Impact evaluation and association with EuroQol 5D health-related utility values in Ménière's disease

Pyykkő e al. Sp inge Plus (2015) 4:717 DOI 10.1186/s40064-015-1527-0 RESEARCH Impac e alua ion andassocia ion wi hEu oQol 5D heal h- ela ed u ili y alues inMéniè e’s disease Ilma i Pyykkő1, Vinaya Manchaiah2,3,4* , Hilla Le o5 and E na Ken ala5 Abs ac The s udy was aimed a e alua ing he alidi y o impac measu es among pa ien s wi h Méniè e’s disease (MD) wi h ou come a iables o Eu oQol gene ic heal h- ela ed quali y o li e (HRQoL) measu es (i.e., EQ-5D) by using Visual Analogue Scale (VAS) and EQ-5D index alues. 183 membe s (ou o 200 con ac ed) o he Finish Méniè e Associa- ion e u ned he ques ionnai es ha hey had illed ou . Va ious open-ended and s uc u ed ques ionnai es ocus- ing on diagnos ic aspec s o symp oms and impai men caused by he disease we e used. Fo ac i i y limi a ion and pa icipa ion es ic ion, s anda dized ques ionnai es we e used. Open-ended ques ions on impac o he disease we e asked, and subsequen ly classi ied based on he WHO-ICF classi ica ion. The gene al HRQoL was e alua ed wi h EQ-5D index alue and EQ VAS ins umen s. Co ela ion and linea eg ession analyses we e used o explo e he asso- cia ion be ween HRQoL and o he aspec s. Based on he explana o y powe o di e en models he disease speci ic semeionic model p o ides he mos accu a e p edic ion in EQ-5D index calcula ions (38 % o he a iance explained). In EQ VAS sco es, HRQoL is mos accu a ely de e mined by pa icipa ion es ic ion (53 % o he a iance explained), bu he wo s p edic ion was in ICF-based limi a ions (8 % o he a iance explained). In e es ingly, a i ude and pe sonal ai explained he educ ion o HRQoL somewha be e han ICF-based a iables. Ac i i y limi a ion and pa icipa ion es ic ions a e signi ican componen s o MD, bu a e less equen ly ecognized as signi ican ac o s in sel -e alua ing he e ec o MD on he quali y o li e. The cu en s udy esul s sugges ha MD pa ien s seem o ha e p oblem iden i ying ac o s causing ac i i y limi a ion and pa icipa ion es ic ions and hence use he semio ic desc ip ion ocusing on complain s. Keywo ds: Méniè e’s disease, Quali y o li e, Eu oQol, EQ-5D, ICF, Ac i i y limi a ions, Pa icipa ion es ic ions © 2015 Pyykkő e al. This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. Backg ound Méniè e’s disease (MD) is commonly app oached as an o gan speci ic disease o he inne ea , and is assessed based on e igo, inni us, and hea ing loss; al hough, he beha io al es ic ions a e a mo e ex ensi e (O ji 2014). Conside ing he di e si y o his condi ion, quan i ying he impac o disease- ela ed di icul ies on measu es o quali y o li e (QoL) and heal h s a us u ili y ep esen s a con inuing challenge o esea che s. QoL is he pe cei ed quali y o an indi idual’s daily li e, and i can be measu ed by using s anda dized ins u- men s. A good QoL in ela ion o an indi idual e e s o a pe son managing daily li e ac i i ies and social ela ion- ships well (Williams 1985). The heal h- ela ed quali y o li e (HRQoL) is mo e speci ic and is ela ed o physi- cal, men al, emo ional, and social unc ioning; how- e e , a heal h s a us e e s o a holis ic concep , which is de e mined by ac o s which a e mo e han he p es- ence o absence o any disease. I is o en summa ized by li e expec ancy o sel -assessed heal h s a us, and mo e b oadly includes indica ions o unc ioning, physical ill- ness, and men al well being. Al hough he de ini ions o hese wo cons uc s a e simila , QOL and heal h s a us a e dis inc cons uc s (Smi h e al. 1999). Fo example, Open Access *Co espondence: inaya.manchaiah@lama .edu 2 Depa men o Speech and Hea ing Sciences, Lama Uni e si y, Beaumon , TX, USA Full lis o au ho in o ma ion is a ailable a he end o he a icle Page 2 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 when a ing QOL, pa ien s gi e g ea e emphasis o men- al heal h han o physical unc ioning. Howe e , his pa - e n is e e sed o app aisals o heal h s a