposium. Urology 1997, 49(Suppl 4A), 66-76.]. We propose to characterise the treatment dilemmas facing patients with prostate cancer, the clinical relevance of HRQOL research, its central conceptual elements, the characteristics of some available instruments to measure it, the use of HRQOL in clinical studies, and some of the remaining challenges we have identified during our 13 years in the field.

Forecasting↗

PubMed2005

Data pooling and analysis to build a preliminary item bank: an example using bowel function in prostate cancer.

Assessing bowel function (BF) in prostate cancer can help determine therapeutic trade-offs. We determined the components of BF commonly assessed in prostate cancer studies as an initial step in creating an item bank for clinical and research application. We analyzed six archived data sets representing 4,246 men with prostate cancer. Thirty-one items from validated instruments were available for analysis. Items were classified into domains (diarrhea, rectal urgency, pain, bleeding, bother/distress, and other) then subjected to conventional psychometric and item response theory (IRT) analyses. Items fit the IRT model if the ratio between observed and expected item variance was between 0.60 and 1.40. Four of 31 items had inadequate fit in at least one analysis. Poorly fitting items included bleeding (2), rectal urgency (1), and bother/distress (1). A fifth item assessing hemorrhoids was poorly correlated with other items. Our analyses supported four related components of BF: diarrhea, rectal urgency, pain, and bother/distress.

Adult↗

PubMed2004

Racial differences in cardiac catheterization as a function of patients' beliefs.

OBJECTIVES: We examined racial differences in cardiac catheterization rates and reviewed whether patients' beliefs or other variables were associated with observed disparities. METHODS: We did a prospective observational cohort study of 1045 White and African American patients at 5 Veterans Affairs (VA) medical centers whose nuclear imaging studies indicated reversible cardiac ischemia. RESULTS: There were few demographic differences between White and African American patients in our sample. African Americans were less likely than Whites to undergo cardiac catheterization. African Americans were more likely than Whites to indicate a strong reliance on religion and to report racial and social class discrimination and were less likely to indicate a generalized trust in people but did not differ from White patients on numerous other attitudes about health and health care. Neither sociodemographic or clinical characteristics nor patients' beliefs explained the observed disparities, but physicians' assessments of the procedure's importance and patients' likelihood of coronary disease seemed to account for differences not otherwise explained. CONCLUSIONS: Patients' preferences are not the likely source of racial disparities in the use of cardiac catheterization among veterans using VA care, but physicians' assessments warrant further attention.

Black or African American↗

PubMed2004

Assessing a prostate cancer brachytherapy technique using early patient-reported symptoms: a potential early indicator for technology assessment?

Brachytherapy for early prostate cancer can cause long-term urinary, bowel, and sexual dysfunction. Modifying technique may mitigate complications, but definitive outcome assessment requires long-term follow-up. Although radiation dose plausibly mediates all treatment-related toxicity, short-term symptoms may indicate long-term outcomes. We sought an early indication of whether a modified brachytherapy technique successfully decreased toxicity in the anticipated direction by assessing changes in symptoms and symptom distress 3 months after treatment. In a prospective study of clinically localized prostate cancer using a validated, patient-reported questionnaire, we assessed 85 men, whose primary treatment was brachytherapy alone, prior to treatment and 3 months after the procedure. Twenty-two men received standard ultrasound-guided brachytherapy (SB), and 63 men received magnetic resonance imaging-guided brachytherapy (MB), a technique intended to decrease urinary toxicity by reducing urethral irradiation. Patient age and other sociodemographic variables were similar in the 2 groups. The MB group experienced a greater increase in urinary obstruction/irritation symptoms (P = 0.02) and sexual function distress, but not sexual dysfunction (P = 0.22), whereas the SB group reported a smaller increase in bowel symptoms (P = 0.04) and bowel distress (P = 0.02). We found reduced short-term urinary obstruction/irritation and increased bowel problems after MB consistent with the hypothesized effects of the modified technique, although no obvious mechanism explains the decreased sexual function distress in MB patients. Whether these short-term changes predict long-term outcome differences will require much longer follow-up. However, these results suggest that measuring early symptoms may indicate whether an altered brachytherapy treatment technique has intended favorable consequences, potentially accelerating technology assessment.

