Does quality of life assessment in palliative care look like a complex screening program?

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by  Catania, Gianluca

Cataniaetal.HealthandQualityofLifeOutcomes2013,11:7
http://www.hqlo.com/content/11/1/7
RESEARCH Open Access
Does quality of life assessment in palliative care
look like a complex screening program?
Gianluca Catania1*, Massimo Costantini1, Monica Beccaro1, Annamaria Bagnasco2 and Loredana Sasso2
Abstract
Background: Palliative Care (PC) is an approach thatimproves the Quality of Life (QoL). A numberof QoL
assessment tools have been developed and validated inPC. It is not clear how QoL should be measuredin PC
practice. A procedure ofQoL assessment in clinical practice can be defined as a clinical interventionfocused on
QoL assessment. This is a typical complex intervention that should be appropriately developed and described inall
itscomponentsand assessed for itseffectiveness. The aim of this study is to define a framework to help researchers
to develop and evaluate clinical interventionsfocused onQoL assessment in PC.
Methods: A study group of experts in PCand inresearch methodology was set up to define a framework that
would describe the principles ofclinical interventions focused onQoL assessment inPC. The study group discussed
theWHO Population Screening Principles as a possible useful framework. The new principleshad to be developed
taking intoaccount thefollowing criteria: 1)specific to PCpractice; 2) address a single underlying characteristic;3)
anchored to relevant literature; 4)consistent with the WHO PC definition.
With regard to contents and theformat of theprinciples, discussions occurred among the study group members
through a cognitiveprocess.
Results: We reviewed each of theWHO Population Screening Principles and adapted them to QoL assessment,
taking intoaccount thedefinedcriteria. As a result, a new framework, the QoL Assessment Principles in PalliativeCare
was developed. It consisted of 4 sections, for a total of11 principles.
Conclusions: The WHO Screening Principlesframework was used to outline the eleven essential principles to be
considered indeveloping and/or evaluating clinical interventions focused on QoL assessment in PC. The QoL
Assessment Principles in PalliativeCare identifiedcould represent a methodological and ethical standard to be
considered when developing and evaluatinga clinical intervention focused on QoL assessment in PC.
Keywords: Quality oflife, Outcome assessment, Palliative care, Complex intervention
Background systems QoL is related to health and its physical and
Qualityoflifeinpalliativecare psychosocial dimensions [2]. In palliative care, a theoret-
Palliative Care is an approach that improves the Quality ical concept with a pragmatic approach is the Calman’s
of Life (QoL) of patients and their families facing the gap theory that described QoL as an individual experi-
problem associated with life-threatening illness, through ence conceptualized as the gap between a person‘s life
the prevention and relief of suffering by means of early experience and expectations [3]. QoL is described as a
identification and impeccable assessment and treatment dynamic, subjective and multidimensional concept in-
of pain and other problems, physical, psychosocial and cluding physical, emotional, psychological, social and
spiritual[1]. spiritual dimensions [4-6]. Such dimensions affect each
According to the World Health Organization (WHO) otheraswell aspatients’overallQoL[4].
definition of health, formulated in 1948, in healthcare The challenge of assessing QoL in palliative care must
take into account that QoL is based on the perspectives
*Correspondence:[email protected] and priorities of the individual patient [7], where all the
1IRCCSA.O.U.SanMartino–ISTIstitutoNazionaleperlaRicercasulCancro,
subjective dimensions interact with each other [4]. In
Genoa,Italy
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Cataniaetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
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addition, response shift phenomenon needs to be consid- definition proposed by the Medical Research Council
ered when measuring QoL, such phenomenon involves a (MRC) [24], it is a typical complex intervention that
change in the meaning of patients’self-evaluation of QoL should be appropriately developed and described in all
asaresultofachangeovertimeintheirinternalstandards, itscomponentsandassessedforitseffectiveness [25].
valuesandpriorities[8]. A basic prerequisite for starting a process of assess-
ment is to identify the optimal intervention and analyse
Qualityoflifeassessment all its components, and identify mechanisms that lead to
A number of QoL assessment tools have been developed improved outcomes and potential barriers to its applica-
and validated in palliative care [9] and their use described tion ina specificcontext[26].