us, o which physical unc ioning is mo e impo an han men al heal h (Smi h e al. 1999). The impac o MD can be e alua ed by using com- plain s a ed on he basis o se e i y (Le o e al. 2010), by di e en impai men ques ionnai es (Le o e al. 2013), o by using disease speci ic measu es (S ephens e al. 2010; Ka o e al. 2004). Va ious gene al measu es ha e been used o assess he e ec on HRQoL on MD pa ien s (Le o e al. 2012; Ande son and Ha is 2001; Sode man e al. 2002; Ya dley e al. 2003), bu only a ew s udies ha e explo ed he ac o s associa ed and esul ing in educed QoL (Le o e al. 2012; Ande son and Ha is 2001; Kin- ney e al. 1997). The disease-speci ic ins umen s end o be mo e esponsi e o psychological s a es and o symp- oms o MD, as compa ed o gene al heal h measu es ha ocus on b oade aspec s o he condi ions (Ka o e al. 2004; Le o e al. 2012; Diaz e al. 2007). Howe e , he applica ion o gene al heal h- ela ed ins umen s may miss clinically signi ican changes in QoL in a spe- ci ic illness because he ques ions a e oo b oad (G een e al. 2007). Mo eo e , he QoL measu es also seem o be in luenced by a i ude owa d he illness, o example, posi i e hinking (S ephens e al. 2010). Hence, a mo e ocused app oach may be necessa y o unde s and he impac o he diso de . The Wo ld Heal h O ganisa ion (WHO) has ecom- mended he In e na ional Classi ica ion o Func ion- ing, Disabili y and Heal h (ICF) o be used o desc ibe he complex associa ion among ac o s such as impai - men , unc ioning, ac i i y limi a ions, and pa icipa ion es ic ions caused by a diso de on human well-being [Wo ld Heal h O ganiza ion (WHO) 2001]. To pe o m such analysis in MD, Le o e al. (2010) used da a om open-ended ques ionnai es and classi ied he impai - men s wi h he ICF amewo k. The p edic ion o impac on QoL was less e icien when using ICF based classi i- ca ion when compa ed o using impai men ques ion- nai es, which deli e ed somewha di e en explana o y a iables (Le o e al. 2013; S ephens and Pyykko 2011). Also, i is impo an o no e ha using he ICF ame- wo k may p o ide much b oade unde s anding o he condi ion’s impac when compa ed o using disease-spe- ci ic ins umen s. The EQ-5D is a widely used su ey ins umen o measu ing economic p e e ences o heal h s a es. I is one o se e al such ins umen s ha can be used o de e mine he quali y-adjus ed li e yea s associa ed wi h a heal h s a e. When epo ing he gene al heal h EQ- 5D-3L (3L— e e ing o h ee le els in he esponse scale) esul s, usually ei he EQ-5D index alue o Visual Analogue Scale (EQ VAS) alue has been epo ed. The index alue and VAS e alua ions may di e be ween sub- jec s due o a ious easons as dynamic a ia ions o he disease (Bagus and Beale 2005). O he easons may be due o changes in social communica ion, pe sonal needs, and accep ance o he impai men . A be e knowledge o di e ences be ween VAS and EQ-5D index alues could help in ehabili a ion by p o iding unde s anding o he need o p ope enablemen p ocedu es o es o e he quali y o li e. Mo eo e , i is also impo an o unde - s and he ela ionship be ween di e en e alua ion app oaches (e.g., b oad s ocused) on he HRQoL. The aim o he cu en s udy was o e alua e he alidi y o impac measu es among pa ien s wi h MD wi h ou - come a iables o Eu oQol gene ic QoL (i.e., EQ-5D-3L) measu es by using VAS and index alue ins umen s. Me hod S udy design andpa icipan s Pe mission was ob ained om he Finnish Méniè e Fed- e a ion (FMF) o con ac hei membe s, asking hem o comple e an ex ensi e ques ionnai e on symp oms ela ed o MD. Unde Finnish law, his kind o ques ionnai e s udy pe o med in collabo a ion wi h pa ien associa ion does no need e hical app o al. Fo his pu pose, e e y six h name on hei membe ship lis was aken; hus, a sample composed o 200 indi iduals was con ac ed. They we e sen a 26-page ques ionnai e by mail as in ou p e- ious s udies (S ephens e al. 2010, 2012), oge he wi h a s amped and add essed en elope o hei esponses. Those no esponding wi hin 12weeks