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1.  Health related quality of life assessment in acute coronary syndrome patients: the effectiveness of early phase I cardiac rehabilitation 
Background
Acute Coronary Syndrome (ACS) is one of the most burdensome cardiovascular diseases in terms of the cost of interventions. The Cardiac Rehabilitation Programme (CRP) is well-established in improving clinical outcomes but the assessment of actual clinical improvement is challenging, especially when considering pharmaceutical care (PC) values in phase I CRP during admission and upon discharge from hospital and phase II outpatient interventions. This study explores the impact of pharmacists’ interventions in the early stages of CRP on humanistic outcomes and follow-up at a referral hospital in Malaysia.
Methods
We recruited 112 patients who were newly diagnosed with ACS and treated at the referral hospital, Sarawak General Hospital, Malaysia. In the intervention group (modified CRP), all medication was reviewed by the clinical pharmacists, focusing on drug indication; understanding of secondary prevention therapy and adherence to treatment strategy. We compared the “pre-post” quality of life (QoL) of three groups (intervention, conventional and control) at baseline, 6 months and 12 months post-discharge with Malaysian norms. QoL data was obtained using a validated version of Short-Form 36 Questionnaire (SF-36). Analysis of variance (ANOVA) with repeated measure tests was used to compare the mean differences of scores over time.
Results
A pre-post quasi-experimental non-equivalent group comparison design was applied to 112 patients who were followed up for one year. At baseline, the physical and mental health summaries reported poor outcomes in all three groups. However, these improved gradually but significantly over time. After the 6-month follow-up, the physical component summary reported in the modified CRP (MCRP) participants was higher, with a mean difference of 8.02 (p = 0.015) but worse in the mental component summary, with a mean difference of −4.13. At the 12-month follow-up, the MCRP participants performed better in their physical component (PCS) than those in the CCRP and control groups, with a mean difference of 11.46 (p = 0.008), 10.96 (p = 0.002) and 6.41 (p = 0.006) respectively. Comparing the changes over time for minimal important differences (MICD), the MCRP group showed better social functioning than the CCRP and control groups with mean differences of 20.53 (p = 0.03), 14.47 and 8.8, respectively. In role emotional subscales all three groups showed significant improvement in MCID with mean differences of 30.96 (p = 0.048), 31.58 (p = 0.022) and 37.04 (p < 0.001) respectively.
Conclusion
Our results showed that pharmaceutical care intervention significantly improved HRQoL. The study also highlights the importance of early rehabilitation in the hospital setting. The MCRP group consistently showed better QoL, was more highly motivated and benefitted most from the CRP.
Trial registration
Medical Research and Ethics Committee (MREC) Ministry of Health Malaysia, November 2007, NMRR-08-246-1401.
doi:10.1186/s12955-016-0583-7
PMCID: PMC5237194  PMID: 28086784
Clinical pharmacy; Cardiac rehabilitation programme; Quality of life; SF-36; Acute coronary syndrome
2.  Assessment of coping: a new french four-factor structure of the brief COPE inventory 
Background
The Brief Coping Orientation to Problems Experienced (Brief COPE) inventory is the most usual measure to identify the nature of coping strategies implemented by individuals and explore 14 coping strategies. The availability of a structure with fewer factors rather than the initial 14-factor structure may be of interest for both healthcare professionals and researchers. We report the validation process of a 4-factor structure of the French version of the Brief COPE in a French sample of individuals facing a singular life event, such as cancer, including patients and their caregivers.
Methods
The cross-sectional study included cancer patients and their caregivers. Self-administered data were collected including: socio-demographic (age, gender, marital status, employment status, and education level), coping strategies using the French version of the Brief COPE, quality of life (QoL) using the French version of the short form health survey questionnaire (SF36). Construct validity, internal consistency, reliability, and external validity were tested.
Results
The sample included 398 individuals. The principal component factor analysis identified a 4-factor structure. The dimensions were labeled according to their constitutive items: social support (8 items), problem solving (4), avoidance (10), and positive thinking (6). The 4-factor structure was supported by different theoretical models of coping and showed satisfactory psychometric properties.
Conclusion
The 4-factor structure of the French version of the Brief COPE, validated in a sample of individuals facing a singular stressful event, including cancer patients and their caregivers, makes the instrument easier to use both in clinical practice and clinical research.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0581-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0581-9
PMCID: PMC5225566  PMID: 28077139
3.  Incremental decreases in quality-adjusted life years (QALY) associated with higher levels of depressive symptoms for U.S. Adults aged 65 years and older 
Background
Quality-adjusted life years (QALY) is a single value index that quantifies the overall burden of disease. It reflects all aspects of heath, including nonfatal illness and mortality outcomes by weighting life-years lived with health-related quality of life (HRQOL) scores. This study examine the burden of disease due to increasing levels of depressive symptoms by examining the association between the 9-item Patient Health Questionnaire (PHQ-9) scores and QALY for U.S. adults aged 65 years and older.
Methods
We ascertained respondents’ HRQOL scores and mortality status from the 2005–2006, 2007–2008, and 2009–2010 cohorts of the National Health and Nutrition Examination Survey (NHANES) with mortality follow-up data through December 31, 2011. This analysis included respondents aged 65 years and older (n = 3,680). We estimated the mean QALY throughout the remaining lifetime according to participants’ depression severity categories: none or minimal (PHQ-9 score 0–4), mild (5–9), moderate (10–14), and moderately severs and severe (15 or higher). We estimated QALY loss due to major depressive disorder (PHQ-9 score 10 or higher) and to mild depression (5–9).
Results
The QALY for persons with none/minimal, mild, moderate, and moderately severe/severe depression were 14.0, 7.8, 4.7, and 3.3 years, respectively. Compared to persons without major depressive disorder, persons with major depressive disorder had 8.3 fewer QALY (12.7 vs. 4.4), or a 65% loss. Compared to persons who reported “none” or minimal depressive symptoms, persons who reported mild depressive symptoms had 6.2 fewer QALY (14.0 vs. 7.8), or a 44% loss. The same patterns were noted in demographic and socioeconomic subgroups and according to number of comorbidities.
