Quality of Life in Allergic Rhinitis and Asthma A Population-based Study of Young Adults BÉNÉDICTE LEYNAERT, CATHERINE NEUKIRCH, RENATA LIARD, JEAN BOUSQUET, and FRANÇOISE NEUKIRCH INSERM Unité 408, Paris; and INSERM Unité 454, Montpellier, France
Quality of life has been found to be impaired both in patients with asthma and in patients with allergic rhinitis, but the relative burden of these diseases has not been investigated. We analyzed answers to the SF-36 questionnaire from 850 subjects recruited in two French centers participating in the European Community Respiratory Health Survey, a population-based study of young adults. Both asthma and allergic rhinitis were associated with an impairment in quality of life. However, 78% of asthmatics also had allergic rhinitis. Subjects with allergic rhinitis but not asthma (n ⫽ 240) were more likely than subjects with neither asthma nor rhinitis (n ⫽ 349) to report problems with social activities, difficulties with daily activities as a result of emotional problems, and poorer mental well-being. Patients with both asthma and allergic rhinitis (n ⫽ 76) experienced more physical limitations than patients with allergic rhinitis alone, but no difference was found between these two groups for concepts related to social/mental health. As asthma was not found to further impair the quality of life in subjects with allergic rhinitis for concepts related to mental disability and wellbeing, and as subjects with asthma often also suffer from allergic rhinitis, further studies on quality of life in asthma should ensure that the impairment in quality of life attributed to asthma could not result from concomitant allergic rhinitis.
Interest in research into the quality of life has been increasing over the last 20 yr but this field is still disregarded by some (1, 2). However, it is now widely acknowledged that the personal burden of illness, as perceived by the patient, cannot be fully assessed by objective measures of disease severity, because for diseases such as asthma and allergic rhinitis, traditional clinical indices only moderately correlate with how patients feel and are able to function on a daily basis (3–5). Asthma is a chronic disease that can result in variable restriction in the physical, emotional, and social aspects of the patient’s life (6). Besides being bothered by the symptoms themselves, many patients have problems with physical activities and their everyday life may be limited by exposure to allergens and other environmental stimuli such as tobacco smoke (7). Allergic rhinitis is much more frequent than asthma (8, 9). Allergic rhinitis has been described as a disease that “may appear quite bearable to the nonsufferer” (10). However, it is associated with impairments in how patients function physically, emotionally, and socially and with difficulties at work or school (7, 9–14). The symptoms of allergic rhinitis (rhinorrhea, nasal congestion, and sneezing) are annoying in themselves, but patients also experience non-nasal symptoms that are troublesome, including headache, thirst, and disturbed sleep (7). Learning is
(Received in original form December 8, 1999 and in revised form April 18, 2000) Supported in part by grants from the Plan-Etat-Région Languedoc-Roussillon, Conseil Général Hérault, Ministre délégué à la Santé, and Glaxo-France. Correspondence and requests for reprints should be addressed to INSERM Unité 408—Epidémiologie, Faculté de Médecine X. Bichat, BP 416, 75870 Paris, Cedex 18, France. E-mail:
[email protected] Am J Respir Crit Care Med Vol 162. pp 1391–1396, 2000 Internet address: www.atsjournals.org
impaired in children, and some adults report a decrease in productivity and concentration (11). Asthma-specific quality-of-life questionnaires have been developed to quantify, in a formal and standardized way, the effects of asthma on the patient’s daily life and well-being, and the extent to which a given treatment reduces these effects (15–19). Disease-specific quality-of-life questionnaires have also been developed for allergic rhinitis (13). Generic qualityof-life questionnaires are also available and may be administered to any individual, thereby making it possible to assess the burden of illness in different conditions. Results of two clinical studies in which quality-of-life was assessed using the same generic questionnaire in subjects with asthma on the one hand, and in subjects with allergic rhinitis on the other hand, suggest that quality-of-life impairment in subjects with allergic rhinitis may be similar or even greater than that experienced by patients with asthma (6, 12, 14). Allergic rhinitis and asthma very often coexist in the same patients and both diseases impair quality of life (9, 20). However, very few studies have assessed the health-related quality of life of individuals with asthma or allergic rhinitis at the population level, and the relative burden of these two diseases has not been investigated (10). We therefore attempted to assess whether there was an interaction between asthma and allergic rhinitis on quality-of-life impairment in a population-based study of young adults. We assessed quality-of-life impairment in subjects with allergic rhinitis but not asthma and in subjects with both allergic rhinitis and asthma, and compared these two groups with healthy subjects.
