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A Measure of Disease-Specific Health-Related

Quality of Life for Achalasia

Article in The American Journal of Gastroenterology September 2005

DOI: 10.1111/j.1572-0241.2005.50141.x Source: PubMed

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American Journal of Gastroenterology ISSN 0002-9270


C 2005 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2005.50141.x
Published by Blackwell Publishing

ORIGINAL CONTRIBUTIONS

A Measure of Disease-Specific Health-Related Quality of

Life for Achalasia
David R. Urbach, M.D.,1,2,3 George A. Tomlinson, Ph.D.,2,3,4 Julie L. Harnish, M.S.,3 Rosemary Martino,
Ph.D.,5 and Nicholas E. Diamant, M.D.6
1
Departments of Surgery, 2 Health Policy, Management and Evaluation, 5 Department of Speech Language
Pathology, and 6 Department of Medicine, University of Toronto, Toronto, Ontario; 3 Division of Clinical
Decision Making and Health Care, Toronto General Hospital Research Institute, Toronto, Ontario;
4
Division of General Internal Medicine, Toronto General Hospital, Toronto, Ontario

OBJECTIVES: To develop a measure of disease-specific health-related quality of life for achalasia for use as an
outcome measure in clinical trials.
METHODS: We generated a list of potential items for a measure of disease-specific health-related quality of life
for achalasia by semistructured interviews with seven persons with achalasia, and by expert opinion.
We then used factor analysis and item response theory methods for item reduction, using responses
on the long-form questionnaire from 70 persons with achalasia. The severity measure underlying the
item responses was constructed using a Rasch model.
RESULTS: We developed a 10-item measure of disease-specific health-related quality of life that sampled the
concepts of food tolerance, dysphagia-related behavior modifications, pain, heartburn, distress,
lifestyle limitation, and satisfaction. The measure was reliable (person separation reliability 0.79,
Cronbachs 0.83), showed evidence of construct validity and good data-to-model fit (mean infit and
outfit statistics for items, 1.00 and 0.98, respectively), and had a wide effective measurement range
(able to discriminate between 87% of subjects with achalasia). The measure was recalibrated onto a
0100 interval-level scale.
CONCLUSIONS: We describe a reliable measure of achalasia disease-specific health-related quality of life that has a
broad effective measurement range, interval-level properties, and evidence of construct validity. This
measure is appropriate for use as an outcome measure in clinical trials and other evaluative studies
on the effectiveness of treatment for achalasia.
(Am J Gastroenterol 2005;100:16681676)

Achalasia is a rare chronic disease of esophageal motor func-
tion characterized by failure of the lower esophageal sphincter
(LES) to relax upon swallowing, and absence of peristalsis in
the esophageal body. Persons with achalasia experience dys-
phagia, regurgitation, and chest pain. Treatment is directed
toward relieving obstruction at the level of the LES, by sur-
gical myotomy, balloon dilatation, or injection of botulinum
toxin (1). These procedures vary with respect to effectiveness,
safety and durability (2). With the introduction of minimally
invasive surgical techniques, laparoscopic surgery for acha-
lasia has become increasingly popular (3, 4), primarily due
to a belief that laparoscopic surgery is more effective than
endoscopic therapy (5) and is associated with less operative
risk and disability than conventional open surgery. However,
there is considerable difference of opinion among clinicians
whether laparoscopic surgery or balloon dilatation is the best
initial approach to treating achalasia (1, 2, 6).
Controversy regarding the optimal management of acha-
lasia has been exacerbated by a paucity of high-quality evi-
dence comparing the effectiveness of alternative treatments.
The low incidence of achalasia (7) and scarcity of random-
ized trials comparing surgical myotomy and balloon dilata-
tion (8) have made it difficult to compare the effectiveness of
alternative therapeutic approaches. However, the biggest im-
pediment to date has been the absence of a valid and reliable
measure of achalasia disease-specific health-related quality
of life. Since achalasia is not curable, the goal of treatment is
to improve symptoms and quality of life of affected persons.
Although there are clinical measures of achalasia symp-
toms, such as dysphagia, these measures were not developed
for use in patients with achalasia (9, 10). We sought to de-
velop a disease-specific measure of health-related quality of
life for use in patients with achalasia that was valid and re-
liable. Further, because we wanted to develop an instrument
that would be useful as an outcome measure in clinical trials,
we desired a measure with interval-level properties (11). In
this article, we describe the development and initial validation
of the measure.