Conclusions
This study not only confirmed the significant burden of disease for major depressive disorder among the U.S. elderly, but also showed an incremental decrease in QALY with an increasing severity of depressive symptoms as well as significant QALY loss due to mild depression. Specifically, individuals with higher (or more impaired) PHQ-9 scores had significantly fewer QALYs and our findings of fewer years of QALY for persons with major depressive disorder and mild depression were not only statistically significant but also clinically important.
doi:10.1186/s12955-016-0582-8
PMCID: PMC5225616  PMID: 28077154
Quality-adjusted life year (QALY); Health-related quality of life (HRQOL); Burden of disease; Depression; Major depressive disorder (MDD)
4.  Multimorbidity and health-related quality of life (HRQoL) in a nationally representative population sample: implications of count versus cluster method for defining multimorbidity on HRQoL 
Background
No universally accepted definition of multimorbidity (MM) exists, and implications of different definitions have not been explored. This study examined the performance of the count and cluster definitions of multimorbidity on the sociodemographic profile and health-related quality of life (HRQoL) in a general population.
Methods
Data were derived from the nationally representative 2007 Australian National Survey of Mental Health and Wellbeing (n = 8841). The HRQoL scores were measured using the Assessment of Quality of Life (AQoL-4D) instrument. The simple count (2+ & 3+ conditions) and hierarchical cluster methods were used to define/identify clusters of multimorbidity. Linear regression was used to assess the associations between HRQoL and multimorbidity as defined by the different methods.
Results
The assessment of multimorbidity, which was defined using the count method, resulting in the prevalence of 26% (MM2+) and 10.1% (MM3+). Statistically significant clusters identified through hierarchical cluster analysis included heart or circulatory conditions (CVD)/arthritis (cluster-1, 9%) and major depressive disorder (MDD)/anxiety (cluster-2, 4%). A sensitivity analysis suggested that the stability of the clusters resulted from hierarchical clustering. The sociodemographic profiles were similar between MM2+, MM3+ and cluster-1, but were different from cluster-2. HRQoL was negatively associated with MM2+ (β: −0.18, SE: −0.01, p < 0.001), MM3+ (β: −0.23, SE: −0.02, p < 0.001), cluster-1 (β: −0.10, SE: 0.01, p < 0.001) and cluster-2 (β: −0.36, SE: 0.01, p < 0.001).
Conclusions
Our findings confirm the existence of an inverse relationship between multimorbidity and HRQoL in the Australian population and indicate that the hierarchical clustering approach is validated when the outcome of interest is HRQoL from this head-to-head comparison. Moreover, a simple count fails to identify if there are specific conditions of interest that are driving poorer HRQoL. Researchers should exercise caution when selecting a definition of multimorbidity because it may significantly influence the study outcomes.
doi:10.1186/s12955-016-0580-x
PMCID: PMC5223532  PMID: 28069026
Multimorbidity; Definition; AQoL-4D; Hierarchical cluster; Health-related Quality of Life (HRQoL)
5.  Decreased physical activity is a predictor for a complicated recovery post cardiac surgery 
Background
Physical activity (PA) reduces the risk of cardiovascular disease and physically active survivors of a cardiac event are at lower risk of recurrent events. We hypothesized that patients with a decreased PA, undergoing cardiac surgery, are at higher risk for a postoperative complicated recovery (PCR).
Methods
Three thousand three hundred eighty two patients undergoing elective cardiac surgery between January 2007 and December 2013 were included. The group was divided into three subgroups: group A, aged ≤ 65 years (N = 1329); group B, aged > 65 years and ≤ 75 years (N = 1250); and group C aged >75 years (N = 803). To assess PA, the criteria of the Corpus Christy Heart Project were used. A PCR consists of the occurrence of a major postoperative event, defined as any of the following complications: reoperation, deep sternal wound infection, renal failure, stroke, postoperative ventilation > 2 days, intensive care stay ≥ 5 days, hospital stay ≥ 10 days, or hospital mortality.
Results
One thousand three hundred sixty seven patients (40%) were considered as patients with a decreased PA. Both in group B (p = 0.001) and in group C (p = 0.003), patients with a decreased PA were significantly associated with an increased risk of a PCR, which was not the case in group A (p = 0.28). Logistic regression analysis identified a decreased PA as an independent predictor for PCR in groups B (p = 0.003, odds 1.71) and C (p = 0.033, odds 1.48), but not in group A (p = 0.11, odds 0.71).
Conclusion
Decreased physical activity is an independent predictor for a PCR in patients aged 65 years or older undergoing elective cardiac surgery.
doi:10.1186/s12955-016-0576-6
PMCID: PMC5220604  PMID: 28069013
Cardiac surgery; Physical activity; Morbidity; Postoperative
6.  Health-related quality of life and unmet healthcare needs in Huntington’s disease 
Background
Huntington’s disease (HD) is a rare neurodegenerative disorder with a prevalence of 6 per 100.000. Despite increasing research activity on HD, evidence on healthcare utilization, patients’ needs for healthcare services and Health-Related Quality of Life (HRQoL) is still sparse. The present study describes HRQoL in a Norwegian cohort of HD patients, and assesses associations between unmet healthcare and social support service needs and HRQoL.
Methods
In this cross-sectional population-based study, 84 patients with a clinical diagnosis of HD living in the South-East of Norway completed the HRQoL questionnaire EuroQol, EQ-5D-3L. Unmet needs for healthcare and social support services were assessed by the Needs and Provision Complexity Scale (NPCS). Furthermore, functional ability was determined using the Unified Huntington’s Disease Rating Scale (UHDRS) Functional assessment scales. Socio-demographics (age, gender, marital status, occupation, residence, housing situation) and clinical characteristics (disease duration, total functional capacity, comorbidity) were also recorded. Descriptive statistics were used to describe the patients’ HRQoL. Regression analyses were conducted in order to investigate the relationship between unmet healthcare needs and self-reported HRQoL.
Results
The patients were divided across five disease stages as follows: Stage I: n = 12 (14%), Stage II: n = 22 (27%), Stage III: n = 19 (23%), Stage IV: n = 14 (16%), and Stage V: n = 17 (20%). Overall HRQoL was lowest in patients with advanced disease (Stages IV and V), while patients in the middle phase (Stage III) showed the most varied health profile for the five EQ-5D-3L dimensions. The regression model including level of unmet needs, clinical characteristics and demographics (age and education) accounted for 42% of variance in HRQoL. A higher level of unmet needs was associated with lower HRQoL (β value - 0.228; p = 0.018) whereas a better total functional capacity corresponded to higher HRQoL (β value 0.564; p < 0.001).