METHODS Study Design Data were collected at two French centers, as part of the European Community Respiratory Health Survey (ECRHS). The methods of this international survey have been extensively described elsewhere (21). Briefly, 20- to 44-yr-old subjects were randomly selected from electoral rolls in the Eighteenth District of Paris and in Montpellier. They were sent a self-administered questionnaire on asthma and asthmalike symptoms derived from the bronchial symptom questionnaire of the International Union Against Tuberculosis and Lung Disease. Those who responded were then invited to attend the university clinic for further testing including an extended interviewer-administered questionnaire, and lung function measurements with methacholine challenge. A Mefar MB3 dosimeter (Mefar srl, Bovezzi, Italy) was used for the administration of methacholine. After phosphate-buffered saline was inhaled, subjects were administered methacholine until FEV1 had fallen by 20% or more from the postsaline value or until the maximal cumulative dose of 4 mg had been given. Subjects with a past history of asthma or wheezing were started on a dose of 0.0078 mg which was doubled for each subsequent administration. In other subjects, the methacholine was administered by quadrupling dose, starting with the minimum dose of 0.0156, and changing to 2-fold steps if FEV1 decreased by 10% or more.
Quality-of-life Questionnaire To assess health-related quality of life, the subjects examined in Paris and Montpellier were asked to complete the French version of the Short Form 36 (SF-36) questionnaire in addition to the general
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ECRHS protocol. The SF-36 questionnaire is based on the Medical Outcome Study survey (22). It is standardized, widely used, and has been validated and translated into several languages (23, 24). It comprises 36 items which are combined to measure eight concepts (Table 1). We used the three-step scoring system to calculate the values for the concepts from the questionnaire items as described in the SF-36 manual and interpretation guide (25). The first step involved recoding some items, the second step involved summing up the coding of the items in each concept scale, and the third step involved transforming the raw scales to 0–100 scales, with 100 indicating the most favorable health state. The Physical (PCS) and Mental (MCS) Component Summary measures were then computed as recommended by developers (26). This involved, first, standardizing the eight SF-36 scales using means and standard deviations from the study population (z-score transformation); second, multiplying each z-score by its respective factor score coefficients and computing the physical and mental aggregate scores; and finally, standardizing the aggregate PCS and MCS scores using a linear T-score transformation to have a mean of 50 and a standard deviation of 10.
Definitions of Asthma and Allergic Rhinitis Subjects were defined as current asthmatics if they (1) had had at least one asthma attack in the previous 12 mo, or (2) had a positive response to methacholine challenge (provocative dose causing a 20% reduction in FEV1 [PD20] ⭐ 4 mg), had smoked less than 12 packyears, and had given a positive answer to at least one of the following questions: “Have you had wheezing or whistling in your chest at any time in the last 12 months?” “Have you had an attack of shortness of breath that came on during the day when you were at rest at any time in the last 12 months?” “Have you been woken by an attack of shortness of breath at any time in the last 12 mo?” Asthmatic subjects with a FEV1 ⭐ 80% predicted, as well as those who reported having had at least 12 attacks of asthma, or having used oral steroids for respiratory problems, or having been hospitalized for respiratory disorders within the last 12 mo were considered to have severe asthma. Other asthmatic subjects were considered to have mild or moderate asthma. Symptoms of perennial rhinitis were defined as an affirmative answer to the question: “When you are near animals, such as cats, dogs or horses, near feathers, including pillows, quilts or duvets, or in a dusty part of the house, do you ever get a runny or stuffy nose or start to sneeze?” Symptoms of seasonal rhinitis were defined as an affirmative answer to the question: “When you are near trees, grass or flowers, or when there is a lot of pollen about, do you ever get a runny or stuffy nose or start to sneeze?” Subjects were considered as having al-
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lergic rhinitis if they answered positively to one or both questions on symptoms of rhinitis. All the subjects who had neither asthma nor allergic rhinitis were considered as control subjects.
