Correlation of the Voice Handicap Index (VHI) and the

Voice-Related Quality of Life Measure (V-RQOL)

Carissa R. Portone, Edie R. Hapner, Laura McGregor,

Kristen Otto, and Michael M. Johns III
Atlanta, Georgia

Summary: The purpose of this study was to investigate the correlation be-
tween the Voice Handicap Index (VHI) and the Voice-Related Quality of
Life Measure (V-RQOL), and to test conversion of scores between the two
instruments. Understanding the relationship between instruments will facili-
tate comparison of voice outcome studies using different measures. A retro-
spective medical chart review of 140 consecutive patients with a chief
complaint related to their voice presenting for speech pathology voice eval-
uation following laryngology evaluation and diagnosis was adopted. Each pa-
tient who filled out the VHI and V-RQOL within a 2-week period with no
intervening treatment was included in the study. Correlation analysis for total
scores was performed for the patients meeting inclusion criteria (n 5 132).
Correlations were also performed as a function of diagnosis. Calculated
VHI score based on measured V-RQOL score was compared to measured
VHI score. Pearson correlation between scores on the VHI and V-RQOL
was 0.82. There was no significant difference between the mean measured
and mean calculated VHI scores. For individual scores, however, regression
analysis did reveal a significant difference between calculated and measured
VHI. The VHI and V-RQOL are highly correlated; however, this study sug-
gests that the two instruments are not interchangeable for individuals.
Key Words: VoiceOutcomesQuality of life.

Accepted for publication June 12, 2006.
Research presented at the Voice Foundations 34th Annual
Symposium: Care of the Professional Voice, June 4, 2005.
From the Emory Voice Center, Department of Otolaryngo-
logy, Emory University, Atlanta, Georgia.
Address correspondence and reprint requests to Michael M.
Johns, III, Department of Otolaryngology, Emory University,
550 Peachtree St. NE, 9th Floor, Suite 4400, Atlanta, GA
30308. E-mail: michael.johns2@emory.edu
Journal of Voice, Vol. 21, No. 6, pp. 723727
0892-1997/$32.00
2007 The Voice Foundation
doi:10.1016/j.jvoice.2006.06.001
INTRODUCTION
Assessment of treatment outcomes in patients
with dysphonia has presented a challenge for clini-
cians and researchers. Attempts to examine treat-
ment outcomes have included the use of perceptual
voice ratings and objective measurements of acous-
tic and aerodynamic voice properties. For both re-
search and clinical purposes, perceptual voice
evaluations are limited by their subjective nature
and difficulties with intra- and inter-rater reliability.1
Due to the variability in the presentation of dyspho-
nia, acoustic and aerodynamic measurements have
not adequately encompassed the impact of