we e sen emind- e s. E e y e u ned ques ionnai e was examined; i he e we e missing da a, he esponden was con ac ed by el- ephone and asked o answe he unanswe ed ques ions so as o achie e comple e da a. In o al, 186 ou o 200 sen ques ionnai es we e e u ned, esul ing in a e u n a e o 93%; howe e , 3 ques ionnai es had signi ican amoun o missing alues and we e emo ed. The 183 pa icipan s had he mean age o 61.5, and he e we e 36 men and 147 women in he sample, e lec ing he gende sp ead in FMF. Ques ionnai es The o al ques ionnai e comp ised he Ve igo Ques ion- nai e (Ken ala 1996), he EQ-5D-3L measu e (Rabin and de Cha o 2001), he In e na ional Tinni us In en o y (ITI;Ché y-c oze and Colle 2005), The Hea ing Disabil- i y and Handicap Scale (HDHS;Philibe 1994), Localiza- ion ques ions based on he Hea ing Measu emen Scale (HMS;Chung and S ephens 1983), a Dizziness Handicap Ques ionnai e (DHQ;Ya dley e al. 1992), a Pa icipa- ion Res ic ion Scale (S ephens 2001), and he Sense o Cohe ence (SOC) Scale-Sho e sion (An ono sky and Sagy 1986). The e we e also some open-ended ques ions. Page 3 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 The speci ic es ic ion and unc ion limi a ion open- ended ques ion was wo ded as ollows: Please make a lis o he main e ec s ha you Méniè e’s disease has on you li e. W i e down as many as you can hink o . In his ask, i e lines we e indica ed o each subjec o ill. The ea e , he i ems we e classi ied based on ICF classi- ica ion [Wo ld Heal h O ganiza ion (WHO) 2001]. The classi ica ion was done independen ly by wo esea ch- e s. Howe e , ou esea che s discussed he analysis and a consensus was achie ed in ela ion o ICF codes. F om he 183 subjec s, 176 epo ed some e ec s o MD ha esul ed in some unc ional limi a ion. The classi ica ion p o ided 64 di e en en i ies belonging o 6 main ca ego- ies (Le o e al. 2010). The indi iduals we e asked o a e he impac o MD by asking, “How much does Méniè e’s disease in luence in you li e?”. The ques ion was scaled in i e s eps anging om no a all o e y se e ely. This ques ion was used as an ou come measu e o disease speci ic impac o MD on li e. In addi ion, he e ec o ca dinal symp oms on MD, as e igo, gai , hea ing, inni us, p essu e in he ea , hype acusis, and possible o he diso de s we e also a ed in a i e s ep scale om no e ec o e y se e e e ec . In modelling o impai men ela ed o MD and i s es ic ions, we used Eu oQol gene al heal h meas- u e, he EQ-5D. The EQ-5D ins umen consis s o wo pa s: i e ques ions ela ing o he dis inc dimensions o a pa ien ’s unc ional capaci y mobili y, sel -ca e, usual ac i i ies, pain/discom o , and anxie y/dep ession) on each o which 3 esponses a e possible, and a isual analogue scale (VAS) on which he pa ien is asked o indica e a sel - a ing o hei cu en heal h s a e. The o me a e combined wi h weigh ings de i ed om a sample o he gene al Eu opean popula ion o p o ide a ‘social a i ’ EQ-5D index alue (Dolan e al. 1995). The la e cons i u es a mo e di ec indica o o pa ien s’ own implici p e e ences. You can ind mo e in o ma ion abou he ques ions and a ing scale used in he EQ-5D by isi ing hei websi e (h p://www.eu oqol.o g/). Da a analysis The associa ion be ween EQ-5D-3L and o he aspec s (e.g., symp oms, ac i i y limi a ions, e c.) was analysed i s by explo ing associa ions wi h he Pea son co ela ion ma ix and hen by using he linea eg ession analysis me hod. In EQ-5D index alue, each s a e o he i e heal h- ela ed dimensions is assigned a he h ee unc ional le els o no p oblem, some p oblem, and ex eme p oblem. Resul s Fo he whole popula ion, he a e age EQ-5D index alue alues and EQ VAS alues a e shown in Table1. I also p o ides he pe cen age o s udy samples in h ee unc- ional le els in he i e dimensions o he EQ-5D. Figu e1 p esen s he EQ-5D index alue and EQ-5D VAS alues in he cu en sample sugges ing skewness in he EQ-5D index alue alues, whe eas EQ VAS alues a e domina ed by an e en en h alue in he scale. When