Quality of life measures can sometimes produce unexpected results. A study evaluated the effects of antihypertensive drug treatment on various aspects of well-being using interviews with the patients themselves, their spouses or "significant" others, and their physicians.2 The physicians reported no noticeable change in their patients' well-being, as blood pressure was usually controlled and the patients had not complained. In contrast, three-quarters of the spouses had noted moderate to severe deterioration in the patients' behaviors and attitudes. Adverse effects noted were a decline in energy and general activity, preoccupation with illness, changes in mood and memory, and reduced libido. Some patients admitted certain negative effects of treatment. In general, the effects of treatment on a person's well-being are best assessed by the patients themselves, or someone who knows them well, rather than by their physician.
The perceptions — "How do you rank your health?" and "How do you rank your well-being?" — are summary global measures that only the patient can address. They represent integrated responses to the overall positive and negative effects of a treatment. For example, does the pain relief of an anti-anginal drug outweigh the potential adverse effects of cold feet, fatigue or headache?
Assessment of HRQL is important not only in the treatment of chronic disorders, where one wants to avoid making symptoms worse, but also in life-threatening conditions, where the patient may regard the quality of life to be as important, or even more important, than the quantity of life. It is always essential that the patient should participate in treatment choice decisions.
Despite a lack of consensus on the definition of HRQL and the importance of measured changes, clinicians embrace the concept of HRQL and allow results from clinical trials to influence their prescribing habits. For example, a heavily promoted report1 comparing three antihypertensive drugs in terms of HRQL contributed to a marked increase in the use of ACE inhibitors for hypertension. Since hypertension is often asymptomatic, patients may be unwilling to accept the many adverse effects attributed to the various classes of antihypertensive compounds — impotence, insomnia, depression, cough, obstipation, dry mouth and reduced exercise performance. The decision to accept these problems may be most difficult in mild hypertension, where the risk for serious hypertensive complications is small for the individual patient.
Even intermittent conditions such as migraine headaches may affect a patient's HRQL, even between symptomatic attacks. For example, the uncertainty of when or where the next migraine headache may occur may cause patients to change their daily routine and avoid meetings, social gatherings, and travel. Despite the fact that HRQL issues such as this can greatly impact family and friends, they can be difficult to identify. Effective treatment of acute migraine not only can reduce the severity of the headaches themselves, but also can improve quality of life between attacks.
HRQL is equally important in life-threatening conditions such as cancers. Physicians, particularly in the past, often assumed that every effort should be made to extend life even if the odds of a successful outcome were small. This attitude has changed in recent years, and many patients with advanced cancers are now pressing for less toxic treatments and wish to spend more time at home. There has been a shift in the management of the cancer patient, with a focus now on improving the quality of life as well as survival.
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