723
724 CARISSA R. PORTONE ET AL
dysphonia on individual patients.2 There has been in-
creasing interest in the measurement of quality of life
impairment as a method of assessing treatment out-
comes in patients with dysphonia.
There are several patient self-assessment instru-
ments designed to measure quality of life specific
to dysphonia. These include the Voice Handicap In-
dex (VHI),3 the Voice-Related Quality of Life Mea-
sure (V-RQOL),4 the Voice Outcome Survey,5 the
Voice Symptom Scale,6 and the Voice Handicap
Index-10 (VHI-10).7 Several studies report voice
outcomes using these instruments. Understanding
the degree to which the instruments are comparable
will facilitate comparison of voice outcome studies
using different measures.
Two of the most commonly used instruments are
VHI and V-RQOL. Both tools ask respondents to
rate the degree to which their quality of life is af-
fected by dysphonia by selecting one of five severity
categories for each item on the scale. The VHI con-
tains 30 total items, 10 in each of the following three
domains: emotional, physical, and functional. Scores
on the VHI range from 0 to 120, with 120 being the
most severely handicapped. The V-RQOL is a 10-
question instrument broken down into two domains:
social-emotional and physical functioning. Raw
scores on the V-RQOL range from 10 to 50 and are
converted using an algorithm to a scale of 0100,
where 0 indicates the worst quality of life and 100
indicates no impact on quality of life.
The purpose of this study was to (1) examine the
correlation of V-RQOL and VHI and (2) test the
ability to convert scores between the two measures.
Because both instruments measure dysphonia-spe-
cific quality of life by patient report, our hypothesis
was that the two tools would be highly correlated
and that a simple arithmetic equation could be
used to convert their scores.
METHODS
Study design
The study involved the retrospective evaluation
of 140 consecutive patients with a chief complaint
related to their voice presenting for speech-lan-
guage pathology voice evaluation and therapy at
the Emory Voice Center following laryngology
evaluation and diagnosis. Data were collected
Journal of Voice, Vol. 21, No. 6, 2007
with Institutional Review Board approval, and
patient confidentiality was protected under Health In-
surance Portability and Accountability Act (HIPAA)
guidelines. No identifying information was collected.
Procedure
Patients were asked to complete the V-RQOL
and the VHI at the time of evaluation or prior to be-
ginning voice therapy. Patients who completed both
the V-RQOL and the VHI within a 2-week period
with no intervening treatment were included in
the study (n 5 132). The majority of patients com-
pleted both instruments in a single sitting following
laryngology evaluation and diagnosis but prior to
initiating treatment. For each patient, the following
information was collected and stored in a database:
diagnosis, score on V-RQOL, and score on VHI.
Diagnoses had been established in a multidisciplin-
ary clinic with a laryngologist and speech-language
pathologist using case history review, perceptual as-
sessment, acoustic and aerodynamic studies, and la-
ryngeal videostroboscopy. Patients with multiple
diagnoses were not excluded.
Using the anchors 0100 and 0120 for the V-
RQOL and VHI, respectively, the V-RQOL score
(x) was used to calculate a VHI score ( y) using
the direct conversion equation y 5 1.2x 120.
Statistical analysis was conducted using MatLab
7.0. Spearman correlation coefficients were ob-
tained for VHI and V-RQOL mean scores; addi-
tional correlation coefficients were computed for
VHI and V-RQOL scores as a function of diagnosis.
A matched-pairs t test was performed to analyze the
difference between mean calculated VHI scores
versus measured VHI. Regression analysis was
used to assess the relationship between calculated
and measured VHI scores for individual subjects.
RESULTS
Of the 140 patients enrolled in the study, 132 met
the inclusion criteria described above. V-RQOL and
VHI scores for those 132 patients were used for anal-
ysis. Spearman correlation coefficient was 0.82
and was statistically significant (P ! 0.0001).
Mean score on the V-RQOL was 65.09 with a stan-
dard deviation (SD) of 23.54. Mean score on the
VHI was 40.23 with SD 25.27. Mean calculated
 CORRELATION OF THE VHI AND THE V-RQOL 725

score on the VHI using the conversion equation was TABLE 1. Pearson correlation coefficients by
41.89 with SD 28.25. diagnosis
Linear regression analysis was used to examine Diagnosis r n
the relationship between the V-RQOL (x) and VHI
( y). Regression analysis yielded the equation Atrophy 0.84653 22
Chronic laryngitis/LPR 0.89757 18
y 5 0.8844x 97.797. Figure 1 shows a scatter
MTD 0.93013 15
plot for all subjects with regression line for the data set. Nodules 0.43233 11
Correlation of the VHI with the V-RQOL was Other 0.79417 66
examined by diagnosis. Table 1 lists the number Total 0.82411 132
of patients with each primary diagnosis represented Abbreviations: LPR, laryngopharyngeal reflux; MTD, muscle
in the study. Correlations were computed for pa- tension dysphonia.
tients with vocal fold atrophy (r 5 0.85), laryng-
opharyngeal reflux (r 5 0.90), muscle tension was analyzed. Mean absolute value of the differ-
dysphonia (r 5 0.93), and vocal fold nodules ence between calculated and measured VHI scores
(r 5 0.43). Other diagnoses were represented by was 12.23  1.81 (95% confidence interval), with
six or fewer subjects; correlations were not per- SD 10.58. For 99 study participants (75%), differ-
formed for these groups. ence between calculated and measured VHI score
A matched-pairs t test was used to analyze the dif- was less than 18 points. For 33 of the patients
ference between calculated VHI scores versus direct (25%), calculated and measured scores on the
measure. No significant difference was found VHI differed by 18 points or more (range: 066).
(P 5 0.24). Mean difference between calculated Regression analysis was used to compare calcu-
VHI scores and measured VHI scores was lated VHI scores versus direct measure VHI scores
1.66  2.75 (95% confidence interval), with SD for individual patients. Analysis demonstrated a sig-
16.13. However, difference between calculated and nificant variance (P ! 0.01) between calculated and
measured VHI scores ranged from 48 to 66, includ- measured scores. Deviation of calculated score from
ing both negative and positive differences. There was direct measure score increased as severity of QOL
a difference of 0 points between calculated and impact increased (Figure 2). Scatter from the regres-
measured VHI scores for five patients (4%). For 63 sion line increased with higher scores on the VHI.
patients (48%), calculated VHI was less than mea-
sured VHI. Calculated VHI score was higher than
measured VHI for 64 patients (48%). DISCUSSION
Because some differences between calculated This is the first English-language study to assess
and measured scores were negative and some correlation of VHI and V-RQOL. Because both
were positive, absolute value of the difference
140
140 120
120 100
Measured VHI

y = -0.8844x + 97.797
R2= 0.6792
100 80
80
60
VHI

60
40
40
20
20
0
0 20 40 60 80 100 120 140
0
0 20 40 60 80 100 120 Calculated/Predicted VHI
V-RQOL
FIGURE 2. Calculated VHI scores (based on measured
FIGURE 1. Measured V-RQOL plotted against VHI scores V-RQOL scores) plotted against direct-measure VHI scores
(n 5 132). (n 5 132).