Characteristics of the Subjects and Completion of the SF-36 Questionnaire Of the 1,116 subjects examined for stage II of the ECRHS in Paris or Montpellier, 881 filled in the SF-36 questionnaire (participation rate: 79%). Nonresponders were statistically different from responders only in age (mean values in Table 2). The prevalences of asthma and allergic rhinitis were similar in responders and nonresponders. Of the 881 subjects who completed the SF-36, 451 (51%) subjects had neither asthma nor allergic rhinitis (controls), 301 (34%) subjects had allergic rhinitis but not asthma, 21 (2%) subjects had current asthma without allergic rhinitis, and 77 (9%) subjects had both allergic rhinitis and current asthma. In the latter group, 10% of patients had a FEV1 lower than 80% of predicted, 12% had six to 11 asthma attacks in the last 12 mo, and 5% had 12 attacks or more. Fifty-two percent have been woken by an attack of shortness of breath in the last 12 mo; and 52% used inhaled 2-agonists. Use of oral steroids was reported by 13% of these asthmatics and use of inhaled steroids by 18%. A group of 31 subjects who reported symptoms (wheezing in chest, attack of shortness of breath at rest, or woken by an attack of shortness of breath) and had not smoked more than 12 pack-years were excluded from the analysis because they had not performed the methacholine challenge test. The characteristics of the responders are described in Table 2. Subjects with allergic rhinitis alone were younger than control subjects (p ⫽ 0.04), and subjects with allergic rhinitis plus asthma were younger than subjects with allergic rhinitis alone (p ⫽ 0.04). Compared with the control group, the proportion of women was higher in subjects with allergic rhinitis alone (p ⫽ 0.007) and in subjects with allergic rhinitis plus asthma (p ⫽ 0.05). Detailed scrutiny of the group of subjects with allergic rhinitis alone showed that 31% of men and 39% of women in this group had both seasonal and perennial symptoms. In subjects with allergic rhinitis plus asthma, the proportion of subjects with both types of symptoms were 59% and 64% in men and women respectively. The proportion of nonsmokers was similar for subjects with allergic rhinitis and for control subjects, whereas subjects with allergic rhinitis plus asthma tended to smoke less than either control subjects (p ⫽ 0.001) or subjects with allergic rhinitis only (p ⫽ 0.008). No differences between groups were found with regard to income. The completion of the SF-36 was excellent: 97% of the responders answered all 36 items. The few missing data were treated as recommended in the SF-36 manual and interpretation guide (25).
TABLE 1 INFORMATION ABOUT SF-36 HEALTH STATUS SCALES*
Concepts Physical functioning
No. of Items 10
Role limitations due to physical problems (“role physical”) Bodily pain General health
4 2 5
Vitality Social functioning
4 2
Role limitations due to emotional problems (“role emotional”) Mental health
3 5
Meaning of Scores Low Limited a lot in performing all physical activities, including bathing or dressing, due to health Problems with work or other daily activities as a result of physical health Very severe and extremely limiting pain Evaluates personal health as poor and believes it is likely to get worse Feels tired and worn out all of the time Extreme and frequent interference with normal social activities due to physical or emotional problems Problems with work or other daily activities as a result of emotional problems Feeling of nervousness and depression all of the time
High Performs all types of physical activities including the most vigorous without limitations due to health No problems with work or other daily activities as a result of physical health No pain or limitations due to pain Evaluates personal health as excellent Feels full of pep and energy all of the time Performs normal social activities without interference resulting from physical or emotional problems No problems with work or other daily activities as a result of emotional problems Feels peaceful, happy, and calm all of the time
* Adapted from Ware and Sherbourne (22). There is a further unscaled single item on changes in respondents’ health over the past year (this item was not relevant to our objective and hence not analyzed).
