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Health Related Quality of Life Differs

Between Male and Female Stone Formers

Kristina L. Penniston and Stephen Y. Nakada*,
From the Department of Surgery, Division of Urology (KLP, SYN) and the Department of Medicine, Nephrology Section (SYN), University
of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Purpose: Chronic urolithiasis often results in long-term health complications, frequent clinic visits, multiple interventions
and disruptions to patients lives. While the most valued treatment end point has been stone-free status, patient health
related quality of life should also be considered. Little is known about health related quality of life in stone formers. We
characterized the health related quality of life of stone formers at our institution.
Materials and Methods: After institutional review board approval all adult stone formers treated at our Metabolic Stone
Clinic from 1995 to 2006 were invited to participate. Of these patients 189 (36%) completed the SF-36v2 Health Survey, a
validated, 36-item, generic health and well-being questionnaire addressing physical, social and emotional domains. Com-
parisons of scores were made with those of U.S. norms and within-sample for demographic and clinical variables. Statistical
analyses included independent sample t tests and ANOVA.
Results: Compared to healthy adults, stone formers reported lower health related quality of life for general health (64.9
1.6) and bodily pain (69.4 1.6), and women reported greater impairment (61.4 2.4 and 66.5 2.4, respectively).
Comorbidities such as depression, diabetes, hypertension and overweight/obesity contributed to lower scores for many health
Conclusions: The health related quality of life of stone formers, especially women, is compromised compared to U.S. norms.
Women stone formers scored lower than men for physical and mental health. Clinicians should be aware of the risk of
impaired health related quality of life in stone formers. A new and promising end point in the management of urolithiasis is
improvement of health related quality of life. Studies that identify treatment strategies that maintain or improve health
related quality of life for individual patients are warranted.
Key Words: quality of life, kidney calculi, urolithiasis
rolithiasis is a debilitating condition with a reported
incidence of 10% to 15% among residents of the
United States.
The total annual direct cost of uro-
lithiasis in the U.S. is estimated to be nearly $2.1 billion.
Urinary stones typically affect people during their most
active and productive stage between 20 and 50 years old.
Urolithiasis is a chronic disease, often with a protracted
clinical course. Decreased productivity, loss of work time or
employment, renal failure and death, although extremely
rare, are documented outcomes of recurrent urolithiasis.
The lifetime recurrence rate for urinary stone formers is
50%, with the interval between recurrences estimated to be
10% within 1 year, 35% to 50% in 5 years and 50% or more
by 10 years.
The primary end point for treatment of urolithiasis has
historically been a stone-free state. Indeed, stone removal
has been improved with the advent of minimally invasive
techniques, but there is increasing interest in health effects,
potentially adverse, of even the least invasive options.
outcome that may be especially relevant to patients is qual-
ity of life. Surprisingly, little is known about the health
related QOL of patients with recurrent urolithiasis, many of
whom undergo multiple procedures during the course of
their disease, report for numerous clinic appointments and
take 1 or more medications to control the metabolic aspects
of the disease. Patients with more active stone disease fre-
quently report missing work and family events due to com-
plications of urolithiasis. Yet it is not known whether active
stone disease predicts decrements in QOL. Pain is a fre-
quently reported effect of recurrent urolithiasis, yet it can be
highly variable among individuals, even among those with
similar stone proles. With no direct one-to-one relationship
between disease severity and symptoms, health related QOL
could help clinicians appreciate the individual and variable
effects of similar disease status and treatment modalities,
and use this information in establishing appropriate goals
for disease management.
To our knowledge no study has previously been published
that assessed the general health related QOL of stone form-
ers at various disease stages. Studies on the health related
QOL of stone formers are limited to those involving patient
preferences in the treatment of urinary stones,
stent place-
and QOL following extracorporeal SWL or other
surgical modalities.
The objective of this cross-sectional
Submitted for publication March 20, 2007.
Study received institutional review board approval.
* Correspondence: Department of Urology, University of Wiscon-
sin School of Medicine and Public Health, 600 Highland Ave.,
G5/339 Clinical Science Center, Madison, Wisconsin 53792-3236
(telephone: 608-263-1359; FAX: 608-262-6453; e-mail: nakada@
Financial interest and/or other relationship with Cook Urologi-
cal, Inc.
