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Published ahead of print on June 1, 2004, doi:10.1164/rccm.200310-1421OC
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American Journal of Respiratory and Critical Care Medicine Vol 170. pp. 547-552, (2004)
© 2004 American Thoracic Society
doi: 10.1164/rccm.200310-1421OC

Original Article

Differences in Patient and Bed Partner–assessed Quality of Life in Sleep-disordered Breathing

J. Gabrielle Breugelmans, Daniel E. Ford, Philip L. Smith and Naresh M. Punjabi

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health; and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Correspondence and requests for reprints should be addressed to Naresh M. Punjabi, M.D., Ph.D., Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Baltimore, MD 21224. E-mail: npunjabi{at}jhmi.edu


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Sleep-disordered breathing (SDB) is associated with daytime sleepiness and impaired quality of life. Clinical experience suggests that there is a discrepancy between the information provided by the patient and the bed partner. Although this discrepancy is widely recognized, it is not known whether there are differences in quality of life ratings as reported by the patient and by the bed partner on the patient's behalf. Using the Short-Form 36 to assess quality of life in 122 patients with SDB (apnea–hypopnea index >= 5 events/hour), this study found that patients with SDB generally rate their quality of life higher than their respective bed partners. Systematic differences existed between the two raters in the following Short-Form 36 domains: physical functioning, general health, and vitality. Moreover, male patients reported a higher functional status compared with female patients relative to their respective bed partners. In contrast, no differences were noted between self and bed partner quality of life in normal subjects (n = 15) without SDB (apnea–hypopnea index < 5 events/hour) recruited from the general community. This study suggests that systematic differences exist between patient- and bed partner–assessed quality of life in SDB. Bed partner ratings provide supplemental information on quality of life impairment in SDB.

Key Words: bed partner • proxy ratings • quality of life • Short-Form 36 • sleep-disordered breathing

Sleep-disordered breathing (SDB) is a chronic condition that is characterized by frequent episodes of partial or complete upper airway collapse during sleep. The resulting decrease or cessation of airflow is often associated with recurrent drops in the oxyhemoglobin saturation and arousals from sleep. Common symptoms include loud snoring, restless sleep, and excessive daytime sleepiness. Epidemiologic data from the Wisconsin Sleep Cohort study indicate that at least 4% of men and 2% of women in the general population have SDB associated with daytime sleepiness (1). Without treatment, patients with SDB often report a general impairment in their daily functioning and demonstrate decrements in attention, vigilance, and memory (2–9). Moreover, there is strong evidence indicating that SDB is independently associated with incident hypertension (10) and prevalent cardiovascular disease (11–13).

It is now recognized that in addition to the cardiovascular morbidity and neurobehavioral consequences, individuals with SDB also manifest lower health-related quality of life compared with those without SDB (14–21). Previous studies on quality of life in SDB have employed a number of self-administered generic instruments, including the Medical Outcomes Study Short-Form 36 (SF-36) (22), Sickness Impact Profile (23), and the Nottingham Health Profile (24). Two disease-specific instruments for health-related quality of life in SDB are also now available and are increasingly being used in ongoing epidemiologic studies related to SDB (25, 26). A major assumption in studies on quality of life is that self-reported information reflects the full extent of the disease-related impairment in general health status.

