Rapid Responses to:

RESEARCH: Despina G Contopoulos-Ioannidis, Anastasia Karvouni, Ioanna Kouri, and John P A Ioannidis Reporting and interpretation of SF-36 outcomes in randomised trials: systematic review BMJ 2009; 338: a3006 [Abstract] [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Quality of Life Nonsense

Roger W Evans   (14 January 2009)

Quality of Life Nonsense 14 January 2009
Roger W Evans, Principal TransplantProfessionals.com, LLC (55902-1311) Send response to journal: Re: Quality of Life Nonsense	This paper is conceptually flawed and, therefore, in my opinion, it is theoretically and substantively insignificant. It does, however, contribute to a growing pile of rubbish associated with “quality of life” assessment. The SF-36 (and its numerous abbreviated iterations, such as the SF-8 and the SF-12) has never been, nor will it ever be, a quality of life index. At best, the SF-36 tells us something about life, but virtually nothing about the quality thereof. Despite a voluminous literature of increasingly dubious quality, few people seem to have any awareness as to the history behind the development of the SF-36. Even the developers apparently suffer from selective amnesia.1-5 From its humble beginnings, the index that eventually became known as the Short Form-36, or SF-36, was conceived of as a health status measure, wherein health was considered to be a multidimensional construct, consisting of physical health, mental health, social health, and the perceptions associated with each of these.5-10 Unfortunately, this conceptual confusion has had disastrous consequences for authentic quality of life research.11-15 Like a ubiquitous after market automobile accessory, the SF-36 has been “bolted on” to clinical trial after clinical trial.15 In turn, the analyses of said data have led to outrageously silly claims by dimwits concerning health care outcomes and accompanying benefits. Quality of life is a concrete, subjective, experiential variable which can only be inferred from relatively crude indicators.11,15 It is not the objective mirage which emerges when conceptual foreplay is followed by creative statistical manipulation in hopes of achieving a theoretically meaningful orgasm. Metaphorically speaking, pornography should not be confused with art, and, by analogy, quality of life should not be equated with health status. Health status is one of many independent predictors of quality of life outcomes which, in turn, are inferred from a variety of objective and subjective indicators.13-15 While such indicators are directly measurable, at the level of an individual, their implications can only be indirectly conjectured. Eventually, I suspect the SF-36 will be replaced with the SF-1, consisting of one item which has always been embedded in the SF-36 – In general, would you say your health is: excellent, very good, good, fair, or poor? Meanwhile, all things must pass, as George Harrison lyrically reminded us, and in the tradition of Neal Young, the proponents of the SF- 36, and the statisticians with whom they collaborate, will continue to sustain the euphoria inherent in their ignorance by merely “rolling another number (for the road).”16,17 1. Brook RH, Ware JE, Davies-Avery A, Stewart AL, Donald CA, Rogers WH, Williams KN, Johnston SA. Overview of adult health status measures fielded in RAND's Health Insurance Study. Med Care 1979; 17(7, Special Supplement):1-131. 2. Stewart AL, Hays RD, Ware JE. The MOS Short-form General Health Survey: reliability and validity in a patient population. Med Care 1988; 26:724-35. 3. Stewart AL, Ware JE. Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press, 1992. 4. Stewart AL, Ware JE, Brook RH. Advances in the measurement of functional status: Construction of aggregate indexes. Med Care 1981; 19(5):473-88. 5. Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36): I. conceptual framework and item selection. Med Care 1992; 30:473 -83. 6. Brook RH, Ware JH, Jr., Davies-Avery A et al. Conceptualization and Measurement of Health for Adults in the Health Insurance Study: Vol. VIII, Overview. Report Number R-1987/8-HEW. Santa Monica, CA: Rand, 1979. 7. Donald CA, Ware JE, Jr., Brook RH et al. Conceptualization and Measurement of Health for Adults in the Health Insurance Study: Vol. IV, Social Health. Report Number R-1987/4-HEW. Santa Monica, CA: Rand, 1979. 8. Stewart AL,Brook RH, Kane RL. et al. Conceptualization and Measurement of Health for Adults in the Health Insurance Study: Vol. II, Physical Health in Terms of Functioning. Report Number R-1987/2-HEW. Santa Monica, CA: Rand, 1979. 9. Ware JE, Jr., Davies-Avery A, Donald CA. Conceptualization and Measurement of Health for Adults in the Health Insurance Study: Vol. V, General Health Perceptions. Report Number R-1987/5-HEW. Santa Monica, CA: Rand, 1978. 10. Ware JE, Jr., Johnston SA, Davies-Avery A, Brook RH. Conceptualization and Measurement of Health for Adults in the Health Insurance Study: Vol. III, Mental Health. Report Number R-1987/3-HEW. Santa Monica, CA: Rand, 1979. 11. Leplege A, Hunt S. The problem of quality of life in medicine. JAMA 1997; 278:47-50. 12. Jim HS, Purnell JQ, Richardson SA et al. Measuring meaning in life following cancer. Qual Life Res 2006; 15:1355-1371. 13. Evans RW, Manninen DL, Garrison LP, Jr. et al. The quality of life of end-stage renal disease patients. N Engl J Med 1985; 312:553-559. 14. Evans RW. Quality of life assessment and the treatment of end- stage renal disease. Transplant Rev 1990; 4:28-51. 15. Evans RW. Reflections on quality-of-life “research” – a sinner’s plea for salvation. Graft 2001; 4:467-468. 16. http://www.youtube.com/watch?v=GytPv_v29lc 17. http://www.youtube.com/watch?v=dzk3zsxfoJA Competing interests: None declared