1668

METHODS
Conceptual Framework
We sought to develop a measure that operationalized the con-
cept of achalasia disease-specific health-related quality of
life, by measuring the extent to which achalasia and its treat-
ment impacts on the emotional and physical functioning and
lifestyle of affected persons (12). Therefore, our focus was
on disease-related symptoms, and their effects on patients
physical and emotional well-being.
Analytic Strategy
Our strategy in designing the measure was to develop a proto-
type long-form questionnaire containing items created from
patient interviews and expert opinion. We then sought to re-
duce the number of items by eliminating those that were fre-
quently omitted or answered homogeneously, as well as items
that measured the same severity of disease as other items. We
used item response theory methods to reduce the number of
items. Briefly, we hypothesized that the severity of achala-
sia is a trait that may be represented by a one-dimensional
construct. Since severity cannot be measured directly at the
patient level, it represents a latent variable that can be esti-
mated by evaluating subjects responses to a series of items in
a questionnaire. Item response theory models assume that the
probability of a subjects responding to a given category of an
item (say, answering yes to the question do you have any
difficulty swallowing?) is related to the severity of the un-
derlying trait (say, having untreated symptomatic achalasia).
The probabilities of responding to the individual categories
can then be mapped onto levels of a continuous scale, which
is an interval-level metric of the underlying disease severity.
By measuring the mean severity among persons who respond
to item categories, it is possible to identify the location on the
measurement continuum of different items and response cat-
egories. Therefore, item response models also allow the raw
score of the unidimensional scale to be converted to a scale
with interval-level properties (1317), an important property
that is useful in developing an outcome measure for use in
clinical trials.
Item Generation
We undertook detailed semistructured telephone interviews
with persons with achalasia, most of whom had already re-
ceived treatment. Subjects were asked how achalasia affected
their lives (before and after treatment), types of foods that
gave them difficulty, and whether they could think of items
that would be useful in a questionnaire measuring achalasia
severity. We also inquired about different questionnaire for-
mats. We conducted interviews until we reached our thresh-
old of item saturation defined by a lack of additional new
items in two successive interviews. In total, we interviewed
seven subjects. Once we compiled a list of potential items and
questionnaire designs, we developed a long-form question-
naire based on the subjects responses. Our semistructured
interviews identified five broad themes: (i) dysphagia; (ii)
nondysphagia symptoms of achalasia (e.g., heartburn, reflux,
A Measure of Achalasia Quality of Life 1669
and regurgitation); (iii) maneuvers patients took to manage
symptoms (e.g., self-induced vomiting, position changes,
drinking water); (iv) social and lifestyle limitations; and (v)
dissatisfaction with treatment or current level of function.
Using these data, we developed a 37-item long-form ques-
tionnaire. The questionnaire was pilot-tested by healthy vol-
unteers to establish its understandability and sensibility.
Study Subjects
We wanted to refine the long-form questionnaire into a con-
cise, valid instrument with good reliability, a broad effective
measurement range, and interval-level response properties.
To permit meaningful analysis, this objective required ad-
ministering the long-form questionnaire to enough subjects
to provide a sufficient number of responses to all items and
response categories. Use of the item response theory models
in our protocol generally requires 10 or more responses for
each item category (16). Because achalasia is a rare disease,
we tried to maximize subject eligibility. By searching clinic
records of a physician with a special interest in the manage-
ment of achalasia, we identified 153 English-speaking per-
sons aged 18 yr and older with a diagnosis of achalasia who
had visited the clinic recently. We mailed long-form question-
naires to 121 of these subjects for whom a current mailing
address was available. This research was conducted with the
approval of the University Health Network Research Ethics
Board.
Rasch Model
The item response theory model we used was the Rasch
model, which specifies a one-parameter logistic function for
the probability of responding a certain way to each item (13,
14). This model allows items to vary in difficulty (i.e., their
location on the spectrum of the underlying trait), but assumes
that all items are equally responsive. The response of each
person to an item may then be modeled as a function of his
or her severity of the latent variable and the difficulty of the