Conclusions
The study findings suggest that patients with HD do not receive healthcare services that could have a positive impact on their HRQoL.
doi:10.1186/s12955-016-0575-7
PMCID: PMC5220609  PMID: 28069034
Huntington’s disease; Health-related Quality of Life; Healthcare needs; Healthcare services; EQ-5D; NPCS
7.  Reliability of health-related quality-of-life assessments made by older adults and significant others for health states of increasing cognitive impairment 
Background
Older adults are encouraged by many organizations to engage in advance care planning in the event of decisional incapacity. Planning for future health care often involves anticipating health-related quality of life (HRQoL) in states of reduced cognitive functioning. No study has yet examined whether anticipated HRQoL is stable over time. The accuracy with which significant others can predict how an older adult envisions HRQoL in a future state of cognitive impairment is also unknown. We investigated the extent to which health-related quality-of-life ratings made by older adults and designated proxies for health states of increasing cognitive impairment are consistent over time and agree with each other.
Methods
Results are based on HRQoL ratings made on a 5-point Likert scale by 235 community-based elder-proxy dyads on three occasions. Ratings were obtained for the older adult’s current health state as well as under the assumption that he/she had a mild to moderate stroke, incurable brain cancer or severe dementia. Data were analyzed using both traditional approaches (e.g., intraclass correlation coefficients, Bland-Altman plots) and the theory of generalizability.
Results
We found ratings to be reasonably consistent over time and in good agreement within dyads, even more so as implied cognitive functioning worsened. Across health states, ratings over time or within elder-proxy dyads were no more than one category apart in over 87% of cases. Using the theory of generalizability, we further found that, of the two facets investigated, rater had a greater influence on score variability than occasion.
Conclusions
These findings underscore the importance of discussing health-related quality-of-life issues during advance care planning and involving designated proxies in the discussion to enhance their understanding of the role that HRQoL should play in actual decision-making situations. Medical decision-making may be influenced by healthcare providers’ and family members’ assessments of an incapacitated patient’s health-related quality of life, in addition to that of the designated proxy. Future studies should investigate whether these two groups of individuals share the views of the patient and the designated proxy on anticipated HRQoL.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0579-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0579-3
PMCID: PMC5220615  PMID: 28069027
Health-related quality of life; Elderly; Proxy; Consistency; Agreement; Cognitive impairment; Generalizability theory
8.  Quality of life in community-dwelling Dutch elderly measured by EQ-5D-3L 
Background
We aimed to evaluate health status and associated factors in community-dwelling elderly in the Netherlands.
Methods
Participants from a placebo-controlled double-blind randomized controlled trial conducted in the Netherlands were invited at the time of enrolment to participate in this study. Data were collected on comorbidities, socio-demographic background and health status, using EQ-5D-3L instrument. EQ-5D-3L summary index values (EQ-5D-indices) was derived using Dutch tariff. Regression analysis was conducted to identify factors associated with EQ-5D-indices and visual analogue scale (EQ-VAS).
Results
48,634 elderly (≥65 years) were included. The most frequently reported complaint was pain/discomfort (29.4%), but for the elder elderly (i.e. ≥85 years) it was mobility (52.9%). The proportion of persons reporting (multiple) problems increased with age from 31.5% for 65–69 years old subjects to 65.9% for elder elderly. The mean EQ-5D-indices and EQ-VAS decreased with age from 0.94 and 84, respectively in those 65 to 69 years old to 0.86 and 76, respectively, in ≥85 years old subjects. Increasing age, female gender, low education, geographic factors and comorbidities were associated with impaired health status.
Conclusions
Within community-dwelling elderly large differences in health status exist. Impairment increases rapidly with age, but health status is also associated with socio-demographic variables and comorbidities.
Trial registration
ClinicalTrials.gov, NCT00812084.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0577-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0577-5
PMCID: PMC5220621  PMID: 28069062
Health-related quality-of-life; Health status; EQ-5D-3L; Elderly; Community-dwelling; The Netherlands
9.  The chinese version of achilles tendon total rupture score: cross-cultural adaptation, reliability and validity 
Background
The Achilles tendon Total Rupture Score (ATRS), which is originally developed in 2007 in Swedish, is the only patient-reported outcome measure (PROM) for specific outcome assessment of an Achilles tendon rupture.Purpose of this study is to translate and cross-culturally adapt Achilles tendon Total Rupture Score (ATRS) into simplified Chinese, and primarily evaluate the responsiveness, reliability and validity.
Methods
International recognized guideline which was designed by Beaton was followed to make the translation of ATRS from English into simplified Chinese version (CH-ATRS). A prospective cohort study was carried out for the cross-cultural adaptation. There were 112 participants included into the study. Psychometric properties including floor and ceiling effects, Cronbach’s alpha, intraclass correlation coefficient, effect size, standard response mean, and construct validity were tested.
Results
The mean scores of CH-ATRS are 57.42 ± 13.70. No sign of floor or ceiling effect was found of CH-ATRS. High level of internal consistency was supported by the value of Cronbach’s alpha (0.893). ICC (0.979, 95%CI: 0.984-0.993) was high to indicate the high test-retest reliability. Great responsive ness was proved with the high absolute value of ES and SRM (0.84 and 8.98, respectively). The total CH-ATRS score had very good correlation with physical function and body pain subscales of SF-36 (r = −0.758 and r = −0.694, respectively, p < 0.001), while poor correlation with vitality and role physical subscales of SF-36 (r = −0.033 and r = −0.025, respectively, p ≥ 0.05), which supported construct validity of CH-ATRS.
Conclusion
This Chinese version of Achilles tendon Total Rupture Score (CH-ATRS) can be used as a reliable and valid instrument for Achilles tendon rupture assessing in Chinese-speaking population.
