背景
健康相關生活品質（health-related quality of life, HRQoL）與功能恢復是高齡髖部骨折手術後病人最重要的病人中心（patient-centered）臨床結果。歐洲五維健康量表三層版（European Quality of Life Five Dimensions Three Level Version, EQ-5D-3L）是一項廣泛使用、以偏好值（preference-based）為基礎的 HRQoL 評估工具，可用於健康效用值（utility）估算及健康經濟評估。然而，目前對於 EQ-5D-3L 在高齡術後族群中的測量特性、縱向穩定性及臨床適用性的證據仍不完整。此外，認知功能障礙可能影響髖部骨折手術後高齡者的 HRQoL 評估及其恢復軌跡。
研究目的
本論文旨在評估 EQ-5D-3L 於高齡術後族群中的應用、測量特性、時間測量恆等性（temporal invariance）、效度及臨床適用性，並特別聚焦於髖部骨折手術後高齡者。此外，本研究亦探討認知功能障礙是否會影響術後前三個月內 HRQoL、功能能力及行動能力的恢復軌跡。
研究方法
本論文由三項相互關聯的研究組成。首先，進行系統性文獻回顧，以統整 EQ-5D-3L 在高齡術後族群中的應用、測量特性及臨床適用性之證據。文獻回顧遵循 PRISMA 指引，並採用 COSMIN 架構評估相關測量特性證據。其次，進行一項縱向心理計量研究，評估 719 位髖部骨折手術後高齡者之 EQ-5D-3L 的時間測量恆等性與效度，分析方法包括驗證性因素分析（confirmatory factor analysis）、時間測量恆等性檢驗、相關分析及迴歸分析。最後，進行一項縱向世代研究，納入 647 位高齡者，其中 377 位無認知功能障礙，270 位具有認知功能障礙。採用重複量數變異數分析（repeated-measures analysis of variance）及廣義估計方程式（generalized estimating equations）評估組間差異及時間與認知狀態交互作用。
研究結果
系統性文獻回顧共檢索到 151 筆文獻，最終納入 11 項研究，涵蓋骨科、骨折、癌症、胸腔外科及其他外科手術族群。EQ-5D-3L 主要作為一般性 HRQoL 評估工具，並常與疾病特異性病人自評結果量表（patient-reported outcome measures）併用。其主要優勢包括施測可行性高、內容精簡、具跨臨床情境可比較性，以及適合用於健康效用值及品質調整生命年（quality-adjusted life year, QALY）分析。然而，目前證據仍有限，其反應性（responsiveness）結果不一致、部分情境下區辨效度不足、存在天花板效應（ceiling effect），且對時間測量恆等性的探討仍相當有限。
在心理計量研究中，EQ-5D-3L 於基線及術後三個月追蹤皆呈現可接受的模型配適度。基線配適指標為 CFI = 0.988、TLI = 0.975、RMSEA = 0.098 及 SRMR = 0.061；三個月追蹤時分別為 CFI = 0.997、TLI = 0.993、RMSEA = 0.088 及 SRMR = 0.056。時間測量恆等性分析顯示，各模型比較之 CFI 變化量皆低於 0.01，整體支持時間測量恆等性；然而，由於 RMSEA 顯示限制最多之模型配適較差，因此其結果仍需審慎解讀。基線 EQ-5D-3L 健康效用值與基線 Barthel Index 總分（r = 0.800, p < .001）及行動能力分量表（r = 0.652, p < .001）呈高度正相關。此外，基線健康效用值亦可顯著預測術後三個月 Barthel Index 總分（B = 64.334, p < .001）及行動能力分量表（B = 9.273, p < .001）。
在恢復軌跡研究中，具有認知功能障礙者於基線及術後三個月追蹤時，其 HRQoL、功能能力及行動能力均顯著低於無認知功能障礙者。認知功能障礙與較低的 EQ-5D-3L 健康效用值（B = -0.114, p < .001）、較低的 Barthel Index 總分（B = -11.569, p < .001）及較低的 Barthel 行動能力分量表分數（B = -1.221, p < .001）顯著相關。此外，Barthel Index 總分及行動能力分量表皆呈現顯著的時間與認知狀態交互作用，顯示具有認知功能障礙者之功能恢復及行動能力恢復軌跡較不理想。然而，EQ-5D-3L 健康效用值之交互作用未達統計顯著，表示認知功能障礙主要與持續較低的 HRQoL 水準相關，而非導致 HRQoL 恢復軌跡隨時間產生顯著差異。
結論
EQ-5D-3L 為一項具有臨床實用性且方法學基礎健全的健康效用型 HRQoL 評估工具，適用於髖部骨折手術後高齡者，但其結果應結合功能恢復及臨床情境加以詮釋。本研究支持對 EQ-5D-3L 健康效用值進行審慎的縱向解讀，並顯示早期 HRQoL 評估可提供後續功能恢復的重要預後資訊。認知功能障礙為影響功能恢復及行動能力恢復的重要調節因子，因此應納入復健規劃、術後追蹤及未來介入研究之考量。髖部骨折手術後的恢復評估應採整合性架構，同時涵蓋 HRQoL、功能能力、行動能力、認知狀態、臨床風險及社會支持等多面向因素。