Clinical experience suggests that information derived from the bed partner or a proxy can be invaluable in the initial evaluation and subsequent follow-up of patients with SDB. Although bed partner– or proxy-derived histories can have a significant role in clinical practice, there are no available studies that have examined whether patients and proxies provide congruent information on the patient's general health status. Numerous studies in other chronic disease states (27–35) illustrate that proxies can provide supplemental information on disease-related symptoms and the patient's functional status. Thus, the primary objective of this study was to determine whether systematic differences existed in the assessment of quality of life provided by the patient and by a bed partner on the patient's behalf. In addition to characterizing the difference between the patient and the bed partner–reported quality of life in SDB, the current investigation sought to determine whether any discernable difference was associated with factors including patient's age, sex, obesity, or severity of underlying disease, as assessed by the apnea–hypopnea index (AHI). Finally, for comparative analyses, differences in self- and bed partner–reported quality of life were also examined in normal subjects recruited from the general community.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Sample and Covariate Data
Patients with SDB were prospectively recruited from a consecutive series of new patients referred for polysomnographic evaluation. Eligibility criteria included age of 18 years or more and presence of a bed partner. Patients with a diagnosis of a sleep disorder other than SDB or on treatment with positive pressure therapy were ineligible. SDB was defined as an AHI of five events or more per hour during sleep. A total of 776 patients had polysomnography over the study period and met the definition of SDB. Of the 776 patients with SDB, 187 patients (24.1%) reported not having a bed partner, 456 patients (58.8%) reported having a bed partner, and 133 patients (17.1%) were nonresponders. From the 456 patients with a bed partner, 122 patient and bed partner pairs volunteered for the study with no discernable bias between participants and nonparticipants. For comparison, a sample of 15 subjects without SDB (AHI < 5 events/hour) or other medical conditions was also recruited from the local community. Approval for the study was acquired from the institutional review board, and informed consent was obtained from each participant and the bed partner.

Each participant completed a questionnaire that included information on age, sex, race, marital status, educational level, and Epworth Sleepiness Scale. Quality of life was assessed with the SF-36, a generic quality of life instrument that yields eight domain scores and two summary measures (36). Information from the patients with SDB was collected before the start of therapy. Bed partners were asked to complete a questionnaire, which included information on age, sex, race, and their assessment of the participant's quality of life using the SF-36. Bed partners also assessed their own quality of life and daytime sleepiness using the SF-36 and the Epworth Sleepiness Scale (37), respectively. To ascertain the bed partner's perspective on the participant's quality of life, the SF-36 was structured such that the bed partner was reporting for the participant (see the online supplement).

The polysomnogram consisted of continuous recordings of C3-A2 and C3-O1 electroencephalographic leads, right and left electrooculographic leads, and submental and bilateral anterior tibialis electromyograms. Respiration was monitored with thermocouples and thoracic and abdominal strain gauges, and oxygen saturation was obtained with a pulse oximeter. Sleep-stage scoring was performed on 30-second epochs according to standard criteria (38). Apnea was defined as a complete cessation of airflow for at least 10 seconds. Hypopnea was defined as any reduction in the airflow associated with an electroencephalographic arousal or a 4% drop in the oxygen saturation. The AHI was calculated as the total number of apneas or hypopneas per hour of total sleep time.

Statistical Analysis
Differences between group mean and median values were assessed with the t test and median test, respectively. Concordance between self- and bed partner–reported quality of life was examined by calculating magnitude and directionality of the difference between the self- and bed partner–reported scores. A positive difference indicates that the participant's rating was higher than the bed partner's rating of the participant. To adjust the observed difference for potential confounders, multivariable linear regression models were used. Because each participant had two ratings (e.g., self and bed partner), linear regression for repeated measures was used to model each SF-36 domain score. Regression models were constructed to account for the correlation between participant- and bed partner–reported data. A covariate was used to assess the difference between the two raters (see the online supplement) in regression models that included variables such as age, sex, body mass index (BMI), and AHI. The interaction between rater type and each of the covariates was also examined. The association between specific bed partner characteristics (e.g., bed partner's self-reported quality of life) and the difference between participant and bed partner score was modeled with multivariable linear regression.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The study sample consisted of 122 patients with 88 male (72.1%) and 34 female patients (27.9%). The characteristics of the patient sample are shown in Table 1. Polysomnography revealed that the patients had, on average, evidence of moderate to severe SDB with a mean AHI of 43.2 events/hour (SD, 25.6). Measurements of daytime sleepiness with the Epworth Sleepiness Scale revealed an average score of 12.9 (SD, 5.2). Bed partners of patients with SDB had a mean age of 49.2 years (SD, 10.4) and an average BMI of 27.6 kg/m2 (SD, 6.1). As a group, bed partners of patients with SDB did not report subjective daytime sleepiness on the Epworth Sleepiness Scale and had a mean score of 6.8 (SD, 4.1). In the sample of normal subjects without SDB (n = 15), the average age was 43.1 years (SD, 4.2), and the mean BMI was 23.8 kg/m2 (SD, 3.7). Table E1 (online supplement) provides a summary of other demographic variables for the normal subjects. There were no same-sex bed partners in either the patient or the normal samples.