forresearchpurposes[10],tosupportclinicalpractice[11], Atheoreticalframeworkforthedevelopment-evaluation-
andaspartofthequalityprograms[12]. implementationprocessofacomplexinterventionhasbeen
For research purposes, a number of observational developed [24]. This framework has never been applied to
studieshavedescribed andanalysedQoL impairmentsof aclinicalinterventionfocusedonQoLassessmentinpallia-
palliative care patients in different settings [13]. More- tive care, and no consensus exists on what should be the
over, QoL has also been used as an outcome measure in essential components of the intervention. A specific
observational [14], quasi-experimental [15] and experi- framework for developing a clinical intervention focused
mental studies [16]. Two systematic reviews [17,18] con- on QoL assessment in palliative care could be a useful
cluded that QoL assessment is feasible in clinical trials guideline that would help stakeholders to better define
and has the potential of providing valuable outcomes to the intervention in all its components and make it suit-
furthersupportclinical decision-making. able for use as a reference either in practice, research or
The European PRISMA group developed a research quality programs purposes.
guidance aimed at improving outcome measures for
patients and families [19]. The Institute of Medicine Aimofthestudy
(IOM) identified Comparative Effectiveness Research The aim of this study is to define a framework to help
(CER) in cancer care as a high priority where the ability researcherstodevelopandevaluate clinicalinterventions
to measure QoL is central to CER in oncology because focused onQoL assessmentinpalliative care.
survival and disease-free survival do not properly in-
corporate outcomes that are significant for policy- Methods
makers,physicians,andpatients[20,21]. In January 2011, a study group of experts in palliative
QoL assessment in research is supported by detailed care and in research methodology (one epidemiologist,
study protocols and rigorous guidelines (i.e. Good Clinical one research nurse,one palliative care physician andtwo
Practice) reporting the rationale of QoL assessment, the university nursing professors) was set up to define a
psychometric characteristics of QoL measures, and the framework that would describe the principles of clinical
detailedproceduresforQoLassessment[22]. interventions focused on QoL assessment in palliative
Higginson & Carr [23] recommended QoL assess- care. The study group’s members came from two differ-
mentsinpalliativecareforpurposesotherthanresearch. ent institutions in the north of Italy – a teaching and re-
As part of the quality programs, QoL assessments can search hospital and a university - and started working
be used as a criterion by which services are evaluated, or together to support one of the authors (GC) in his doc-
aimed at improving assessment skills among healthcare toral program.
professionals or at ensuringthat clinical audit focuses on As outlined in the latest MRC framework guidelines
what is important to patients rather than on the tech- and from the standardization perspective, we used here
nical aspectsofquality. the term “component” according to Hawe’s view [27]
In support to clinical practice, QoL assessments have where the constant aspects of the intervention are the
been proposed to assess variations in individual patients essential functions and the variable aspects are their
over the disease trajectory and to ensure that the indi- form tailored tolocalconditions.
vidual plan of care is centered on the patient rather than The study group discussed the WHO Population
onthedisease[15,16,23]. Screening Principles [28] as a possible useful framework,
asboth interventionsshare anumberofcharacteristics:
Thechallengeofqualityoflifeassessmentinclinical
practice (cid:1) bothare complexinterventions with anumberof
A procedure of QoL assessment in clinical practice (i.e. interactingcomponentssensitive tofeaturesoflocal
a routine procedure and a thorough QoL assessment in contextsthatpresent specific problems in
palliative care patients) can be defined as a clinical inter- standardizingand implementingtheintervention,
vention focused on QoL assessment. According to the andinassessingitseffectiveness;
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(cid:1) both interventions are focused on assessment 1.specifictothepalliative carepractice;
procedures. The screening is focused on 2.addressa singleunderlyingcharacteristic;
diagnostic tests (i.e. smear test) offered to 3.anchoredtorelevantliteratureinthePubmed
apparently healthy people for the early detection databaseusingkeywordsandsynonymousrelatedto
of a disease or condition. The QoL clinical each singleprinciples (e.g.palliative care, disease
intervention is focused on assessment tools (i.e. trajectory, assessment tool);
the Palliative Outcome Scale – POS [29] offered 4.consistentwith theWHO palliative caredefinition.