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PubMed2003

Time course and predictors of symptoms after primary prostate cancer therapy.

PURPOSE: Understanding the distinctive patterns of treatment-related dysfunction after alternative initial treatments for early prostate cancer (PC) may improve patients' choice of treatment and later help them adjust to its consequences. We characterized the time course of treatment complications while adjusting for potentially confounding pretreatment factors hindering other observational studies. PATIENTS AND METHODS: In a prospective cohort study of 417 men we assessed urinary, bowel, and sexual function from before primary treatment to 24 months after. To control for potential confounding, we measured sociodemographic and PC prognostic factors, medical comorbidity, and pretreatment function commonly affected by PC and its treatment. RESULTS: Patients who underwent external beam radiotherapy (EBRT), radical prostatectomy (RP), and brachytherapy (BT) differed significantly in sociodemographic factors, cancer prognostic factors, and pretreatment symptom status, especially sexual function. Urinary incontinence increased sharply after RP, while bowel problems and urinary irritation/obstruction rose after EBRT and BT. Sexual dysfunction increased in all patients, particularly after radical prostatectomy, and nerve-sparing surgical technique had little apparent benefit. There was no change in urinary function and little change in overall bowel function after 12 months, but the time course of sexual dysfunction varied by treatment and, for bowel function, by symptom. Multiple regression modeling confirmed that treatment influences all 24-month outcomes, but residual confounding persisted. CONCLUSION: Pretreatment function and the primary treatment modality for early stage PC strongly predict the affected organ systems and time course of dysfunction. With this information, patients and their physicians may refine their choice of treatment and better anticipate its consequences.

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PubMed2003

Patients' perceptions of quality of life after treatment for early prostate cancer.

PURPOSE: Treatment for early prostate cancer produces problematic physical side effects, but prior studies have found little influence on patients' perceived health status. We examined psychosocial outcomes of treatment for early prostate cancer. PATIENTS AND METHODS: Patients with previously treated prostate cancer and a reference group of men with a normal prostate-specific antigen (PSA) level and no history of prostate cancer completed questionnaires. Innovative scales assessed behavioral consequences of urinary dysfunction, sexuality, health worry, PSA concern, perceived cancer control, treatment decision making, decision regret, and cancer-related outlook. Urinary, bowel, and sexual dysfunction were assessed with symptom indexes; health status was assessed by the Physical and Mental Summaries of the Short Form (SF-12) Health Survey. RESULTS: Compared with men without prostate cancer, prostate cancer patients reported greater urinary, bowel, and sexual dysfunction, but similar health status. They reported worse problems of urinary control, sexual intimacy and confidence, and masculinity, and greater PSA concern. Perceptions of cancer control and treatment decisions were positive, but varied by treatment: prostatectomy patients indicated the highest and observation patients indicated the lowest cancer control. Bowel and sexual dysfunction were associated with poorer sexual intimacy, masculinity, and perceived cancer control; masculinity and PSA concern were associated with greater confidence in treatment choice; and diminished sexual intimacy and less interest in PSA were associated with greater regret. CONCLUSION: The lack of change in global measures of health status after treatment for early prostate cancer obscures important influences in men's lives; cancer diagnosis and treatment complications may result in complex outcomes. Aggressive treatment may confer confidence in cancer control, yet be countered by diminished intimate relationships and masculinity, which accompany sexual dysfunction.

Adult↗

PubMed2003

Measuring patients' perceptions of the outcomes of treatment for early prostate cancer.

