Are health-related quality-of-life and self-rated health associated with mortality? Insights from Translating Research Into Action for Diabetes (TRIAD)
Introduction
Persons with diabetes and those with diabetic complications have an increased risk of mortality [1]. Measures of health-related quality-of-life (HRQoL) and self-rated health provide a subjective weighting of health problems that may not be captured with objective physical health assessments and may predict mortality in persons with diabetes [2]. Such measures can capture physical limitations which may impact mental functioning, which in turn can impact health by altering health behaviors, adherence with treatment plans, or the function of the immune, endocrine, and cardiovascular systems [2]. Self-rated health may also predict mortality because it provides a dynamic evaluation that reflects not only the current level of health but the trajectory of health, or the presence or absence of resources that can attenuate a decline in health [3]. Davis et al. suggested that the psychosocial impact of having diabetes might predict mortality, but their study, conducted 20 years ago, was limited by small sample size and their inability to adjust for demographic and socioeconomic risk factors for death such as race, education, or income [4]. Another study by Dasbach et al. showed that self-rated health predicted mortality in persons with diabetes after adjustment for physical health [5]. However, the authors did not examine cause-specific mortality and the study population was composed primarily of non-Hispanic white persons [5].
The purpose of this study was to reexamine the associations between HRQoL, self-rated health, and mortality, and to expand upon the previous research by assessing different measures of quality-of-life (the EQ-5D and self-rated health), by studying a racially and ethnically diverse population, and by examining both cardiovascular and noncardiovascular mortality. Our primary aim was to determine if HRQoL and self-rated health are associated with mortality in patients with diabetes after controlling for demographic, socioeconomic, and clinical risk factors for mortality and whether their assessment might identify persons at increased risk for death.
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Study setting and population
Translating Research Into Action for Diabetes (TRIAD) has been described in detail elsewhere [6]. In brief, six centers collaborate with 10 managed care health plans and 68 provider groups that serve approximately 180,000 Americans with diabetes. Patients ≥ 18 years of age with diabetes were sampled. Institutional Review Boards at each participating site and the Centers for Disease Control and Prevention approved the study. All participants provided informed consent.
A baseline survey was
Results
Of the 7892 persons included in our analyses, 749 (9%) died before January 1, 2005. The average length of follow-up was 3.7 years. The median age at death was 71 years and 54% of decedents were men. Fourteen percent of decedents were Hispanic, 18% black, 51% white, 9% Asian/Pacific Islander, and 8% of other races/ethnicities (Table 1). Of the 749 patients who died, 320 (43%) had a cardiovascular cause and 429 (57%) had a noncardiovascular cause listed as the underlying cause of death.
Compared
Discussion
Research has highlighted the importance of HRQoL and self-rated health in predicting health outcomes [3], [14], [15], [16], [17], [18], [19], [20]. We have shown a consistent relationship between the EQ-5D score and mortality after adjusting for demographic, socioeconomic, and clinical risk factors for death. While the mechanism for this relationship is unknown, we hypothesize that the long-term complications of diabetes may contribute to lower HRQoL that in turn affect self-care and survival.
Conflict of interest statement
The authors have no conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript.
Acknowledgements
This study was jointly funded by Program Announcement number 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding organizations. Significant contributions to this study were made by members of the TRIAD Study Group. A complete listing of the TRIAD
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