With the release of the Institute of Medicine’s report, To Err Is Human: Building a Safer Health System, the quality of our health care system has been at the center of the nation’s attention. The quality of health care has traditionally been measured by evaluating the structure and processes of the health care system. However, with the renewed awareness that patient outcome is the ultimate measure of quality, there has been a fundamental shift towards concentrating quality improvement efforts on patient-focused outcomes.

Accrediting organizations for health care providers— including the Joint Commission on Accreditation of Health Organizations and the National Committee for Quality Assurance—are increasingly interested in the measurement and documentation of patient-focused outcomes. Purchasers of health care services—including state and federal governments, insurers, and employers—are starting to concentrate on measuring important patient-focused outcomes such as health-related quality of life (HRQoL). For some chronic conditions, such as migraine or depression, HRQoL can be an important indicator of health care quality.
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Because of this fundamental shift, hospitals and pharmacists are beginning to collect and capture patients’ HRQoL as part of outcomes management programs. One of the most commonly used methods for capturing HRQoL is through self-administered questionnaires such as the Short Form-8 (SF-8), Short Form-12 (SF-12), or Short Form-36 (SF-36). The New England Medical Center has implemented outcomes management programs, assessing HRQoL via the SF-36, as part of routine clinical practice. In summary, patients complete an optically scannable SF-36 during hemodialysis treatment, peritoneal dialysis clinic, or nephrol-ogy clinic visits. Completed questionnaires are reviewed by staff for errors and then scored for results. Within one week, a report of individual patients’ responses is generated, reviewed, and placed on the patients’ medical charts. The patients’ responses are compared to previous SF-36 scores and any significant changes are discussed with the patients to help determine potential reasons for the differences. In this way, the SF-36 provides clinicians with a quantitative record of patients’ experience with illness as well as treatment.

The SF-36 is a widely accepted survey instrument for assessing a patient’s HRQoL. The SF-36 measures HRQoL in eight domains: Physical Functioning, Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, Mental Health, and it has two summary scores (Physical and Mental). The SF-36 has demonstrated its reliability and validity in multiple populations and can be administered in various ways. The SF-12 is an abbreviated version of the SF-36 health profile, consists of the two summary scores, and can be completed within three minutes. The SF-8 is an eight-question survey in which each of the eight dimensions of health measured by the SF-36 is represented by a single question. However, because of the brevity of both the SF-8 and the SF-12, they are usually embedded into longer, condition-specific surveys and not used as a single measure to capture HRQoL.
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There are four different methods for administering the SF-36. Traditionally, patients complete the questionnaire with a pencil and a scannable paper form. The completed surveys are then analyzed to generate scoring results and reports. This is the method that is used by the New England Medical Center. This requires some expertise and specialized computer software. Three newer methods for self-administration and analysis of SF-36 questionnaires rely on faxes, computer technology, and the Internet.

For fax-based scoring, a patient completes the SF-36 survey by the paper-and-pencil method, but the completed questionnaire is sent by fax to a vendor for analysis and scoring. The scored results are faxed back to the practice site within minutes. For the computer-based system, touch-screen technology allows patients to view each SF-36 question on a computer screen, and then touch the computer screen with a light pen to indicate their responses. Patients’ SF-36 questionnaire results are directly downloaded into a computer database. The computer touch-screen system provides SF-36 scoring results and reports them immediately, so the data are available for clinical review during the office visit. The last method of SF-36 administration and scoring is via the Internet. For the Internet, a service is offered in which an electronic database of patients’ completed SF-36 survey data can be developed, maintained, scored, and analyzed. The service allows clinicians to collect patients’ HRQoL data, monitor changes in patients’ health status over time, and download results for further analysis and reporting.
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With these different systems available, how does a health care organization or provider decide which system to implement to measure HRQoL as part of an outcomes management program to improve health care quality? There are various factors and issues that institutions need to consider before choosing the system that is most appropriate for them.