to patients to identify and prioritise issues in one
or more dimensions of QoL; Oneoftheauthors(GC)developedafirstdraftversion
(cid:1) theassumption forboth ofthese interventions is of the WHO Screening Principles adapted to QoL as-
thatearlydetectioncanpositivelymodify,for sessment. The format and the contents of the principles
screeningprograms,thenatural historyofthe were discussed and emended during five meetings
diseaseand,forQoL clinicalinterventions can guided by one of the author (MC) through a cognitive
modifythe natural historyofimpairmentsor process [33].
problems; Such meetings wereaimedat gettingtoan agreed final
(cid:1) bothdealwith specific difficultiesindefining, version of the principles. Consensus was reached when
developing,documenting,andreplicatingthe all the study group’s members agreed a unanimous deci-
interventionand bothrequire theuseofqualitative siontothe finalversion.
andquantitative methodologies fortheirevaluation.
Results
The framework of reference for developing a scree- According to the development stage of the MRC frame-
ning program in all its components is the WHO Po- work for complex interventions [24], we assumed that a
pulation Screening Principles [28] that identifies and clinicalinterventionfocusedonQoLassessmentshouldbe
describes ten principles that could be used as a guide- based on a number of components that form a coherent
line to plan a new screening intervention. In breast structure, and that all such components - standardized by
cancer, for instance, such principles have proved to be form and functions - linked the interventions to the
effective in detecting early-stage disease and reducing expectedoutcomes.
overall mortality [30]. In this article, we hypothesized a supporting theory
Wilson & Junkner [28] listed the WHO Population based on the WHO Population Screening Principles [28]
Screening Principles at the time when technological that we modified and contextualized to QoL assessment
advances in medicine made screening a topic of growing in palliative care practice. The WHO Population Screen-
importance [31]. Similarly, patients’ QoL is the core ing Principles [28] describe the principles of a “complex
elementof healthcarepracticeinpalliativecare,inwhich intervention” (i.e. the population screening program) for
QoL assessment has been proposed as the intervention an early identification of a disease or a pre-disease con-
aimedatimprovingpracticerelatedtoscreening forpro- dition inhealthysubjects.
blems,targetinginterventions,andmonitoringoutcomes The QoL Assessment Principles in Palliative Care con-
in palliative care [23]. It showed a positive effect of QOL sisted of thefollowing4sections,for atotal of11princi-
data on physician–patient communication specifically ples (see Table 1): section one includes three principles
focusing on continuity of information, facilitating rap- related to “the problem” (i.e. the QoL impairment); sec-
portandinter-personalcommunicationbetweenpatients tion two includes two principles dealing with the assess-
andhealthcareprofessionals [32]. ment tool; section three includes one principle focusing
By using the ten WHO Population Screening Princi- on the treatment/intervention; and section four includes
ples [28] as a framework, we developed the principles of five principles dealing with “the clinical intervention fo-
clinical interventions focused on QoL assessment in pal- cused onQoL assessment”.
liative care, asspecifiedinthefollowingprocedures. The original WHO Population Screening Principles
[28] are reported in Table 1 and, hereafter, the QoL As-
Procedures sessment Principles in Palliative Care are italicised and
Firstly, the study group members met to sharing the described.
proposal of one of the author (MC) to use the WHO
ScreeningPrinciples asaframeworktodevelop the prin- TheProblem(theQoLimpairment)(3principles)
ciples of clinical interventions focused on QoL assess-
ment in palliative care. We all agreed that the principles 1.The problem should be a serious condition for
had to be developed taking into account the following the patient either in terms of prevalence (e.g.
criteria: pain, depression) and/or distress for the patient
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Table1ApplicationofWHOscreeningprinciplestoQoLassessmentsinpalliativecare
THEWHOSCREENINGPRINCIPLES THEQoLASSESSMENTPRINCIPLESINPALLIATIVECARE
Thedisease,condition Theproblem(theQoLimpairment)
1.Theconditionshouldbeanimportanthealthproblem,intermsof 1.Theproblemshouldbeaseriousconditionforthepatienteitherintermsof
prevalence(e.g.breastcancer)orfortheseriousconsequencesifnot prevalence(e.g.pain,depression)and/ordistressforthepatient(e.g.itch,hiccup)
earlydiscoveredandtreated(e.g.phenylketonuria). ortheresultoflatedetectionandmanagementoftheproblem(e.g.anewor
unusualdistressingsymptomoccurredoverthediseasetrajectory).
