Background
Hypotheses
- Agreement between conventional and retrospective change of HRQL, as measured with EQ-VAS, is lower compared to the agreement if HRQL was measured with EQ-5D-3 L, because recall bias and response shift more easily distort subjective scales (like a VAS) than a classification-like scale like EQ-5D-3 L.
- Agreement between conventional and retrospective change of HRQL is higher among trauma patients with less severe injuries (ISS < 16), because low impact trauma requires less adaptation to ones (final) health status compared severe trauma.
- Recall bias rather than response shift causes disagreement between conventional and retrospective change because with the time lapse chosen (3 months) memory problems affecting recall are no longer trivial.
- In older patients, in patients with traumatic brain injury (TBI) and patients with posttraumatic stress disorder (PTSD) the size of recall bias is higher compared to their counterparts, because these patients experience more memory problems.
Methods
Study design
BIOS study population
Self-report measures
Injury data
Data analysis
Results
Study population
Characteristic | Study population (n = 550) |
---|---|
Gender: Male | 308 (56.0%) |
Age (Mean, SD) | 61.0 (16.0) |
Education | |
Low | 127 (23.1%) |
Middle | 214 (38.9%) |
High | 199 (36.2%) |
Unknown | 10 (1.8%) |
Comorbidity status | |
No comorbidity | 231 (42.0%) |
Comorbidity | 309 (56.2%) |
Unknown | 10 (1.8%) |
Length of hospital stay in days (Median, IQR) | 4.0 (2.0–6.0) |
Number of injuries | |
1 | 275 (50.0%) |
2 | 129 (23.5%) |
≥ 3 | 146 (26.5%) |
Type of injuryb | |
Mild TBI | 159 (28.9%) |
Hip fracture | 114 (20.7%) |
Pelvic injury | 71 (12.9%) |
Rib fracture | 71 (12.9%) |
Tibia, complex foot or femur fracture | 71 (12.9%) |
Shoulder and upper arm injury | 57 (10.4%) |
Stable vertebral fracture or disc injury | 40 (7.3%) |
Radius, ulna or hand fracture | 40 (7.3%) |
Thoracic injury | 31 (5.6%) |
Facial fracture | 29 (5.3%) |
Severe TBI | 15 (2.7%) |
Mild abdominal injury | 14 (2.5%) |
Severe abdominal injury | 5 (0.9%) |
Spinal cord injury | 2 (0.4%) |
Injury Severity Score | |
< 8 | 320 (58.2%) |
8–16 | 193 (35.1%) |
≥ 16 | 35 (6.4%) |
Unknown | 2 (0.4%) |
PTSD symptomsa | |
No PTSD (IES < 35) | 451 (82.0%) |
PTSD (IES ≥ 35) | 41 (7.5%) |
Unknown | 58 (10.5%) |
EQ-5D-3 L scores at T1 | |
Utility score (Mean, SD) | 0.482 (0.298) |
EQ-VAS (Mean, SD) | 56.3 (20.5) |
Mobility (% reporting moderate or extreme problems) | 72.0% |
Self-care (% reporting moderate or extreme problems) | 69.8% |
Usual activities (% reporting moderate or extreme problems) | 85.5% |
Pain/discomfort (% reporting moderate or extreme problems) | 88.0% |
Anxiety/depression (% reporting moderate or extreme problems) | 24.9% |
