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Construct Overview of Health Status

Please note that this section is an archive and is no longer being updated.

Background

The World Health Organization (WHO) defines health as a state of "physical, mental, and social well-being, and not merely the absence of disease and infirmary."¹ This inclusive definition signifies a historical focal shift from simple mortality to broader concepts of well being and general functioning in assessing health². Accordingly, the term "health status" is often used interchangeably with "health-related quality of life" and "functional status"^2-4. However, despite a widespread implicit acceptance of the WHO definition of health, there is no broad consensus as to how health status should be operationalized⁵. For instance, recent empirical studies of "health status" have reported a wide variety of outcome variables, including objective clinical measurements6, behavioral health risk factors⁷, diagnoses and symptoms8, and functional and role limitations⁹.

Thus, depending on the theoretical framework adopted by the researcher, health status may reflect morbidity and symptoms, subjective perceptions of illness, limitations in daily activities, or other consequences of health state. Acknowledging the imprecision of the construct in a review of health status assessment methods, McHorney³ wrote, "...the common currency of health status assessment tools is the measurement of objective and subjective components of human functioning and well-being."

VA Relevance

Recent studies indicated that self-reported health status among veterans significantly predicted health care service utilization and mortality^12-14, although the value of health status information for predicting total health care costs is unclear¹⁵.

Differences in health status between sub-populations served by the VA may help inform targeted interventions and resource allocation. Clearly, varying levels of health burden are associated with different diagnoses and symptoms (see, for example, results of the Veterans Health Study for the contribution of different conditions to health status outcome scores¹⁰). In addition, health status disparities in veterans have been reported according to sociodemographic variables such as sex¹¹, age¹⁰, race/ethnicity¹⁶, rural versus urban setting¹⁷, and service era¹⁸.

In addition to characterizing the needs of VA service users, health status may also be measured as an outcome to evaluate the impact of clinical interventions, health care delivery systems, and other care-related parameters^19-21.

Measurement

Health status is conceptualized as a multidimensional construct that includes physical, mental, and social health components, all of which are subsumed by modern, comprehensive health status measures. Many measures yield a summary or total score that serves as a single index of health status. Summary scores are not especially meaningful at the individual level of analysis, as potentially thousands of combinations of item responses may result in the same score³. However, many health status measures also provide subscores reflecting specific conceptual (e.g., mental health) or functional (e.g., work performance, mobility) domains that may be more useful in detecting change within individuals or small samples over time.

Imprecision in the definition of health status has yielded a number of measures that differ meaningfully in the breadth and content of their items. Many of the commonly used health status measures reflect a broad conceptualization of health that includes concepts such as functional status and quality of life. The ultimate selection of a health status measure should be consistent with the researcher's conceptualization of health and the goals for measurement.

Ideally, generic health status measures should be reliable and valid across a broad range of clinical populations, with good sensitivity to clinically relevant change. The utility of existing generic health status measures in clinical outcome studies has not been consistently supported^3,22. Disease-specific health status measures offer an alternative means of assessing functioning and health status change within specific populations. Disease-specific measures may be most appropriate when evaluating outcomes of an intervention within a well-defined clinical sample, although generic health status may also be an appropriate secondary endpoint in some cases.

Although interviewer-administered health status instruments are available, patient-derived self-report measures of health are typically favored for their ease of use and for their emphasis on subjective health perceptions. Monitoring respondent compliance is important to minimize data loss, particularly when there is a risk of systematic bias resulting from non-response²². Having respondents complete measures in the clinical setting facilitates compliance monitoring.

Through literature review, METRIC identified three commonly used health status self-report instruments and ranked them according to number of citations, as determined by ISI Web of Knowledge²³. What follows is a brief summary of each instrument and three applicable references.

Most Frequently Cited Instruments

1. Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)
   [5,065 Citations]
2. Sickness Impact Profile (SIP)
   [2,208 Citations]
3. Nottingham Health Profile (NHP)
   [403 Citations]

