Predictors of health-related quality of life after coronary artery bypass surgery

Living alone predicts 30-day hospital readmission after coronary artery bypass graft surgery

BACKGROUND

Earlier studies show that medical factors and disease severity predict early readmission to hospital after coronary artery bypass graft surgery (CABGS). Few studies have investigated psychosocial predictors. This study investigated medical, sociodemographic and psychosocial predictors of 30-day hospital readmission.

METHODS

A consecutive sample of 181 patients wait-listed for CABGS completed self-report questionnaires before surgery, and at 2 and 6 months after surgery.

RESULTS

Twenty-six (14.4%) patients were readmitted within 30 days of hospital discharge. Readmitted patients were older (t=2.12, df=179, P=0.035), and more likely to be unmarried (chi=5.80, df=1, P=0.016), live alone (chi=8.33, df=1, P=0.004), have a history of hypertension (chi=2.731, df=1, P=0.098) and have higher anxiety before surgery (t=1.67, df=175, P=0.097). When these variables were entered into a backward stepwise logistic regression, the only significant unique predictor of 30-day readmission was living alone (Wald=7.08, odds ratio=3.42, P=0.008). Patients living alone were over three times more likely than those living with others to be readmitted to hospital. Disease severity and other medical factors were not associated with readmission.

CONCLUSION

Living alone was identified as the single most important risk factor for early readmission after CABGS. Patients who live alone may benefit from additional support during early convalescence. Intervention studies could explore support options for these patients.

A long-term follow-up study of chest pain patients: effect of panic disorder on mortality, morbidity, and quality of life

AIMS

The aim was to assess the association between panic disorder (PD) and the long-term outcome of chest pain patients with or without coronary artery disease (CAD).

METHODS

Patients (n = 199) consecutively referred to a cardiology outpatient clinic because of chest pain were reassessed after 9 years. At the initial examination 16% suffered from CAD and 38% from PD. Data were collected on mortality, cardiac events, cardiac risk factors, chest pain, anxiety and depression (SCL-90-R), and health-related quality of life (SF-36).

RESULTS

The death rate in the study population was not significantly different from that in the general population and no significant associations were found between PD at baseline and mortality and cardiac morbidity at follow-up. PD was associated with significantly higher follow-up scores of chest pain intensity (p = 0.025), depression (p = 0.005), anxiety (p = 0.039), and poorer health-related quality of life: physical functioning (p = 0.004), role physical (p = 0.001), body pain (p = 0.007), and general health (p < 0.001).

CONCLUSIONS

PD has a negative long-term effect on psychological and physical well-being of chest pain patients which emphasizes the necessity of identifying PD patients and offering them adequate treatment.

Comparison of functional status after coronary artery bypass grafting in patients with and without diabetes mellitus

Although previous studies have shown increased risk of morbidity and mortality in patients with diabetes mellitus (DM) who undergo coronary artery bypass grafting (CABG), data are conflicting on whether the gains in physical function and mental health after CABG achieved by patients with DM are similar to, or less than, those achieved by patients without DM. We compared the gains in physical function and mental health at 6 months after CABG surgery between 696 consecutive patients with DM and 376 without DM who underwent their first CABG from February 1999 to February 2001. Physical function and mental health were measured using the Short Form 36-item Health Survey. From the baseline and follow-up Short Form 36-item Health Survey data, the physical and mental component scales were derived. At 6 months, the patients with and without DM had significant improvement in physical function and mental health, but those without DM had improved significantly more than those with DM with respect to physical functioning. After adjusting for baseline characteristics, a lower proportion of patients with DM had experienced improvement (an increase of > or = 5 points) in the physical component scale score compared with those without DM (45.0% vs 58.0.%, RR = 0.78, p = 0.002). Moreover, a higher proportion of patients with DM experienced a decrease in the physical component scale score compared with those without DM (14.9% vs 7.8%, RR = 1.91, p = 0.006). In contrast, no significant differences were found in the mental component scale score changes by DM status. In conclusion, CABG is associated with lower gains in physical function in those with DM than in those without DM. Special attention should be paid to the physical function of patients with DM after CABG, and any barriers to functional recovery in this group should be promptly identified and addressed.

Health related quality of life trajectories and predictors following coronary artery bypass surgery

BACKGROUND

Many studies have demonstrated that health related quality of life (HRQoL) improves, on average, after coronary artery bypass graft surgery (CABGS). However, this average improvement may not be realized for all patients, and it is possible that there are two or more distinctive groups with different, possibly non-linear, trajectories of change over time. Furthermore, little is known about the predictors that are associated with these possible HRQoL trajectories after CABGS.