EQ-5D-3 L – conventional change versus retrospective change
n | Mean EQ-5D T1 | Mean EQ-5D T2 | Mean Then Test | Conventional change | Retrospective change | ICCa | Mean Recall Test | Recall bias | Response shift | ICCb | |
---|---|---|---|---|---|---|---|---|---|---|---|
Total | 550c | 0.482 (SD 0.30) | 0.735 (SD 0.24) | 0.419 (SD 0.35) | 0.254 (SD 0.29) | 0.316 (SD 0.31) | 0.489* | 0.462 (SD 0.34) | −0.020 (SD 0.30) | − 0.063 (SD 0.31) | 0.681* |
Gender | |||||||||||
Males | 308 | 0.500 (SD 0.31) | 0.741 (SD 0.25) | 0.450 (SD 0.36) | 0.242 (SD 0.31) | 0.292 (SD 0.33) | 0.545* | 0.506 (SD 0.35) | 0.007 (SD 0.31) | −0.050 (SD 0.30) | 0.705* |
Females | 242 | 0.459 (SD 0.28) | 0.728 (SD 0.23) | 0.380 (SD 0.33) | 0.269 (0.26) | 0.348 (SD 0.30) | 0.391* | 0.405 (SD 0.33) | −0.054 (SD 0.29) | − 0.079 (SD 0.31) | 0.648* |
Age | |||||||||||
< 65 years | 285 | 0.452 (SD 0.29) | 0.741 (SD 0.24) | 0.373 (SD 0.34) | 0.289 (SD 0.29) | 0.369 (SD 0.32) | 0.516* | 0.425 (SD 0.34) | −0.028 (SD 0.31) | − 0.080 (SD 0.30) | 0.749* |
65+ years | 265 | 0.513 (SD 0.30) | 0.729 (SD 0.24) | 0.469 (SD 0.35) | 0.216 (SD 0.29) | 0.260 (SD 0.30) | 0.435* | 0.501 (SD 0.35) | −0.012 (SD 0.29) | − 0.044 (SD 0.31) | 0.608* |
Educational level1 | |||||||||||
Low | 127 | 0.503 (SD 0.33) | 0.697 (SD 0.26) | 0.443 (SD 0.37) | 0.193 (SD 0.30) | 0.254 (SD 0.30) | 0.439* | 0.489 (SD 0.35) | −0.015 (SD 0.32) | − 0.060 (SD 0.32) | 0.661* |
Middle | 214 | 0.492 (SD 0.30) | 0.740 (SD 0.25) | 0.406 (SD 0.350) | 0.248 (SD 0.30) | 0.334 (SD 0.30) | 0.458* | 0.451 (SD 0.36) | −0.041 (SD 0.32) | −0.086 (SD 0.31) | 0.717* |
High | 199 | 0.447 (SD 0.27) | 0.752 (SD 0.23) | 0.403 (SD 0.34) | 0.305 (SD 0.26) | 0.349 (SD 0.33) | 0.543* | 0.448 (SD 0.33) | 0.012 (SD 0.26) | −0.044 (SD 0.28) | 0.650* |
Comorbidity status2 | |||||||||||
No comorbidity | 231 | 0.499 (SD 0.28) | 0.784 (SD 0.24) | 0.437 (SD 0.33) | 0.285 (SD 0.28) | 0.347 (SD 0.31) | 0.532* | 0.480 (SD 0.32) | −0.019 (SD 0.30) | −0.062 (SD 0.29) | 0.736* |
Comorbidity | 309 | 0.472 (SD 0.31) | 0.702 (SD 0.24) | 0.407 (SD 0.36) | 0.230 (SD 0.29) | 0.295 (SD 0.32) | 0.450* | 0.452 (SD 0.36) | −0.020 (SD 0.30) | −0.065 (SD 0.32) | 0.655* |
ISS3 | |||||||||||
ISS < 16 | 513 | 0.493 (SD 0.29) | 0.741 (SD 0.24) | 0.433 (SD 0.34) | 0.248 (SD 0.29) | 0.308 (SD 0.31) | 0.503* | 0.474 (SD 0.34) | −0.019 (SD 0.30) | −0.060 (SD 0.30) | 0.670* |
ISS > = 16 | 35 | 0.350 (SD 0.30) | 0.659 (SD 0.28) | 0.229 (SD 0.40) | 0.309 (SD 0.29) | 0.429 (SD 0.36) | 0.315* | 0.289 (SD 0.38) | −0.061 (SD 0.34) | −0.120 (SD 0.39) | 0.740* |
TBI | |||||||||||
No TBI | 384 | 0.432 (SD 0.28) | 0.721 (SD 0.24) | 0.383 (SD 0.33) | 0.290 (SD 0.28) | 0.338 (SD 0.31) | 0.461* | 0.428 (SD 0.33) | −0.004 (SD 0.30) | −0.048 (SD 0.31) | 0.656* |
