Beyond definition, quality in health care is determined by the application of the right method of care to the patient's condition in the most effective manner possible and by the nature of the interaction between the patient and the provider . This subjective aspect of quality is the portion of the outcome measures that BrQ is attempting to quantify.
Climent and Sanchez in their study of adolescents with spinal deformities contended that QoL variables include the Risser sign, clinical diagnosis, duration of brace treatment, and degree of correction . These variables do not constitute a significant measurement of patient wellbeing, are more related to the diagnostic evaluation and do nothing to alter one's perception of happiness. Health educators, school nurses, and clinicians need to be aware of social well-being factors, and how these factors relate to psychosocial functioning .
In order to evaluate the effectiveness of brace treatment, we need to determine three major factors, namely the patient, the multidisciplinary team that provides care and the brace itself. Although it would seem intuitive that a patient's physical, emotional, and social well-being would all have a powerful effect on his or her ability to benefit from brace treatment, there has been little research on this important determinant of brace effectiveness. The conservative treatment that is provided by the team of professionals is the method. The brace is the mean. There are very few data indicating that improvements in the type of the brace have a significant effect on the patient's QoL.
In this study we have described the development and preliminary validation of the BrQ, a questionnaire to measure the effect of brace in conservatively treated children with AIS. To our knowledge this is the first questionnaire specifically developed and validated to measure clinical success in the management of AIS patients with a brace. The items were generated by literature search and interviewing clinicians and patients. Items were thereafter selected on their clinical importance and were grouped to eight domains.
It could be argued that a possible bias was present in the item selection phase. While we cannot rule out that some kind of biased selection of items may have been present during one or more steps of the development of the questionnaire, we find it important to underline that in our view selection of items is always a qualitative process, and thus somehow subjective. However, the resulting instrument has been subjected to a quantitative analysis based on classical test theory approaches with fairly acceptable results .
A specific instrument such as BrQ has its self-evident strengths as compared with generic instruments by virtue of its increased sensitivity to the unique problems related to the brace itself.
Minimal important differences or minimal important change over time were not examined for the BrQ scales. Knowledge of minimal important differences are important for interpreting the meaning of health related QoL results, thus, in future studies some attempt should be made to define minimal important differences for the BrQ.
The internal consistency reliability of items in the BrQ overall score was acceptable, with Cronbach's coefficients exceeding the accepted standard (≥ 0.70). There were no floor or ceiling effects in the present study.
BrQ overall score was able to distinguish between patients with mild and moderate scoliosis. The results indicate that patients with moderate scoliosis also had lower BrQ overall scores (poorer QoL). Adolescents with severe scoliosis were excluded from the study because these patients are considered potential candidates for surgical correction, thus other specific instruments such as SRS 22 would be applied .
The responsiveness of the BrQ to change over time was confirmed by comparing change scores from two different measurements, at the initiation of treatment and at follow up. Correlation of changes in BrQ overall score in patients with improved, stable and increased curves was statistically significant. BrQ overall change scores were able to distinguish between these subgroups at a statistically significant level. ES's indicated the improvements were always greater in those patients rated as "improved" but only small or moderate in those rated as "stable". Sample sizes for the three groups were small and results for these subgroups should be interpreted with caution. The sensitivity of the BrQ to change could not be fully evaluated in this study owing to the small sample size and should be investigated further in a larger sample of patients. Therefore, responsiveness to change of the BrQ will be assessed with further research.