indi idual sco es a e agg ega ed o a popula- ion sample, he esul an unc ion is inhe en ly nonlin- ea . Figu es2 demons a es he EQ-5D index alue and VAS alues o di e en age g oups. In EQ-5D index al- ues, he e ec o age was no signi ican ly dependen on age (F=1.206, p=0.305). Howe e , in he heal h sco e e alua ion on VAS scale in he age g oup o 50yea s, he VAS alues di e ed signi ican ly om olde age g oups (F=4.401, p<0.01), wi h olde age g oups sco ing wo se VAS alues. We he e o e s anda dized he e ec o age in linea eg ession analysis when he VAS ins umen was he ou come a iable. Table 1 The demog aphic de ails andsumma y o EQ-5D quali y o li e alues Pa ame e Mean (±SD) Lowe ange Uppe ange Age (in yea s) 61.5 (10.5) 22 91 Symp om du a ion (in yea s) 18.4 (11.1) 1 63 EQ-5D Index alue 0.75 (0.19) 0.29 1.0 EQ-5D VAS alue 71.2 (17.1) 20 100 No p oblem Some p oblem Ex eme p oblem EQ-5D Dimensions (% o popula ion epo ing he p oblem) Mobili y 59.6 40.4 0 Sel -ca e 97.3 3.7 0 Usual ac i i ies 74.3 33.4 3.3 Pain/discom o 44.8 50.8 4.4 Anxie y/dep ession (mood) 76.5 22.4 1.1 Page 4 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 In e nal associa ion o EQ sco e andi s associa ion wi h a ious symp oms andcomplain s associa ed wi hMD Table 2 p esen s co ela ion esul s o a ious symp- oms and componen s o MD wi h i e dimensions o he EQ-5D dimensions. In co ela ion analysis, mo ili y co ela ed wi h usual ac i i ies (0.55, p<0.001) and pain ( =0.33, p<0.001). The mood co ela ed wi h sel -ca e (0.20, p<0.001), usual ac i i ies ( =0.25, p<0.001), and pain ( =0.32, p<0.001). The sel -ca e co ela ed wi h usual ac i i ies ( =0.29, p<0.001) and mood ( =0.20, p < 0.001). Only mo ili y was biased by ageing o he subjec s wi h olde subjec s ha ing mo e p oblems wi h mobili y. Males also had mo e pain- ela ed complain s han emales. The du a ion o disease did no co ela e wi h any o he QoL componen s. Quali y o li e measu ed wi hICF o ien ed app oach Table3 demons a es linea eg ession model wi h he ICF-based limi a ions when EQ-5D index alue and VAS a e ou come a iables. In VAS e alua ion, he model consis ing om e igo, hea ing loss, and a sal - ee die was s a is ically signi ican ( =0.293, p < 0.001) and explained only 8.6% o a iance in VAS. In EQ-5D index alue model, wo a iables we e signi ican : impai men die a y impac and nausea. Also, his model was s a is i- cally signi ican ( =0.257, p<0.001) and explained 6.6% o a iance in EQ-5D index alue. Fig. 1 Dis ibu ion o EQ-5D Index alues (le ) and VAS sco es ( igh ) among 183 pa icipan s Fig. 2 Linea eg ession model ou come o age in EQ-5D index alues (le ) and VAS sco es ( igh ) Page 5 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 Quali y o li e measu ed wi hsymp oms o ien ed app oach Table4 demons a es a linea eg ession model consis ing o symp oms when EQ-5D index alue and VAS ins u- men s we e ou come a iables. In VAS e alua ion, he model consis ed o gai p oblems, balance p oblems, phys- ical s ain induced e igo, and sho age o ene gy. This model was s a is ically signi ican ( =0.624, p<0.001) and explained 38.9% o he a iance in VAS. In EQ-5D index alue model, h ee a iables we e signi ican : impai men o gai , balance p oblems and sho age o ene gy. Also, his model was s a is ically signi ican ( =0.634, p<0.001) and explained 37.8% o he a iance in EQ-5D index alue. No ewo hy was ha nei he hea ing p oblems no e igo co ela ed wi h quali y o li e in his s udy. Quali y o li e measu ed wi hac i i y limi a ions o ien ed app oach Fo assessmen o ac i i y limi a ions, inni us was assessed on a ITI ques ionnai e wi h 8 ques ions. The unc ional limi a ion o hea ing was assessed by a ques- ionnai e consis ing o 10 ques ions. Localiza ion o sound was assessed by a sound localiza ion ques ionnai e consis ing o 4 ques ions. The e igo was e alua ed wi h a e igo handicap ques ionnai e consis ing o 8 ques- ions. A o al o 24 ques ions we e analyzed. Table5 p esen s he linea s epwise eg ession