1. World Health Organization. Constitution of the World Health Organization. Accessed August 2005. http://www.who.int/about/en/.
2. McDowell I, Newell C. Measuring Health. 2nd ed. New York: Oxford University Press; 1996.
3. McHorney CA. Health status assessment methods for adults: Past accomplishments and future challenges. Ann Rev Public Health 1999;20:309-335. [Abstract]
4. Patrick DL, Bergner M. Measurement of health status in the 1990s. Ann Rev Public Health 1990;11:165-183. [Abstract]
5. Bergner M, Rothman ML. Health status measures: An overview and guide for selection. Ann Rev Public Health 1987;8:191-210. [Abstract]
6. McNaughton SA, Mishra GD, Paul AA, Prynne CJ, Wadsworth MEJ. Supplement use is associated with health status and health-related behaviors in the 1946 British birth cohort. J Nutr 2005;135:1782-1789. [Abstract]
7. Centers for Disease Control and Prevention. Health status of Cambodians and Vietnamese - Selected communities, United States, 2001-2002. MMWR Morb Motal Wkly Rep 2004;53:760-765. [Abstract]
8. Selim AJ, Fincke G, Berlowitz DR, Miller DR, Qian SX, Lee A, Cong Z, Rogers W, Selim BJ, Ren XS, Spiro A 3rd, Kazis LE. Comprehensive health status assessment of centenarians: Results from the 1999 large health survey of veteran enrollees. J Gerontol A Biol Sci Med Sci 2005;60:515-519. [Abstract]
9. Hudson MM, Mertens AC, Yasui Y, Hobbie W, Chen H, Gurney JG, Yeazel M, Recklitis CJ, Marina N, Robison LR, Oeffinger KC; Childhood Cancer Survivor Study Investigators. Health status of adult long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. JAMA 2003;290:1583-1592. [Abstract]
10. Kazis LE, Miller DR, Clark J, Skinner K, Lee A, Rogers W, Spiro A 3rd, Payne S, Fincke G, Selim A, Linzer M. Health-related quality of life in patient served by the Department of Veterans Affairs: Results from the Veterans Health Study. Arch Intern Med 1998;158:626-632. [Abstract]
11. Skinner KM, Furey J. The focus on women veterans who use Veterans Administration health care: The Veterans Administration Women's Health Project. Mil Med 1998;163:761-766. [Abstract]
12. Payne SM, Lee A, Clark JA, Rogers WH, Miller DR, Skinner KM, Ren XS, Kazis LE. Utilization of medical services by Veterans Health Study (VHS) respondents. J Ambulatory Care Manage 2005;28:125-140. [Abstract]
13. Singh JA, Borowsky SJ, Nugent S, Murdoch M, Zhao Y, Nelson DB, Petzel R, Nichol KL. Health-related quality of life, functional impairment, and healthcare utilization by veterans: Veterans' quality of life study. J Am Geriatr Soc 2005;53:108-113. [Abstract]
14. Sprenkle MD, Niewoehner DE, Nelson DB, Nichol KL. The Veterans Short Form 36 questionnaire is predictive of mortality and health-care utilization in a population of veterans with a self-reported diagnosis of asthma or COPD. Chest 2004;126:81-89. [Abstract]
15. Pietz K, Ashton CM, McDonell M, Wray NP. Predicting healthcare costs in a population of veterans affairs beneficiaries using diagnosis-based risk adjustment and self-reported health status. Med Care 2004;42:1027-1035. [Abstract]
16. Villa VM, Harada ND, Washington D, Damron-Rodriguez J. The health and functional status of US veterans aged 65+: Implications for VA health programs serving an elderly, diverse veteran population. Am J Med Qual 2003;18:108-16. [Abstract]
17. Weeks WB, Kazis LE, Shen Y, Cong Z, Ren XS, Miller D, Lee A, Perlin JB. Differences in health-related quality of life in rural and urban veterans. Am J Public Health 2004;94:1762-1767. [Abstract]
18. Villa VM, Harada ND, Washington D, Damron-Rodriguez J. Health and functioning among four war eras of U.S. veterans: examining the impact of war cohort membership, socioeconomic status, mental health, and disease prevalence. Mil Med 2002;167:783-789. [Abstract]
19. Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, Buchanan J, Bagala R, Greenberg D, Paden G, Fihn SD, Katon W. Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care. J Gen Intern Med 2003;18:9-16. [Abstract]
20. Pitale S, Kernan-Schroeder D, Ameanuele N, Sawin C, Sacks J, Abraira C, et al. Health-related quality of life in the VA feasibility study on glycemic control and complications in Type 2 diabetes mellitus. J Diabetes Complications 2005;19:207-11. [Abstract]
21. Rumsfeld JS, Ho PM, Magid DJ, McCarthy M Jr, Shroyer AL, MaWinney S, et al. Predictors of health-related quality of life after coronary artery bypass surgery. Ann Thorac Surg 2004;77:1508-1513. [Abstract]
22. Calvert MJ, Freemantle N. Use of health-related quality of life in prescribing research. Part 2: Methodological considerations for the assessment of health-related quality of life in clinical trials. J Clin Pharm Ther 2004;29:85-94. [Abstract]
23. ISI Web of Knowledge, Accessed August 2005. http://isi01.isiknowledge.com/portal.cgi/wos/.