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HAYDUK2
INTRODUCTION
Over the last decade, quality of life (QOL) has emerged as a focal
concern in the treatment of patients with chronic health conditions.
An improved QOL is often cited as an outcome goal of medical inter-
ventions (Schipper, 1992), but confusion remains over the definition
and measurement of this elusive concept (Campbell, Converse, and
Rodgers, 1976; Coyle, 1992; Carter, 1989; Young and Longman,
1983; Bowling, 1991; Ebersole, 1995; Kinney, 1995; Phillips, 1995).
Many researchers assert that QOL is a multidimensional construct
(Shye, 1989; Palys and Little, 1980; Gillingham, 1982; Cella and
Tulsky, 1990; Roy, 1992; Lim et al., 1993; Fletcher, 1995; Grady et
al., 1995) but the arguments supporting this view usually confound
the dimensionality of a concept with the multiplicity of the causal
sources of that concept, as we explain below.
There is no gold standard for measuring QOL, and there is little
evidence for the construct-related validity of the various measures
that have been proposed. Consequently, the current health care litera-
ture is composed of studies using measures that are inconsistent, and
often of questionable relevance to the QOL construct. This makes
the caliber of the research related to QOL uneven, and it becomes
nearly impossible to consolidate the accumulating studies through
meta-analyses.
This paper attempts to improve our understanding of QOL in two
ways. The early portions of this paper resolve several confusions
in current conceptualizations of QOL. These discussions lead us to
consider QOL as a global personal assessment of a single dimension
which may be causally responsive to a variety of other distinct dimen-
sions. The later segments of this paper attempt to determine whether
the currently available global measures do indeed tap into a common
global dimension. Evidence from structural equation models based
on data from coronary artery bypass graft (CABG) patients provide
some support for this contention, but some cautions are in order.
RESULTS
participants was 61.8 years (sd = 9.7). The majority of the partici-
pants had attained a formal education of at least high school (70.1%)
and 49 patients had received a university degree. Most of the patients
were either employed full-time (35%) or retired (47.1%) at the time
of surgery.
Most participants waited less than a month for CABG surgery with
a modal wait of 7 days and a median wait of 22 days. Eight percent
had required immediate surgery and 21% were elective cases. Most
patients (70.3%) underwent revascularization of 3 or 4 coronary
arteries.
The means (and standard deviations) of the indicators for the
CABG patients are: Life Satisfaction 5.55(1.00), Life 1 5.46(0.91),
Life 2 5.36(0.83), Life 3 5.41(0.76), Faces 5.43(0.98), MDT1
5.10(0.83), SASS 6.80(1.67). Thus the distributions for all the QOL
indicators display a clustering of cases slightly nearer the very satis-
fied/delighted end of the QOL scales, with a thinner tail extending
off toward the dissatisfied/terrible values.
TABLE I
Maximum likelihood estimates for the models of quality of life (n = 306)
Models
One Two Three Four Five
Df 6 10 17 16 15
2
9.35 13.29 13.50 13.04 6.66
p 0.155 0.208 0.702 0.670 0.966
Lambda coefficients
MDT1 0.492 0.490 0.490 0.489 0.500
FACES 0.540 0.536 0.536 0.537 0.528
SASS y1.00 y1.00 y1.00 y1.00 y1.00
SWB11 0.583 0.595 0.595 0.595 0.610
LIFE 1 na 0.483 y1.00 y1.00 y1.00
LIFE 2 na 0.582 y1.00 y1.00 y1.00
LIFE 3 0.523 na y0.50 y0.50 y0.50
+y0.50 +y0.50 +y0.50
Error variance
MDT1 0.341 0.348 0.348 0.346 0.346
FACES 0.547 0.559 0.559 0.555 0.586
SASS y1.421 y1.421 y1.421 y1.421 y1.421
SWB11 0.519 0.504 0.504 0.502 0.499
LIFE 1 na 0.494 0.494 0.504 0.496
LIFE 2 na 0.208 0.208 0.214 0.201
LIFE 3 0.189 na y0.00 y0.00 y0.00
y = fixed coefficient
na = not applicable
= p < 0.05.
