Knowledge Item:
CA-Medical Outcomes-13
Length of Time a Participant is Maintained at the
Same or an Improved Quality of Life as a Function of the Type of
Medical Project Providing Treatment: II. Additional Control for Level
of Medical Functioning Near Enrollment
This Knowledge Item is a
follow-up to Knowledge
Item: CA-Quality of Life and Health-50 and Knowledge
Item: CA-Quality of Life and Health-51 which also present data on the days
that quality of life is maintained for a third group of projects,
Community Based Organizations, that provide psychosocial services with
linkages to medical care. This Knowledge Item follows up on the earlier
work by explicitly controlling for the clients stage of HIV disease, as
measured by a control factor of the earliest known CD4 count, and the
classification of factor as to whether the client had an AIDS-defining
condition during the course of the treatment episode. Since the CBO
projects did not collect data on medical test results or opportunistic
infections, their data is not used here. The data
from one Managed Care project
(with 38 patients) were not used because that project explicitly targeted AIDS patients at the
end of their lives by providing home healthcare under a managed care
model, and it was felt that the data from that project would skew the
results for the Managed Care projects. This Knowledge Item is also a follow-up to
Knowledge Item: CA-Medical
Outcomes-11 and Knowledge Item:
CA-Medical Outcomes-12; additional indicators of initial
functioning are used here. Note: this additional
Knowledge Item was developed instead of just using the additional
medical functioning indicators in the earlier Knowledge Items because
missing data on some indicators cuts the sample size and the earlier Knowledge
Items can accordingly use more of the patients in the analyses. The same
substantive conclusions are drawn here as were drawn in Knowledge Items:
CA-Medical Outcomes-11, and -12.
The probability of maintaining an
individual at or above the baseline Total Quality of Life Score was
estimated from a Cox (proportional
hazards) regression or survival analysis. Initial levels of quality of
life and initial levels of physical functioning (as measured by CD4
count, viral load, and clinician-rated severity of the illness on the
Karnofsky Severity scale) were controlled. The maximum improvement in
quality of life over time was also studied.
More than half of the
individuals, in this progressive disease, may be maintained at the same
or higher quality of life for a period of time approaching the maximum
in our evaluation study, of about three years. Different rates of
maintaining patients at full quality of life are found
for Managed Care projects not utilizing wrap-around psychosocial
services and University-based Comprehensive Healthcare programs that
do utilize wrap-around psychosocial services. Different maximum levels
of improvement in quality of life are also found for Managed Care
projects not utilizing wrap-around psychosocial services and
University-based Comprehensive Healthcare programs that do utilize
wrap-around psychosocial services. All
results are controlled for initial differences in medical functioning.
There is a very
important result in the overall sequence of analyses presented here.
Using survival analysis to study the time that quality of life is
maintained at full levels, there is a significant difference between
the University-based Comprehensive Healthcare projects and the Managed
Care projects controlling for medical functioning as assessed by
objective laboratory tests (CD4 counts, viral loads) and clinician
assessments of disease severity (Karnofsky
Severity Ratings). When examining
the maximum quality of life improvement rate, there is a significant
difference between the two kinds of projects when controlling for
medical functioning by objective laboratory tests (CD4 counts, viral
loads). If, however, clinician assessments of disease severity are
controlled, the difference between projects is explained. That is,
objective
differences (as assessed by laboratory tests) in the functioning of
the patient populations near enrollment at the University-based
Comprehensive Healthcare projects and the Managed Care projects do not
explain differences found between the projects in the patient-rated
quality of life outcomes. However, the fact that the clinicians at
the Managed Care projects rate their patients to be sicker near
enrollment does partially "explain" the difference in outcomes.
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More Information:
CHAID and CHAID Diagram
In interpreting this
Knowledge Item, and all others in this section on Medical Outcomes, remember that the ratings of quality of life, symptom
impact, and healthcare utilization are based on patient self reports
unless noted otherwise.
Knowledge Item Citation: Huba, G. J., Melchior, L. A., Panter, A. T., and the HRSA/HAB SPNS Cooperative Agreement Steering Committee (1998-2001). Knowledge Item:
CA-Medical Outcomes-13 from
HRSA/HAB's SPNS Cooperative Agreements on Innovative Models of Care, The Measurement Group Knowledge Base on HIV/AIDS Care, Online at www.TheMeasurementGroup.com.
Last Updated:
March 25, 2005; data through June 15,
1999; analyses conducted March - November 2000.
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