Level of evidence II
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0574-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0574-8
PMCID: PMC5220618  PMID: 28069003
Achilles tendon rupture; ATRS; Cross-cultural; Chinese; Reliability; Validity
10.  Impact of smoking on health-related quality of Life after percutaneous coronary intervention treated with drug-eluting stents: a longitudinal observational study 
Background
Smoking has been shown to reduce health-related quality of life (HRQOL) in patients with coronary artery disease (CAD) undergoing percutanous coronary intervention (PCI) either by means of balloon angioplasty or with the use of bare-metal stents (BMS). Drug-eluting stents (DES) have now been widely used and are related to substantial reduction of restenosis and significantly improved HRQOL compared with BMS. This study aimed to evaluate the effects of smoking on HRQOL in patients after PCI in DES era.
Methods
A cohort of 649 patients admitted for CAD and treated with drug-eluting stents were included in this prospective, observational study. Patients were classified as non-smokers (n = 351, 54.1%), quitters (n = 126, 19,4%), or persistent smokers (n = 172, 26.5%) according to their smoking status at the time they first admitted to hospital and during the first year of follow-up. Each patient was prospectively interviewed at baseline, 6 months and 1 year following PCI. HRQOL was assessed with the use of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Results
For the overall population, HRQOL scores at 1-year follow-up were significantly higher than baseline for all 8 domains. At 1-year follow-up, the HRQOL scores in persistent smokers were still lower than that in non-smokers in 6 domains except for bodily pain and mental health, and than that in quitters in 5 domains except for bodily pain, role emotional and mental health. There were no significant differences with regard to the scores between non-smokers and quitters except role emotional for which non-smokers had higher scores. After adjustment, persistent smokers demonstrated significantly less improvements in HRQOL than non-smokers in 6 domains except for bodily pain and social functioning and significantly less improvement than quitters for general health. Improvements of quitters were comparable to that of non-smokers in all domains. Multivariate linear regression analyses showed persistent smoking was an independent risk factor for PCS and MCS improvements.
Conclusions
Persistent smoking substantially diminishes the potential quality-of-life benefits of DES. Efforts should be made to promote smoking cessation after DES implantation which could greatly improve the health quality outcomes.
doi:10.1186/s12955-016-0578-4
PMCID: PMC5220611  PMID: 28069015
Smoking; Quality of life; Drug-eluting stent; Percutaneous coronary intervention
11.  From early detection to rehabilitation in the community: reading beyond the blog testimonies of survivors’ quality of life and prostate cancer representation 
Background
Survivors’ testimonies can reveal much about men’s experiences of prostate cancer and impacts on their quality of life (QOL) during the clinical trajectory of the disease. These survivors’ shared thoughts and views were hypothesized to reflect salient features of their lived social representation of prostate cancer.
Context
We explored the content of testimonies posted by men to a public blog hosted by a French national prostate cancer patients’ association. The study question, “What do French bloggers’ testimonies reveal about their lived experiences with prostate cancer, especially regarding their quality of life in community settings, that underpin their social representation of prostate cancer?” guided the exploration and analysis of the textual data. The aims were to better understand men’s experiences and predominant thoughts and views, to elucidate patients’ behaviours, and to enlighten medical policy and practice.
Purpose
Explore issues of QOL as reported by French prostate cancer survivors in a public blog by: (a) identifying the salient aspects and issues of the experience of living with prostate cancer from the perspective of survivors; and (b) analyzing the content in the posted testimonies regarding perceived and lived impacts of prostate cancer on QOL.
Methods
A critical ethnographic study guided the selection of textual data from 196 male bloggers’ testimonies about prostate cancer posted in the period from 2008 to 2013. Media content analysis method was undertaken on blog testimonies, framed by a multidimensional conceptual framework of QOL.
Results
Testimonies focused mainly on medical care and rehabilitation, recovery, health education and self-care, as well as on a global vision of prostate cancer and its impacts on personal views of manhood and masculinity. The language used indicated that political, educative and compassionate discourses were intertwined to create a complex representation of the experience and effects of prostate cancer; this multi-faceted representation can inform the public and professional debate about men’s capacity to provide emotional support and problem-solve within a community of interest.
Conclusion
Findings, while based on data limited to mostly one-time entries to a French blog, contribute to understanding a unique, collective expression of men’s lived experiences of prostate cancer. These anonymous survivors shared their varied reactions, ways of coping, and thoughts on needed change.
doi:10.1186/s12955-016-0568-6
PMCID: PMC5162078  PMID: 27986091
12.  Psychometric properties of the Satisfaction with Life Scale (SWLS): secondary analysis of the Mexican Health and Aging Study 
Background
The Satisfaction with Life Scale (SWLS) has been widely used and has proven to be a valid and reliable instrument for assessing satisfaction with life in diverse population groups, however, research on satisfaction with life and validation of different measuring instruments in Mexican adults is still lacking. The objective was to evaluate the psychometric properties of the Satisfaction with Life Scale (SWLS) in a representative sample of Mexican adults.
Methods
This is a methodological study to evaluate a satisfaction with life scale in a sample of 13,220 Mexican adults 50 years of age or older from the 2012 Mexican Health and Aging Study. The scale’s reliability (internal consistency) was analysed using Cronbach’s alpha and inter-item correlations. An exploratory factor analysis was also performed. Known-groups validity was evaluated comparing good-health and bad-health participants. Comorbidity, perceived financial situation, self-reported general health, depression symptoms, and social support were included to evaluate the validity between these measures and the total score of the scale using Spearman’s correlations.
Results
The analysis of the scale’s reliability showed good internal consistency (α = 0.74). The exploratory factor analysis confirmed the existence of a unique factor structure that explained 54% of the variance. SWLS was related to depression, perceived health, financial situation, and social support, and these relations were all statistically significant (P < .01). There was significant difference in life satisfaction between the good- and bad-health groups.
Conclusions
Results show good internal consistency and construct validity of the SWLS. These results are comparable with results from previous studies. Meeting the study’s objective to validate the scale, the results show that the Spanish version of the SWLS is a reliable and valid measure of satisfaction with life in the Mexican context.
doi:10.1186/s12955-016-0573-9
PMCID: PMC5148901  PMID: 27938407
Psychometric properties; Satisfaction with life; Adults; Mexico
13.  Diet and physical activity in people with intermediate cardiovascular risk and their relationship with the health-related quality of life: results from the MARK study 
Background
To analyze the interplay between diet, physical activity and health-related quality of life in a Spanish randomly selected sample of individuals attended in general practitioners offices with intermediate cardiovascular risk.
