title: Detecting When "Quality of Life" Has Been "Enhanced": Estimating Change in Quality of Life Ratings.
abstract: OBJECTIVE
  To demonstrate challenges in the estimation of change in quality of life (QOL).
  
  
  METHODS
  Data were taken from a completed clinical trial with negative results. Responses to 13 QOL items were obtained 12 months apart from 258 persons with Alzheimer's disease (AD) participating in a randomized, placebo-controlled clinical trial with two treatment arms. Two analyses to estimate whether "change" in QOL occurred over 12 months are described. A simple difference (later - earlier) was calculated from total scores (standard approach). A Qualified Change algorithm (novel approach) was applied to each item: differences in ratings were classified as either: improved, worsened, stayed poor, or stayed "positive" (fair, good, excellent). The strengths of evidence supporting a claim that "QOL changed", derived from the two analyses, were compared by considering plausible alternative explanations for, and interpretations of, results obtained under each approach.
  
  
  RESULTS
  Total score approach: QOL total scores decreased, on average, in the two treatment (both -1.0,p< 0.05), but not the placebo (=-0.59,p> 0.3) groups. Qualified change approach: Roughly 60% of all change in QOL items was worsening in every arm; 17% - 42% of all subjects experienced change in each item.
  
  
  CONCLUSIONS
  Totalling the subjective QOL item ratings collapses over items, and suggests a potentially misleading "overall" level of change (or no change, as in the placebo arm). Leaving the items as individual components of "quality" of life they were intended to capture, and qualifying the direction and amount of change in each, suggests that at least 17% of any group experienced change on every item, with 60% of all observed change being worsening.
  
  
  CONCLUSIONS
  Summarizing QOL item ratings as a total "score" collapses over the face-valid, multi-dimensional components of the construct "quality of life". Qualified Change provides robust evidence of changes to QOL or "enhancements of" life quality.
authors.affiliation: Departments of Neurology, Biostatistics, Bioinformatics & Biomathematics, and Psychiatry, Georgetown University Medical Center, Washington, D.C., USA ; Collaborative for Research on Outcomes and-Metrics.
authors.forename: Rochelle E
authors.initials: RE
authors.lastname: Tractenberg
authors.affiliation: Collaborative for Research on Outcomes and-Metrics ; IMPAQ International, Columbia, USA.
authors.forename: Futoshi
authors.initials: F
authors.lastname: Yumoto
authors.affiliation: Department of Neurology, University of California, San Diego, USA.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Aisen
keywords: Data Interpretation; Longitudinal Analysis; Scale Type; Statistical Method