2.Thereshouldbearecognizablelatentorearlysymptomaticstage. 2.Theproblemshouldbehighlyunlikelytobereportedbyallthepatientsor
recognizedbytheprofessionalifnotactivelyassessed.
3.Thenaturalhistoryofthecondition,includingdevelopmentfrom 3.Thetrajectoryoftheproblemshouldbesufficientlyunderstoodtoassure
latenttodeclareddisease,shouldbeadequatelyunderstood. atimelyassessmenttoanticipateandappropriatelyaddresstheproblem.
Thediagnostictest Theassessmenttool
1.Thereshouldbeasuitabletestorexamination 1.Avalidated,reliableandsensitive-to-changetoolfordetectingand
measuringtheproblemshouldbeavailable.
2.Thereshouldbeacceptableforthepopulation 2.Thetoolshouldbepractical,easytouseandquestionsmustnotbe
distressingforthepatients.
Thetreatment Thetreatment-intervention
1.Thereshouldbeanacceptedtreatmentforpatientswithrecognized 1.Thereshouldbeanappropriatetreatment/interventionforpatientswiththe
disease. recognizedproblem.
Thescreeningprogramme TheclinicalinterventionfocusedonQoLassessment
1.Thereshouldbeanagreedpolicyonwhomtotreataspatients 1.Thereshouldbeanagreedpolicyonwhichaproblem(oraproblemwitha
certaindegreeofimpairment)hastobeaddressedwithappropriatetreatment
orintervention.
2.Facilitiesfordiagnosisandtreatmentshouldbeavailable. 2.Thereshouldbethepossibilitytoappropriatelyadministerthetool,
includingprofessionalstrainedwiththeprocedure.
3.Thetreatment-interventionforpatientswithQoLimpairmentsshouldbe
available,includingprofessionalstrainedforthetreatment-intervention.
3.Thecostofcase-finding(includingdiagnosisandtreatmentofpatient 4.Thecostofproblem-finding(includingallthestepsfromtheadministration
diagnosed)shouldbeeconomicallybalancedinrelationtopossible ofthetooluntiltheendofthetreatment–interventiondelivered)shouldbe
expenditureonmedicalcareasawhole economicallyjustified.
4.Case-findingshouldbeacontinuingprocessandnota“onceand 5.QoLassessmentshouldbeacontinuingprocessandnota“onceand
forall”project. forall”project.
(e.g. itch, hiccup) or the result of late detection Especiallyinthe caseofneedsthatareeithernot regu-
and management of the problem (e.g. a new or larly assessed by staff or not reported by all the patients
unusual distressing symptom occurred over the including spiritual, psychosocial and physical problems
disease trajectory). such as loneliness, anxiety, dry mouth and pain. As
reported by Lunder et al. [35] and LeMay et al. [36]
The assumption underlying this principle is that when patients’ needs are not addressed patients may
screening and monitoring for patients’ problems allow considerendingtheirlives prematurely.
these to be noticed by the healthcare professionals
[19]. There is some evidence that when problems are 3.Thetrajectoryoftheproblemshouldbesufficiently
identified, as well as those not necessarily obvious, understoodto assure atimelyassessmentto
some or all of them could be addressed by palliative anticipateand appropriatelyaddressthe problem.
care staff contributing significantly to the improve-
ment of the patients’ QoL [34]. This principle suggests the need to adequately under-
stand the trajectory of patient-centered outcomes before
2.Theproblem shouldbehighly unlikely tobereported implementing clinical interventions focused on QoL
byallthepatientsorrecognizedbytheprofessionalif assessment.
notactivelyassessed. It is crucial to palliative care recognize the trajec-
tory of the problems influencing the QoL dimensions
Thisprinciple ismet because using QoL assessment to inpalliativecarepatients[37].Forexample,beingawareof
identify which patients are mostly at risk of developing the changing prevalence and severity of the physical, psy-
impairments in QoL dimensions that are primary in pal- chological,social,andspiritualneedsovertheillnesstrajec-
liative care. tory [38,39] is necessary to choose the most appropriate
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self-reportmeasuresofascreeningprogrammeandtopre- side effects [43]. Conversely, looking at spirituality, al-
ventandaddresssuchimpairedconditions. though it is recognized as an essential dimension of
quality by the National Consensus Project for Quality
Theassessmenttool(2principles) Palliative Care [44] and the National Quality Forum
(NQF), there is little evidence on what kind of spiritual
1.Avalidated, reliableand sensitive-to-change toolfor care interventions effectively address spiritual needs
detecting and measuringthe problem should be whiledeliveringpalliative care [45].