0022-5347/07/1786-2435/0 Vol. 178, 2435-2440, December 2007

Printed in U.S.A.
Copyright 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.08.009
study was to characterize the relationships between demo-
graphic and clinical variables and the health related QOL of
patients with urolithiasis from our metabolic stone center.
Participants were recruited from the database of patients
treated at the Metabolic Stone Clinic of the University of
Wisconsin Hospital and Clinics (Madison, Wisconsin), a
comprehensive program including a multidisciplinary team
of nephrologists, urologists and a Registered Dietitian. Typ-
ically patients with a putative metabolic basis for urolithia-
sis are referred to the MSC by urologists. Since its inception
in 1995 the MSC has treated nearly 600 patients, the ma-
jority of whom have calcium stones. Of the patients with
viable addresses and contact information, 520 received an
invitation to participate in this cross-sectional survey study.
We did not select for patients with a particular stone
prole or for any other criteria other than having been or
currently being a patient of the MSC. A total of 189
subjects completed and returned the questionnaires
within the requested time frame resulting in a response
rate of 36.4%. A statistical comparison of the age of re-
sponders (189) and nonresponders (331) demonstrated
both groups to be comparable (p 0.05, table 1). Women
slightly overresponded compared to their percentage of
the total patient population. While women represent 44%
of the patient population within the MSC, the survey
respondents were 47% women. However, the gender com-
position of responders vs nonresponders was not statisti-
cally signicant (p 0.05, table 1).
We used a cross-sectional design to assess the health related
QOL of patients with urolithiasis. The University of Wiscon-
sin-Madison Health Sciences institutional review board ap-
proved all procedures in compliance with the Health Insur-
ance Portability and Accountability Act. Data collection
included a self-administered questionnaire which was
sent in the mail to each subject who provided consent, as
well as followup telephone calls to remind subjects to
return the questionnaire and/or to obtain missing infor-
mation, and medical record abstraction. Subjects who pro-
vided consent received up to 3 followup telephone calls as
reminders to return the questionnaires. The survey in-
strument was the SF-36v2 Health Survey, a validated,
36-item, generic health and well-being questionnaire ad-
dressing 8 QOL domains and including 1 general health
rating item, which asks respondents about the amount of
change in their general health during a 1-year period.
Subjects who returned the questionnaires were given a
$10 gift certicate to a restaurant with multiple locations
in the region.
Demographic information, stone composition, date(s) and
visit(s) to the MSC, history of surgical procedures and emer-
gency room visits, comorbidities, and other medical history
data were collected (table 2) using a data collection form and
extraction of data from medical records. A statistical com-
parison of these demographic variables between men and
women responders was made (table 2). Information about
stone composition was obtained from the medical records
and included reports of actual stone analyses as well as
reports by the nephrologist and/or urologist who evalu-
ated the patients. Participants with evaluable informa-
tion were overwhelmingly calcium stone formers (94%).
Those known or presumed to have any type of calcium
stone, including those in combination with other stone
types, accounted for 93% and 97% of the women and men,
respectively. Within our sample 5 women and 1 man had
cystine stones, and 2 women and 7 men had pure uric acid
Statistical Analysis
Scores for the 8 domains of the SF-36 were transformed to a
100-point scale and higher scores indicated better health
related QOL. We compared QOL scores within our sample
using 2-sample t tests under the assumption of equal vari-
ances. When a test for equal variances showed that they
were unequal, we used a Satterthwaite correction. In situa-
tions in which more than 2 groups were being compared we
TABLE 1. Age and gender characteristics of responders vs nonresponders
Responders Nonresponders All Invited p Value*
No. pts (%) 189 (36.3) 331 (63.7) 520 (100)
Mean pt age at rst clinic visit SEM 50.9 0.94 48.9 0.75 49.6 0.59 0.092
No. male (%) 100 (53) 193 (58) 293 (56) 0.23
No. female (%) 89 (47) 138 (42) 227 (44)
Mean male age SEM 52.3 1.2 51.1 0.92 51.5 0.73 0.43
Mean female age SEM 49.3 1.4 45.7 1.2 47.2 0.94 0.060
No. male age (%):
1824 1 (33) 2 (67) 3
2534 8 (28) 20 (71) 28
3544 18 (30) 41 (69) 59
4554 30 (36) 54 (64) 84
5564 25 (33) 51 (67) 76
65 or Older 18 (42) 58 (13) 43
No. female age (%):
1824 4 (25) 12 (75) 16
2534 10 (30) 23 (70) 33
3544 21 (38) 35 (62) 56
4554 22 (46) 26 (54) 48
5564 21 (43) 28 (57) 49
65 or Older 11 (44) 56 (10) 25
* p Values comparing age of responders to nonresponders are from 2 sample t tests under the assumption of equal variances. p Value comparing the percentage
of male responders vs nonresponders is from Fishers exact test.