BACKGROUND: Compared with careful attention to the physical (eg, urinary, bowel, sexual) dysfunction that may follow treatment, little attention has been given to the behavioral, emotional, and interpersonal changes that the diagnosis of early prostate cancer and subsequent physical dysfunction may bring. OBJECTIVE: To construct patient-centered measures of the outcomes of treatment for early prostate cancer. RESEARCH DESIGN: Qualitative study followed by survey of early prostate cancer patients and group of comparable patients with no history of prostate cancer. Analysis of focus groups identified relevant domains of quality of life, which were represented by Likert scale items included in survey questionnaires. Psychometric analyses of survey data defined scales evaluated with respect to internal consistency and validity. RESULTS: Qualitative analysis identified three domains: urinary control, sexuality, and uncertainty about the cancer and its treatment. Psychometric analysis defined 11 scales. Seven were generically relevant to most older men: urinary control (eg, embarrassment with leakage), sexual intimacy (eg, anxiety about completing intercourse), sexual confidence (eg, comfort with sexuality), marital affection (eg, emotional distance from spouse/partner), masculine self esteem (eg, feeling oneself a whole man), health worry (eg, apprehensiveness about health changes), and PSA concern (eg, closely attending to one's PSA). Four scales were specific to the treatment experience: perceived cancer control, quality of treatment decision making, regret of treatment choice, and cancer-related outlook. CONCLUSION: The scales provide definition and metrics for patient-centered research in this area. They complement measures of physical dysfunction and bring into resolution outcomes of treatment that have gone unnoticed in previous studies.

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PubMed2003

Organ conservation in invasive bladder cancer by transurethral resection, chemotherapy and radiation: results of a urodynamic and quality of life study on long-term survivors.

PURPOSE: Transurethral resection, chemotherapy and radiation with salvage cystectomy may be used as alternatives to immediate radical cystectomy in the management of invasive bladder cancer. Concern exists about the function of the retained bladder after such therapy. MATERIALS AND METHODS: Of 221 patients with clinical T2-4a bladder cancer treated at Massachusetts General Hospital from 1986 to 2000 with trimodality therapy, 71 were alive with native bladders and disease-free in 2001. These patients were asked to undergo a urodynamic study and to complete a quality of life questionnaire. A total of 69% participated in some component of this study with a median time from trimodality therapy of 6.3 years (range 1.6 to 14.9). RESULTS: Of 32 patients 24 had normally functioning bladders by urodynamic study. Decreased bladder compliance was seen in 7. Bladder hypersensitivity, involuntary detrusor contractions and incontinence were present in 2 women. The questionnaire showed that flow symptoms occurred in 6%, urgency in 15% and control problems in 19%. Of all women 11% wore pads. Distress from urinary symptoms was half as common as prevalence. Bowel symptoms occurred in 22% with 14% recording any level of distress. The majority of men retained sexual function. Global health related quality of life was high. CONCLUSIONS: The majority of patients treated with trimodality therapy retain good bladder function. A fifth have evidence of bowel dysfunction.

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PubMed2002

Racial differences in how patients perceive physician communication regarding cardiac testing.

OBJECTIVES: Recent studies documenting racial variation in the use of cardiac procedures highlight the need to understand if there are racial differences in processes of communication and decision making. Investigations of patients' perceptions of their interaction with providers regarding cardiac testing were conducted. METHODS: Four focus groups were convened with 13 patients who had undergone cardiac stress testing with positive results, stratified by race (white vs. black). Verbatim transcripts of discussions of their interactions with providers relating to their cardiac problems were analyzed qualitatively by a team of behavioral scientists and general internists to identify significant dimensions of communication and patient-provider relationships. RESULTS: Four domains of communication were identified that appeared to bear on patients' comfort and preferences regarding cardiac procedures. First, the substance of the information that was provided by physicians and other providers was described as incomplete, vague, ambiguous, and unclear. Second, some recommendations either were inconsistent with expectations or awakened fears based on distressing previous experiences. Third, patients said they needed to be convinced of the need for additional, invasive tests and therapeutic procedures, and in some cases providers' arguments failed in this regard. Fourth, the patients highlighted the importance of trusting their provider. Although there were no apparent differences by race in patients' perception of the information they received, black patients consistently expressed a preference for building a relationship with physicians (trust) before agreeing to an invasive cardiac procedure, and just as consistently complained that trust was lacking. Conversely, white patients tended to emphasize that they were inadequately convinced of the need for recommended procedures. CONCLUSIONS: This study provided qualitative information regarding patients' perceptions of physician-patient communication and racial differences in such perceptions. For both black and white patients, we found problematic aspects of the patients' experiences regarding communication about cardiac testing. Our findings suggest that although patients desire clarity from physicians, they are often confused regarding the information received. Both a lack of substance and vagueness of the information received may be linked to feelings of mistrust toward physicians when considering further diagnostic testing. Mistrust may be a source of some of the documented racial variation in health care utilization.