analysis o ac o s desc ibing ac i i y limi a ions in MD on VAS and EQ-5D index based measu es o 5D QoL. The VAS ins umen based model consis ed o wo e igo linked a iables (walking on he sidewalk, bending p o oked e - igo, and ac i i y limi a ion by ea o ha ing an a ack), one inni us ela ed a iable ( equency o unbea able inni us), and one hea ing linked a iable (p oblems o hea ing a doo bell). The model was s a is ically signi ican ( =0.622, p<0.001) and explained 38.7% o he a iance in VAS. The EQ-5D index alue could be explained by e - igo-linked a iables ( empo a y ac i i y limi a ions and walking in open space), and one inni us linked a iable Table 2 Co ela ion o EQ-5D componen s wi h a ious aspec s o  he Méniè e’s disease includingsymp oms o  he dis- ease, ac i i y limi a ions andpa icipa ion es ic ions, pe sonal ai s, anda i ude *p≤0.05; **p≤0.01 Mo ili y Sel -ca e Usual ac i i ies Pain Mood Ve igo se e i y n.s. 0.19* n.s. n.s. n.s. Nausea AND omi ing n.s. 0.15* n.s. n.s. n.s. Tuma kin a ack 0.184* n.s. 0.252** 0.216** n.s. Balance p oblems 0.496** n.s. 0.451** 0.258** n.s. Uns eadiness 0.506** 0.198** 0.514** 0.321** n.s. Mo ing abili y 0.559** 0.357** 0.446** 0.386** n.s. Chai ise 0.442** 0.271** 0.381** 0.350** 0.176* Impac o e igo 0.249** 0.158* 0.272** 0.236** n.s. Tinni us impac 0.156* n.s. n.s. 0.125 n.s. Balance impac 0.569** 0.327** 0.433** 0.371** 0.225** Hea ing impac n.s. n.s. n.s. n.s. n.s. P essu e impac 0.226** 0.229** 0.214** 0.198** Anxie y/ne ousness 0.181* n.s. 0.219** 0.214** 0.349** Ene ge ics/ a igue 0.286** 0.159* 0.356** 0.344** 0.316** Sense o cohe ence −0.185* −0.182* −0.264** −0.272** −0.417** Table 3 Linea s epwise eg ession analysis o ICF-based limi a ions by he Méniè e’s disease wi hEQ-5D VAS andEQ-5D index alues asou come a iables Va iable VAS model, =0.293 EQ-5D index alue model, =0.293 Coe S.E. PCoe S.E. P Cons an 69.1 1.7 <0.001 0.78 0.02 <0.001 Ve igo −7.6 2.9 0.010 n.s n.s 0.168 Hea ing 6.9 3.9 0.012 n.s n.s 0.192 Die 0.7 4.2 0.022 n.s n.s 0.996 Nausea n.s n.s 0.543 −0.13 0.07 0.011 D ugs n.s n.s 0.161 0.22 0.05 0.003 Page 6 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 ( equency o unbea able inni us). The model was s a- is ically signi ican ( =0.558, p<0.001) and explained 29.6% o he a iance in EQ-5D index alue. Quali y o li e measu ed wi hpa icipa ion es ic ions o ien ed app oach The ques ionnai e ocuses on pa icipa ion es ic ions (consis ing o 30 ques ions) caused by heal h condi ion on con e sa ions, a eling, shopping, a eling o medical appoin men s, banks and o ices, a ending lea ning ci - cles, ela ionship o o he s, wo k ela ed ac i i ies,among o he s. Table 6 p esen s he linea s epwise eg es- sion analysis o ac o s desc ibing pa icipa ion es ic- ion in MD on VAS and EQ-5D index based measu es o 5D QoL. In VAS based model o quali y o li e, six a iables u ned ou o be indica i e (see Table6). The model was s a is ically signi ican ( =0.580, p<0.001) and explained 33.7% o VAS a iabili y. In EQ-5D index alue based model, only h ee a iables we e included in he model ha was s a is ically signi ican ( =0.457). EQ-5D index alue, p<0.001) could explain 17.3% o he a iabili y o EQ-5D index alue. In ac o ial analysis, he pa icipa ion es ic ion consis ed o 7 ac o s co e ing 68% o he da a. B oadly, he a iables associa ed wi h VAS-measu e consis ed o communica ion, lis ening, daily ac i i ies, social ac i i y, and lea ning es ic ions. The EQ-5D index alue associa ed a iables consis ed o es ic ions in social ac i i y and in daily ac i i y. In VAS measu e he hea ing impai men associa ed es ic ions domina ed, whe eas in EQ-5D index alue he pa icipa- ion es ic ion consis ed mainly om balance impai - men associa ed p oblems. The di e ence be weenEQ-5D index alue andVAS measu emen Table7 p esen s he summa y om he easibili y o di - e en pa ame e desc ip ions in he e alua ion gene al HRQoL wi h EQ-5D index alue and VAS ins umen s. Fo compa ison, a model consis ing o