HRB PhD Scholar Programme in Health Services Research

Transcription

1 RESEARCH THEMES Cardiovascular and related diseases Integration of care older populations, epilepsy, stroke, diabetes Pharmacoepidemiology Health informatics Health economics and health policy Oral health Quality of life and quality of care Gerontology Global health HRB PhD Scholar Programme in Health Services Research Integrated healthcare: from research to policy and practice Modelling the Relationship between Disease and Quality of Life at Older Ages Eithne Sexton Royal College of Surgeons in Ireland Supervisors: Anne Hickey (RCSI), Bellinda King-Kallimanis (TCD), Richard Layte (ESRI), George Savva (UEA)

2 Background Treatment and management of chronic conditions is increasingly a key focus and challenge for health services in Ireland Quality of life is a key outcome for chronic disease care Currently, we lack a detailed understanding of how chronic disease affects quality of life Complex relationship, especially for older people Evidence for maintenance of high levels of well-being with chronic conditions

3 Research Questions 1. How does Disease affect Quality of Life at Older Ages? Which domains of quality of life is it associated with? What factors mediate this relationship? 2. How does Context affect the Relationship between Disease and Quality of Life at Older Ages? What factors moderate or buffer the relationship between chronic disease and quality of life? Focus on: Socioeconomic Status, Social Relationships, Healthcare Resources Irish Longitudinal Study of Ageing (TILDA) (aged 50+)

4 Systematic Literature Review Evaluation of CASP-19 Measure of QoL Path Model of Disease and Quality of Life Model of Contextual Influences Longitudinal Analysis

5 Systematic Literature Review Evaluation of CASP-19 Measure of QoL Path Model of Disease and Quality of Life Model of Contextual Influences Longitudinal Analysis

6 Systematic Literature Review Studies examining the relationship between selected chronic diseases and quality of life among representative, general population samples aged 40+ Results Strong evidence for effect of chronic disease on physical domains of quality of life Weaker evidence for effect on psychological domains Few studies of mediating factors in population samples Most measures of QoL do not distinguish between determinants and constituents

7 Conceptual Framework Conceptualise Quality of Life as a pathway? Wilson-Cleary (1995) Disease Symptoms Function QoL WHO International Classification of Disability, Health and Function Framework Disease Bodily Impairment Activity Limitations Participation Restriction Overall Quality of Life

8 Psychometric Evaluation of CASP-19 Measures satisfaction of 4 key higher needs: Control, Autonomy, Self-Realisation, Pleasure Conceptually Distinct from Health; Functional Limitations Until now, problems with establishing validity of factor structure Evaluation with TILDA: Two potential measurement models: 1. Single Factor Structure 2. Two Distinct Factors: Control-Autonomy; Self-Realisation- Pleasure

9 Potential Model of Quality of Life & Disease Disease Bodily Impairment Activity Limitations Participation Restrictions CASP

10 Potential Model of Quality of Life & Disease Perceived Control has been identified as a key mediator of health and well-being relationship Incorporate CASP into model as further pathway Disease Bodily Impairment Activity Limitations Participation Restrictions Control/ Autonomy Self- Realisation /Pleasure

11 Testing this Model: Data and Methods TILDA Stratified clustered sample of 8,178 individuals, representative of Irish community dwelling aged 50+ Face to face computer aided interview; selfcompletion questionnaire; health assessment Timeframe: Oct 2009 June 2011 Method: Path Analysis and Structural Equation Modelling using MPlus

12 Variables Disease Bodily Impairment Activity Limitations Participation Restrictions Control/ Autonomy Number of Physical Conditions Pain Balance Grip Strength Polypharmacy ADLs IADLs Mobility Subjective limitation Social Activity Volunteering Community Participation Paid Work Self- Realisation /Pleasure Stratified by Sex and Age (under 65, 65+) Covariates: Age, Education

13 Results: Path Analysis Disease Bodily Impairment Control/ Autonomy Self- Realisation /Pleasure Number of Physical Conditions Pain Balance

14 Results: Structural Equation Modelling Disease Number of Physical Conditions Bodily Impairment Activity Limitations ADLs IADLs Mobility Subjective limitation Pain Balance Grip Strength Polypharmacy Control/ Autonomy Self- Realisation /Pleasure

15 Conclusions Difficult to empirically distinguish bodily impairments and activity limitations: highly inter-related Combined physical impairment factor appears to mediate relationship between chronic disease and quality of life Weak evidence for participation restriction as a mediator, once physical impairment, education controlled for Control/Autonomy appears to mediate the effect of chronic disease and physical impairment on Self- Realisation/Pleasure

16 Next Phase: Contextual Factors We know that chronic disease does not inevitably result in disability and poor quality of life to what extent does context matter? Health Care Resources Socioeconomic Social Support Disease Bodily Impairment Activity Limitations Control/ Autonomy Self- Realisation /Pleasure

17 Anticipated PhD Outcomes Conceptual Measurement of Quality of Life Measurement of Disease Burden Practical Service Content: e.g. Enhancing patient control? Targetting services at those most at risk of poor quality of life Evidence for re-organisation linking health resource context with quality of life outcomes

18 Thank you! Questions?

19 Variables Disease Bodily Impairment Activity Limitations Participation Restrictions Control/ Autonomy Number of Physical Conditions Pain Balance Grip Strength Polypharmacy ADLs IADLs Mobility Subjective limitation Social Activity Volunteering Community Participation Paid Work Self- Realisation /Pleasure Stratified by Sex and Age (under 65, 65+) Covariates: Age, Education

20 Challenges of Measuring Impact of Contextual Resources Reverse Causation: People with worse quality of life tend to use more health care resources, receive more social support Need to examine match between need and resource use Examples access to healthcare (insurance status; subjective unmet need) quality of healthcare receipt of indicated care quality of social support