item. The fact that the Rasch model locates items and per-
sons on a logit scale allows the raw scores to be recalibrated
into an interval-level scale based on logits. Because our ques-
tionnaire included items with different numbers of response
categories, we fit a partial credit model (18) using the program
WINSTEPS (Winsteps, Chicago, IL).
Factor Analysis
To determine whether our scale measured a unidimensional
construct, we first conducted a principal components analysis
of the items in the long-form questionnaire. It has been sug-
gested that there is sufficient evidence of unidimensionality
if the first factor extracted in a principal components analysis
accounts for 20% or more of the total variance (19). We also
examined a scree plot to determine whether more than one
factor should be retained.
Item Reduction
We eliminated items from the 37-item questionnaire that were
frequently omitted (e.g., there was one question that included
1670 Urbach et al.
Figure 1. Item probability curve for the question: How often in the past month have you needed to drink water while eating to deal with
food caught in your esophagus? The probability of responding to each of the item categories is plotted according to the recalibrated overall
score (0100) on the measure.
4 items on dysphagia symptoms scored yes or no; many
respondents answered only 1 of 4 items), or items for which
there was uniformity of response across respondents. Using
this method, we were able to reduce the instrument to a 17-
item measure. We also collapsed response categories within
items, to ensure that there was the minimum of 10 responses
per response category required for our modeling strategy.
Further item reduction was accomplished by use of the Rasch
model, by retaining one item of a group whose mean severity
score across response categories overlapped. This method
enabled us to retain those items that measured severity across
different locations of the underlying scale.
Analysis of Fit
Both person and item trait level are mapped onto the same
logit scale in the Rasch model. The probability of responding
a certain way to each item can be estimated for each person.
Fit of the model to the data can then be calculated, and is usu-
ally quantified using statistics called infit (a 2 fit statistic
sensitive to lack of fit for persons responding to items close
to their severity level) and outfit (a 2 fit statistic sensitive
to lack of fit for persons responding to items far from their
severity level). The expected value of mean-square infit and
outfit statistics is 1.0, and a range of 0.61.4 is considered
reasonable (16, 20). These statistics may also be standardized
to a mean of 0 and standard deviation of 1.0.
Reliability
We estimated the scale reliability using the person separa-
tion reliability statistic (the proportion of variance not due to
measurement error) and Cronbachs (internal consistency
reliability).
Recalibration to an Interval-Level Scale
The Rasch model allows raw scores to be mapped onto a
logit scale, which has interval-level properties. The 1-logit
distance between 2 logits and 1 logits is the same as the
distance between 0 logits and +1 logits, and the same as the
distance between +2 logits and +3 logits. We used the logit
scale to recalibrate the raw score on the final measure into
a scale ranging from 0 to 100, with 0 indicating very low
severity and 100 indicting the highest possible severity.
Effective Measurement Range
For each item the probability of responding a certain way can
be modeled as a function of the severity of the underlying trait.
For example, the probability of answering never/rarely to
the question How often in the past month have you needed
to drink water while eating to deal with food caught in your
esophagus? should be higher among persons with milder
achalasia than the probability of answering sometimes or
frequently/every time I eat. This relationship can be plot-
ted as an item probability curve (Fig. 1). There is a score on
the measure that corresponds to the point where the proba-
bility of responding never/rarely is the same as responding
sometimesthis is the score where the probability curves
for these two responses intersect. The score at which this oc-
curs (i.e., the probability of responding to both categories is
the same) is called the Thurstone Threshold. When all such
thresholds for all items are plotted on the scale, the effective
measurement range extends from the threshold closest to the
lowest trait severity to the threshold closest to the highest
trait severity level. We estimated the proportion of persons
whose trait severity was more extreme than the levels at which
the lowest and highest thresholds were located. The measure
cannot reliably discriminate between persons with trait levels
that are either all below the lowest threshold or all above the
highest threshold.
Validity Assessment
We assessed the construct validity of our measure by com-
paring the scale scores among different response severity
 A Measure of Achalasia Quality of Life 1671

