Ian Coulter,Ph.D., Health Consultant, RAND Corporation, Santa Monica, CA

The development of HRQOL research at RAND arose out of four fundamental issues of health services research in the 1970's:

  • the measurement of clinical effectiveness in terms of outcomes assessment
  • the measurement of the quality of care
  • the growing acceptance of the validity of the perspective of the patient in measuring outcomes
  • the need of develop psychometrically acceptable instruments with known reliability and validity.
  • All of these concerns found their expression in two seminal research projects at RAND: the Health Insurance Experiment (1975); the Medical Outcomes Study (1986). Ware (1992) has noted that the HIE was one of the most extensive uses of psychometric methods for developing health status, particularly self-administered surveys, establishing these as reliable and valid. The HIE established a broad range of instruments to measure functioning and well-being. The MOS was also unique in at least one other respect in that it established the use of generic functioning and well-being measures. However, Ware further notes that the HIE left unanswered whether the same instruments and methods were valid for sicker and older populations and whether more efficient forms of the scales could be developed.

    The subsequent history of HRQOL work at RAND may be construed as continuing attempts to answer these questions over a broad range of patient groups (and various illnesses) and health care settings. Beginning with the MOS, and using a multi-dimensional model of health, the attempt has been to further refine existing measures, standardizing the measures, testing them over varying populations, and where necessary, developing new items and scales. However, this subsequent work differs from the MOS in two fundamental respects. The MOS project bought together a team of researchers with the specific purpose of creating the psychometrically acceptable instruments. To this extent, there was an identifiable group that developed the instruments. Since that time no such team existed at RAND where ongoing work tended to be project specific with HRQOL being an integral part of all projects. The recent award of a twenty million dollar HCSUS study for HIV positive patients, is possibly the only current equivalent to the MOS. For the most part however, the magnitude of the MOS is not likely to be duplicated in today's funding climate (some three dozen scales were developed in the MOS).

    This paper examines the post MOS history at RAND, documenting some of the work that has been done on HRQOL, which is currently being done, and what the future challenges are likely to be.

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