Examining interrater agreement between self-report and proxy-report responses for the quality of life-aged care consumers (QOL-ACC) instrument

Abstract

Background: Quality of life is an important quality indicator for health and aged care sectors. However, self-reporting of quality of life is not always possible given the relatively high prevalence of cognitive impairment amongst older people, hence proxy reporting is often utilised as the default option. Internationally, there is little evidence on the impact of proxy perspective on interrater agreement between self and proxy report.

Objectives: To assess the impacts of (i) cognition level and (ii) proxy perspective on interrater agreement using a utility instrument, the Quality of Life-Aged Care Consumers (QOL-ACC).

Methods: A cross-sectional study was undertaken with aged care residents and family member proxies. Residents completed the self-report QOL-ACC, while proxies completed two proxy versions: proxy-proxy perspective (their own opinion), and proxy-person perspective (how they believe the resident would respond). Interrater agreement was assessed using quadratic weighted kappas for dimension-level data and concordance correlation coefficients and Bland-Altman plots for utility scores.

Results: Sixty-three residents (22, no cognitive impairment; 41, mild-to-moderate cognitive impairment) and proxies participated. In the full sample and in the mild-to-moderate impairment group, the mean self-reported QOL-ACC utility score was significantly higher than the means reported by proxies, regardless of perspective (p < 0.01). Agreement with self-reported QOL-ACC utility scores was higher when proxies adopted a proxy-person perspective.

Conclusion: Regardless of cognition level and proxy perspective, proxies tend to rate quality of life lower than residents. Further research is needed to explore the impact of such divergences for quality assessment and economic evaluation in aged care.

Keywords: Family members; Long-term care; Older adults; Proxy assessment; QOL-ACC; Quality indicators; Quality of life; Residential aged care.

Fig. 1

Bland-Altman plots showing the mean difference between self-report and proxy-report QOL-ACC utility scores (dark solid line) and associated 95% limits of agreement (dashed lines) when adopting the proxy-proxy perspective (panel A) and the proxy-person perspective (panel B). The markers plot the ‘difference between scores’ and the ‘average score’ for the respective analyses. For illustration, grey-fill circles identify the mild-to-moderate impairment subgroup and white-fill squares identify the no impairment subgroup. Panel A (self-report & proxy-proxy) Panel B (self-report & proxy-person)