Cited by 3,027Health Systems, Economic Evaluations, Quality of LifeCancer survivorship and careMusculoskeletal pain and rehabilitation

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Linking Clinical Variables With Health-Related Quality of Life: A Conceptual Model of Patient Outcomes

Wilson, Ira B.·1995·JAMA

DOI 10.1001/jama.1995.03520250075037

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Abstract

HEALTH-related quality of life (HRQL) is increasingly used as an outcome in clinical trials, effectiveness research, and research on quality of care. Factors that have facilitated this increased usage include the accumulating evidence that measures of HRQL are valid and "reliable,"1the publication of several large clinical trials showing that these outcome measures are responsive to important clinical changes,2-5and the successful development and testing of shorter instruments that are easier to understand and administer.6-13Because these measures describe or characterize what the patient has experienced as the result of medical care, they are useful and important supplements to traditional physiological or biological measures of health status. Given this improved ability to assess patients' health status, how can physicians and health care systems intervene to improve HRQL? Implicit in the use of measures of HRQL in clinical trials and in effectiveness research is the concept that clinical

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“(4) The Wilson and Cleary model [28] describes HRQoL as consisting of (a sequence of causal effects between) 5 groups of latent variables: physiological states, symptom status, functional status, general health perception, and overall HRQoL.”
Method
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“As a result, less is known about the actual role of the latter factors pertaining to three domains and two characteristics (biological variables, symptom status, general health perception and individual and environmental characteristics) of the Wilson and Cleary model, and their association with HRQL.”
MethodInfluential
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MethodResult
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Background
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“Theoretical models have provided the framework that links clinical conditions with patient perceptions and impacts on their oral health-related quality of life (OHRQoL) [4,5].”
Background
Tests of Muscle Strength and Physical Function: Reliability and Discrimination of Performance in Younger and Older Men and Older Men with Mobility Limitations
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The association of health-related quality of life with survival among persons with HIV infection in the united states
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Background
Self-assessment of the quality of vision: association of questionnaire score with objective clinical tests
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“However, other relevant variables may exist, such as individual characteristics (gender, grade, and major) and environmental characteristics (family economic annual income and parents’ education level) that Wilson and Cleary had put forward [71].”
Background
How to ‘count the cost’ and measure burden? A review of health-related quality of life in people with eating disorders
Hay, P., & Mond, J. (2005) · Journal of Mental Health · doi:10.1080/09638230500400274 · Cited by 86
“HRQOL reflects the variable relationships between severity of illness, functional status and disability (Wilson & Cleary, 1995; Revicki et al., 2000) and has been argued to be the ‘‘primary end-point’’ in clinical settings (Pais-Ribeiro, 2004).”
Background
The Health and Quality of Life Outcomes Among Youth and Young Adults With Cerebral Palsy
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“In medical health care there is consensus that QOL should reflect the subjective perception of a patient's well-being and functioning, pertaining to physical, emotional and social aspects as well as everyday life activities (Wilson & Cleary, 1995).”
Background
Pain is Independently Associated with Impaired Physical Function in HIV-Infected Patients
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“Potential variables postulated as influential in the HRQL of chronically ill patients were investigated [7].”
Background
Health-Related Quality of Life in Persons Younger and Older than 50 Who are Living with HIV/AIDS
Nokes, K. M., Holzemer, W. L., Corless, I. B., et al. (2000) · Research on Aging · doi:10.1177/0164027500223004 · Cited by 79