TBI | 166 | 0.598 (SD 0.30) | 0.768 (SD 0.25) | 0.501 (SD 0.38) | 0.171 (SD 0.28) | 0.267 (SD 0.31) | 0.525* | 0.539 (SD 0.37) | −0.058 (SD 0.29) | −0.096 (SD 0.29) | 0.742* |
PTSD symptoms4d | |||||||||||
No PTSD | 451 | 0.490 (SD 0.29) | 0.759 (SD 0.22) | 0.423 (SD 0.34) | 0.269 (SD 0.28) | 0.337 (SD 0.31) | 0.518* | 0.471 (SD 0.34) | −0.019 (SD 0.30) | −0.068 (SD 0.29) | 0.684* |
PTSD | 41 | 0.345 (SD 0.35) | 0.487 (SD 0.35) | 0.270 (SD 0.43) | 0.142 (SD 0.41) | 0.216 (SD 0.35) | 0.294* | 0.252 (SD 0.36) | −0.093 (SD 0.37) | − 0.075 (SD 0.45) | 0.780* |
EQ-5D-3 L – recall bias versus response shift
Initial model | Final model | |||
---|---|---|---|---|
Unstandardized B | p-value | Unstandardized B | p-value | |
Constant | 0.070 | 0.342 | 0.009 | 0.603 |
Agea | 0.000 | 0.769 | ||
Sex (male/female) | −0.044 | 0.119 | ||
Education (dichotomized) | 0.025 | 0.379 | ||
Comorbidity (no/yes) | 0.031 | 0.312 | ||
TBI (no/yes) | −0.051 | 0.093 | ||
ISSa | 0.001 | 0.764 | ||
PTSDa | −0.003 | 0.001 | −0.004 | < 0.001 |
F value | 2.96 | 0.05 | 13.73 | < 0.001 |
Adjusted R-square | 0.028 | 0.026 |
Initial model | Final model | |||
---|---|---|---|---|
Unstandardized B | p-value | Unstandardized B | p-value | |
Constant | − 0.039 | 0.603 | −0.049 | |
Agea | < 0.001 | 0.750 | ||
Sex (male/female) | −0.025 | 0.387 | ||
Education (dichotomized) | 0.037 | 0.201 | ||
Comorbidity (no/yes) | 0.002 | 0.945 | ||
TBI (no/yes) | −0.039 | 0.200 | ||
ISSa | 0.000 | 0.983 | ||
PTSDa | −0.002 | 0.037 | −0.002 | 0.016 |
F value | 1.40 | 0.20 | 5.83 | 0.016 |
Adjusted R-square | 0.006 | 0.010 |
EQ-VAS – conventional change versus retrospective change
EQ-VAS T1 | Mean EQ-5D T2 | Mean Then Test | Conventional change | Retrospective change | ICCα | Mean Recall Test | Recall bias | Response shift | ICC§ | |
---|---|---|---|---|---|---|---|---|---|---|
Total | 56.3$ (SD 20) | 72.6 (SD 17.0) | 54.7 (SD 21.0) | 16.3 (SD 19) | 17.9 (SD 18) | 0.483* | 55.7 (SD 21.0) | −0.62 (SD 20) | −1.59 (SD 19) | 0.783* |
Gender | ||||||||||
Males | 58.3 (SD 21) | 73.4 (SD 17.0) | 56.4 (SD 22.5) | 15.0 (SD 12) | 17.0 (SD 14) | 0.464* | 57.6 (SD 22.5) | −0.74 (SD 21) | −1.94 (SD 19) | 0.793* |
Females | 53.8 (SD 19) | 71.7 (SD 16.9) | 52.7 (SD 18.8) | 17.9 (SD 19) | 19.0 (SD 18) | 0.503* | 53.3 (SD 18.7) | −0.46 (SD 17) | −1.14 (SD 19) | 0.768* |
Age | ||||||||||
< 65 years | 54.1 (SD 20) | 72.1 (SD 17.9) | 51.4 (SD 21.2) | 17.9 (SD 19) | 20.7 (SD 19) | 0.459* | 51.7 (SD 20.9) | −2.46 (SD 18) | −2.74 (SD 20) | 0.740* |
65+ years | 58.7 (SD 21) | 73.2 (SD 15.9) | 58.3 (SD 20.2) | 14.5 (SD 20) | 14.8 (SD 16) | 0.498* | 60.0 (SD 20.2) | 1.362 (SD 21) | −0.34 (SD 18) | 0.825* |
Educational level1 | ||||||||||
Low | 56.1 (SD 21) | 69.7 (SD 16.9) | 54.6 (SD 19.6) | 13.6 (SD 21) | 15.1 (SD 19) | 0.561* | 55.8 (SD 20.7) | −0.32 (SD 20) | −1.51 (SD 19) | 0.798* |
