Mayo Nancy E, Scott Susan C, Bayley Mark, Cheung Angela, Garland Jayne, Jutai Jeffrey, Wood-Dauphinee Sharon
Division of Clinical Epidemiology, Royal Victoria Hospital Site, McGill University Health Center, Ross Pavilion R4.29, Montreal, QC, Canada,
Qual Life Res. 2015 Jan;24(1):41-53. doi: 10.1007/s11136-013-0605-4. Epub 2013 Dec 19.
The Wilson-Cleary (W-C) model of health-related quality of life (HRQL) has not been tested in stroke, and a better understanding of the components of HRQL during recovery would lead to a more integrated and person-centered approach to health management and outcome optimization for this vulnerable population.
To enhance our understanding for how QOL emerges from the sequelae of stroke during the recovery period, the aim was to empirically test a biopsychosocial conceptual model of HRQL for people recovering from stroke.
We present a multi-site longitudinal study of an inception cohort of 678 persons recruited at stroke onset and studied at key intervals over the first post-stroke year. As the most pronounced recovery after stroke occurs in the first 3 months, this time frame was chosen as the focus of this analysis. The measures for this study were chosen for their relevance to key constructs of stroke impact and for their optimal psychometric properties. Multiple measures for each of the W-C rubrics were available from instruments such as the Stroke Impact Scale, RAND-36, HUI, and EQ-5D, among others. A structural equation model (SEM) was fit using MPlus. To minimize potential bias arising from the missing data, multiple imputation was performed on the longitudinal data using SAS proc MI.
Of the 678 subjects who entered the cohort, 618 were interviewed at 1 month post-stroke and 533 at 3 months (486 and 454 had data at 6 and 12 months, respectively). A 3-month model with paths from biological factors to symptoms and symptoms to function fits well (CFI:0.966, RMSEA:0.044), though one model with paths from function to health perception did not (CFI:0.934, RMSEA:0.058). Allowing additional paths across non-adjacent rubrics improved fit considerably (CFI:0.962, RMSEA:0.044). A final model included emotional well-being under the symptom rubric (CFI:0.955, RMSEA:0.047). Including social support as an environmental factor had little impact on the model. Total variance in health perception explained was 76.3 %.
These results emphasize that to optimize overall HRQL during the crucial first 3 months of recovery, interventions need to continue to focus on comorbid health conditions and on reducing stroke impairments. A function-only focus too soon in the recovery process may not produce the desired impact to optimize HRQL.
健康相关生活质量（HRQL）的威尔逊 - 克利里（W - C）模型尚未在中风患者中进行测试，更好地了解康复期间HRQL的组成部分将有助于为这一弱势群体制定更综合、以患者为中心的健康管理和优化结果的方法。
为了加深我们对中风恢复期后遗症如何产生生活质量的理解，目的是通过实证检验中风康复患者HRQL的生物心理社会概念模型。
我们对678名在中风发作时招募的初始队列进行了多中心纵向研究，并在中风后的第一年的关键时间间隔进行研究。由于中风后最明显的恢复发生在头3个月，因此选择这个时间段作为本分析的重点。本研究的测量方法因其与中风影响的关键结构的相关性及其最佳心理测量特性而被选中。W - C每个分类的多个测量方法可从诸如中风影响量表、兰德36项健康调查、健康效用指数（HUI）和欧洲五维度健康量表（EQ - 5D）等工具中获得。使用MPlus拟合结构方程模型（SEM）。为了最小化缺失数据产生的潜在偏差，使用SAS过程MI对纵向数据进行多次插补。
在进入队列的678名受试者中，618人在中风后1个月接受了访谈，533人在3个月接受了访谈（分别有486人和454人在6个月和12个月时有数据）。一个从生物因素到症状再到功能的3个月模型拟合良好（比较拟合指数（CFI）：0.966，均方根误差近似值（RMSEA）：0.044），尽管一个从功能到健康感知的模型拟合不佳（CFI：0.934，RMSEA：0.058）。允许跨非相邻分类的额外路径显著改善了拟合度（CFI：0.962，RMSEA：0.044）。最终模型在症状分类下纳入了情绪幸福感（CFI：0.955，RMSEA：0.047）。将社会支持作为环境因素纳入对模型影响不大。健康感知的总方差解释率为76.3%。
这些结果强调，为了在关键的头3个月康复期优化整体HRQL，干预措施需要继续关注合并的健康状况并减少中风损伤。在康复过程中过早只关注功能可能无法产生优化HRQL的预期效果。