categories for items not included in the final instrument. We
tested for an association between the instrument score and
severity across response categories using the test for linear
trend and t-tests where appropriate.
RESULTS
Study Subjects
After subsequent mailings to initial nonresponders, we re-
ceived 70 usable questionnaires from the 121 mailed to
subjects with a known address (58% response). The seven
subjects who were interviewed for the item generation pro-
cess also completed questionnaires. Characteristics of the re-
spondents are presented in Table 1.
Figure 2 shows the location of the item responses for all 10
items on the recalibrated measure (scored 0100, see below),
as well as the recalibrated score for each person (depicted as
tick marks along the horizontal). The items are spaced along
the vertical axis in order of the mean location of the entire
item on the measure, in decreasing order of disease severity.
Goodness of Fit
Goodness-of-fit statistics are presented in Table 2. The infit
and outfit statistics for all 10 items were within a range in-
dicating good fit of the model to the data. The infit statistic
ranged from 0.78 to 1.34 and the outfit statistic ranged from
0.72 to 1.53 for all 10 items. The mean (mean-square) infit
and outfit statistics were 1.00 and 0.98, respectively

Dimensionality of the Construct Reliability

In a principal components analysis, the first factor extracted The person separation reliability statistic was 0.79, and Cron-
accounted for 43% of the total variance. The difference be- bachs was 0.83, indicating good scale reliability.
tween the first (7.4) and second (1.7) Eigenvalues was large
(5.7), supporting our assumption of unidimensionality of the Interval-level Recalibration
underlying construct. Analysis of a scree plot indicated that While changes in the raw scores approximated changes in the
only one factor should be retained. underlying measure at the middle of the scale, a unit change in
the raw score substantially underestimated the actual amount
Item Reduction of change in the measure at the extremes of high and low
After eliminating 20 of the initial 37 items, we eliminated severity (Fig. 3). To create an interval-level scale, the loca-
7 additional items because the mean severity scores across tions of the raw scores were repositioned on the logit scale.
response categories were identical to other items that were re- Scores on the logit scale were then recalibrated onto a mea-
tained in the final measure. This allowed us to include items sure ranging from 0 to 100 in order of increasing severity
that measured severity of achalasia at different locations of (Table 3).
the severity continuum. The final result was a 10-item scale
that is described in the Appendix. The raw scores assigned Effective Measurement Range
to each item response are included in the description of the The effective range of the recalibrated scale extended from
items. These are provided as a guide for scoring the instru- 23.4 to 72.0 (Fig. 4). Three persons (4.3%) scored better than
ment, and should not be included in the questionnaire pro- the lowest threshold and six persons (8.6%) scored worse
vided to patients. The summary raw score is calculated by than the highest threshold. The scale has sufficient range to
summing the response score for each item. A summary score discriminate severity between 87.1% of respondents.
can only be estimated for subjects who respond to every item
on the instrument. Construct Validity
We were not able to validate our questionnaire on persons
Table 1. Characteristics of 70 Persons with Achalasia Who Com- not involved in the construction of the measure, because of
pleted the Long-Form Questionnaire the paucity of subjects available. However, we assessed the
Characteristic Value construct validity of the measure by comparing the mean
Gender, number (%) scores of persons who endorsed various item responses for
Male 35 (50) items included in the long questionnaire, but not retained in
Female 35 (50) the final instrument. The mean scores according to the item
Age, year response endorsed by the subjects are presented in Table 4.
Mean (SD) 50.34 (17.18) In general, the scores were higher (indicating higher disease
Range 1887
Duration of achalasia, year severity) among subjects who endorsed item responses indi-
Mean (SD) 16 (9.41) cating more severe disease.
Range 343
Prior treatment, number (%)
Medication 47 (61.4) DISCUSSION
Botulinum toxin injection 2 (2.9)
Pneumatic dilatation 61 (87.1) We used item response theory methods to develop a disease-
Surgery 22 (31.4) specific measure of health-related quality of life for achalasia
SD denotes standard deviation that is reliable, valid, covers a wide effective measurement
1672 Urbach et al.