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Leynaert, Neukirch, Liard, et al.: Quality of Life in Rhinitis and Asthma TABLE 2 CHARACTERISTICS OF THE STUDY POPULATION SF-36 Responders
Age, yr Mean ⫾ SD Sex, n (%) Male Female Smoking habit, n (%) Nonsmoker Ex-smoker Current smoker ⬍ 12 pack-years Current smoker ⭓ 12 pack-years Household income per year*, n (%) ⬍ $18,180 $18,180–$30,624 ⬎ $30,624 SF-36 fully completed, n (%)
Asthma Alone (n ⫽ 21)
Allergic Rhinitis Plus Asthma (n ⫽ 77)
SF-36 Nonresponders (n ⫽ 235)
Controls (n ⫽ 451)
Allergic Rhinitis Alone (n ⫽ 301)
36.9 ⫾ 7.0
35.8 ⫾ 7.3
34.8 ⫾ 6.8
33.0 ⫾ 6.4
32.9 ⫾ 7.9
101 (43) 134 (57)
243 (54) 208 (46)
132 (44) 169 (56)
8 (38) 13 (62)
32 (42) 45 (58)
98 (42) 50 (21) 36 (15) 50 (21)
175 (39) 101 (22) 73 (16) 102 (23)
129 (43) 68 (23) 43 (14) 61 (20)
8 (38) 6 (29) 7 (33) 0 (0)
46 (60) 17 (22) 13 (17) 1 (1)
67 (32) 71 (34) 71 (34)
109 (26) 140 (34) 167 (40) 436 (97)
82 (29) 90 (32) 108 (39) 295 (98)
4 (21) 9 (47) 6 (32) 20 (95)
22 (32) 29 (42) 18 (26) 75 (97)
* Converted to dollars based on 1 US$ ⫽ 6.27 FrF.
Statistical Analysis In a first analysis, subjects with asthma were compared with subjects without asthma, regardless of allergic rhinitis, and subjects with allergic rhinitis were compared with subjects without allergic rhinitis, regardless of asthma. Then, subjects with allergic rhinitis alone and subjects with both asthma and allergic rhinitis were each compared with the control group and compared with each other (as there were only 21 subjects in the group of asthmatics without allergic rhinitis, comparison with this group may be hazardous and this group was excluded from this analysis). Chi-square tests were used to analyze contingency tables. Unpaired t tests were used to test differences in mean age. Mann-Whitney’s U-test was used to test if the distribution of the SF-36 scores was the same across the different groups, and to assess whether SF-36 scores were associated with sex, town, age (three age groups), income (three levels) and smoking habits (four categories). Subjects who reported having smoked more than 1 g tobacco a day for 1 yr or more were defined as heavy smokers if they had smoked more than 12 pack-years, and as moderate smokers otherwise. All smokers who had stopped at least 1 yr before the examination were defined as ex-smokers. A multivariate analysis of variance was performed to test differences in PCS and MCS scores between control subjects, subjects with rhinitis alone, and subjects with both rhinitis and asthma, after adjustment for sex, age, and smoking status. The SAS-PC statistical package (SAS Institute Inc., Cary, NC) was used for statistical analysis; p values less than 0.05 were considered significant.
RESULTS Factors Associated with Quality of Life
Table 3 shows the mean SF-36 scores across different groups according to the characteristics of the subjects. In this population of young adults, age was not an important determinant of quality-of-life scores. Men had significantly higher scores than women for physical functioning (p ⫽ 0.001), role physical (p ⫽ 0.004), bodily pain (p ⫽ 0.001), and vitality (p ⫽ 0.006). No differences in SF-36 scores were found between nonsmokers, ex-smokers, and moderate smokers. In contrast, heavy smokers had a worse quality of life than the other subjects for physical functioning, general health, vitality, role emotional, and mental health. Finally, no consistent association was found between income and quality of life.