Middle | 57.4 (SD 21) | 74.3 (SD 17.2) | 54.8 (SD 22.7) | 17.0 (SD 20) | 19.6 (SD 18) | 0.402* | 55.7 (SD 22.5) | −1.71 (SD 21) | −2.61 (SD 21) | 0.773* |
High | 55.1 (SD 20) | 72.8 (SD 16.3) | 54.3 (SD 20.0) | 17.7 (SD 17) | 18.5 (SD 16) | 0.519* | 55.4 (SD 19.6) | 0.32 (SD 18) | −0.80 (SD 16) | 0.784* |
Comorbidity status2 | ||||||||||
No comorbidity | 57.3 (SD 20) | 77.0 (SD 16.3) | 56.2 (SD 20.9) | 19.7 (SD 20) | 20.8 (SD 19) | 0.524* | 56.7 (SD 20.5) | −0.58 (SD 20) | −1.06 (SD 19) | 0.772* |
Comorbidity | 55.6 (SD 20) | 69.6 (SD 16.6) | 53.9 (SD 20.8) | 14.1 (SD 19) | 15.7 (SD 17) | 0.421* | 55.3 (SD 21.1) | −0.27 (SD 20) | −1.676 (SD 19) | 0.793* |
ISS3 | ||||||||||
ISS < 16 | 57.3 (SD 20) | 73.1 (SD 16.8) | 55.9 (SD 20.3) | 15.8 (SD 19) | 17.11 (SD 17) | 0.503* | 56.6 (SD 20.4) | −0.69 (SD 19) | −1.31 (SD 19) | 0.802* |
ISS > = 16 | 44.6 (SD 20) | 66.5 (SD 18.3) | 37.9 (SD 23.6) | 21.9 (SD 23) | 28.5 (SD 19) | 0.199 | 43.8 (SD 25.3) | −0.77 (SD 29) | −6.66 (SD 27) | 0.661* |
TBI | ||||||||||
No TBI | 54.5 (SD 20) | 71.8 (SD 17.0) | 54.3 (SD 20.6) | 17.3 (SD 20) | 17.5 (SD 18) | 0.503* | 55.1 (SD 20.5) | 0.57 (SD 20) | −0.22 (SD 19) | 0.787* |
TBI | 60.5 (SD 21) | 74.4 (SD 16.7) | 55.8 (SD 22.1) | 13.9 (SD 17) | 18.6 (SD 17) | 0.445* | 57.2 (SD 22.2) | −3.37 (SD 19) | −4.75 (SD 18) | 0.765* |
PTSD symptoms4& | ||||||||||
No PTSD | 56.9 (SD 20) | 73.7 (SD 16.3) | 55.6 (SD 21.1) | 16.8 (SD 19) | 18.2 (SD 18) | 0.495* | 56.2 (SD 20.8) | −0.72 (SD 19) | −1.39 (SD 18) | 0.774* |
PTSD | 51.8 (SD 21) | 58.1 (SD 17.7) | 44.2 (SD 20.8) | 6.2 (SD 22) | 13.9 (SD 19) | 0.556* | 44.5 (SD 21.2) | −7.29 (SD 20) | −7.61 (SD 19) | 0.753* |
EQ-VAS – recall bias versus response shift
Initial model | Final model | |||
---|---|---|---|---|
Unstandardized B | p-value | Unstandardized B | p-value | |
Constant | −5.977 | 0.342 | 0.482 | 0.674 |
Agea | 0.059 | 0.769 | ||
Sex (male/female) | 2.146 | 0.119 | ||
Education (dichotomized) | 1.482 | 0.379 | ||
Comorbidity (no/yes) | 0.351 | 0.312 | ||
TBI (no/yes) | −3.922 | 0.093 | −4.037 | 0.032 |
ISSa | −0.138 | 0.764 | ||
PTSDa | −0.142 | 0.001 | −0.135 | 0.029 |
F value | 2.15 | 0.038 | 5.09 | 0.007 |
Adjusted R-square | 0.017 | 0.017 |
Initial model | Final model | |||
---|---|---|---|---|
Unstandardized B | p-value | Unstandardized B | p-value | |
Constant | −8.476 | 0.069 | 1.127 | 0.333 |
Agea | 0.083 | 0.178 | ||
Sex | 1.727 | 0.331 | ||
Education (dichotomized) | 1.889 | 0.299 | ||
Comorbidity (yes/no) | 1.400 | 0.474 | ||
TBI (yes/no) | −3.685 | 0.055 | −3.808 | 0.047 |
ISSa | 0.100 | 0.521 | ||
PTSDa | −0.147 | 0.022 | −0.134 | 0.033 |
F value | 2.16 | 0.036 | 4.62 | 0.010 |
Adjusted R-square | 0.017 | 0.015 |