Methods
This study analyzed 314 subjects, aged 35–74 years (50.6% women), from the MARK study, conducted in Spain. Health related quality of life was measured by the SF-12 questionnaire. The assessment of the lifestyles included the diet quality index, the adherence to the Mediterranean diet and the leisure time physical activity practice.
Results
The highest values of health related quality of life were obtained in the area of vitality (51.05 ± 11.13), while the lowest were found in the general health (39.89 ± 8.85). In the multiple linear regression analysis, after adjustment for age, gender and other confounders, for each point of increase in the Mediterranean diet adherence score, there was an increase of 1.177 points in the mental component value (p < 0.01). Similarly, for each point of increase in the Diet Quality Index Score, there was an increase in the mental component of 0.553 (p < 0.05). Likewise, the physical activity was positively associated with the physical function and vitality (β = 0.090 and 0.087, (p < 0.01 and p < 0.05), respectively).
Conclusions
In people with intermediate cardiovascular risk, better food habits and greater adherence to the Mediterranean diet are associated with higher scores on the mental component of quality of life. Likewise, increased physical activity is related with positive scores on the physical function.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0572-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0572-x
PMCID: PMC5142320  PMID: 27927210
Health-related quality of life; Life style; Food habits; Exercise
14.  Cross-cultural adaptation and validation of the French version of the Expanded Prostate cancer Index Composite questionnaire for health-related quality of life in prostate cancer patients 
Background
Health-related quality of life (HRQoL) has been positioned as one of the major endpoints in oncology. Thus, there is a need to validate cancer-site specific survey instruments. This study aimed to perform a transcultural adaptation of the 50-item Expanded Prostate cancer Index Composite (EPIC) questionnaire for HRQoL in prostate cancer patients and to validate the psychometric properties of the French-language version.
Methods
The EPIC questionnaire measures urinary, bowel, sexual and hormonal domains. The first step, corresponding to transcultural adaptation of the original English version of the EPIC was performed according to the back translation technique. The second step, comprising the validation of the psychometric properties of the EPIC questionnaire, was performed in patients under treatment for localized prostate cancer (treatment group) and in patients cured of prostate cancer (cured group). The EORTC QLQ-C30 and QLQ-PR25 prostate cancer module were also completed by patients to assess criterion validity. Two assessments were performed, i.e., before and at the end of treatment for the Treatment group, to assess sensitivity to change; and at 2 weeks’ interval in the Cured group to assess test-retest reliability. Psychometric properties were explored according to classical test theory.
Results
The first step showed overall good acceptability and understanding of the questionnaire. In the second step, 215 patients were included from January 2012 to June 2014: 125 in the Treatment group, and 90 in the Cured group. All domains exhibited good internal consistency, except the bowel domain (Cronbach’s α = 0.61). No floor effect was observed. Test-retest reliability assessed in the cured group was acceptable, expect for bowel function (intraclass coefficient = 0.68). Criterion validity was good for each domain and subscale. Construct validity was not demonstrated for the hormonal and bowel domains. Sensitivity to change was exhibited for 5/8 subscales and 2/4 summary scores for patients who experienced toxicities during treatment.
Conclusions
The French EPIC questionnaire seems to have adequate psychometric properties, comparable to those exhibited by the original English-language version, except for the construct validity, which was not available in original version.
doi:10.1186/s12955-016-0571-y
PMCID: PMC5139103  PMID: 27923377
Health-related quality of life; Cross-cultural adaptation; Validation; Psychometric properties; EPIC questionnaire; Prostate cancer; Classical test theory
15.  Socioeconomic inequalities in health-related quality of life between men and women, 5 years after a coronary angiography 
Background
The aim of this study is to measure gender differences in health-related quality of life (HRQOL) among men and women patients with cardiovascular diseases (CVD), and to assess the impact of socioeconomic factors on HRQOL between men and women, 5 years after a coronary angiography.
Methods
The study included 1,289 out of 4,391 patients who had undergone an angiography in the National Institute for Cardiac Surgery and Interventional Cardiology, Luxembourg in 2008/2009. Four indicators of the WHOQOL-BREF questionnaire (Self-rated health, Quality of life, Physical health, and Psychological health) were used in this study as interest variables. To assess the socioeconomic inequalities in HRQOL between men and women, general linear models were constructed for every indicator, with educational level and living conditions as predictors, and demographic variables, cardiovascular risk factors, and cardiovascular events as covariates.
Results
Women were older than men (71.5 versus 68.1, p <0.0001) and less likely to be married. HRQOL was significantly different between men and women despite the fact they had the same socioeconomic status. The average score for overall health was 3.7/5 for men versus 3.5/5 for women; similarly, the life quality score was 3.8/5 for men versus 3.6/5 for women. Education level and living conditions were associated with lower HRQOL scores in men and women.
Conclusion
The findings showed that women have lower HRQOL than men regarding self-rated health, quality of life, and the WHOQOL-BREF physical and psychological domains 5 years after a coronary angiography. Socioeconomic inequalities affect HRQOL, and their influence was similar in both men and women. Socioeconomic inequalities in HRQOL in women and men with CVD are strong 5 years after a coronary angiography. Taking into account differences in gender and socioeconomic status in intervention strategies to substantially reduce the differences observed between women and men could help improve the effectiveness of secondary prevention.
doi:10.1186/s12955-016-0570-z
PMCID: PMC5135793  PMID: 27912774
Cardiovascular diseases; Health-related quality of life; Gender; WHOQOL-BREF; Socioeconomic status; Luxembourg
16.  Impact of the occurrence of a response shift on the determination of the minimal important difference in a health-related quality of life score over time 
Background
An important challenge of the longitudinal analysis of health-related quality of life (HRQOL) is the potential occurrence of a Response Shift (RS) effect. While the impact of RS effect on the longitudinal analysis of HRQOL has already been studied, few studies have been conducted on its impact on the determination of the Minimal Important Difference (MID). This study aims to investigate the impact of the RS effect on the determination of the MID over time for each scale of both EORTC QLQ-C30 and QLQ-BR23 questionnaires in breast cancer patients.