Relationships between Quality of Life, Asthma, and Allergic Rhinitis
Subjects with asthma (regardless of allergic rhinitis) had lower SF-36 scores than subjects without asthma, and the impairment in quality of life increased with asthma severity (Table 3). Similarly, subjects with allergic rhinitis (with or without asthma) had lower SF-36 scores than subjects without allergic rhinitis. No difference could be found between subjects with only seasonal symptoms of rhinitis and subjects with only perennial symptoms. Compared with control subjects, quality of life was impaired in subjects with only one kind of symptom of rhinitis (seasonal or perennial), and further impaired in subjects with both seasonal and perennial symptoms of rhinitis. Because heavy smoking was strongly related to SF-36 scores and was also strongly related to health status (there were almost no heavy smokers in subjects with asthma, whereas 20% of subjects with allergic rhinitis smoked more than 12 pack-years), heavy smokers were excluded from the following analyses of the eight SF-36 scales. As one can see in the lowest part of Table 3, exclusion of these subjects did not change the association between asthma and SF-36 scores nor between allergic rhinitis and SF-36 scores. Figure 1 shows the mean SF-36 scores for control subjects, subjects with allergic rhinitis alone, and subjects with both allergic rhinitis and asthma, after exclusion of heavy smokers. Compared with control subjects, subjects with allergic rhinitis alone experienced no impairment of physical functioning, and only slight limitation of physical activities (role physical). For these two concepts, subjects with both allergic rhinitis and asthma had a worse quality of life than either control subjects or subjects with allergic rhinitis only. The score for bodily pain was somewhat lower in subjects with allergic rhinitis alone than in control subjects. General health and vitality were worse in subjects with allergic rhinitis alone than in control subjects, and were still worse in subjects with both allergic rhinitis and asthma. Finally, allergic rhinitis alone, as well as allergic rhinitis plus asthma were associated with impaired social functioning, role emotional, and mental health. For these concepts, quality of life was not worse in subjects with both allergic rhinitis and asthma than in those with allergic rhinitis alone.
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TABLE 3 MEAN SF-36 SCORES ⫾ SD ACCORDING TO THE SUBJECTS’ CHARACTERISTICS Physical Functioning Age, yr 20–29 (n ⫽ 222) 92 ⫾ 11 30–39 (n ⫽ 333) 91 ⫾ 14 ⭓ 40 (n ⫽ 295) 90 ⫾ 14‡ Sex Male (n ⫽ 415) 92 ⫾ 13 Female (n ⫽ 435) 89 ⫾ 13§ Smoking habits Nonsmoker (n ⫽ 358) 91 ⫾ 14 Ex-smoker (n ⫽ 192) 92 ⫾ 11 Smoker ⬍ 12 pack-years (n ⫽ 136) 92 ⫾ 11 Heavy smoker (n ⫽ 164) 87 ⫾ 16§ Asthma No asthma (n ⫽ 752) 92 ⫾ 13 Mild/moderate asthma (n ⫽ 77) 86 ⫾ 14§ Severe asthma (n ⫽ 21) 78 ⫾ 20§ Rhinitis No symptoms (n ⫽ 472) 91 ⫾ 13 S or P* (n ⫽ 224) 91 ⫾ 13 S and P† (n ⫽ 154) 88 ⫾ 14§ Mean SF-36 Scores ⫾ SD after exclusion of heavy smokers Asthma No asthma (n ⫽ 589) 93 ⫾ 11 Mild/moderate asthma (n ⫽ 76) 86 ⫾ 14§ Severe asthma (n ⫽ 21) 78 ⫾ 20§ Rhinitis No symptoms (n ⫽ 370) 93 ⫾ 12 S or P* (n ⫽ 182) 92 ⫾ 12 S and P† (n ⫽ 132) 88 ⫾ 13§