available. Such principle focuses primarily on clarifying aspects
of palliative care teams decision making that should be
This principle suggests the need to measure QoL with evidence based by integrating “the best research evi-
instruments that can be comfortably used in clinical pal- dence with clinical expertiseandpatientvalues”[46].
liative care practice and that are valid, reliable and have
the characteristic to detect over time any changes in the TheclinicalinterventionfocusedonQoLassessment
dimension(s) being measured (i.e. responsiveness). Al- (5principles)
though there is no agreement on how QoL should be
measured [9] a number of literature reviews identified a 1.Thereshouldbean agreedpolicy inrelationto
number of QoL instruments as appropriate for use in whichaproblem (oraproblem with acertaindegree
palliative care [9,40,41]. For example, the Palliative care ofimpairment)hastobeaddressedwithappropriate
Outcome Scale (POS) [29] is one of the most compre- treatmentorintervention.
hensive, valid, and reliable QoL instruments applied in
palliative care patients with a variety of diagnoses – de- This principle underlines the importance of defining
mentia, chronic heart failure, chronic kidney disease, individualized care plans based on impaired QoL di-
COPD. It showed a statistically significant responsive- mensions where interventions are proposed to patients
ness to change between scores on admission and over and their families according to the QoL assessment. Im-
time [34]. paired conditions should be discussed with patients and
a careful evaluation of the causes should be included
2.Thetoolshouldbepractical,easytouseand andfollowedup.AsaresultofpoorQoL scoresorwhen
questionsmustnotbedistressingforthe patients. conditions are worse compared to earlier assessments,
policies related to dimensions included in the QoL as-
This principle underscores the importance of having sessment should be considered to ensure special atten-
QoL measures that are acceptable for the palliative care tion and an appropriate treatment. As part of a larger
population. Acceptability means that the instrument has clinical intervention aimed at fostering the screening of
to be practical, easy to use and not distressful for pallia- impaired conditions where early detection and ongoing
tive care patients, especially when the disease is at avery assessment would make a difference in the intervention
advanced stage . For example, the Palliative care Out- and outcome, QoL measurement should trigger a pro-
come Scale (POS) [29] was considered by patients as a cess within policies defining what to do and how (i.e.
valuable and not burdensome communication tool that intervention, treatment, professionals trained in deliver-
helped themtoidentifytheirindividual needs[42]. ing the intervention, service to which the patient refers)
accordingtothepatients’care expectations.
Thetreatment/intervention(1principle)
2.Thereshouldbethe possibilitytoappropriately
1.Thereshouldbeanappropriatetreatment/intervention administerthe tool,includingprofessionalstrained
forpatientswiththerecognizedproblem. with theprocedure.
This principle is particularly important when develop- This principle indicates that palliative care patients
ing and implementing a clinical intervention focused on should be assessed for their needs. As palliative care fo-
theassessmentofQoLinpalliative caresettings,because cuses on improving patients’ QoL, resources and facil-
it highlights which criteria such intervention should ities (i.e. treatments and services) should be available
meet, the availability of appropriate treatments, inter- where patients can find skilled and trained healthcare
ventions and/or services to treat the recognized problem professionals abletoscreen andmonitor QoL overtime.
that is the impaired QoL. For example, an impaired
physical dimension is commonly treated with an effect- 3.Thetreatment-intervention forpatientswith QoL
ive medical treatment and despite symptoms are clus- impairmentsshouldbeavailable,including
tered they are controlled without inducing unacceptable professionalstrainedforthetreatment-intervention.