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  		TABLE 1. Characteristics of patient sample

 
Figure 1 shows the average SF-36 domain scores for patients with SDB and for male and female patients separately. Using SF-36 data from the general population as a reference, patients with SDB reported a lower functional status on all SF-36 domains and summary component scores. Moreover, female patients consistently reported more impairment than male patients on each of the SF-36 domains (Figure 1). Women had a lower AHI compared with men (median AHI, 26.4 vs. 43.0 events/hour, p < 0.016) despite a higher BMI (median BMI, 35.9 vs. 31.1 kg/m2, p < 0.005). In contrast to patients with SDB, self-reported SF-36 scores in normal subjects were at or higher than the age- and sex-adjusted values from the general population (see Figure 1 in the online supplement).



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  		Figure 1. Self-reported quality of life on the Short-Form 36 (SF-36) in patients with sleep-disordered breathing (SDB). Left panel: p < 0.02 comparing each SF-36 domain in the patient sample to age- and sex-adjusted expected values. Right panel: *p < 0.02, **p < 0.0001 comparing male and female patients.

 
In patients with SDB, statistically significant differences were observed between self- and bed partner assessments of several SF-36 domains. Bed partner–reported quality of life scores (Figure 2) were consistently lower compared with those provided by the patient for physical functioning, general health, vitality, and physical component summary score resulting in a positive and significant difference (p < 0.001) for these domains that was independent of age, sex, BMI, and AHI. The associations between the observed difference between the two quality of life assessments and factors including patient's sex, age, and the AHI were subsequently examined. Men and women demonstrated a similar tendency to underestimate their functional status compared with their bed partners on the physical functioning and general health domains (Figure 3). However, a statistically significant (p < 0.01) and negative interaction between sex and rater was noted for several SF-36 domains with the opposing differences in men compared with women. Male patients generally reported a higher vitality score compared with their bed partners, whereas female patients reported a lower vitality score compared with their bed partners (Figure 3). A negative interaction between sex and rater was also observed for social functioning and the mental component summary scores (Figure 3). Patient's age and physiologic measures of disease severity, including the degree of nocturnal desaturation and AHI, were not associated with the difference in SF-36 scores between the two raters.



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  		Figure 2. Difference in quality of life ratings between the bed partner and the patient in SDB. *p < 0.01 for a difference > 0. {dagger}Point estimates and 95% confidence intervals for the difference between the patient and the bed partner are shown. Values are adjusted for the patient's age, sex, body mass index (BMI), and apnea–hypopnea index (AHI).

 


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  		Figure 3. Sex-based differences in quality of life ratings between the bed partner and the patient in SDB. *p < 0.01 for comparing the difference in ratings for males versus females. {dagger}Point estimates and 95% confidence intervals are shown for the average difference between patient and bed partner adjusted for the patient's age, BMI, and AHI.

 
Figure 4 displays the bed partner's self-reported quality of life. No significant differences were noted for any of the SF-36 domains between the bed partner sample and the expected normative values. Of the bed partner variables, age, BMI, and the Epworth score were not associated with the difference between the patient- and the bed partner–assessed SF-36 values. The effect of bed partner's own quality of life on the difference between the two raters was then examined. Using a cut-point of the median score in the bed partner's physical and mental component scores to define high and low quality of life subgroups, no systematic associations between the bed partner's own quality of life, as defined by either one of the two summary scores, were noted with the difference in assessments provided by the patient and the bed partner.