Role Physical
Bodily Pain
General Health
Vitality
Social Functioning
Role Emotional
Mental Health
90 ⫾ 23 88 ⫾ 26 89 ⫾ 25
81 ⫾ 25 82 ⫾ 23 78 ⫾ 23‡
77 ⫾ 16 75 ⫾ 18 76 ⫾ 17
64 ⫾ 18 64 ⫾ 18 67 ⫾ 16‡
90 ⫾ 17 89 ⫾ 15 90 ⫾ 16
78 ⫾ 32 79 ⫾ 32 80 ⫾ 32
67 ⫾ 17 66 ⫾ 17 68 ⫾ 17
91 ⫾ 23 87 ⫾ 26§
83 ⫾ 22 78 ⫾ 25§
76 ⫾ 17 76 ⫾ 17
67 ⫾ 16 64 ⫾ 18§
90 ⫾ 15 89 ⫾ 17
80 ⫾ 31 78 ⫾ 32
68 ⫾ 16 66 ⫾ 18‡
89 ⫾ 25 89 ⫾ 26 92 ⫾ 21 88 ⫾ 27
81 ⫾ 23 80 ⫾ 24 81 ⫾ 23 79 ⫾ 24
77 ⫾ 18 77 ⫾ 17 77 ⫾ 15 71 ⫾ 17§
65 ⫾ 17 67 ⫾ 18 65 ⫾ 15 63 ⫾ 17‡
90 ⫾ 16 89 ⫾ 16 90 ⫾ 16 88 ⫾ 18
80 ⫾ 31 82 ⫾ 29 80 ⫾ 31 74 ⫾ 35
66 ⫾ 18 69 ⫾ 16 67 ⫾ 15 64 ⫾ 17‡
90 ⫾ 24 84 ⫾ 29‡ 75 ⫾ 40‡
80 ⫾ 24 81 ⫾ 23 73 ⫾ 27
77 ⫾ 17 71 ⫾ 19‡ 61 ⫾ 22§
66 ⫾ 17 61 ⫾ 17§ 57 ⫾ 21‡
90 ⫾ 16 88 ⫾ 16 85 ⫾ 19
80 ⫾ 31 72 ⫾ 33 70 ⫾ 35
67 ⫾ 17 65 ⫾ 17 63 ⫾ 19
91 ⫾ 23 89 ⫾ 25 84 ⫾ 29§
82 ⫾ 23 79 ⫾ 24 77 ⫾ 25‡
78 ⫾ 16 74 ⫾ 19‡ 71 ⫾ 18§
67 ⫾ 16 63 ⫾ 17§ 60 ⫾ 18§
91 ⫾ 14 89 ⫾ 18 85 ⫾ 19§
83 ⫾ 30 77 ⫾ 32‡ 72 ⫾ 35§
70 ⫾ 16 66 ⫾ 17‡ 66 ⫾ 17§
90 ⫾ 23 84 ⫾ 29‡ 75 ⫾ 40‡
81 ⫾ 24 81 ⫾ 23 73 ⫾ 27
78 ⫾ 16 71 ⫾ 20§ 61 ⫾ 22§
66 ⫾ 17 61 ⫾ 17§ 57 ⫾ 21‡
90 ⫾ 15 88 ⫾ 16 85 ⫾ 19
82 ⫾ 30 72 ⫾ 33§ 70 ⫾ 35
68 ⫾ 17 65 ⫾ 17 63 ⫾ 19
92 ⫾ 21 88 ⫾ 26‡ 83 ⫾ 29§
83 ⫾ 23 79 ⫾ 24‡ 77 ⫾ 25‡
81 ⫾ 15 74 ⫾ 18‡ 72 ⫾ 19§
69 ⫾ 16 63 ⫾ 17§ 60 ⫾ 18§
92 ⫾ 13 89 ⫾ 18 85 ⫾ 19§
85 ⫾ 27 77 ⫾ 32§ 71 ⫾ 34§
71 ⫾ 15 66 ⫾ 18§ 61 ⫾ 17§
* Subjects with only seasonal symptoms, or with only perennial symptoms. † Subjects with both seasonal and perennial symptoms. ‡ p ⬍ 0.05, §p ⬍ 0.01 for comparison of SF-36 scores in a group as compared with the group presented on the first line, for each factor considered.
As women had lower SF-36 scores than men, and there were more women in subjects with allergic rhinitis and/or asthma than in control subjects, we redid the analysis separately for men and women. Asthma and allergic rhinitis had a smaller impact on quality of life in men than in women. In men, subjects with only rhinitis had lower scores than control subjects for the concept “mental health” and the only concept for which subjects with rhinitis plus asthma had lower scores than subjects with rhinitis alone was “physical functioning.” In women, rhinitis alone was associated with an impairment in all
Figure 1. SF-36 mean scores in control subjects (white bars; n ⫽ 349), patients with allergic rhinitis (hatched bars; n ⫽ 240), and patients with both asthma and allergic rhinitis (black bars; n ⫽ 76); after exclusion of heavy smokers. The first three concepts, on the left, are primarily related to physical health; the last three concepts, on the right, are primarily related to mental health; the two other concepts (general health and vitality) are related to both. The results of the Wilcoxon tests for comparison between the different groups and control subjects are expressed with stars; no star indicating a p value ⬎ 0.05; one star: 0.01 ⭐ p ⬍ 0.05; two stars: 0.001 ⭐ p ⬍ 0.01; three stars: p ⬍ 0.001; the written p values correspond to the test between subjects with rhinitis alone and subjects with both asthma and rhinitis.