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This principle states that patients requiring treatment interventions focused on QoL assessment implemented in
should be able to obtain it [28] from trained profes- clinicalpracticeislacking[52].
sionals who have the skills to answer to patients needs Before undertaking a study for evaluating how an
with appropriateinterventions. intervention focused onQoL assessment worksin every-
day practice, it is essential to define the intervention and
4.Thecost ofproblem-finding(includingallthesteps itscomponents.
fromthe administrationofthe tooluntil theend of In this article, we defined a clinical intervention fo-
thetreatment–interventiondelivered) shouldbe cused on QoL assessment as a complex intervention be-
economicallyjustified. cause its components interact with one other in a
system that, by its very nature, is complex. There is a
This principle suggests that according to the Agency need to identify and then include the key components of
for Healthcare Research and Quality (AHRQ) [47] a the clinical intervention in an coherent evidence-based
cost-effectiveness analysis of interventions is essential. structure. Since clinical interventions focused on QoL
Similarly, a clinical intervention focused on QoL assess- assessment and the screening programs shared a number
ment to establish whether the improvement in patients of characteristics, the WHO Screening Principles frame-
outcomes justified the expenditures relative to other work [28] was used to outline the eleven essential princi-
choices should be considered. As an example, costs ples to be considered in developing and/or evaluating
could be related to staff time to (1) develop the clinical clinical interventions focused on QoL assessment in pal-
intervention focused on QoL assessment; (2) administer liative care. Moreover, the principles identified could
the QoL measure; (3) train the staff to use the tool; (4) represent a methodological and ethical standard to be
help patients and their families to understand and moni- considered when developing and evaluating a clinical in-
torQoL changes[48]. terventionfocusedonQoLassessmentinpalliativecare.
Furthermore, in palliative care the decision to imple- The QoL Assessment Principles in Palliative Care
ment this type of clinical intervention should not be could be a methodological standard because they in-
made on the basis of costs alone, but also considering tended to provide a guidance aimed at developing an
the ethical issues. Researchers have shown that cost sav- organized integrated clinical intervention where all the
ings are accrued when clinical decision making recog- components along the QoL assessment are planned and
nizes patients’ preferences, values and needs. From an interrelated. A single underlying characteristic of the
ethical perspective this means that when treatments that principles was developed in the attempt to provide a
no longer produce a benefit for the patient are discon- detailed guidance to evaluate each component of the
tinued, theycan improvethepatients’QoL[49]. clinical interventions focused on QoL assessment. The
QoL Assessment Principles in Palliative Care here pro-
5.QoL assessment shouldbeacontinuingprocessand posedcouldalsoimproveclinicalpracticebyconsidering
nota“onceand forall”project. QoL assessment as a complex intervention and not sim-
ply a task where the introduction of the tool in clinical
Thisprincipleaddressestheissue thatQoL assessment practiceistheonlyimportant element.
should be made at the baseline and then monitored over TheprinciplesdefiningtheQoL AssessmentPrinciples
time. This approach allows to understand how symp- in Palliative Care may be considered as an ethical stand-
toms and suffering develop, and fluctuate during the ill- ard because they are provided in a way that respects
ness trajectory [50] and recognize patients’ experiences people’s rights with palliative care needs. These princi-
andevaluatetheeffectivenessoftheinterventions[51]. ples could ensure that palliative care patients have
recognized their right to have poor QoL identified early
Discussion and followed-up, thus permitting to define appropriate
Palliative care aims to help patients and their families interventions that would maximize benefits and
have a better QoL by preventing and treating symptoms minimize harms and positively influence the quality of
related to the disease and to the treatment itself, and patientcaredeliveryandoutcomes.
addressing patients’ psychosocial and spiritual needs [1]. We started developing the QoL Assessment Principles
The QoL assessment in clinical practice is an important in Palliative Care in a way that has not been previously
part of palliative care resulting in several advantages for considered, by identifying both the theoretical basis and
patientsinterms of:1)problem identification[37];2)fa- the key components using the MRC framework ap-
cilitating patient decision making; 3) monitoring for proach. Although the MRC framework approach here
changes[23],and 4)facilitatingcommunication[32]. applied gives strength to this development stage and to
AlthoughmanyQoLmeasureshavebeendevelopedspe- the next steps, the paucity of strong evidence in includ-
cifically for palliative care [9], evidence about effective ing each component in the QoL Assessment Principles
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Abbreviations
T,KurdowR:Clinicaloutcomesandhealth-relatedqualityoflifeafter
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