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  		Figure 4. Bed partner self-reported quality of life on the SF-36.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The primary objective of this study was to compare quality of life assessments provided by patients with SDB with the assessments provided by bed partners on the patient's behalf. This study has several key findings. First, self-reported quality of life scores were generally lower in patients with SDB compared with age- and sex-adjusted normative values. Second, systematic differences exist between quality of life as assessed by the patient and the bed partner. Bed partner–reported quality of life scores were lower compared with those reported by the male patient. In contrast, bed partner–reported quality of life scores were generally higher compared with those reported by the female patient. Third, except for the patient's sex, other characteristics such as age, BMI, AHI, and bed partner's own quality of life were not associated with the difference between patient and bed partner scores on the SF-36. Finally, no significant differences were noted in self- and bed partner–reported quality of life in normal subjects without SDB recruited from the general community.

The finding that there are systematic differences between self- and bed partner–reported quality of life in SDB was not unexpected. Patients are often unaware of the nocturnal signs of SDB, such as witnessed apneas and restless sleep, and tend to underreport the symptoms of daytime sleepiness. This study indicates that in addition to the underreporting of symptoms and signs associated with SDB, patients generally score higher on quality of life assessments compared with information provided by their bed partners. The discrepancy between self and bed partner reports may, in part, be related to patient's lack of recognition or denial of the potential impact that SDB has on general health. Because SDB is often insidious, patients may unknowingly adjust their expectations of general health during the preclinical phase. Alternatively, the observed differences between patient- and bed partner–reported quality of life might result if bed partners exaggerate the disease-related impairment from SDB. Nocturnal symptoms of SDB (i.e., loud snoring) often interfere with the bed partner's ability to sleep (39) that may, in turn, cause a reduction in their functional status and bias their reports. However, in this study, no significant associations were noted between the bed partner's own quality of life and the difference in ratings provided by the patient and the bed partner. In fact, bed partner reports of their own quality of life were, on average, not significantly different than age- and sex-adjusted expected values. The fact that SDB does not have a significant impact on the bed partner's quality of life, as assessed by the SF-36, has also been noted in a recent study by Parish and Lyng (40). Surprisingly, despite the absence of any significant differences from normative data, these investigators observed significant improvements in the bed partner's quality of life 6 weeks after the patients had initiated positive pressure therapy.

The results of this study demonstrate that the difference in perceived quality of life is influenced by sex, as reflected in male patients reporting a higher functional status compared with female patients relative to their respective bed partners. The effect of sex could be related to the fact that female bed partners in the study sample may have felt burdened by the patient's impairment and therefore rated the patient's quality of life lower compared with their male bed partners. Alternatively, men may not fully appreciate the impairment caused by SDB on their affected bed partners. Thus, it remains to be determined whether men underestimate and/or women overestimate the decrements in their bed partner's health status from SDB. It is also possible that the observed discrepancies in quality of life ratings are related to the differences in the clinical manifestations of SDB in men and women (41). Finally, differences in thresholds for seeking medical attention between men and women could also explain the sex differences in perceived quality of life. Referrals to sleep laboratories for women are significantly less than for men (42) possibly because of differences in symptom profiles and/or failure of the healthcare professionals in responding to the subtle symptoms of SDB in women (41, 43).

Although differences in quality of life as assessed by the patient and the bed partner have not been previously examined in SDB, the results of this study are consistent with several reports in other chronic diseases that have used proxy assessments of quality of life. In a study of patients with stroke, Segal and Schall (44) showed a poor correlation between patient- and proxy-reported health status. Similarly, in a study of people who are older and disabled, Pierre and colleagues (45) showed poor to moderate agreement between patient and proxy-reported quality of life. Studies in other chronic illnesses (46) including cancer (32, 34, 35) have confirmed that patients often underestimate the impairment in their quality of life compared with their proxies. Because many chronic illnesses are associated with major decrements in cognitive and neuropsychological function, the proxy serves as an invaluable source of patient-related information that would be otherwise unavailable. Despite the fact that SDB is associated with relatively mild neurocognitive impairment (2–8), this study provides support for the notion that proxies (i.e., bed partners) of patients with SDB may provide an additional and an alternative source of information with regard to the functional impact of SDB. Although the clinical value of patient- and bed partner–derived histories was not examined in this study, the disparity in health status as reported by the patient and the bed partner provides indirect evidence on questions of potential clinical significance. Of the eight SF-36 domains, significant differences between the patient and bed partner were observed for vitality, general health, and physical functioning. Thus, responses to questions regarding patient's level of fatigue, energy level, and limitations in performing physical activities should also be obtained from a bed partner or proxy when available (see the online supplement for specific questions).