used an ANOVA and performed pairwise comparisons with
Fishers protected least signicant difference tests. To de-
termine which comorbidities had the largest impact on
health related QOL scores we used a multiple regression
approach. We also applied the multiple regression approach
with respect to gender after differences for some domains be-
tween men and women were detected. p values 0.05 were
considered signicant. All analyses were performed using
SAS statistical software version 9. To determine the
magnitude of the differences between our sample popula-
tion and those of published U.S. norms (derived from a
racially diverse, nationwide, cross-sectional study of 2,474
persons without chronic disease 18 years old or older), a
difference of 5 or more points from the norms was consid-
ered clinically relevant for all health related QOL do-
mains except for role-physical and role-emotional, for
which a 10-point difference was required for a sample of
this size.
Comparison to U.S. Norms
Compared to healthy U.S. adults patients with urolithiasis
reported lower health related QOL for general health and
bodily pain (64.9 1.6 and 69.4 1.6, respectively) but not
for other domains (table 3). Compared to respective gender
norms from the U.S. population sample, women with uro-
lithiasis reported greater impairment than men in these
domains. The score of women stone formers in our sample
for general health was 61.4 2.4 compared to 70.6 for
healthy female norms. For bodily pain the scores for women
stone formers vs female norms were 66.5 2.4 vs 73.6. The
gure is a graphical representation of the scores for all
domains of men and women in our sample compared with
those of healthy men and women.
Within-sample comparisons and statistical analyses were
performed to explore differences based on gender, comorbid-
ity, number of surgeries, surgery type and other variables.
Statistically relevant gender differences were apparent with
women scoring lower then men in our sample for all domains
(transformed scores and 95% condence intervals for each
domain are presented in table 4). The differences were most
apparent for physical functioning (p 0.0092) and vitality
(p 0.0007), for which men and women stone formers
TABLE 2. Characteristics of survey respondents
Women Men Whole Group p Value*
No. pts 89 100 189
Mean pt age SEM 49.3 1.4 52.3 1.2 50.9 0.94 0.11
Mean kg/m
BMI SEM 29.8 0.78 29.1 0.56 29.4 0.48 0.65
No. family medical history pos for stones (%) 37 (42) 41 (41) 78 (41) 1.00
Mean MSC visits from 1/1/1995 (range) 3.4 (111) 3.7 (116) 3.5 (116) 0.48
No. pts with any stone surgery before 1/1/1996 (%) 21 (24) 31 (31) 52 (28) 0.33
No. pts with 1 or more surgeries (nonextracorporeal SWL)
from 1/1/1996 (%)
68 (76) 59 (59) 127 (67) 0.53
No. pts with 1 or more extracorporeal SWL from 1/1/1996 (%) 30 (34) 33 (33) 63 (33) 0.69
No. pts with 1 or more stone related emergency room visits from
1/1/2000 (%)
38 (43) 37 (37) 75 (40) 0.89
No. comorbidities (%):
Back pain/sciatica 9 (10) 9 (9) 18 (10) 0.81
Depression 17 (19) 5 (5) 22 (12) 0.0029
Coronary artery disease 1 (1) 10 (10) 11 (6) 0.011
DM 2 11 (12) 7 (7) 18 (10) 0.22
HTN 34 (38) 42 (42) 76 (40) 0.66
Irritable bowel disease/Crohns disease 13 (15) 11 (11) 24 (13) 0.52
MCS 25 (28) 12 (12) 37 (20) 0.0061
Osteoporosis/osteopenia 11 (12) 2 (2) 13 (7) 0.0074
More than 1 urinary tract infection 31 (35) 5 (5) 36 (19) 0.0001
Hyperlipidemia 20 (22) 31 (31) 51 (27) 0.19
Gastroesophageal reux disease 17 (19) 16 (16) 33 (17) 0.70
% Overweight 26 35 31 0.45
% Obese 40 33 36 0.63
% Normal wt 34 32 33 1.00
* p Values for continuous variables are from 2-sample t tests under the assumption of equal variances, and represent the difference between men and women
in the sample. p Values for discrete variables are from Fishers exact test and represent the difference in prevalence of comorbidity between men and women
in the sample.
