Quality of Life Research

, Volume 27, Issue 10, pp 2699–2707 | Cite as

Negligible impact of differential item functioning between Black and White dialysis patients on the Kidney Disease Quality of Life 36-item short form survey (KDQOLTM-36)

  • John D. PeipertEmail author
  • Peter Bentler
  • Kristi Klicko
  • Ron D. Hays



Black dialysis patients report better health-related quality of life (HRQOL) than White patients, which may be explained if Black and White patients respond systematically differently to HRQOL survey items.


We examined differential item functioning (DIF) of the Kidney Disease Quality of Life 36-item (KDQOLTM-36) Burden of Kidney Disease, Symptoms and Problems with Kidney Disease, and Effects of Kidney Disease scales between Black (n = 18,404) and White (n = 21,439) dialysis patients. We fit multiple group confirmatory factor analysis models with increasing invariance: a Configural model (invariant factor structure), a Metric model (invariant factor loadings), and a Scalar model (invariant intercepts). Criteria for invariance included non-significant χ2 tests, > 0.002 difference in the models’ CFI, and > 0.015 difference in RMSEA and SRMR. Next, starting with a fully invariant model, we freed loadings and intercepts item-by-item to determine if DIF impacted estimated KDQOLTM-36 scale means.


ΔCFI was 0.006 between the metric and scalar models but was reduced to 0.001 when we freed intercepts for the burdens and symptoms and problems of kidney disease scales. In comparison to standardized means of 0 in the White group, those for the Black group on the Burdens, Symptoms and Problems, and Effects of Kidney Disease scales were 0.218, 0.061, and 0.161, respectively. When loadings and thresholds were released sequentially, differences in means between models ranged between 0.001 and 0.048.


Despite some DIF, impacts on KDQOLTM-36 responses appear to be minimal. We conclude that the KDQOLTM-36 is appropriate to make substantive comparisons of HRQOL between Black and White dialysis patients.


Health-related quality of life KDQOL-36 Measurement invariance Differential item functioning 





Confirmatory factor analysis


Comparative fit index


Centers for Medicare and Medicaid Services


Differential item functioning


Dialysis outcomes and practice patterns study


End-stage renal disease


Health-related quality of life


Kidney Disease Component Summary


Kidney Disease Quality of Life 36-item survey


KDQOL-short form


Mental Component Summary


Physical Component Summary


Peritoneal dialysis


Root mean squared error of approximation


Standardized root mean square residual


United States


Weighted least squares with mean and variance adjustment



We are grateful to Dori Schatell and Ryne Estabrook for their insightful suggestions on this manuscript. There was no direct financial support for the research reported in this manuscript.


This study was not funded.

Compliance with ethical standards

Conflict of interest

All authors declare no conflict of interest.

Ethical approval

This article does not contain any studies with human subjects performed by any of the authors.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • John D. Peipert
    • 1
    • 2
    • 3
    Email author
  • Peter Bentler
    • 4
  • Kristi Klicko
    • 5
  • Ron D. Hays
    • 6
  1. 1.Department of Medical Social Sciences, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.Division of Nephrology, David Geffen School of MedicineUniversity of California, Los AngelesLos AngelesUSA
  3. 3.Terasaki Research InstituteUniversity of California, Los AngelesLos AngelesUSA
  4. 4.Departments of Psychology and StatisticsUniversity of California, Los AngelesLos AngelesUSA
  5. 5.Medical Education Institute, Inc.MadisonUSA
  6. 6.Division of General Internal Medicine and Health Services ResearchUniversity of California, Los AngelesLos AngelesUSA

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