Quality of life and health status in middle-aged presumed healthy Slovenian family practice attendees

Health-related quality of life (HRQoL) is an important measure of medical outcomes which has been shown to be associated with demographic factors and the most common mental and chronic somatic diseases (1).

Today’s family doctors (FD) encounter more patients suffering from more than one chronic condition than they did in the past (2). Since a cure for such patients is often impossible, an important goal of medical practice is now to improve patients’ quality of life (QoL) (3). QoL is an individual’s perception of their position in life in the context of the culture and value system in which they live, related to their goals, expectations, standards and concerns (4, 5). It has been increasingly used as an outcome measure to evaluate patients with chronic diseases (6, 7). HRQoL has been shown to be suitable for use in medicine due to its focus on patients’ health-related expectations. Generally, HRQoL is interpreted as the impact that health conditions and symptoms have on an individual’s QoL (8); with that in mind, the components of HRQoL are physical functioning, mental health, physical pain, general health, vitality, and social functioning (9, 10).

As an multidimensional way of measuring patients’ experience of their health, HRQoL is an important health outcome measure (11), and the concept of HRQoL has been recognised in its practical applications (12) and also as a central public health goal (13).

Disease-specific and multimorbidity-related impacts on HRQoL have already been well studied (14, 15, 16), but data about HRQoL in a population presumed healthy is scarce. In Slovenia, a study on HRQoL in family practice attendees was carried out in 2001 (17), but lacked objective information on health status. Ten years later a Slovenian study on HRQoL, which was carried out in the general population, included some self-reported data on health status, but no objective measurements such as laboratory tests (18).

Because most of the studies that have been performed so far were cross-sectional, little is known about changes in HRQoL over several years, or about any factors predicting a change in HRQoL. However, in a longitudinal, multi-centred study between 2003 and 2005, data were collected from 1118 consecutive attendees from 60 family medicine practices in Slovenia on QOL, socio-demographic factors, and the presence of mental disorders, with follow-ups after 6 and 24 months. Retrospective information on chronic diseases was obtained from the patients’ health records. In three time-sequential multiple linear regression models, data on 601 patients (53.8%) were analysed to determine the factors associated with each component score of QoL (1), aimed at identifying those factors which predict a change in HRQoL over a longer time interval. Average QoL was seen to improve over the two-year period. Factors significantly and consistently associated with a better mental component score of QoL were social support, satisfactory circumstances in the patient’s household, and absence of anxiety. Major life events in the past year and depression were shown to be risk factors for both mental and physical components, while the level of education, absence of long-term disability, and chronic pain were identified as predictors of the physical component (1). Besides condition-specific interventions for improving patients’ HRQoL (19), FDs are in need of evidence-based interventions for family practice attendees presumed healthy.

The primary objective of this study was to determine the overall Health-Related Quality of Life (HRQoL) of the presumed healthy, middle-aged, Slovenian population. The results were expected to be in concordance with research findings from neighbouring countries, with a relatively high overall HRQoL score. The secondary objective was to find associations between demographic characteristics, lifestyle data, clinical variables and self-reported HRQoL. The study hypothesis was that at least some indications of a mental disease would result in lower HRQoL scores. Similar results were expected in participants of greater age, higher body weight and those with a history of alcohol abuse.

A total of 986 participants completed the check-up. Almost two thirds (64.9%; n= 649) were women, aged 42.7±8.6 (30-66) years, with MEQ-5D-3L 0.91±0.15. The range of the EQ-5D-3L utility index was between -0.498 and 1.0.

The vast majority of the participants (95.8%) did not show any signs of depression. Their physical activity was inadequate in 7.6% cases and adequate or borderline adequate in 92.4% cases, and 62% had their nutritional habits marked as inappropriate. Only 5.0% abstained from alcohol; 90.1% were low-risk and 4.1% high-risk drinkers. Of the total, 86.4% were non-smokers; 63.7% had a Framingham cardiovascular risk score of less than 5%, and 4.3% had more than a 20-40% risk. The perception of stress was of low risk in the majority (96.6%). High blood pressure was measured in 12.2%, high levels of blood glucose in 0.6%, serum cholesterol in 22.8%, serum triglyceride in 10.3%, and LDL in 64.6% of the participants, respectively, and low serum HDL in 11.7% (Table 1).

Biochemical and other measures are presented in Table 2.

In the multivariate model, adequate physical activity was associated with higher EQ-5D-3L utility index (p=0.003). Lower EQ-5D-3L utility index was obtained in participants who were older (p<0.001), women (p=0.009), had signs of depression (p<0.001) or had high-risk perception of stress (p=0.013) (Table 3).