Figure 2. Location of item responses and persons along the spectrum of achalasia severity. Items are listed along the vertical axis in
descending order of severity as measured by the item location parameter of the Rasch model. The horizontal axis has been recalibrated onto
a 0100 interval-level scale.

range, and has interval-level measurement properties. We Lack of an outcome measure with good measurement
developed this instrument for use as an outcome measure properties has been an important limitation of clinical tri-
in evaluative research on the effectiveness of treatment for als of achalasia therapy. The only clinical trial ever under-
achalasia. Use of a common metric with good measurement taken comparing surgery with balloon dilatation used an ad
properties will facilitate the design and interpretation of clin- hoc instrument with undefined measurement properties (8).
ical trials of achalasia therapy, and will also provide a method In a recent trial comparing surgery with botulinum toxin
to compare case series reported by different institutions. injection, the principal outcome measure was a symptom
The methods used in the development of this instrument score for dysphagia and regurgitation calculated by adding
allowed us to ensure that it had good coverage of the quality a severity score (06) to a frequency score (05) for each
of life concepts that were important to persons with achala- of these two symptoms (21). Treatment failure in this study
sia. Our methodology also allowed us to create an efficient was defined as a posttreatment score that was greater than
instrument, by including items that sampled unique points the 10th percentile of scores obtained from an untreated
on the continuum of the underlying measure of quality of population (22). Conversion of a continuous measure to a
life. Although the final measure included items that covered dichotomous outcome, as was done in this study, poten-
many aspects of achalasia, such as swallowing difficulty, pain, tially results in a loss of important information on treat-
heartburn, food tolerance and diet-related behavior modifi- ment outcome. Use of a continuous measure as an outcome
cations, we found that the combination of these items repre- measure may benefit the efficiency of a clinical trial, by
sented a one-dimensional construct. reducing the sample size required to detect a treatment effect,
and by allowing explicit estimation of a clinically important
Table 2. Goodness-of-Fit Statistics for the 10 Measured Items difference.
A potential limitation of our analysis was the fact that
Statistic
we developed and validated the measure on the same pop-
Infit Outfit ulation. However, identifying a large population of subjects
Mean Mean with achalasia for validation studies is difficult because of
Measure Square Standardized Square Standardized the rarity of the disease. Further validation of our measure in
Mean 1.00 0.2 0.98 0.2 external populations is essential. Studies using this measure
Standard deviation 0.17 1.2 0.22 1.2 in other centers will contribute information to further assess
Maximum 1.34 1.9 1.53 2.6 the validity and reliability of the instrument in other settings.
Minimum 0.78 1.8 0.72 1.7 Despite aggressive efforts to maximize response to our

Standardized to a mean of 0 and standard deviation of 1.0. long-form questionnaire, we had a response rate of 58%.
 A Measure of Achalasia Quality of Life 1673

Figure 3. Relation of raw scores to the measure. The raw scores did not have interval-level properties. While there was a linear relationship
between raw scores and interval-level recalibrated scores along the middle of the scale, a one-unit increment in the raw score substantially
underestimated the amount of real change among high and low levels of severity.