Several limitations should be considered in the interpretation of this study. First, the patient sample used in this study was recruited from a clinical population. The use of a clinical sample can bias the difference in quality of life assessments between the patient and the bed partner away from the null as male patients with SDB are frequently referred for clinical evaluation because of concerns of their spouse or bed partner. Second, patient and bed partner pairs included in this study represent a convenient sample and thus may not provide generalizable estimates. However, comparisons between patients that were and were not enrolled revealed no significant differences in age, sex, BMI, or physiologic measures of disease severity. Third, this study required that bed partners complete the SF-36 on the behalf of the patient. The SF-36 was designed and validated as a self- and not as a proxy-administered instrument. Previous studies in other chronic illnesses have used a similar paradigm by employing self-administered instruments to assess proxy ratings. Moreover, data from normal individuals in this study indicate that self and bed partner reports on general health are not significantly disparate.

In conclusion, the results of this study reveal systematic differences in the perception of quality of life as assessed by the patient and a bed partner. Clinicians frequently need to consider quality of life when making decisions about the need for treatment of SDB. Depending exclusively on patient report of quality of life may be insufficient. Additional ratings from a bed partner or other family members that observe the patient on a daily basis could provide useful information on the impairment associated with SDB. Finally, future clinical and epidemiologic studies that examine quality of life in SDB should consider inclusion of bed partner–assessed quality of life as a supplemental measure for assessing the impact of SDB and the degree of improvement with therapy.


   Acknowledgments
 
The authors thank Terri E Weaver, Ph.D., F.A.A.N., R.N., C.S. (University of Pennsylvania School of Nursing), for her assistance in the review and interpretation of the data presented in this article.


   FOOTNOTES
 
Supported by the Agency for Healthcare Research and Quality (HS10786) and the National Institutes of Health (HL04065 and HL75078).

This article has an online supplement, which is accessible from this issue's table of contents online at www.atsjournals.org

Conflict of Interest Statement: J.G.B. does not have a financial relationship with a commercial entity that has an interest in the subject of this article; D.E.F. does not have a financial relationship with a commercial entity that has an interest in the subject of this article; P.L.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this article; N.M.P. does not have a financial relationship with a commercial entity that has an interest in the subject of this article.