BMI 18 to 25 characterizes desired or normal weight for height, BMI 25 to 30 represents overweight and BMI greater than 30 represents obese. Numbers
represent 36% of total sample for whom weight and height were available for BMI calculation.
Median 1.0.
Comorbidities have a prevalence of 10% or more for any group.
Back pain associated solely with kidney stones was not counted as back pain/sciatica.
TABLE 3. Health related quality of life scores of stone formers
vs healthy U.S. norms
Mean Stone
Score SEM
U.S. Norms
Difference Required
for Clinical
Physical functioning 83.8 1.6 84.2 5
Role-physical 82.1 1.8 81.0 10
Bodily pain 69.4 1.6 75.2 5
General health 64.9 1.6 72.0 5
Vitality 59.3 1.4 61.0 5
Social functioning 85.4 1.6 83.3 5
Role-emotional 85.4 1.5 81.3 10
Mental health 74.9 1.2 74.7 5
* Scores for U.S. norms are from Ware et al.
Criteria for clinically and socially relevant differences, which are domain
specic and sample size dependent, are dened by Ware et al.
Clinically signicant differences from U.S. norms, ie those exceeding the
criteria required by Ware et al.
scored 87.7 2.0 vs 79.4 2.4 and 63.7 1.7 vs 54.2
2.2, respectively. Of these 2 domains only vitality re-
mained signicantly different between genders in the
multivariable analysis (p 0.0019, table 5). Other statis-
tically signicant differences between men and women in
our sample were shown for role-emotional (p 0.022),
mental health (p 0.024) and general health (p 0.049).
However, differences for role-emotional and general
health were not signicant in the multivariable approach.
Table 5 tabulates the univariate and multivariable differ-
ences for women stone formers for all domains.
Results by comorbidity and BMI revealed differences
within the sample (table 5). QOL impairment was accen-
tuated among those who were overweight and obese, and
among those with depression, diabetes mellitus, hyper-
tension and musculoskeletal complaints. Other comor-
bidities (table 2) did not appear to affect QOL scores.
Neither the number of stone surgeries nor SWL proce-
dures were associated with differences in health related
QOL (data not shown).
In this cross-sectional survey we compared the health prole
of patients with stone disease from our clinical practice to
U.S. norms. Results indicate that stone formers have lower
health related QOL for general health and bodily pain.
Women stone formers scored lower against their gender
norms for general health and bodily pain than did male
stone formers. Comparisons within our sample showed that
women stone formers have clinically and statistically signif-
icant lower health related QOL than men for multiple do-
mains, more specically for physical functioning, general
health, vitality and mental health.
Comorbidities accentuate impairment in health related
QOL among stone formers. Overweight and obesity (preva-
lence of 66%for men and women in our sample) was associated
with decrements in physical functioning, role-physical and
general health. Diabetes mellitus (type 2) and hypertension,
distributed similarly among men and women stone formers,
were both associated with reduced health related QOL for
physical functioning and general health. Hypertension was
also associated with lower scores for role-physical, vitality
and social functioning. The presence of depression and mus-
culoskeletal complaints further reduced health related QOL
scores, specically for physical functioning, role-physical,
bodily pain, general health and social functioning.
In addition, depression decreased the score for the role-
emotional domain, and musculoskeletal complaints were
associated with a lower score for vitality. Of note, depres-
sion and musculoskeletal complaints were unevenly dis-
tributed among men and women in our sample. Depres-
sion prevalence was 19% for women and 5% for men. For
Comparison of health related quality of life of male and female stone formers (striped bars) with respective gender norms (solid bars).
, statistically signicant differences (p 0.05) determined from 2-sample t tests under assumption of equal variance, reecting differences
between men and women within stone former sample (striped bars). *, clinically signicant differences, those that met criteria dened by
Ware et al,
reecting differences between men and women within stone former sample (striped bars). PF, physical functioning. RP,
role-physical. BP, bodily pain. GH, general health. VT, vitality. SF, social functioning. RE, role-emotional. MH, mental health.