but one concept (physical functioning), and women with both rhinitis and asthma had lower scores than women with rhinitis alone for the two “physical” concepts (physical functioning, role physical) and for “general health.” By contrast, for the concepts related to mental health, women with both asthma and rhinitis did not experience further impairment in quality of life than those with rhinitis alone. The results of the final analysis comparing the PCS and MCS scores in control subjects, subjects with allergic rhinitis alone, and subjects with both rhinitis and asthma, adjusted for sex, age, and smoking status are shown in Figure 2. For PCS, subjects with both asthma and rhinitis had lower mean scores than either control subjects or subjects with rhinitis alone. For MCS, subjects with rhinitis alone had lower scores than con-
Figure 2. Adjusted SF-36 mean PCS and MCS scores in control subjects (white bars; n ⫽ 448), patients with allergic rhinitis (hatched bars; n ⫽ 297) and patients with both asthma and allergic rhinitis (black bars; n ⫽ 76). Multivariate analysis of variance adjusted for sex, age, and smoking status.
Leynaert, Neukirch, Liard, et al.: Quality of Life in Rhinitis and Asthma
trol subjects, and there was no difference between subjects with rhinitis alone and subjects with rhinitis plus asthma.
DISCUSSION In this population-based study of young adults, patients with allergic rhinitis had a poorer general health and a lower vitality than subjects without allergic rhinitis. Allergic rhinitis alone was strongly associated with impaired quality of life for concepts related to mental disability and well-being. For these concepts, the quality of life was not worse if the patient also had asthma. Patients with allergic rhinitis plus asthma had a greater impairment in physical functioning. The differential effect of rhinitis and asthma on mental health and physical health respectively observed with the eight SF-36 scales was confirmed by the analysis of the PCS and MCS scores. The validity of our data is supported by the high participation rate and the completeness of the data. The quality-of-life assessment tool (the SF-36 and its translations) has been extensively validated in terms of internal consistency, reliability (test–retest and interobserver), discriminative properties (the ability to distinguish different levels of disease between patients), and evaluative properties (the ability to detect changes in health) (24, 27). Although the SF-36 is not a utility scale, it may be used to compare the burden of illnesses across different diseases (22). For all SF-36 concepts, the scores recorded in our study for the control subjects were similar to the published norms calculated for various population samples (25, 28–30). Asthma was defined according to answers to the most relevant questions pertinent to asthma in the ECRHS questionnaire and airway responsiveness. This definition has been proved to be valid in a published study on undertreatment in asthma (31). Identification of subjects with symptoms of allergic rhinitis also relied on answers to the ECRHS questionnaire. This definition has been shown to closely correlate with positivity to skin test (32). In this study, the burden of allergic rhinitis was investigated in a population sample. Thus, the group of patients with allergic rhinitis included subjects with various degrees of rhinitis severity, who were, or were not, being treated for allergic rhinitis. Several studies have shown that treatments for allergic rhinitis (and especially the new nonsedative agents) may reduce the quality-of-life impairment experienced by allergic rhinitis sufferers (11). Therefore, the impact of untreated allergic rhinitis on the patient’s everyday life is likely to be greater than the impact of allergic rhinitis observed in our study. Most of the asthmatics within the group of subjects with both asthma and allergic rhinitis had mild to moderate asthma (only 18 asthmatics with rhinitis had severe asthma). Because quality-of-life impairment increases with the severity of asthma (6), the relative burden of asthma and allergic rhinitis might be more contrasted if subjects with more severe asthma were considered; thus, the results may not be generalizable to more severe asthmatics. Demographic and socioeconomic factors have been shown to be important determinants of health-related quality of life in asthmatic patients (33). In this study, in which most of the subjects were middle class and the age range was very narrow (20 to 44 yr old), neither income nor age was found to be associated with quality-of-life scores. Comparison with data from the French population showed that the study participants were not selected from relatively higher socioeconomic backgrounds. The mean income per person per year was $16,047 for the Paris sample and $10,353 for the Montpellier sample, versus $16,523 and $12,455 for the habitants from the Paris and Montpellier regions. Smoking habits (and especially heavy smoking) were associated with quality of life. We therefore ana-