pe sonal ai s measu ed wi h SOC and sel - a ed anxie y is included. Based on he explana o y powe o di e en models, i seems ha he disease symp om speci ic semeionic model p o ides he mos accu a e p edic ion in EQ-5D index alue calcula ions (37.8%). In VAS sco es, QoL is mos accu a ely de e mined by pa icipa ion es ic ion (53.3%). The wo s p edic ion in bo h EQ-5D index alue and VAS models was in ICF-based limi a ions (5.6 and 7.9 % espec i ely). In e es ingly enough, a i ude and pe sonal ai s explained he educ ion o QoL somewha be e han he ICF-based a iables. Discussion The aim o he p esen s udy was o e alua e he alid- i y o impac measu es among pa ien s wi h MD wi h Table 4 Linea s epwise eg ession analysis o symp oms o  he Méniè e’s disease wi hEQ-5D VAS andEQ-5D index al- ues asou come a iables Va iable VAS model, =0.624 EQ-5D index alue model, =0.558 Coe SE PCoe SE P Cons an 84.8 1.8 <0.001 0.90 0.02 <0.001 Balance −3.8 1.6 0.017 −0.26 0.11 0.019 Gai −7.6 2.1 <0.001 −0.79 0. 14 <0.001 Physical s ain −3.3 1.3 0.013 n.s. n.s. 0.879 Ene gy −2.5 1.3 0.048 −0.06 0.01 <0.001 Table 5 Linea s epwise eg ession analysis o  ac o s desc ibing ac i i y limi a ions caused by he Méniè e’s disease wi hEQ-5D VAS andEQ-5D index alues asou come a iables Va iable VAS model, =0.622 EQ-5D index model, =0.558 Coe SE PCoe SE P Cons an 91.8 2.9 <0.001 0.94 0.03 <0.001 P oblems wi h gai on sidewalk −6.8 1.6 <0.001 −0.05 0.02 <0.032 Unbea able inni us occu ence −3.9 1.1 0.001 −0.04 0.02 0.020 Bending p o oking e igo −7.4 1.7 <0.001 -0.05 0.02 0.006 Hea ing doo bell inging −3.1 1.3 <0.05 n.s. n.s. 0.522 Ac i i y limi a ion (e.g., shopping) caused by e igo n.s. n.s. 0.144 −0.071 0.022 0.002 Page 7 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 ou come a iables o Eu oQol gene ic QoL. Fu he - mo e, di e ences be ween wo gene ic heal h e alua ion me hods in EQ-5D (EQ-5D index alue and VAS) we e explo ed. We ound ha he symp om p o ile o he dis- ease p o ided he majo ou come in gene ic HRQoL. The VAS ins umen had seemingly an inhe en p op- e y o include age-associa ed changes in pe o mance as well as in a i ude and pe sonal ai . I hese a i- ables we e added in he VAS-ins umen ha con ained he symp om p o ile, he eg ession (38.9–39.2 %) did no signi ican ly imp o e. In con as , he EQ-5D index alue -ins umen was ma kedly imp o ed by a i ude and pe sonal ai (i.e., 37.8–45.3 %). As hese meas- u es a e no wi hin he EQ-5D index alue –ins umen , he VAS-ins umen p o ides di e en aspec s o QoL in MD, which can be missed i only one ins umen is inspec ed. The a i udes owa ds he disease and pe - sonal ai played a mino ole in he es ima ion o QoL in MD, which is consis en wi h esul s om p e ious s udies by Le o e al. (2012) and S ephens e al. (2010). Vigo and ene gy a e no no mally explo ed in ela ion o MD, al hough he pa ien o en complains abou a lack o ene gy (S ephens e al. 2010). This a iable could pa ly explain he educ ion in QoL, and he di e ence in EQ-5D index alue and VAS scaling me hods. Values and alue judgmen s a e in insic o measu emen s o his so and need o be made explici . The esul s con i m he p e ious obse a ion ha he e is a sho age o el- e an and alida ed ques ionnai es assessing he impac o e igo o dizziness on gene ic QoL (Du acinsky e al. 2007). Co ela ion analysis indica ed ha mood (e.g., anxie y/ dep ession) was ela ed o e y ew aspec s o complain s and symp oms, whe eas he o he ou dimensions o he EQ-5D (mobili y, sel -ca e, usual ac i i ies and pain) we e associa ed wi h mo e complain s and symp oms o MD (see Table2). In addi ion, a ious in e nal co ela- ions we e obse ed (e.g., mo ili y co ela ed wi h usual ac i i ies and pain; mood co ela ed wi h sel -ca e, usual ac i i ies, and pain; sel -ca e co ela ed wi h usual ac i i- ies and mood). Mo eo e , some age and gende e ec s we e also no iced, al hough he du a ion o he disease Table 6 Linea s epwise eg ession analysis o  ac o s desc ibing pa icipa ion es ic ions caused