Methods
Patients with breast cancer completed the EORTC QLQ-C30 and the EORTC QLQ-BR23 questionnaires at baseline (time of diagnosis; T0), three months (T1) and six months after surgery (T2). Four hospitals and care centers participated in this study: cancer centers of Dijon and Nancy, the university hospitals of Reims and Strasbourg At T1 and T2, patients were asked to evaluate their HRQOL change during the last 3 months using the Jaeschke transition question. They were also asked to assess retrospectively their HRQOL level of three months ago.
The occurrence of the RS effect was explored using the then-test method and its impact on the determination of the MID by using the Anchor-based method.
Results
Between February 2006 and February 2008, 381 patients were included of mean age 58 years old (SD = 11). For patients who reported a deterioration of their HRQOL level at each follow-up, an increase of RS effect has been detected between T1 and T2 in 13/15 dimensions of QLQ-C30 questionnaire, and 4/7 dimensions of QLQ-BR23 questionnaire. In contrast, a decrease of the RS effect was observed in 8/15 dimensions of QLQ-C30 questionnaire and in 5/7 dimensions of QLQ-BR23 questionnaire in case of improvement. At T2, the MID became ≥ 5 points when taking into account the RS effect in 10/15 dimensions of QLQ-C30 questionnaire and in 5/7 dimensions of QLQ-BR23 questionnaire.
Conclusions
This study highlights that the RS effect increases over time in case of deterioration and decreases in case of improvement. Moreover, taking the RS into account produces a reliable and significant MID.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0569-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0569-5
PMCID: PMC5135836  PMID: 27914467
Health-related quality of life; Response shift; Minimal important difference; Then-test; Anchor-based method
17.  Relationship between weight status and health-related quality of life in Chinese primary school children in Guangzhou: a cross-sectional study 
Background
To investigate the association between weight status and health-related quality of life (HRQOL) among pupils in Guangzhou, China.
Methods
The study comprised 5781 children aged 8–12 years from 29 schools. Height and weight were objectively measured using standardized methods, and BMI z-score derived using the age and sex specific WHO reference 2007 for 5–19 years. Weight status was classified as underweight (<−2SD), healthy weight (between -2SD and 1SD), overweight/obesity (>1SD). HRQOL was measured by the self-report version of the Pediatric Quality of Life Inventory 4.0.
Results
After controlling for gender, age, school type, parental education, and family income, HRQOL scores were significantly lower in overweight/obese compared with healthy weight children only in the social functioning domain (β = −1.93, p = 0.001). Compared with healthy weight children, underweight children had significantly lower total (β = −1.47, p = 0.05) and physical summary scores (β = −2.18, p = 0.02). Subgroup analysis for gender indicated that compared to healthy weight, total (β = −1.96, p = 0.02), psychosocial (β = −2.40, p = 0.01), social functioning (β = −3.36, p = 0.001), and school functioning (β = −2.19, p = 0.03) scores were lower in overweight/obese girls, but not boys. On the other hand, being underweight was associated with lower physical functioning (β = −2.27, p = 0.047) in girls, and lower social functioning (β = −3.63, p = 0.01) in boys. The associations were mainly observed in children aged 10 and over, but were not significant in younger children. Children from private schools had generally lower HRQOL compared to those in public schools, but the associations with weight status were similar in both groups.
Conclusions
The relationship between overweight/obesity and HRQOL in children in China is not as prominent as that seen in children in western or high-income countries. However, there appears to be gender and age differences, with more of an impact of overweight on HRQOL in girls and older children compared with boys and younger children. Underweight is also associated with lower HRQOL. Future intervention to prevent both obesity and undernutrition may have a positive impact on the HRQOL in children in China.
doi:10.1186/s12955-016-0567-7
PMCID: PMC5135837  PMID: 27912761
Weight status; Children; Health-related quality of life
18.  The impact of shift and night work on health related quality of life of working women: findings from the Korea Health Panel 
Background
Night and shift work status has been associated with health related quality of life (HRQoL) in economically active women. This study aimed to investigate the association between night or shift work status and HRQoL of economically active women and to further analyze how marital status interplays in the objected relationship.
Methods
Data were from the Korea Health Panel, 2011 to 2013. A total of 2238 working women were included for analysis. Work status was categorized into day work, night work, and rotating shift work and its association with HRQoL, measured using the EuroQol-5D (EQ-5D) index, was investigated using the generalized estimating equation (GEE) model.
Results
Compared to the day work reference group, the night work group (β: −0.9757, P = 0.0202) and the rotating shift work group (β: −0.7947, P = 0.0363) showed decreases in EQ-5D scores. This trend was maintained regardless of marital status, although decreases in health related quality of life were particularly pronounced among night shift workers with a spouse.
Conclusion
Night and rotating shift work status was associated with HRQoL of economically active women as individuals working night and rotating shifts showed decreases in EQ-5D scores compared to individuals working day shifts. The findings of this study signify the importance of monitoring the HRQoL status of women working night and rotating shifts as these individuals may be comparatively vulnerable to reduced HRQoL.
doi:10.1186/s12955-016-0564-x
PMCID: PMC5126815  PMID: 27894317
Quality of life; Night shift; Rotating shift; Economically active women; Marital status
19.  Estimation of utility weights for human papilloma virus-related health states according to disease severity 
Background
A cost-utility study of a human papilloma virus (HPV) vaccine requires that the utility weights for HPV-related health states (i.e., cervical intraepithelial neoplasia (CIN), cervical cancer, and condyloma) be evaluated. The aim of the present study was to determine the utility weights for HPV-related health states.
Methods
Hypothetical standardised health states related to HPV were developed based on patient education material and previous publications. To fully reflect disease progression from diagnosis to prognosis, each health state comprised four parts (diagnosis, symptoms, treatment, and progression and prognosis). Nine-hundred members from the Korean general population evaluated the HPV-related health states using a visual analogue scale (VAS) and a standard gamble (SG) approach, which were administered face-to-face via computer-assisted interview. The mean utility values were calculated for each HPV-related health state.