30 THERESA M. BECKIE AND LESLIE A. HAYDUK
SASS indicator, and a fixed error variance for this indicator has been
specified as suggested by Hayduk (1987, 1996). Our specification
of the error variances as accounting for half the variance in SASS
MEASURING QUALITY OF LIFE 31
connected in this way, though the overall model might not work as
well when the model segment for Life 3 is included. If the Life 1 and
2 indicators were at odds with the other indicators, any such conflict
would be enhanced by adding in Life 3, and hence the overall model
fit could potentially decline with inclusion of the model segment
containing Life 1, 2, and 3.
In fact, the model 2 (13.50) stays about the same, indicating no
such conflict, and the 2 probability (0.702) actually increases due
to the additional degrees of freedom created by inclusion of the Life
3 indicator. With this model as a baseline, we can now proceed with
the test for the potential memory effect from Life 1 to Life 2, as
indicated in Figure 4.
When an effect from Life 1 to Life 2 is introduced into this
model, the estimated effect is small (0.036, 0.039 standardized) and
insignificant. While a significant effect here would have substantially
challenged the QOL model by challenging one of the strongest indi-
cators, the insignificance of this effect stands as an equally substantial
confirmation of the basic model. That is, we now have some direct
evidence that even repeating a globally worded question about one’s
QOL does not lead the respondents to merely repeat a previous
response. The respondents developed their response for even an
identically worded question by drawing upon the same common
source that underlies all of the QOL indicators. That is, it appears
the CABG patients actually performed a reassessment of their
QOL. Furthermore, this reassessment appears to provide a slightly
better measure of QOL because there is a slightly stronger loading
on QOL and because there is slightly less error in the repeat measure.
That is, fewer or weaker extraneous sources contribute to the repeat
measure.
The final model (Figure 5) introduces one additional coefficient
into the previous model. The modification indices for the previous
models had suggested that there might be some covariance between
the errors on the Faces and SASS indicators. When a covariance
between these errors was permitted, this did indeed result in a signifi-
cant improvement in the model (a difference 2 of 6.38 with 1 df, p
< 0.05) and a correspondingly significant error covariance. The esti-
mated covariance (0.149) corresponds to a rather weak correlation of
0.16. This correlation asserts that there is some source of consistency
MEASURING QUALITY OF LIFE 35
between the Faces and SASS indicators over and above the consis-
tency provided by QOL. This observation must be treated with some
caution, however, because by freeing the coefficient with the largest
modification index we are implicitly selecting the most significant of
the possible error covariances. Hence, this estimate has an unusually
high likelihood of capitalizing on chance. Consequently, though we
report this correlation, we treat this as a suspicion, but not as strong
evidence, that some common source other than QOL is required to
connect the Faces and SASS indicators.
The most problematic aspect of the estimates from this model was
the relatively large proportion of error variance in all the indicators.
About half the variance in the available indictors arose from sources
unique to each indicator, and not from QOL.
The indicator with the smallest proportion of error variance, Life
3, was the average of two identical questions. We developed a series
of models to investigate these items, and we found that the superior
performance of the repeated measure definitely could not be attri-
buted to a memory effect, or a direct carryover from the identical
prior question. The good fit of this model, combined with a small
and insignificant memory effect, provides strong and independent
support for the contention that the patients were drawing upon the
same source that led to all their global QOL assessments when they
responded to the replicate measure.
At the moment we can not make a recommendation as to which
global measure is best. The repeated Life 2 indicator was clearly
the best in terms of explained variance, even though the identically
worded Life 1 indicator was the worst in terms of explained variance.
The repeated assessments of QOL during the interview may have
sharpened the patient’s focus, but lacking specific evidence for this,
inclines us to reserve judgment until we have pursued the second way
of evaluating these measures, namely through structural equation
modeling of the sources of QOL assessments.
ACKNOWLEDGEMENTS
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MEASURING QUALITY OF LIFE 39