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“It is based on the conceptual model of Wilson and Cleary (Figure 1) [21] and items were chosen to fit the symptom and functional status levels on the health continuum in addition to characteristics of the individual and environment (Figure 2).”
Method
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“HRQoL is defined as a person’s health status and is viewed as a continuum of very complex health outcomes where the person is capable of functioning and has a general perception of health and well-being [8].”
Background
The current clinical approach to feeding and eating disorders aimed to increase personalization of management
Schmidt, U. H., Claudino, A. M., Fernández‐Aranda, F., Giel, K. E., Griffiths, J., Hay, P., Kim, Y., Marshall, J., Micali, N., Monteleone, A. M., et al. (2025) · World Psychiatry · doi:10.1002/wps.21263 · Cited by 90
“Health-related quality of life measures assess people’s apprais al of the impact of disease and treatment on their physical, psychological, social and somatic functioning and well-being, and the re-la tionships between severity of illness, functional status and disability 199,200 .”
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Method
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“Covariates were selected for the present study based on their potential for imbalances across fluorosis or caries levels and their associations with OHRQoL measures using the Wilson and Cleary (1995) model as a guide for initial selection.”
BackgroundMethod
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Gajria, K., Kosinski, M. R., Sikirica, V., Huß, M., Livote, E. E., Reilly, K., Dittmann, R., & Erder, M. H. (2015) · Health and Quality of Life Outcomes · doi:10.1186/s12955-015-0379-1 · Cited by 77
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Background
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der Weide, M. C. J., Gaasterland, C. M. W., Roes, K. C. B., Pontes, C., Vives, R., Sancho, A., Nikolakopoulos, S., Vermeulen, E., & van der Lee, J. H. (2018) · Orphanet Journal of Rare Diseases · doi:10.1186/s13023-018-0836-0 · Cited by 77
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“In fact, this suggestion resonates with the influential conceptual model of HRQoL by Wilson and Cleary [65].”
Result
Relationships between changes in patient-reported health status and functional capacity in outpatients with heart failure
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The Reliability and Validity of the Health of the Nation Outcome Scales: Validation in Relation to Patient Derived Measures
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“Recently, a number of models of the relationships between various health outcome measures have been developed [7–10].”
Background
Using quality-of-life instruments to assess surgical outcomes
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“Wilson and Cleary (1995) described the subjective nature of symptom experience as being an important consideration in individual appraisals of quality of life.”
Background
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“As social support has a central position in different conceptual models of HRQoL [42,43], more studies that take social support into consideration are needed to reach a deeper understanding of HRQoL in elderly persons with chronic HF.”
Background
Determinants of children's oral‐health‐related quality of life over time
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Background
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Oral Health Inequalities
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“The Wilson and Cleary (1995) model postulates that environmental and individual factors influence subjective oral health outcomes, such as OHQoL, but does not detail the exact processes by which these factors may interact.”
Background
Is Thyroid Autoimmunity per se a Determinant of Quality of Life in Patients with Autoimmune Hypothyroidism?
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“It is hypothesised that the patient’s subjective symptoms are influenced by external factors such as the patient’s age, culture, expectations, and physical and mental capabilities, which modify the effects of disease severity [5].”
Background
What do children's global ratings of oral health and well‐being measure?