Results
According to the VAS, the highest utility (0.73) was HPV-positive status, followed by condyloma (0.66), and CIN grade I (0.61). The lowest utility (0.18) was cervical cancer requiring chemotherapy without surgery, followed by cervical cancer requiring chemoradiation therapy (0.42). SG revealed that the highest utility (0.83) was HPV-positive status, followed by condyloma (0.78), and CIN grade I (0.77). The lowest utility (0.43) was cervical cancer requiring chemotherapy without surgery, followed by cervical cancer requiring chemoradiation therapy (0.60).
Conclusions
This study was based on a large sample derived from the general Korean population; therefore, the calculated utility weights might be useful for evaluating the economic benefit of cancer screening and HPV vaccination programs.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0566-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0566-8
PMCID: PMC5126850  PMID: 27894347
Cervical cancer; Human papilloma virus; Visual analogue scale; Standard gamble
20.  “When I saw walking I just kind of took it as wheeling”: interpretations of mobility-related items in generic, preference-based health state instruments in the context of spinal cord injury 
Background
In health economic analyses, health states are typically valued using instruments with few items per dimension. Due to the generic (and often reductionist) nature of such instruments, certain groups of respondents may experience challenges in describing their health state. This study is concerned with generic, preference-based health state instruments that provide information for decisions about the allocation of resources in health care. Unlike physical measurement instruments, preference-based health state instruments provide health state values that are dependent on how respondents interpret the items. This study investigates how individuals with spinal cord injury (SCI) interpret mobility-related items contained within six preference-based health state instruments.
Methods
Secondary analysis of focus group transcripts originally collected in Vancouver, Canada, explored individuals’ perceptions and interpretations of mobility-related items contained within the 15D, Assessment of Quality of Life 8-dimension (AQoL-8D), EQ-5D-5L, Health Utilities Index (HUI), Quality of Well-Being Scale Self-Administered (QWB-SA), and the 36-item Short Form health survey version 2 (SF-36v2). Ritchie and Spencer’s ‘Framework Approach’ was used to perform thematic analysis that focused on participants’ comments concerning the mobility-related items only.
Results
Fifteen individuals participated in three focus groups (five per focus group). Four themes emerged: wording of mobility (e.g., ‘getting around’ vs ‘walking’), reference to aids and appliances, lack of suitable response options, and reframing of items (e.g., replacing ‘walking’ with ‘wheeling’). These themes reflected item features that respondents perceived as relevant in enabling them to describe their mobility, and response strategies that respondents could use when faced with inaccessible items.
Conclusion
Investigating perceptions to mobility-related items within the context of SCI highlights substantial variation in item interpretation across six preference-based health state instruments. Studying respondents’ interpretations of items can help to understand discrepancies in the health state descriptions and values obtained from different instruments. This line of research warrants closer attention in the health economics and quality of life literature.
doi:10.1186/s12955-016-0565-9
PMCID: PMC5127051  PMID: 27894349
Preference-based health state instruments; Validity; HRQoL; Mobility; Spinal cord injury; Reframing; Item interpretation
21.  Patient-reported outcome measures in patients with peripheral arterial disease: a systematic review of psychometric properties 
Background
Peripheral arterial disease (PAD) is generally associated with considerable morbidity and reduced quality of life. Patient-reported outcome measures (PROMs) provide important information about the burden of disease and impact of treatment in affected patients.
Objectives
The objective of the review was to identify and appraise studies reporting the psychometric evaluation of PROMs administered to a specified population of patients with PAD with a view to recommending suitable PROMs.
Methods
A systematic review of peer-reviewed English language articles was undertaken to identify primary studies reporting psychometric properties of PROMs in English-speaking patients with various stages of PAD. Comprehensive searches were completed up until January 2015. Study selection, data extraction and quality assessment were undertaken independently by at least two researchers. Findings were presented as tabular and narrative summaries based on accepted guidance.
Results
Psychometric evaluation of 6 generic and 7 condition-specific PROMs reported in 14 studies contributed data to the review. The frequently reported measure was the SF-36 (n = 11 studies); others included the Walking Impairment Questionnaire (n = 8 studies), EQ-5D (n = 5 studies) and the Vascular Quality of Life Questionnaire (n = 3 studies). Studies included a diverse PAD population and varied in methodology, including approach to validation of PROMs.
Conclusions
Various PROMs have been validated in patients with PAD but no study provided evidence of a full psychometric evaluation in the patient population. Careful selection is required to identify reliable and valid PROMs to use in clinical and research settings.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0563-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0563-y
PMCID: PMC5121983  PMID: 27881127
Patient-reported outcome measures; Peripheral arterial disease; Psychometric; Validation; Systematic review
22.  Perceptions and experiences of patients living with implantable cardioverter defibrillators: a systematic review and meta-synthesis 
Background
Sudden cardiac deaths have become a growing major public health concern that affects the world. Despite the various etiologies, life-threatening cardiac arrhythmias attribute the main cause of sudden cardiac deaths. Therefore in certain groups of high-risk patients, the Implantable Cardioverter Defibrillator (ICD) has been recommended as either a secondary or primary prophylactic method of prevention.
Objective
To summarise the perceptions of ICD recipients and provide an overview of their experiences with regards to the quality of life, coping strategies, and learning needs.
Methods
A systematic search was conducted using CINAHL, MEDLINE, PsycINFO, Scopus, Cochrane Library, and Web of Science. Primary research articles published from January 2005 to January 2016 that met the inclusion criteria were selected and assessed for methodological quality.
Results
Thirty-nine articles consisting of 16 qualitative studies, 22 quantitative studies, and 1 mixed methods study were included for the meta-synthesis. Findings extracted from these studies were grouped into eight subthemes with ‘living the ICD experience: a constant process of redefining oneself’ emerging as an over-arching theme.
Conclusion
This review provides insight into the perspectives and experiences of ICD recipients. Current evidence highlights the need for healthcare professionals to improve future care standards and develop a patient-centric holistic program that meets the specific needs of ICD recipients. Moreover, future studies are required to address the research gaps identified and also explore the perceptions of patients living with ICD in the Asian context.
doi:10.1186/s12955-016-0561-0
PMCID: PMC5114828  PMID: 27855698
Implantable cardioverter defibrillator; Perceptions; Experiences; Quality of life; Coping strategies; Leaning needs; Systematic review
23.  Sleep quality in Chinese patients with rheumatoid arthritis: contributing factors and effects on health-related quality of life 
Background
Poor sleep quality is common in rheumatoid arthritis (RA) patients and may lead to disease aggravation and decreased health-related quality of life (HRQoL). The increasing prevalence of poor sleep in RA patients is associated with adverse demographic, clinical, and psychological characteristics. However, there are currently no known reported studies related to the effects of sleep quality on HRQoL in RA patients from China. This cross-sectional study aims to evaluate the contributors of poor sleep and the effects of sleep quality on HRQoL in Chinese RA patients.