Black or African American↗

PubMed2002

Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application.

OBJECTIVES: To deternine whether there are racial differences in patients' health-related attitudes, beliefs, and experiences regarding invasive cardiac procedures, and to develop psychometrically and conceptually valid scales and single items to assess these dimensions. METHODS: A survey was designed and administered to 854 white and black patients with ischemic heart disease at five VA medical centers. Patients were queried about the domains proposed to be important to treatment decision making by the Health Decision Model: sociodemographic characteristics, social interactions, health care experiences, patient preferences for care, knowledge about diseases and potential treatments, and health beliefs. Using multitrait analysis, the psychometric properties of scales assessing these domains were examined. It was then assessed whether there were racial differences in scale or individual item scores using chi2 and t test analyses. RESULTS: The analyses yielded eight psychometrically valid scales: disease severity, patient evaluation of physician's interpersonal style, patient evaluations of VA care, satisfaction with treatment decision making, perceived urgency of catheterization, vulnerability to catheterization, bodily impact of catheterization, and attitudes toward religion. There were only racial differences on mean scores for the latter scale. Individual item analyses indicated that black patients were less likely to have been encouraged by friends or family to have cardiac catheterization, and had less personal or familial experiences with this or other surgical procedures. In contrast to expectations, white patients were more likely to be skeptical of medical care. CONCLUSIONS: The multiple dimensions of white and black patients' health-related attitudes, beliefs, and experiences were examined, and few differences were found. These results suggest that racial differences in patients' attitudes, beliefs, and experiences are not a likely source of racial disparities in cardiac care. Future research will examine the association of beliefs, attitudes and experiences with actual use of invasive cardiac procedures.

Black or African American↗

PubMedDate not supplied

Patient-reported measures of health: The Veterans Health Study.

The goal of the Veterans Health Study (VHS) was to extend the work of the Medical Outcomes Study (MOS) into the VA, by developing methodology for monitoring patient-based outcomes of care for use in ambulatory outpatient care. The principal objective of the VHS was developing valid and reliable measures to assess general health-related quality of life (HRQoL) and identifying the presence of selected health conditions, their severity, and their impact on HRQoL. In this article, we provide an overview of the historical context, framework, objectives, and applications of the VHS for the purpose of assessing the health outcomes of veteran patients. The VHS is a prospective observational study that has followed 2425 VA patients for up to 2 years. The patients were sampled from users of the Veterans Affairs (VA) ambulatory care system in the Boston area. The health conditions selected were hypertension, diabetes, chronic lung disease, osteoarthritis of the knee, chronic low-back pain, and alcohol-related problems. These conditions were chosen because they are both prevalent in the VA and have measurable impacts on HRQoL. One of the cornerstones of the VHS was the development of the Veterans SF-36, modified from the MOS SF-36 for use in veteran ambulatory populations. Other key accomplishments included the development of patient-based disease-specific measures of health and the establishment of methods and logistics for comprehensive health outcomes research in large health care systems such as the VA, using these patient-based measures. Selected measures developed in the VHS, eg, the Veterans SF-36, have been integrated into the VA outcomes measurement system. The scope of the VHS is unique; it resulted in the development of a broad range of patient-focused process and outcome measures, as well as methodologies for assessing large numbers of patients, that have been widely used in the VA outpatient health care system for monitoring health outcomes across the nation.

Adult↗

PubMedDate not supplied

Comparing the health status of VA and non-VA ambulatory patients: the veterans' health and medical outcomes studies.