TABLE 4. Health related quality of life scores of men
and women within study sample
Mean Score (95% CI)
p Value* Men Women
Physical functioning 88 (84, 92) 79 (75, 84) 0.0092
Role-physical 85 (81, 89) 79 (73, 84) 0.062
Bodily pain 72 (68, 76) 66 (62, 71) 0.098
General health 68 (64, 72) 61 (57, 66) 0.049
Vitality 64 (60, 67) 54 (50, 59) 0.0007
Social functioning 88 (84, 92) 82 (77, 88) 0.10
Role-emotional 89 (85, 92) 82 (77, 87) 0.022
Mental health 77 (74, 80) 72 (68, 76) 0.024
* 2-Sample t tests under the assumption of equal variances.
musculoskeletal complaints prevalence was 28% vs 12%
for women and men, respectively. As more women than
men had depression and musculoskeletal complaints in
their medical histories, these comorbidities may partially
explain the gender differences in health related QOL de-
tected within the sample.
Studies of the health related QOL of recurrent stone
formers are needed for several reasons. The acuity of the
disease is driven largely by individual patient percep-
tions. Success in the treatment of urolithiasis may not be
eradication of the disease but control of patient symptoms,
which may improve patient QOL. Patient perceptions are
increasingly recognized as a factor in the quality of uro-
logical care. QOL is a primary end point in other clinical
settings including, but not limited to, those related to
cardiac, respiratory, neurological, musculoskeletal and
oncological diseases. The health related QOL of patients
with several urological diseases (erectile dysfunction,
prostate cancer, urinary continence and overactive blad-
der) have been studied.
There are potential limitations to our study. The ret-
rospective and cross-sectional design resulted in the in-
ability to assess baseline health related QOL of patients
before the development of stone disease. Future studies
could address this limitation by assessing and comparing
patients at similar points along the continuum of the
disease. In addition, although study subjects were similar
to nonrespondents with respect to age and gender (table
1), they may have differed with respect to the complexity
or activity of their disease, comorbidities, number of in-
terventions, etc. These differences could have inuenced
the results. As with other QOL studies, we cannot den-
itively conclude that we measured QOL and not the var-
ious effectors of it. Stress, for example, has been proposed
to have a role in calcium oxalate urolithiasis
and symp-
tomatic kidney stones.
Stress and other factors, in-
cluding psychosocial and socioeconomic elements, are
thought to inuence QOL.
Studies could be designed to
elucidate the true health related QOL of stone disease vs
that of various other QOL effectors. Finally, as our results
describe patients at a tertiary care center, results from
this study may not be clearly relevant to patients treated
in the community.
Regardless, we reliably identied impaired health related
QOL among stone formers, particularly women, compared
with U.S. norms. Certain comorbidities accentuated the de-
creased health related QOL including obesity, DM 2, HTN,
depression and MCS. Considering that obesity has been
linked to uric acid stone disease,
diabetes mellitus to risk
of urosepsis and HTN to renal failure, the importance of this
work is evident. Reports conrming an increased prevalence
of stones in women further add to the emphasis of this
Impaired health related QOL was identied in patients
with stones at our metabolic stone center in Wisconsin.