by he Méniè e’s dis- ease wi hEQ-5D VAS andEQ-5D index alues asou come a iables Va iable VAS model, =0.580 EQ-5D index model, =0.457 Coe S.E. PCoe S.E. P Cons an 109.7 4.04 <0.001 0.89 0.07 <0.001 Pa icipa ing in lec u es −5.16 1.66 0.007 n.s. n.s. 0.968 Res ic ion on pe o ming household asks −5.50 1.89 0.036 −0.114 0.03 <0.001 Hea ing quie con e sa ion −5.38 1.92 0.006 n.s. n.s. 0.444 P oblems in isi ing doc o −6.22 2.15 0.005 n.s. n.s. 0.917 Loss o in e es in wa ching TV −5.78 1.91 0.003 n.s. n.s. 0.734 Res ic ion on ela ionships o close people by hea ing p oblem 8.22 2.23 <0.000 n.s. n.s. 0.40 Res ic ion on isi ing close people by hea ing p oblem −6.74 1.90 0.001 n.s. n.s. 0.223 T a eling alone n.s. n.s. 0.547 −0.34 0.02 0.059 P oblems s aying home alone n.s. n.s. 0.633 0.138 0.62 0.029 Table 7 Goodness o  i models desc ibing heal h ela ed quali y o li e wi hEQ-5D index alue andVAS ins umen s whene alua ed wi hICF-based limi a ions, symp om speci ic complain s, ac i i y limi a ions, andpa icipa ion es ic- ions a iables Fo compa ison, a i ude and pe sonal ai measu es a e included Measu able VAS (%) EQ-5D index alue (%) Méniè e impac (%) ICF-based limi a ions 8.6 7.9 8.7 Symp oms 38.9 34.2 48.3 Ac i i y limi a ions 38.7 32.1 47.2 Pa icipa ion es ic ions 33.7 17.3 53.4 A i ude and pe sonal ai 8.8 22.7 23.4 Symp oms, a i ude and pe sonal ai 39.2 44.8 51.1 Page 8 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 does no seem o be ela ed o any o he QoL compo- nen s. These obse a ions p o ide use ul in o ma ion o clinicians in managemen and ehabili a ion planning o MD pa ien s. This indica es ha lea ning o cope wi h he disease (Ken ala e al. 2013) does no necessa ily imp o e QoL as has been sugges ed (Ty ell e al. 2015). In he p esen s udy, he indi iduals wi h MD end o e alua e hei heal h wi h a symp oms based app oach a he han wi h he limi a ion o unc ion. Con ol o symp oms may be a mo e unde s andable way o imp o e he QoL and in luence he ins umen alues when com- pa ed o he e ec s o limi a ions and a ious es ic ions expe ienced by he pa ien . In his espec , ou obse a- ions con i m he concep ha condi ion speci ic symp- om measu es ha mi o ea men o condi ion o ce ain illness ha e high accep abili y and ele ance o pa ien s and doc o s (Kind 2001). They also can be in lu- enced by ea men , and a e sensi i e o change. In he he apeu ic p ocess, in e es has he e o e been ocused o change he medical ac o s educing he EQ-5D index alue and VAS sco es. Howe e , as indica ed in he p e- sen s udy, no all he i ems a e ela ed o medical con- di ions. Some o he VAS and EQ-5D index alue sco es a e linked o pe sonal ai and a i ude. Pe sonal ai is, howe e , esis an o changes as SOC is di icul o change in adul subjec s. Howe e , possibly some a i ude dependen a iables in ac i i y limi a ion and pa icipa- ion es ic ion can be in luenced by he apy as sho age o ene gy, abili y o d i e a ca , capabili y o do shopping, and he unce ain y wi h managemen a wo k. I medi- cal condi ions canno be alle ia ed, hen he ehabili a- i e e o s migh be ocused on hese domains in o de o imp o e accessibili y and emo e hind ances. One such e o is a pee suppo sys em, in ol ing pa ien - o- pa ien help, and also suppo om signi ican o he s can be enhanced. The WHO-ICF is a mul ipu pose classi ica ion designed o se e a ious disabili ies and heal h con- di ions [Wo ld Heal h O ganiza ion (WHO) 2001]. I speci ically aims o p o ide a scien i ic basis o unde - s anding h ough s udying heal h and heal h ela ed s a us, ou comes and de e minan s. ICF can be used as an explana o y amewo k ha may allow mo e com- p ehensi e unde s anding o he cha ac e o illness, and how i may be desc ibed and po en ially alle ia ed (Wade and Halligan 2003). The ICF p o ides a pa ien - cen e ed illness desc ip ion ha may p o ide use ul insigh s in o inding solu ions o o e come he impac o he condi ion. I was, he e o e, in e es ing o s udy he applicabili y o ICF o be used