The purpose of this study was to compare health status and disease profiles of ambulatory patients in specific Veterans Administration (VA) and civilian healthcare settings. A random sample of 2425 male veterans seeking care at 4 Boston-area VA outpatient clinics, who took part in the Veterans Health Study (VHS) in 1993-1995, were compared to 1318 male patients seeking civilian outpatient care in 3 major metropolitan areas covered in the Medical Outcomes Study (MOS) in 1986. The MOS sampled patients who had 1 of 5 conditions--hypertension, noninsulin-dependent diabetes, recent myocardial infarction, congestive heart failure, or depression. These 2 samples were age adjusted and compared in terms of the SF-36 Health Status/Quality of Life measures, and a list of 100 clinical variables (diagnostic, symptom, and medical event reports) collected with comparable instruments by a trained clinical observer. Individual odds ratios (VHS to MOS) were calculated for each measure and clinical variables. SF-36 measures of patient health in the VHS were lower than those in the MOS by more than one half of a standard deviation (SD) on 4 of 8 scales, by more than one quarter of a SD on the other 4, by 58% of a SD on the physical health summary scale, and by 37% of a SD on the mental health summary scale (P < .0001 in all cases). The median odds ratio was 2.2 among the SF-36 scales and 1.9 among clinical variables. Outpatients in the 4 VA clinics had more than twice the illness burden than did patients in the MOS. Current economic condition and service-connected disability explain most, if not all, of the differences. The differences were clinically and socially meaningful and would be consistent with substantially higher expected healthcare use.

Ambulatory Care Facilities↗

PubMedDate not supplied

Improving the response choices on the veterans SF-36 health survey role functioning scales: results from the Veterans Health Study.

Role functioning and its limitations due to one's health is an important aspect of health-related quality of life (HRQoL). The Medical Outcomes Study (MOS) SF-36 includes 2 role functioning scales: role limitations due to physical health problems (RP) or emotional problems (RE). Although they capture important concepts of HRQoL, these 2 scales have some limitations in their measurement properties. Using dichotomized sets of response choices, the scales are limited in their distributional properties (eg, higher standard deviation than other SF-36 scales) and ability to discriminate between clinically relevant groups. In this study, we ascertain the improvements to these 2 scales using 5-point ordinal response choices for each of the scale items. Two thousand one hundred sixty-two patients from the Veterans Health Study (VHS), an observational study of health outcomes in patients receiving ambulatory care, completed a health status questionnaire and a medical history. The health questionnaire included (1) the MOS SF-36, in which the RP and RE items used dichotomized yes/no responses; and (2) a set of modified RP and RE items that used 5-response choices for each of the items, ranging from "no, none of the time" to "yes, all of the time." We compared the original and modified RP and RE scales using internal consistency reliability and factor analysis. We tested item convergent and discriminant validity using multitrait scaling, and scale discriminant validity using ordinary least squares regression. Results indicate that the modifications to the original RP and RE scales accomplish important gains in the distributional properties of the scales. The floor and ceiling effects of the 2 scales have been reduced and the reliability of the RP scale has increased (0.87-0.95). Factor analysis and multitrait scaling tests indicate that the modified items have the same interpretation as the original items. Tests of discriminant validity indicate that the modified RP and RE scales have greater explanatory power for measures of disease burden, depression, and disease severity. The modified SF-36 role scales are clearly superior to the original versions. The modifications have increased the explained variability, suggesting greater explanatory power and more information obtained by the role functioning measures. The modified RP and RE are capturing a wider spectrum of disease severity, in part due to the lowering of the floor and raising of the ceiling of the scales. Additional work needs to test these improvements in other populations and to expand the analysis to track the responsiveness of the modified scales to clinically and socially important changes over time.

Activities of Daily Living↗

PubMedDate not supplied

The influence of place of administration on health-related quality-of-life assessments: findings from the Veterans Health Study.