The results suggest a need for further studies of the
health related QOL of stone formers with the aim of
improving health outcomes. By understanding the health
related QOL of patients with urolithiasis, clinicians may
TABLE 5. Univariate and multivariable regression analyses of the
impact of gender and comorbidities on the health related
quality of life of stone formers
Univariate Multivariable
(effect size) SEM p Value Beta SEM p Value
Female 8.26 3.14 0.0092 7.20 5.01 0.16
Overweight* 13.62 6.24 0.033 13.68 6.27 0.033
Obese* 16.94 5.99 0.0061 12.21 5.94 0.044
Depression 10.97 4.89 0.026 2.11 6.81 0.76
Diabetes 16.47 5.28 0.0021 5.94 7.98 0.46
HTN* 10.67 3.16 0.0009 9.36 5.96 0.12
MCS 8.41 3.96 0.035 14.84 5.49 0.0088
Female 6.60 3.52 0.062
Overweight* 16.00 7.09 0.027 15.77 7.15 0.031
Obese* 15.06 6.80 0.030 12.20 6.86 0.080
Depression 16.44 5.39 0.0026 2.08 7.63 0.79
Diabetes 10.20 5.99 0.090
HTN 11.40 3.52 0.0014 7.61 5.99 0.21
MCS 14.97 4.33 0.0007 16.18 6.37 0.014
Bodily pain:
Female 5.42 3.26 0.098
Overweight* 10.79 7.30 0.14
Obese* 14.76 7.00 0.039 14.25 6.79 0.040
Depression 10.86 5.05 0.033 4.65 7.77 0.55
Diabetes 9.86 5.54 0.077
HTN 5.30 3.32 0.11
MCS 14.50 3.99 0.0004 14.89 6.43 0.024
General health:
Female 6.53 3.29 0.049 4.27 3.23 0.19
Overweight* 6.98 6.89 0.31
Obese* 6.33 6.60 0.34
Depression 10.80 5.11 0.036 2.70 5.09 0.60
Diabetes 18.26 5.48 0.001 10.24 5.66 0.072
HTN 12.99 3.26 <0.0001 11.14 3.42 0.0014
MCS 12.13 4.08 0.0034 11.01 4.05 0.0072
Female 9.52 2.77 0.0007 8.81 2.80 0.0019
Overweight* 5.68 6.13 0.36
Obese* 9.12 5.93 0.13
Depression 6.63 4.40 0.13
Diabetes 8.71 4.80 0.071
HTN 5.86 2.88 0.043 6.47 2.78 0.021
MCS 7.75 3.54 0.030 5.84 3.50 0.097
Female 5.35 3.28 0.10
Overweight* 9.18 7.15 0.20
Obese* 3.77 6.86 0.58
Depression 17.54 4.97 0.0005 13.82 5.12 0.0076
Diabetes 3.79 5.60 0.50
HTN 7.55 3.32 0.024 6.66 3.27 0.043
MCS 9.82 4.13 0.018 7.61 4.15 0.068
Female 6.83 2.95 0.022 5.11 2.97 0.088
Overweight* 7.26 5.78 0.21
Obese* 9.24 5.54 0.10
Depression 13.97 4.54 0.0024 12.22 4.63 0.009
Diabetes 7.97 5.05 0.12
HTN 4.09 3.03 0.18
MCS 5.71 3.74 0.13
Mental health:
Female 5.59 2.45 0.024 5.59 2.45 0.024
Overweight* 1.93 4.86 0.69
Obese* 4.33 4.66 0.36
Depression 7.31 3.83 0.058
Diabetes 6.30 4.20 0.14
HTN 0.0012 2.53 1.00
MCS 1.68 3.12 0.59
If the univariate analysis was signicant (p 0.05), multivariable regres-
sion analysis was performed. Data for factors with statistical signicance
are shown in bold.
* p Values represent the difference from normal weight respondents (BMI
less than 25). Data for factors with statistical signicance (p 0.05) are
shown in bold.
Refers to type 2 diabetes only.
Musculoskeletal complaints independent of complaints associated solely
with urolithiasis.
better understand the differential effects of the disease on
patients lives.
Abbreviations and Acronyms
BMI body mass index
DM 2 diabetes mellitus type 2
HTN hypertension
MCS musculoskeletal complaints
MSC Metabolic Stone Clinic
QOL quality of life
SWL shock wave lithotripsy
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In what is arguably the rst methodologically rigorous as-
sessment of quality of life in patients with recurrent uroli-
thiasis, the authors have denitively conrmed that kidney
stones are associated with bodily pain. Although men bear
about twice the stone burden as women in health care use,
the authors showed in multivariate analyses that women
stone formers bear the greater human cost when measured
as patient centered health outcomes (reference 2 in article).
This report conrms in stone formers the well established
general observation that women score worse than men
across the domains of the SF-36.
That these quality of life
impairments are magnied in individuals with depression,
diabetes, musculoskeletal disease or obesity is consistent
with the extensive literature on patient reported outcomes
and comorbidity ( and As
the authors acknowledge, this work serves as a solid descrip-
tive foundation on which to base hypothesis driven research.
Mark S. Litwin
Department of Urology
David Geffen School of Medicine at UCLA
Los Angeles, California
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MOS 36-item Short-Form Health Survey (SF-36): III. Tests
of data quality, scaling assumptions, and reliability across
diverse patient groups. Med Care 1994; 32: 40.