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“Most conceptualizations of health related QOL include dimensions of physical functioning, social functioning, role functioning, mental health and general health perceptions, with important concepts such as energy, fatigue, pain, and cognitive functioning included in these broader categories [1].”
Background
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“Furthermore, health-related QoL is distinguished from general QoL [18, 19].”
Background
Implications of Apathy for Everyday Functioning Outcomes in Persons Living with HIV Infection
Kamat, R., Woods, S. P., Marcotte, T. D., Ellis, R. J., & Grant, I. (2012) · Archives of Clinical Neuropsychology · doi:10.1093/arclin/acs055 · Cited by 72
Correlation of Low Back Pain With Functional Status, General Health Perception, Social Participation, Subjective Happiness, and Patient Satisfaction
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“These factors were associated with QOL in Wilson and Cleary’s conceptual model [58].”
Background
Differences by sex in correlates of work status in rheumatoid arthritis patients
Roos, A. J. D., & Callahan, L. F. (1999) · Arthritis & Rheumatism · doi:10.1002/1529-0131(199912)12:6 · Cited by 53
Quality of life after treatment for prostate cancer
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The prevalence, severity, and correlates of psychological distress and impaired health-related quality of life following treatment for testicular cancer: A survivorship study
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“, anxiety, depression, and stress) in TC survivors would be significantly associated with demographics (age, employment, and relationship status), disease and treatment factors (treatment type and presence of chronic illness), individual factors (coping style), and environmental factors (social support), as predicted…”
Impact of Spiritual Symptoms and Their Interactions on Health Services and Life Satisfaction
Katerndahl, D. A. (2008) · The Annals of Family Medicine · doi:10.1370/afm.886 · Cited by 73
The Quality of Life and Psychosocial Implications of Cancer-Related Lower-Extremity Lymphedema: A Systematic Review of the Literature
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“QOL is a multifaceted concept that encompasses different domains of one’s life, including physical well‐being, social/familial well‐being, emotional well‐being, and functional well‐being [7].”
Background
Waiting for healthcare: a concept analysis
Fogarty, C., & Cronin, P. (2008) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2007.04507.x · Cited by 73
Domains of quality of life: results of a three-stage Delphi consensus procedure among patients, family of patients, clinicians, scientists and the general public
Pietersma, S., de Vries, M., & Marle, M. E. V. D. A. (2013) · Quality of Life Research · doi:10.1007/s11136-013-0578-3 · Cited by 73
“possible that some specific domains are part of another larger and more abstract domain [29].”
Background
The Spanish version of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ): Metric characteristics and equivalence with the original version
Tauler, E., Vilagut, G., Grau, G., González, A., Sánchez, E., Figueras, G., Vall, O., Ferrer, M., & Alonso, J. (2001) · Quality of Life Research · doi:10.1023/a:1016622519987 · Cited by 71
Assessing the quality of life—reality or impossible dream?
Holmes, S. (2004) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2004.06.014 · Cited by 72
The effects of an emotional intelligence program on the quality of life and well-being of patients with type 2 diabetes mellitus
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Quality-of-life measures for use within care homes: a systematic review of their measurement properties
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Health‐Related Quality of Life in an Inception Cohort of Children With Juvenile Idiopathic Arthritis: A Longitudinal Analysis
Oen, K., Guzmán, J., Dufault, B., Tucker, L. B., Shiff, N. J., Duffy, K. W., Lee, J. J. Y., Feldman, B. M., Berard, R. A., Dancey, P., et al. (2017) · Arthritis Care & Research · doi:10.1002/acr.23236 · Cited by 73
Reflective, causal, and composite indicators of quality of life: A conceptual or an empirical distinction?
Costa, D. S. J. (2015) · Quality of Life Research · doi:10.1007/s11136-015-0954-2 · Cited by 71
“Alongside this definition, Patrick and Erickson [32] proposed a causal model of quality of life, similar to that of Wilson and Cleary [33], which explicitly treats the aspects”
Result
Gender Differences in the Effects of Physical and Emotional Symptoms on Health-Related Quality of Life in Patients with Heart Failure
