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September 27, 2000

Quality of Life at the End of Life

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(12):1513-1515. doi:10.1001/jama.284.12.1512

To the Editor: Dr Liao and colleagues1 addressed the important issue of compression of morbidity by analyzing data from the 1986 and 1993 National Center for Health Statistics National Mortality Followback Surveys, and found an overall improvement in quality in the last year of life among persons aged 85 years and older.

Unfortunately, this work is flawed because of major methodological differences in the 2 surveys. First, the questions used to estimate prevalence of impairments in activities of daily living (ADLs) are strikingly different in the 2 surveys. Questions in 1986 asked about help or use of special equipment to perform ADLs, whereas those in 1993 asked whether the decedent had any difficulty performing these tasks. These are very different concepts and may provoke different responses, thus introducing bias into the results. For example, persons using special equipment to walk or bathe may not be perceived as having difficulty. A recent study shows that individuals respond very differently to these 2 types of questions.2

The 1986 survey was primarily a mail survey; the 1993 survey was primarily a telephone survey with no mail interviews. Different modes of data collection may produce different results, but the authors did not identify these differences or evaluate this impact. Moreover, the 2 series of questions used to assess overnight stays in hospitals and nursing homes were quite different.

Unfortunately, Liao et al suggest that methods on the 2 surveys were identical and state that "considerable effort was made to maintain comparability of the 2 surveys, including design and data collection." They should provide readers with the information necessary to understand how these differences might have affected their results.

Liao  YMcGee  DLCao  GCooper  RS Quality of the last year of life of older adults: 1986 vs 1993.  JAMA. 2000;283:512-518.Google Scholar
Rodgers  WMiller  B A comparative analysis of ADL questions in surveys of older people.  J Gerontol B Psychol Sci Soc Sci. 1997;52:21-36.Google Scholar