Journal of Voice, Vol. 21, No. 6, 2007

726 CARISSA R. PORTONE ET AL
instruments measure dysphonia-specific quality of
life by patient report, our hypothesis was that the
two tools would be highly correlated. Results sup-
port this hypothesis. Clinicians and researchers
may prefer one test or the other, and our results sup-
port limiting patient quality of life self-report mea-
sures to one tool.
The small sample sizes must be taken into ac-
count when assessing correlation between VHI
and V-RQOL by diagnosis. We did find that pa-
tients with nodules (n 5 11) had a less robust corre-
lation than patients with other diagnoses. However,
there was no obvious trend in the scores of the pa-
tients with nodules: VHI scores ranged from 7 to
84, and V-RQOL scores ranged from 48 to 100.
Differences between calculated and measured
VHI ranged from 48 to 29. There was one patient
in the sample who scored 84/120 on the VHI but
70/100 on the V-RQOL; with this outlier removed
from the sample, the correlation coefficient for pa-
tients with nodules (n 5 10) increased to 0.56.
Line item analysis would be helpful in assessing re-
sponse trends based on diagnosis. Unfortunately,
responses to individual questions were not recorded
for the purposes of this study; only raw scores were
documented. Future research may further examine
differences between the two instruments measure-
ment of quality of life impairment by diagnosis.
In addition to assessing the correlation between
V-RQOL and VHI, we examined the use of an
equation to convert scores between the two instru-
ments based on the anchors of the two tests. On av-
erage, calculated scores were not significantly
different from those obtained by direct measure.
For individuals, however, the scores were signifi-
cantly different. This difference was more pro-
nounced with higher VHI scores, indicating that
the conversion equation may be more reliable
when patients have reduced impairment in voice-
specific quality of life. A posttreatment change of
18 points on the VHI is considered the critical score
to demonstrate significant change from treatment.3
For 33 of the patients in this study (25%), calcu-
lated and measured scores on the VHI differed by
18 points or more. Based on these results, use of
calculated scores to assess outcome for individual
patients would be inappropriate. Although we
found no statistical difference between calculated
Journal of Voice, Vol. 21, No. 6, 2007
and measured VHI scores on average, caution
should be taken when interpreting this finding until
it is reproduced for other data sets.
A study published in German in 20048 estimated
the correlation of VHI and V-RQOL with respect to
gender and diagnosis. The two instruments were
found to be significantly correlated (r 5 0.9).
Neither gender nor organic versus functional voice
disorder was found to significantly affect the corre-
lation. The researchers concluded that for clinical
purposes, only one test or the other need be admin-
istered. Results of our study indicate that there may
be significant differences between individuals
QOL scores measured by different instruments.
The VHI-10 is a recently developed short form of
the VHI, consisting of 10 of the 30 questions from
the original VHI. The validation study conducted
by Rosen et al7 demonstrates a strong relationship
between VHI and VHI-10. The degree to which
the VHI-10 and V-RQOL are comparable has not
yet been examined.
Limitations of the current study must be consid-
ered when applying findings. The study population
was limited to 140 subjects. The exact number of
subjects required for use of the conversion equation
with a high degree of confidence cannot be deter-
mined. All subjects included presented with a chief
complaint related to their voice, and no normal con-
trol group was included for comparison. Addition-
ally, the VHI was designed to assess a change in
quality of life after treatment; however, this study
was cross-sectional, and included only one time
point per patient.
CONCLUSIONS
The VHI and the V-RQOL are highly correlated.
For large sample sets, results of studies using V-
RQOL scores are highly likely to be comparable
to those using the VHI, and vice-versa. Our data
do not support conversion of scores between the
V-RQOL and VHI for individual scores.
Acknowledgments: The authors would like to ac-
knowledge Andrew Smith, MS, Erika L. Johnson, BA,
and Deborah S. Johnson, MS, for their assistance with
the statistical analysis presented in this manuscript.
 CORRELATION OF THE VHI AND THE V-RQOL
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