Heo, S., Moser, D. K., & Widener, J. (2006) · European Journal of Cardiovascular Nursing · doi:10.1016/j.ejcnurse.2006.06.008 · Cited by 71
“Wilson and Cleary [11] proposed a theoretical HRQOL model suggesting the relationships among clinical variables, individual and environmental variables, and HRQOL.”
BackgroundInfluential
The impact of socioenvironmental characteristics on domains of oral health-related quality of life in Brazilian schoolchildren
de Paula, J. S., Leite, I. C. G., de Almeida, A. B., et al. (2013) · BMC Oral Health · doi:10.1186/1472-6831-13-10 · Cited by 71
“With this in mind, it is reasonable to assume that the relationship between Oral Heath-related Quality of Life (OHRQoL) and clinical conditions is also mediated by personal socio-environmental characteristics [12-16].”
Background
Subjective Well-Being Among the Old-Old: The Role of Health, Personality and Social Support
Landau, R., & Litwin, H. (2001) · The International Journal of Aging and Human Development · doi:10.2190/rumt-ycdx-x5hp-p2vh · Cited by 71
“On the whole, subjective health perception represents an integration of all the health concepts and is among the best predictors of the use of general medical and mental health services, as well as being a strong predictor of mortality (Wilson & Cleary, 1995).”
BackgroundInfluential
Relationships between dental appearance, self-esteem, socio-economic status, and oral health-related quality of life in UK schoolchildren: A 3-year cohort study
Benson, P. E., Da'as, T., Johal, A., et al. (2014) · European Journal of Orthodontics · doi:10.1093/ejo/cju076 · Cited by 70
Sports participation and health-related quality of life: a longitudinal observational study in children
Moeijes, J., van Busschbach, J. T., Bosscher, R. J., & Twisk, J. W. R. (2019) · Quality of Life Research · doi:10.1007/s11136-019-02219-4 · Cited by 88
Pathways between parental and individual determinants of dental caries and dental visit behaviours among children: Validation of a new conceptual model.
Buldur, B. (2020) · Community Dentistry and Oral Epidemiology · doi:10.1111/cdoe.12530 · Cited by 83
The physical and mental health effects of housing homeless people: A systematic review
Onapa, H., Sharpley, C. F., Bitsika, V., McMillan, M., MacLure, K., Smith, L., & Agnew, L. L. (2021) · Health & Social Care in the Community · doi:10.1111/hsc.13486 · Cited by 94
Disease Severity and Health‐Related Quality of Life Across Different Chronic Conditions
Ferrucci, L., Baldasseroni, S., Bandinelli, S., Alfieri, W. D., Cartei, A., Calvani, D., Baldini, A., Masotti, G., & Marchionni, N. (2000) · Journal of the American Geriatrics Society · doi:10.1111/jgs.2000.48.11.1490 · Cited by 70
Other Paradigms: Health-Related Quality of Life as a Measure in Cancer Treatment
Trask, P. C., Hsu, M., & McQuellon, R. P. (2009) · The Cancer Journal · doi:10.1097/ppo.0b013e3181b9c5b9 · Cited by 71
Measuring pediatric patient-reported outcomes: good progress but a long way to go
Huang, I., Revicki, D. A., & Schwartz, C. E. (2013) · Quality of Life Research · doi:10.1007/s11136-013-0607-2 · Cited by 72
“However, the term ‘‘HRQOL’’ used by the above-mentioned two articles actually captures the notion ‘‘general health perception’’ that was described in Wilson and Cleary’s classical model [11].”
Background
Outcomes assessment in hand surgery: When are they meaningful?
Szabo, R. M. (2001) · The Journal Of Hand Surgery · doi:10.1053/jhsu.2001.29487 · Cited by 69
The symptom experience of people living with HIV and AIDS in the Eastern Cape, South Africa
Peltzer, K., & Phaswana-Mafuya, N. R. (2008) · BMC Health Services Research · doi:10.1186/1472-6963-8-271 · Cited by 70
“Wilson and Cleary [4] described a symptom as a person's perception of an abnormal physical, emotional, or cognitive state.”
Background
Meaningful health outcomes for paediatric neurodisability: Stakeholder prioritisation and appropriateness of patient reported outcome measures
Morris, C., Janssens, A. I. W. A., Shilling, V. M., Allard, A., FELLOWES, A. P., Tomlinson, R., Williams, J., Coon, J. T., Rogers, M., Beresford, B., et al. (2015) · Health and Quality of Life Outcomes · doi:10.1186/s12955-015-0284-7 · Cited by 70
“This view is consistent with Wilson and Cleary’s model linking clinical variables to measures of health related quality of life [25].”
Result
Health-Related Quality of Life in Athletes: A Systematic Review With Meta-Analysis
Houston, M. N., Hoch, M. C., & Hoch, J. M. (2016) · Journal of Athletic Training · doi:10.4085/1062-6050-51.7.03 · Cited by 79