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lyzed the data for the eight SF-36 scales after excluding heavy smokers, to ensure that the results were not biased by this factor. We found that the relationship between allergic rhinitis and quality of life was stronger in women than in men. This may be because women had more severe rhinitis than men, as suggested by the finding that the proportion of women with allergic rhinitis that experienced both seasonal and perennial symptoms was higher than that for men. However, the results were consistent in both men and women, showing an impairment in quality of life for those concepts primarily related to mental health in patients with allergic rhinitis alone, and a further impairment for concepts primarily related to physical health in patients with both asthma and allergic rhinitis. Meltzer and coworkers carried out a population-based study to assess health-related quality of life in patients with allergic rhinitis (10). A total of 1,065 subjects with nasal/ocular symptoms were selected from a sample of 15,000 households representative of the U.S. population. The responses of the 312 subjects with rhinitis symptoms who completed both the SF-36 and a rhinitis-specific quality-of-life questionnaire (Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] were compared with those of healthy control subjects. Statistically significant differences between patients and control subjects were observed in seven concepts of the SF-36, and in all of the seven dimensions and the aggregate scores of the RQLQ. Both physical and mental health status were adversely affected by rhinitis. However, the possibility that patients with rhinitis also had asthma, and that concomitant asthma could contribute to quality-of-life impairment was not considered. Because there were no studies assessing the relative burden of asthma and allergic rhinitis in a single population, the results obtained by one of us (J.B.) in two studies have been used to suggest that the quality-of-life impairment experienced by allergic rhinitis sufferers may be similar or even greater than that experienced by asthmatic subjects (13, 14). The SF-36 questionnaire was administered, in one of these studies, to a sample of asthmatics with various degrees of asthma severity, recruited in an outpatient clinic (6), and, in the other study, to a sample of subjects with moderate to severe perennial allergic rhinitis, recruited by allergy specialists and ear, nose, and throat doctors (12). However, the two studies were not set up with the aim of comparing the relative burden of asthma and allergic rhinitis, so asthmatics for the first study were recruited independently of allergic rhinitis, and some of the subjects with perennial allergic rhinitis in the second study may also have had asthma. Although we did not assess quality of life in patients with asthma alone (because the number of patients in this group was too small), this study is the first to investigate quality of life in allergic rhinitis and asthma, in the same population. However, results from previous studies with disease-specific questionnaires may help us to interpret our results. Such studies have shown that patients with allergic rhinitis are particularly bothered by not being able to sleep well at night, and often feel tired and exhausted during the day; they experience limitations in their daily activities and complain of a decrease in alertness, lower productivity and concentration, and they experience mood changes and cognitive disturbances (7, 11). In contrast, patients with asthma are more likely to have problems with physical activities such as sports, hurrying, going upstairs, and face limitations in their everyday life in terms of activities such as vacuuming and other household tasks (7). This is consistent with our finding that allergic rhinitis alone was mostly associated with quality-of-life impairment for concepts related to mental health whereas subjects with allergic rhinitis plus asthma had a greater impairment of physical functioning.
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Interpretation of the differences in quality-of-life scores between control and patient groups is difficult because differences that are statistically significant may not be clinically meaningful from the patient’s point of view (1, 34). However, the main finding of this study is that asthma was not found to further impair quality of life in subjects with allergic rhinitis for concepts primarily related to mental health. As subjects with asthma often also have allergic rhinitis, further studies on quality of life in asthma should take into account the presence of allergic rhinitis in the asthmatic patients in order to ensure that the impairment in quality of life attributed to asthma could not result from concomitant allergic rhinitis. Symptoms of allergic rhinitis are likely to be neglected, particularly in patients with asthma, because, from a clinical point of view, allergic rhinitis is minor as compared with asthma. However, our results suggest that allergic rhinitis may be as bothering as asthma in the patient’s everyday life, at least with respect to mental health. These findings stress the need for early and appropriate management of allergic rhinitis (11, 35).
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