Patient-based assessments of functional status and well-being, such as the short form survey (SF-36) developed in the Medical Outcomes Study, are increasingly used to monitor patient health status and the effects of medical care. Although they have been used in many populations under a variety of circumstances, little is known about how environmental factors, such as place of administration, influence patients' responses. We administered the SF-36 as part of comprehensive quality-of-life assessments to 304 participants in the pilot phase of the Veterans Health Study, a large observational study of health outcomes in VA ambulatory care. SF-36 questionnaires were self-administered twice by patients, once at home and again as part of an interview in a clinic setting. For most participants, less than a week passed between the 2 administrations. Scores from these questionnaires were compared as a measure of reliability and of the possible influence of place of administration. Questionnaires self-administered at the time of the interview yielded mean scores that were significantly (P<.05) higher across all 8 SF-36 scales (physical function, role function with physical and emotional limitations, vitality, bodily pain, social function, mental health, general health perceptions) and both the physical and mental component summary scales. With scores scaled from 0 to 100, differences ranged from 2.1 (bodily pain) to 5.7 (role limitations due to emotional problems). Mean physical function was 56.8 at the time of the interview, and 52.4 at home. Higher scores from questionnaires administered at interview outnumbered lower scores by 3 to 2 for most scales. These differences remained even after restricting the sample to those with the highest cognitive function scores and the shortest interval between administrations. Because selection factors and order of administration could not be completely dismissed, a large number of other administrative, clinical, and sociodemographic factors were examined, which, however, failed to provide adequate explanation for these differences. Careful consideration should be given concerning the physical and social environment in the administration of health-related quality-of-life assessments. Findings from this study suggest that more favorable measures of self-reported functional status and well-being may be expected from clinic administrations of instruments.

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PubMedDate not supplied

Utilization of medical services by Veterans Health Study (VHS) respondents.

The first objective of this study was to profile Veterans Health Study (VHS) respondents' use of medical services-the types of services used, use of a regular source of care, and the propensity to use services for selected symptoms. We focused on differential use of VA and non-VA services and highlighted differences in use by age group. The second objective was to use multivariate analysis to identify factors associated with respondents' use of any medical services and with VA services specifically. We incorporated 2 self-reported variables not used in previous studies of VA utilization-health status and disease burden. Patients receiving ambulatory care services in 4 VA ambulatory outpatient clinics in the greater Boston area were eligible for inclusion in the VHS. A sample of 2425 community-dwelling male veterans was randomly selected from among veterans receiving ambulatory services at Boston-area VA facilities. This analysis focuses on 1909 respondents for whom we had complete data. Interviews and questionnaires were used to collect cross-sectional, observational data on sociodemographic, economic, and clinical characteristics; health status; disease burden; and service-connected disability (SCD) rating. To measure health status, we used 2 summary measures, the Physical Component Summary (PCS) and the Mental Component Summary (MCS), derived from the 8 scales of the Medical Outcomes Study Short Form 36-item Health Survey (MOS SF-36). To measure disease burden, we used the Physical Comorbidity Index (PHYCI) and Mental Comorbidity Index (MENCI), composed of 30 physical and 6 mental health conditions and symptoms, respectively. Information on the availability of non-VA insurance was obtained from administrative VA files. Information on utilization prior to the interview was self-reported. Recall periods of 3 and 12 months were used for ambulatory and inpatient services, respectively. We used descriptive statistics to profile respondents and their utilization patterns. We used multivariate probit models to identify respondent characteristics associated with use of any medical services, medical visits, mental health visits, and hospital stays. Independent variables used in the models were socioeconomic and demographic characteristics, and measures of disease burden, health status, and VA eligibility. The respondents relied heavily on the VA for medical care: 74% of the respondents said the VA was their regular source of care; 72% of all the respondents and 87% of those who had used any medical service in the recall period had used a VA service; 68% of those who were hospitalized used a VA hospital; and 76% of the medical care the respondents received and 60% of their hospital stays were in VA facilities. Younger veterans (aged 22-44) used substantially more mental health services than older respondents, but they were less likely than older veterans to have seen a doctor recently for most of the medical symptoms studied. PHYCI and PCS were significantly related to use of any medical services and to use of inpatient services; MENCI and MCS were significantly related to use of mental health services (P<.05 for each, respectively). Lower income and lack of alternatives to VA care were directly related to use of any VA services and VA inpatient services. Information on the reasons for differential use of VA and non-VA services can be useful to the VA as it serves an aging veteran population, seeks to provide comprehensive care to a wider spectrum of veterans, and moves into a more competitive healthcare marketplace.

Adult↗