in a model desc ib- ing QoL. Wi h EQ-5D index alue and VAS alue, he ICF based limi a ions p o ides he possibili y o exam- ine di e ences om pa ien s’ pe spec i es and compa e hem wi h he pe spec i es o he obse e . Al hough he VAS and EQ-5D index alue based models yielded a he poo explana o y powe (8 %), he limi a ions loaded pa ly di e en ly in o he EQ-5D index and VAS models. The poo pe o mance in connec ion wi h QoL ins umen s may be due o wo ac o s: (1) pa ien s had p oblems iden i ying i ems limi ing hei ac i i ies when asked open-ended ques ions; o (2) al e na i ely hey had adap ed o hei cu en si ua ions and had hus no iden i ied exis ing p oblems i no speci ied by a ques- ionnai e. The o me op ion migh occu due o empo- a y changes in he disease, as pa ien s end o ocus on mo e ecen symp oms. The la e op ion would occu i he measu es o QoL would e lec o he aspec s o he illness as, o example, own will ha is no di ec ly desc ibed in ICF-classi ica ion. Bo h o hese aspec s may be ue and should be e alua ed in u he s ud- ies. One way o doing ha migh be o unde s and how he ICF-based app oach will ela e o QoL measu es when used wi h open-ended and s uc u ed ques ion- nai es. Howe e , he cu en s udy esul s indica e ha he pa ien s we e no able o iden i y he c ucial ac o s desc ibing he illness, o ha illness has mo e dimen- sions han de ined by ICF. In MD, he VAS alues seem o con ain addi ional i ems ha will con ound he e alua ion o he impac o he disease. Such con ounde s in he p esen s udy we e mood, a i ude, expec a ions o p og ess o he disease, and ageing among o he s. We also obse ed ha VAS includes some impo an i ems as cogni i e abili y, mem- o y, i ali y, and a la ge scale o social es ic ions ha we e no me in EQ-5D index alue -ins umen . In MD, he EQ-5D index alue measu es complain associa ed educ ion o ac i i y, and is adap ed o he ageing p o- cess. The EQ-5D index alue and VAS a e measu ing hus somewha di e en dimensions o he impac on gen- e al HRQoL in MD. The ICF-based i ems desc ibed by he pa ien s did no con ain elemen s ha could explain educ ion o QoL in he p esen s udy. This seems o be due o he e ogeneous esponses o he pa ien s exhibi ing a la ge scale o di e en opics in hei eplies. Conclusions The cu en s udy sugges s ha a mo e ocused symp- om o ien ed app oach is mo e sensi i e in ela ion o gene al HRQoL, whe eas he mo e comp ehensi e ICF- based app oach explained less a iance. The s udy iden- i ied di e ences be ween VAS and EQ-5D index alue, indica ing ha hey may assis in unde s anding di e en aspec s o QoL. O e all, hese indings sugges ha MD pa ien s seem o ha e p oblems iden i ying ac o s caus- ing ac i i y limi a ion and pa icipa ion es ic ions and use he semio ic desc ip ion ocusing on complain s. Page 9 o 9 Pyykkő e al. Sp inge Plus (2015) 4:717 Au ho s’ con ibu ions IP w o e he pape , pa icipa ed in collec ion and analysis o he da a. VM pa - icipa ed in he w i ing o he pape and con ibu ed in hea ing da a analysis. HL pa icipa ed in he w i ing o he pape and in collec ion and analysis o he da a. She made he analysis o quali y o li e, au al ullness and ICF s a egy. EK pa icipa ed in he w i ing o he pape and in collec ion and analysis o he da a. She made he analysis o pe sonal ai and coping s a egy. All au ho s ead and app o ed he inal manusc ip . Au ho de ails 1 Depa men o O ola yngology, Uni e si y o Tampe e, Tampe e, Finland. 2 Depa men o Speech and Hea ing Sciences, Lama Uni e si y, Beaumon , TX, USA. 3 Depa men o Beha iou al Sciences and Lea ning, The Swedish Ins i u e o Disabili y Resea ch, Linköping Uni e si y, Linköping, Sweden. 4 Audiology India, Myso e, Ka na aka, India. 5 Depa men o O ola yngology, Uni e si y o Helsinki, Helsinki, Finland. Acknowledgemen s This s udy has been conduc ed in coope a ion wi h he Finnish Méniè e’s Fed- e a ion (FMF) and has been inancially suppo ed by he Finnish Slo Machine Associa ion, RAY. 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