Received in original form October 18, 2003; accepted in final form May 28, 2004


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230–1235.[Abstract/Free Full Text]
  2. Jennum P, Sjol A. Self-assessed cognitive function in snorers and sleep apneics: an epidemiological study of 1,504 females and males aged 30–60 years: the Dan-MONICA II Study. Eur Neurol 1994;34:204–208.[Medline]
  3. Naegele B, Thouvard V, Pepin JL, Levy P, Bonnet C, Perret JE, Pellat J, Feuerstein C. Deficits of cognitive executive functions in patients with sleep apnea syndrome. Sleep 1995;18:43–52.[Medline]
  4. Feuerstein C, Naegele B, Pepin JL, Levy P. Frontal lobe-related cognitive functions in patients with sleep apnea syndrome before and after treatment. Acta Neurol Belg 1997;97:96–107.[Medline]
  5. Kim HC, Young T, Matthews CG, Weber SM, Woodward AR, Palta M. Sleep-disordered breathing and neuropsychological deficits: a population-based study. Am J Respir Crit Care Med 1997;156:1813–1819.[Abstract/Free Full Text]
  6. Kotterba S, Rasche K, Widdig W, Duscha C, Blombach S, Schultze-Werninghaus G, Malin JP. Neuropsychological investigations and event-related potentials in obstructive sleep apnea syndrome before and during CPAP-therapy. J Neurol Sci 1998;159:45–50.[CrossRef][Medline]
  7. Naegele B, Pepin JL, Levy P, Bonnet C, Pellat J, Feuerstein C. Cognitive executive dysfunction in patients with obstructive sleep apnea syndrome (OSAS) after CPAP treatment. Sleep 1998;21:392–397.[Medline]
  8. Engleman HM, Kingshott RN, Martin SE, Douglas NJ. Cognitive function in the sleep apnea/hypopnea syndrome (SAHS). Sleep 2000;23:S102–S108.
  9. Adams N, Strauss M, Schluchter M, Redline S. Relation of measures of sleep-disordered breathing to neuropsychological functioning. Am J Respir Crit Care Med 2001;163:1626–1631.[Abstract/Free Full Text]
  10. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342:1378–1384.[Abstract/Free Full Text]
  11. Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D'Agostino RB, Newman AB, Lebowitz MD, Pickering TG. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study: Sleep Heart Health Study. JAMA 2000;283:1829–1836.[Abstract/Free Full Text]
  12. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Javier NF, Javier Nieto F, O'Connor GT, Boland LL, Schwartz JE, Samet JM. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19–25.[Abstract/Free Full Text]
  13. Mooe T, Franklin KA, Holmstrom K, Rabben T, Wiklund U. Sleep-disordered breathing and coronary artery disease: long-term prognosis. Am J Respir Crit Care Med 2001;164:1910–1913.[Abstract/Free Full Text]
  14. Gall R, Isaac L, Kryger M. Quality of life in mild obstructive sleep apnea. Sleep 1993;16:S59–S61.[Medline]
  15. Smith IE, Shneerson JM. Is the SF 36 sensitive to sleep disruption? A study in subjects with sleep apnoea. J Sleep Res 1995;4:183–188.[Medline]
  16. Jenkinson C, Stradling J, Petersen S. Comparison of three measures of quality of life outcome in the evaluation of continuous positive airways pressure therapy for sleep apnoea. J Sleep Res 1997;6:199–204.[CrossRef][Medline]
  17. Finn L, Young T, Palta M, Fryback DG. Sleep-disordered breathing and self-reported general health status in the Wisconsin Sleep Cohort Study. Sleep 1998;21:701–706.[Medline]
  18. Jenkinson C, Stradling J, Petersen S. How should we evaluate health status? A comparison of three methods in patients presenting with obstructive sleep apnoea. Qual Life Res 1998;7:95–100.[CrossRef][Medline]
  19. D'Ambrosio C, Bowman T, Mohsenin V. Quality of life in patients with obstructive sleep apnea: effect of nasal continuous positive airway pressure: a prospective study. Chest 1999;115:123–129.[Abstract/Free Full Text]
  20. Baldwin CM, Griffith KA, Nieto FJ, O'Connor GT, Walsleben JA, Redline S. The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep 2001;24:96–105.[Medline]
  21. McArdle N, Kingshott R, Engleman HM, Mackay TW, Douglas NJ. Partners of patients with sleep apnoea/hypopnoea syndrome: effect of CPAP treatment on sleep quality and quality of life. Thorax 2001;56:513–518.[Abstract/Free Full Text]
  22. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I: conceptual framework and item selection. Med Care 1992;30:473–483.[Medline]