Several factors may explain this relatively low response, such outcome, it would not necessarily affect the validity of our
as the fact that many subjects had not received treatment for instrument development process. For example, if our inten-
several years, and the length of the questionnaire. Respon- tion was to sample subjects in relation to treatment outcome,
ders and nonresponders were not significantly different in a large proportion of nonresponders would bias our estimate
terms of measurable characteristics, such as their age, gen- of treatment outcome substantially, since the probability of
der, and the year of last visit. However, even if responders responding to a survey is likely to be influenced by treat-
were significantly different from nonresponders in terms of ment outcome. However, our methods relied on the empirical
relationships between responses within individuals. There-
fore, nonresponse would bias our final instrument only to the
extent that responders and nonresponders differ in the rela-
Table 3. Conversion of Raw Scores to Interval-Level Scores Recal- tionships between their responses to different items on the
ibrated onto a 0 to 100 Scale
instrument. It is not likely that the probability of response
Raw Score Converted Score is strongly related to the interrelationships of items on the
10 0 instrument.
11 14 In this study, we did not specifically intend to compare
12 23 quality of life scores between patients treated with different
13 29
modalities. In fact, most study subjects had more than one
14 33
15 37 type of treatment. When subjects who had surgery (most of
16 40 whom also had one or more dilatation) were compared with
17 43 subjects who had not had surgery, the scores were slightly
18 45 higher in the surgery group (54.9, SD 13.6) than the non-
19 47
surgery group (46.9, SD 18.0).
20 50
21 52 In conclusion, we developed a valid and reliable mea-
22 54 sure of achalasia disease-specific health-related quality of
23 57 life with interval-level properties. It is scored on a 0100
24 59 scale, with higher values indicating greater disease sever-
25 62
ity. Further work is required to evaluate the reliability and
26 65
27 69 validity of the scale in different populations, and to deter-
28 73 mine the magnitude of a clinically meaningful change in the
29 78 scale. This scale is suitable for use as an outcome measure
30 86 in a clinical trial comparing the effectiveness of therapies for
31 100
achalasia.
1674 Urbach et al.

Figure 4. Effective measurement range of the scale. Each bubble represents the recalibrated score of one person. The effective measurement
range extends from the lowest Thurstone Threshold to the highest Thurstone Threshold. Three persons (4.3%) scored better than the
lowest threshold, and six persons (8.6%) scored worse than the highest threshold. The measure cannot reliably discriminate between subjects
who score outside the effective measurement range.

WHAT THIS STUDY ADDS r We developed a disease-specific measure of health-related

r Surgery and pneumatic dilatation are the mainstays of r
treatment for achalasia. There is controversy regarding
whether one treatment is preferred over the other. r
r A limitation of clinical trials comparing treatment for acha-
lasia has been the lack of a measure of disease-specific
health-related quality of life for patients with achalasia.
quality of life for achalasia.
The instrument has good measurement characteristics, and
produces a score with interval-level properties.
The instrument described in this article can be
used as an outcome measure in studies of achalasia
treatment.

Table 4. Mean Scores Among Subjects Who Endorsed Responses for Items Not Included in the Final Instrument
Question and Responses
Mean Score (Number of Respondents) p Value
No problem Some difficulty Much difficulty
How difficult is it for you to eat the following foods?
Bagel 26.3 (10) 47.0 (31) 60.6 (27) p < 0.001
Steak 29.3 (12) 48.6 (31) 61.1 (26) p < 0.001
Soft vegetables 41.1 (39) 60.9 (29) 47.5 (1) p < 0.001
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree
I feel comfortable eating in a restaurant
40.7 (16) 32.3 (9) 50.0 (12) 55.6 (18) 64.6 (14) p < 0.001
No problem Mild problem Moderate problem Severe problem Very severe problem
How much of a problem for you is reflux and/or regurgitation?
39.2 (21) 49.6 (24) 52.7 (15) 65.5 (5) 71.0 (4) p < 0.001
Never Rarely Sometimes Frequently Every time I eat
How often in the past month have you made yourself vomit to deal with food caught in your esophagus?
41.8 (31) 50.8 (19) 58.9 (14) 69.2 (4) 89.3 (1) p < 0.001
Scores are recalibrated onto the 0100 interval-level scale.

p values are for the test for linear trend across groups.