Background
Health-related quality of life (HRQoL) and functional recovery are central patient-centered outcomes among older adults following hip fracture surgery. The European Quality of Life Five Dimensions Three Level Version (EQ-5D-3L) is a widely used preference-based HRQoL instrument that enables utility estimation and health-economic evaluation. However, evidence regarding its measurement properties, longitudinal stability, and clinical applicability in older post-surgical populations remains incomplete. In particular, cognitive impairment may influence both HRQoL assessment and recovery trajectories after hip fracture surgery.
Objectives
This dissertation aimed to evaluate the use, measurement properties, temporal invariance, validity, and clinical applicability of the EQ-5D-3L in older post-surgical populations, with particular emphasis on older adults following hip fracture surgery. It also examined whether cognitive impairment modified trajectories of HRQoL, functional ability, and mobility during the first three months after surgery.
Methods
The dissertation consisted of three interconnected studies. First, a systematic review was conducted to synthesize evidence regarding the use, measurement properties, and clinical applicability of the EQ-5D-3L in older post-surgical populations. The review followed PRISMA principles and used a COSMIN-informed approach to evaluate relevant measurement-property evidence. Second, a longitudinal psychometric study assessed temporal invariance and validity of the EQ-5D-3L among 719 older adults following hip fracture surgery. Confirmatory factor analysis, temporal invariance testing, correlation analysis, and regression analysis were performed. Third, a longitudinal cohort study examined recovery trajectories among 647 older adults, including 377 participants without cognitive impairment and 270 participants with cognitive impairment. Repeated-measures analysis of variance and generalized estimating equations were used to evaluate group differences and time-by-cognitive-status interactions.
Results
The systematic review identified 151 records and included 11 studies across orthopedic, fracture, cancer, thoracic, and other surgical populations. The EQ-5D-3L was mainly used as a generic HRQoL outcome measure, often alongside condition-specific patient-reported outcome measures. Its principal strengths were feasibility, brevity, comparability across clinical settings, and suitability for utility-based and quality-adjusted life year analyses. However, the evidence base was incomplete, with variable responsiveness, limited discriminative validity in some settings, ceiling effects, and limited examination of temporal invariance.

In the psychometric study, the EQ-5D-3L demonstrated acceptable comparative model fit at baseline and three-month follow-up. Baseline fit indices were CFI = 0.988, TLI = 0.975, RMSEA = 0.098, and SRMR = 0.061, while follow-up fit indices were CFI = 0.997, TLI = 0.993, RMSEA = 0.088, and SRMR = 0.056. Temporal invariance was generally supported because changes in CFI remained below 0.01 across model comparisons, although RMSEA values indicated that the most constrained model should be interpreted cautiously. Baseline EQ-5D-3L utility was strongly associated with baseline Barthel Index total score (r = 0.800, p < .001) and mobility subscore (r = 0.652, p < .001). Baseline utility also predicted three-month Barthel Index total score (B = 64.334, p < .001) and mobility subscore (B = 9.273, p < .001).
In the trajectory study, participants with cognitive impairment had significantly lower HRQoL, functional ability, and mobility at baseline and three-month follow-up than participants without cognitive impairment. Cognitive impairment was associated with lower EQ-5D-3L utility (B = -0.114, p < .001), lower Barthel Index total score (B = -11.569, p < .001), and lower Barthel mobility subscore (B = -1.221, p < .001). Significant time-by-cognitive-status interactions were observed for Barthel Index total score and mobility subscore, indicating less favorable functional and mobility trajectories among participants with cognitive impairment. However, the interaction for EQ-5D-3L utility was not statistically significant, suggesting that cognitive impairment was associated with persistently lower HRQoL levels rather than a significantly different HRQoL trajectory over time.
Conclusion
The EQ-5D-3L is a clinically useful and methodologically defensible instrument for utility-based HRQoL assessment in older adults following hip fracture surgery when interpreted alongside functional outcomes and clinical context. The findings support cautious longitudinal interpretation of EQ-5D-3L utility scores and demonstrate that early HRQoL assessment may provide prognostic information regarding subsequent functional recovery. Cognitive impairment is a key modifier of functional and mobility recovery and should be incorporated into rehabilitation planning, postoperative monitoring, and future intervention research. Recovery after hip fracture surgery should therefore be evaluated through an integrated framework that includes HRQoL, functional ability, mobility, cognitive status, clinical risk, and social support.

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