The effects of optimism and gratitude on adherence, functioning and mental health following an acute coronary syndrome
Millstein, R. A., Celano, C. M., Beale, E. E., Beach, S. R., Suarez, L. S. K., Belcher, A. M., Januzzi, J. L., & Huffman, J. C. (2016) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2016.08.006 · Cited by 70
Untitled work
(1997) · doi:10.1002/(sici)1099-1611(199703)6:1
Evidence on the measurement properties of health-related quality of life instruments is largely missing in patients with low back pain: A systematic review
Chiarotto, A., Terwee, C. B., Kamper, S. J., Boers, M., & Ostelo, R. W. (2018) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2018.05.006 · Cited by 69
Quality of life considerations in head and neck cancer: United Kingdom National Multidisciplinary Guidelines
Rogers, S. N., Semple, C. J., Babb, M., & Humphris, G. M. (2016) · The Journal of Laryngology & Otology · doi:10.1017/s0022215116000438 · Cited by 69
Impact of developmental and epileptic encephalopathies on caregivers: A literature review
Gallop, K., Lloyd, A. J., Olt, J., & Marshall, J. D. (2021) · Epilepsy & Behavior · doi:10.1016/j.yebeh.2021.108324 · Cited by 71
“As DEEs are complex disorders, the specific impact on caregivers is unlikely to be captured by a generic HRQL model such as that proposed byWilson and Cleary [8].”
Background
Clinician and Patient Reporting of Symptomatic Adverse Events in Cancer Clinical Trials: Using CTCAE and PRO-CTCAE® to Provide Two Distinct and Complementary Perspectives
Minasian, L. M., O’Mara, A. M., & Mitchell, S. A. (2022) · Patient Related Outcome Measures · doi:10.2147/prom.s256567 · Cited by 75
The impact of developmental defects of enamel on young people in the UK
Marshman, Z., Gibson, B., & Robinson, P. G. (2008) · Community Dentistry And Oral Epidemiology · doi:10.1111/j.1600-0528.2008.00453.x · Cited by 69
Prostate Cancer Survivors' and Partners' Self-Reports of Health-Related Quality of Life, Treatment Symptoms, and Marital Satisfaction 2.5-5.5 Years After Treatment
Galbraith, M. E., Aréchiga, A. E., Ramirez, J., & Pedro, L. W. (2005) · Oncology nursing forum · doi:10.1188/05.onf.e30-e41 · Cited by 67
Framing the Problem of Measuring and Improving Healthcare Quality
Mitchell, P. H., & Lang, N. M. (2004) · Medical Care · doi:10.1097/01.mlr.0000109122.92479.fe · Cited by 69
Predicting quality of life impairment in chronic schizophrenia from cognitive variables
Ritsner, M. S. (2007) · Quality of Life Research · doi:10.1007/s11136-007-9195-3 · Cited by 68
“In other words, HRQL includes dimensions of physical and social functioning: mental health and general health perceptions including such important concepts as energy, fatigue, pain, and cognitive functioning [2].”
Measuring outcomes of cataract surgery using the Quality of Well-Being Scale and VF-14 Visual Function Index
Rosen, P. N., Kaplan, R. M., & David, K. (2005) · Journal of Cataract & Refractive Surgery · doi:10.1016/j.jcrs.2004.04.043 · Cited by 69
Health related quality of life trajectories and predictors following coronary artery bypass surgery
Grande, M. R. L., Elliott, P. C., Murphy, B. M., Worcester, M. C., Higgins, R. O., Ernest, C. S., & Goble, A. J. (2006) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-4-49 · Cited by 68
“Wilson and Cleary [ 14 ] provide a useful organizing framework for categorising predictors of HRQoL.”
Influential

Authors: Wilson, I. B.
Corresponding author: Wilson, Ira B.
ORCID: Wilson, Ira B.
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 1995-01-04
Volume: 273
Issue: 1
Pages: 59
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.1995.03520250075037
OpenAlex: W4292024189
Cited by: 3,027
References: 0
Citations by year: 2026: 151 · 2025: 168 · 2024: 134 · 2023: 141 · 2022: 176 · 2021: 183 · 2020: 197 · 2019: 137 · 2018: 138 · 2017: 130 · 2016: 145 · 2015: 131 · 2014: 128 · 2013: 123 · 2012: 106
FWCI: 96.54
Type: journal article
Language: en
Open access: closed
Locations: JAMA (publishedVersion)
Funders: Agency for Healthcare Research and Quality (1-R01-HS06239)
Topics: Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
Health Sciences › Medicine › Oncology › Cancer survivorship and care
Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Keywords: health-related quality of life, clinical factors, patient-reported outcomes, outcome measures, quality of care, effectiveness research, health assessment

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Linking Clinical Variables With Health-Related Quality of Life: A Conceptual Model of Patient Outcomes

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