Methods
A self-report survey was administered to 131 RA patients and 104 healthy individuals using the Pittsburgh Sleep Quality Index (PSQI) for sleep quality. RA patients completed the Hospital Anxiety and Depression Scale for anxiety and depression, the 28-joint Disease Activity Score for disease activity, the 10 cm Visual Analog Scale for pain, the Health Assessment Questionnaire-Disability Index for functional capacity and the Short Form 36 health survey for HRQoL. Blood samples were taken to gain some biochemical indicators (e.g., erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and anti-cyclic citrullinated peptide). Independent samples t-tests, Chi square analysis, logistic regression modeling and linear regression were used to analyze these data.
Results
Our results found that the prevalence of poor sleep (PSQI ≥ 5) was 78.6% and the mean global score of PSQI was 7.93 (SD 3.98) in patients, which were significantly higher than the controls (18.7% and 3.88 (SD 1.89), respectively). There were significant correlations among synthetic disease-modifying antirheumatic drugs, erythrocyte sedimentation rate, pain, disease activity, functional capacity, anxiety/depression and sleep quality in RA patients. Meanwhile, logistic regression models identified disease activity and depression as predictors of poor sleep quality. Poor RA sleepers had impaired HRQoL than good RA sleepers, and sleep quality was independently and significantly associated with social function and mental components summary.
Conclusions
The majority of Chinese RA patients suffered from poor sleep, which significantly impairs their HRQoL. The data suggested the need for holistic assessment and management of RA patients and the importance of objective interventions to improve their sleep quality and finally to improve their HRQoL.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-016-0550-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12955-016-0550-3
PMCID: PMC5111274  PMID: 27852301
Rheumatoid Arthritis; Sleep quality; Quality of life; Depression; Disease activity
24.  Comorbidities and characteristics of coronary heart disease patients: their impact on health-related quality of life 
Background
Patients with coronary heart disease (CHD) commonly present with more than one comorbid condition, contributing to poorer health-related quality of life (HRQoL). The aim of our study was to identify the associations between HRQoL and patient characteristics, vascular comorbidities and anxiety/depression disorders.
Methods
This observational study was conducted in 36 family medicine practices selected by random stratified sampling from all regions of Slovenia. HRQoL was assessed using the European Quality of Life - 5 Dimensions (EQ-5D) questionnaire and EQ Visual Analogue Scale (EQ-VAS). The associations between HRQoL and patient characteristics stratified by demographics, vascular comorbidities, health services used, their assessment of chronic illness care, and anxiety/depression disorders were identified by ordinal logistic regression and linear regression models.
Results
The final sample included 423 CHD patients with a mean age of 68.0 ± SD 10.8 years; 35.2% were female. Mean EQ-VAS score was 58.6 ± SD 19.9 (median: 60 with interquartile range of 45–75), and mean EQ-5D index was 0.60 ± SD 0.19 (median: 0.56 with interquartile range of 0.41–0.76). The statistically significant predictors of a lower EQ-VAS score were higher family physician visit frequency, heart failure (HF) and anxiety/depression disorders (R² 0.240; F = 17.368; p < 0.001). The statistically significant predictor of better HRQoL, according to EQ-5D was higher patient education, whereas higher family physician visit frequency, HF and peripheral artery disease (PAD) were predictors of poorer HRQoL (Nagelkerke R 2 = 0.298; χ 2 = 148.151; p < 0.001).
Conclusions
Results of our study reveal that comorbid conditions (HF and PAD), family physician visit frequency and years in education are significant predictors of HRQoL in Slovenian CHD patients.
doi:10.1186/s12955-016-0560-1
PMCID: PMC5111348  PMID: 27846850
Coronary heart disease patient; Health-related quality of life; Vascular comorbidities; Anxiety/depression disorders
25.  Health-related quality of life in patients with Barrett’s esophagus 
Background
Gastroesophageal reflux disease (GERD) has become a major health problem globally, affecting patients’ health-related quality of life (HRQOL). Barrett’s esophagus (BE) is a precancerous lesion associated with GERD. BE patients might not only suffer from HRQOL losses by GERD but also face psychological distress due to the increased risk of developing cancer. However, the majority of patients in Asia have shorter BE segment which is different from the West. This study aimed to determine whether the HRQOL in BE patients were worse than in healthy referents in Taiwan.
Methods
Patients who received referral esophagogastroduodenoscopy for various symptoms were evaluated for the existence of BE. Lesions were judged as endoscopically suspected esophageal metaplasia (ESEM) if they showed morphological resemblances to BE by endoscopy. The diagnosis of BE was confirmed by histology with intestinal metaplasia or gastric metaplasia based on the Montreal definition. The World Health Organization Quality of Life (WHOQOL-BREF) was administered to BE patients before treatment. For each BE patient, we selected 2 age-, sex-, educational background and municipality-matched healthy referents, sampled by simple randomization method from a national survey in Taiwan. Multiple linear regression models were constructed to control the potential confounders.
Results
A total of 84 patients diagnosed with BE were enrolled as BE group and then compared with 168 healthy referents. The BE group had significantly lower WHOQOL-BREF scores than those of healthy referents in the physical domain (P < 0.05) but higher scores in the environment domain (P < 0.05). In the physical domain, the BE group had significantly lower scores in various facets, including pain, discomfort, sleep and rest and dependence on medications or treatments. There was no significant difference in social and psychological domains between the BE group and healthy referents.
Conclusions
BE patients suffer from poor sleep and rest and high dependence on medications, which significantly reduce their quality of life. Individual facets of each domain warrants a better clinical healthcare to improve quality of life of BE patients.
doi:10.1186/s12955-016-0551-2
PMCID: PMC5109675  PMID: 27842547
Barrett’s esophagus; Quality of life; GERD

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