This study firstly aimed at assessing the overall QOL of the presumably healthy, middle-aged Slovenian population, and secondly at identifying the associations between demographic characteristics, lifestyle data, clinical variables and self-reported HRQoL. The average HRQoL (the mean EQ-5D-3L utility index) was very similar to the scores of the general population of comparable countries (0.91 for Slovenia, 0.915 for Italy, 0.915 for Germany) (25, 26); older age was associated with lower HRQoL (Table 3), similarly to several other studies (26, 27, 28, 29); and the same was true for perception of stress or signs of depression (27, 30, 31). Previous research in Slovenia focused on the correlation between the quality of life, chronic diseases and several other characteristics of patients in family medicine, and found the physical health score to be negatively associated with higher age, depression and a number of chronic somatic diseases (32). In Slovenian research, HRQoL has been shown to improve significantly in more highly educated people with good social support and satisfactory circumstances in their household, the absence of major life events in the past 12 months, good self-assessment of health, and the absence of depression, anxiety disorders or chronic pain (1); the results of this longitudinal research project expanded the previous evidence from cross-sectional population-based and clinical studies that investigated the association of several variables with HRQoL. A small number of studies have found a correlation between female gender and lower HRQoL (26, 29, 33), but others did not find such associations (18). The results of our study (Table 3) matched a positive correlation between physical activity and higher HRQoL with previous studies (28) (34), but contrary to our hypothesis, alcohol consumption did not lower HRQoL scores. As Černe et al. concluded in their review (35), the association between alcohol consumption and QoL in Slovenia has not yet been well studied; however, the results from other countries show a clear negative correlation between alcohol consumption and HRQoL (36). The explanation for our findings could lie in the inability of the EQ-5D to detect lower psychological well-being in alcohol-dependent subjects without signs of anxiety and/or depression, as Günther et al. observed in their study (37).

The population norms presented by Prevolnik Rupel et al. (38) were also very informative in interpreting this study’s results, since participants were “presumed healthy” and comparisons with various patient groups would not make a lot of sense. In our study, blood pressure, fasting glucose and lipid levels were not associated with statistically significant variability in EQ-5D-3L utility index (Table 3). Studies on patients with a diagnosis of hypertension found a lower HRQoL in people with a confirmed diagnosis than in those without a diagnosis of hypertension (39, 40), but this is not concordant with our study’s results, which showed that even patients with higher blood pressure values did not have statistically significant lower EQ-5D-3L utility index scores. However, in a previous study carried out in Slovenia, Selič et al. (41) reported the burden of somatic co-morbidity to be smaller than the impact of psychosocial determinants when identifying patterns of physical co-morbidity and factors associated with the onset of depression. Psychosocial determinants, i.e. the feeling of safety at home and the absence of problems in intimate relationships, were interpreted as a protective factor (41). On the other hand, in a longitudinal study of the predictors of HRQoL in patients with arterial hypertension, Maatouk et al. reported that most somatic diseases were associated with a lower HRQoL after five years (42). In another Slovenian study, Černe et al. (1) reported that neither the impact of the severity of chronic somatic disease, nor the time since diagnosis could be proven, although these are known to have a particular impact on HRQoL according to patients’ adaptation to disease, as stated by Schwartz and Sprangers in their response shift theory (43). We embrace the explanation that individuals experiencing a change in their health status may also change their appraisals, internal standards and values with regard to HRQoL, and will try to research possible associations further.

On the other hand, it could be speculated that the results of this study (Table 3) could be due to a shorter duration of the negative effects of high blood pressure. A similar explanation could be used to explain lower HRQoL scores in patients with dyslipidemia (44). In people with diabetes mellitus, the results from previous studies are not so univocal, as Jain et al. found no degradation of HRQoL scores in patients with the diagnosis (16), while Lu et al. found significantly lower scores in these patients (45). Again, we can assume that this study’s participants had mostly not had diabetes for an extended period of time, which would result in complications and degrade the HRQoL, as has been studied before (46).

This study showed that even presumably healthy family practice attendees may have a lower HRQoL due to certain demographic and/or clinical characteristics. This is an important finding for preventive medicine, and warns that targeted interventions may also be necessary for people without known diseases.

If we were to improve the quality of life of people presumed healthy, one would need to turn towards the determinants that were found to be associated with lower HRQoL values. Dealing with stress, improving physical activity and addressing the signs of depression should be some of the main topics at preventive check-ups in family care practices. Although FDs are not able to control stressful life events affecting their patients, they can explore patients’ coping mechanisms, and provide information about active, rather than passive, coping strategies.