  23. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Med Care 1981;19:787–805.[Medline]
  24. Hunt SM, McKenna SP, McEwen J, Backett EM, Williams J, Papp E. A quantitative approach to perceived health status: a validation study. J Epidemiol Community Health 1980;34:281–286.[Abstract/Free Full Text]
  25. Flemons WW, Reimer MA. Development of a disease-specific health-related quality of life questionnaire for sleep apnea. Am J Respir Crit Care Med 1998;158:494–503.[Abstract/Free Full Text]
  26. Weaver TE, Laizner AM, Evans LK, Maislin G, Chugh DK, Lyon K, Smith PL, Schwartz AR, Redline S, Pack AI, et al. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep 1997;20:835–843.[Medline]
  27. Rothman ML, Hedrick SC, Bulcroft KA, Hickam DH, Rubenstein LZ. The validity of proxy-generated scores as measures of patient health status. Med Care 1991;29:115–124.[Medline]
  28. Sprangers MA, Aaronson NK. The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease: a review. J Clin Epidemiol 1992;45:743–760.[CrossRef][Medline]
  29. Hays RD, Vickrey BG, Hermann BP, Perrine K, Cramer J, Meador K, Spritzer K, Devinsky O. Agreement between self reports and proxy reports of quality of life in epilepsy patients. Qual Life Res 1995;4:159–168.[CrossRef][Medline]
  30. Dorman PJ, Waddell F, Slattery J, Dennis M, Sandercock P. Are proxy assessments of health status after stroke with the EuroQol questionnaire feasible, accurate, and unbiased? Stroke 1997;28:1883–1887.[Abstract/Free Full Text]
  31. Magaziner J. Use of proxies to measure health and functional outcomes in effectiveness research in persons with Alzheimer disease and related disorders. Alzheimer Dis Assoc Disord 1997;11:168–174.
  32. Sneeuw KC, Aaronson NK, Osoba D, Muller MJ, Hsu MA, Yung WK, Brada M, Newlands ES. The use of significant others as proxy raters of the quality of life of patients with brain cancer. Med Care 1997;35:490–506.[CrossRef][Medline]
  33. Sneeuw KC, Aaronson NK, de Haan RJ, Limburg M. Assessing quality of life after stroke: the value and limitations of proxy ratings. Stroke 1997;28:1541–1549.[Abstract/Free Full Text]
  34. Sneeuw KC, Aaronson NK, Sprangers MA, Detmar SB, Wever LD, Schornagel JH. Evaluating the quality of life of cancer patients: assessments by patients, significant others, physicians and nurses. Br J Cancer 1999;81:87–94.[CrossRef][Medline]
  35. Sneeuw KC, Albertsen PC, Aaronson NK. Comparison of patient and spouse assessments of health related quality of life in men with metastatic prostate cancer. J Urol 2001;165:478–482.[CrossRef][Medline]
  36. Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 health survey manual and interpretation guide. Boston: New England Medical Center, The Health Institute; 1993.
  37. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14:540–545.[Medline]
  38. Rechtschaffen A, Kales A. Manual of standardized terminology, techniques and scoring system for sleep stages of human subjects. Washington, DC: U.S. Government Printing Office; 1968.
  39. Beninati W, Harris CD, Herold DL, Shepard JW Jr. The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc 1999;74:955–958.[Abstract]
  40. Parish JM, Lyng PJ. Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuous positive airway pressure. Chest 2003;124:942–947.[Abstract/Free Full Text]
  41. Kapsimalis F, Kryger MH. Gender and obstructive sleep apnea syndrome, part 1: Clinical features. Sleep 2002;25:412–419.[Medline]
  42. Larsson LG, Lindberg A, Franklin KA, Lundback B. Gender differences in symptoms related to sleep apnea in a general population and in relation to referral to sleep clinic. Chest 2003;124:204–211.[Abstract/Free Full Text]
  43. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20:705–706.[Medline]
  44. Segal ME, Schall RR. Determining functional/health status and its relation to disability in stroke survivors. Stroke 1994;25:2391–2397.[Abstract]
  45. Pierre U, Wood-Dauphinee S, Korner-Bitensky N, Gayton D, Hanley J. Proxy use of the Canadian SF-36 in rating health status of the disabled elderly. J Clin Epidemiol 1998;51:983–990.[CrossRef][Medline]
  46. Sneeuw KC, Sprangers MA, Aaronson NK. The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease. J Clin Epidemiol 2002;55:1130–1143.[CrossRef][Medline]



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