This p value is for a t-test of the comparison of no problem, with some difficulty and much difficulty combined.
 A Measure of Achalasia Quality of Life 1675

ACKNOWLEDGMENTS 6. How often have you experienced pain when eating dur-
ing the past month? (Please circle one.)
Dr. Urbach is a Career Scientist of the Ontario Ministry of
Health and Long-Term Care, Health Research Personnel De-
velopment Program. This study was supported by a grant Never Rarely Sometimes Frequently/Every Time I Eat
from the Canadian Association of General Surgeons and by [1] [2] [3] [4]
the physicians of Ontario through the Physicians Services
Incorporated Foundation.
7. During the past month, how much of a problem for you
was heartburn (a burning pain behind the lower part of the
APPENDIX
chest)? (Please circle one.)
A Measure of Achalasia Disease Severity
The raw score assigned to each item response is indicated
in bold in square brackets (these scoring weights should not No Mild Moderate Severe Very Severe
be included in a questionnaire given to patients). Total raw Problem Problem Problem Problem Problem
scores are calculated by summing the score for each item to [1] [2] [3] [4] [5]
yield a score between 10 and 31, and are only valid if there
are no missing responses.
1. How much has achalasia limited the types of food you 8. When you sit down to eat a meal, are you bothered by
have been able to eat in the last month? (Please check one.) how long it takes you to finish eating? (Please check one.)
r Not limited at all (I can eat and drink all the foods that I r No, I eat as quickly as I like. [1]
would like to.) [1] r
r Somewhat limited (I can eat and drink most of the foods
Yes, I am bothered by how long it takes me to eat. [2]

that I would like to.) [2]
r Moderately or severely limited (I can eat and drink very
few of the foods that I would like to.)[3]
The following is a list of food types that may or may not
cause you difficulty in swallowing. Please indicate which of
the following types of foods you are able to swallow without
experiencing any problems such as pain or food sticking as
it goes down. If you are not sure if you can swallow a type of
food, please make your best guess at whether you would be
able to swallow it without problems. Please check one box
for each type of food.
9. Has having achalasia limited your lifestyle? (Please
check one.)
r No, it is not at all limiting (My daily activities have not
changed.) [1]
r Yes, it has limited my lifestyle (It has affected some areas,
and I can no longer participate in all the activities I want
to do.) [2]
10. How much do you agree with the following statement
about how satisfied you are with your health in regard to
achalasia? (Please circle the number that best describes your
feelings.)
I am satisfied with my health in regard to achalasia.

Can Can Swallow, Can Swallow

Type Swallow but with with Great Strongly Neither Agree Strongly
of with a Little Difficulty or Agree Agree or Disagree Disagree Disagree
Food no Problem Difficulty not at all
[1] [2] [3] [4] [4]
2. Raw hard fruits



and vegetables [1] [2] [3]
3. Rice



[1] [2] [3] Reprint requests and correspondence: David R. Urbach, M.D.,
4. Clear fluids


Division of Clinical Decision Making and Health Care, Toronto
(water, juice, General Hospital, 200 Elizabeth Street, Room 9EN-236A, Toronto,
coffee, tea) [1] [2] [2] ON M5G 2C4, Canada.
Received January 28, 2005; accepted March 22, 2005.

5. How often in the past month have you needed to drink

REFERENCES
water while eating to deal with food caught in your esopha-
gus? (Please circle one answer.) 1. Spiess AE, Kahrilas PJ. Treating achalasiaFrom whale-
bone to laparoscope. JAMA 1998;280:63842.
2. Urbach DR, Hansen PD, Khajanchee YS, et al. A deci-
Never/Rarely Sometimes Frequently/Every Time I Eat sion analysis of the optimal initial approach to achalasia:
[1] [2] [3] Laparoscopic Heller myotomy with partial fundoplication,
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