METHODS

182 patients listed for elective CABGS at The Royal Melbourne Hospital completed a postal battery of questionnaires which included the Short-Form-36 (SF-36), Profile of Mood States (POMS) and the Everyday Functioning Questionnaire (EFQ). These data were collected on average a month before surgery, and at two months and six months after surgery. Socio-demographic and medical characteristics prior to surgery, as well as surgical and post-surgical complications and symptoms were also assessed. Growth curve and growth mixture modelling were used to identify trajectories of HRQoL.

RESULTS

For both the physical component summary scale (PCS) and the mental component summary scale (MCS) of the SF-36, two groups of patients with distinct trajectories of HRQoL following surgery could be identified (improvers and non-improvers). A series of logistic regression analyses identified different predictors of group membership for PCS and MCS trajectories. For the PCS the most significant predictors of non-improver membership were lower scores on POMS vigor-activity and higher New York Heart Association dyspnoea class; for the MCS the most significant predictors of non-improver membership were higher scores on POMS depression-dejection and manual occupation.

CONCLUSION

It is incorrect to assume that HRQoL will improve in a linear fashion for all patients following CABGS. Nor was there support for a single response trajectory. It is important to identify characteristics of each patient, and those post-operative symptoms that could be possible targets for intervention to improve HRQoL outcomes.

Persistent Effect of Red Cell Transfusion on Health-Related Quality of Life After Cardiac Surgery

BACKGROUND

Although red blood cell transfusion has been associated with an increase in early morbid outcomes and reduced long-term survival after cardiac surgery, its relationship to functional quality of life after surgery has not been previously explored. Our objective was to investigate the relationship between perioperative red blood cell and component transfusion and functional health-related quality of life 6 to 12 months after cardiac surgery.

METHODS

Of 12,536 patients undergoing cardiac surgical procedures between May 1995 and January 1999, 7,321 completed a self-administered Duke Activity Status Index (DASI) survey preoperatively and least one follow-up survey at nominally 6 or 12 months postoperatively. The influence of baseline DASI, preoperative risk factors, clinical status, laboratory values, operative events, and postoperative morbidities on follow-up DASI were examined with ordinal regression modeling.

RESULTS

After adjustment for preoperative DASI, demographic, cardiac and noncardiac comorbidity, type of surgery, postoperative complications, and interval between follow-up DASI, during which patients continued to improve (p < 0.0001), postoperative functional status after cardiac surgery was incrementally worse the more perioperative red cells (p < 0.0001) and platelets (p = 0.02) that had been transfused.

CONCLUSIONS

Red blood cell and platelet transfusion have an unintended persistently negative risk-adjusted effect on health-related quality of life after cardiac surgery that extends well beyond initial hospitalization. Reductions in functional recovery paralleled increasing units of red blood cells transfused.

Gender Analysis After Elective Open Heart Surgery: A Two-Year Comparative Study of Quality of Life

BACKGROUND

The aim of this prospective study, based on the iterative completion of the 36-item short form health survey questionnaire (SF36) after open heart surgery, was twofold: to evaluate the changes in quality of life (QOL) scores (over time and by gender, and also in comparison with scores from a normal population) and to identify possible gender differences in two-year cardiac functional status.

METHODS

From July 2000 to July 2002, 590 elective patients were included in this study. Baseline and follow-up QOL surveys were obtained for 439 patients (307 males and 132 females). The QOL scores were compared by gender, by analysis of variance, and by the Student t test. Factors influencing two-year cardiac functional status were determined by logistic regression.

RESULTS

The comparison of baseline and follow-up scores showed a significant improvement (a sharp increase between baseline and year one, then stabilization) in all dimensions of the SF36, two years after surgery in all patients. However, QOL was significantly lower in women than in men in all but two dimensions; at baseline and during follow-up. When compared with the normal population, men and women over 75 had a similar QOL. The best independent predictive factor of two-year cardiac functional status in women was the physical component summary score and in men, the mental component summary score.

CONCLUSIONS

The benefit of open heart surgery at two-year follow-up is equivalent in both genders in terms of QOL, although women had lower baseline QOL scores.

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Consecutive Patients: Decision-Making Algorithm and Outcomes

BACKGROUND

Debate continues between on-pump or off-pump approach for coronary artery bypass grafting (CABG). We used off-pump coronary artery bypass grafting (OPCAB) as a tool within a decision-making algorithm driven by the patient-related factors of coronary anatomy and comorbidity. Our analysis presents this decision algorithm and describes outcomes using this approach.

METHODS

From January 2000 to December 2003, 592 consecutive patients undergoing isolated CABG were assigned by one surgeon to a technique: on-pump CABG or OPCAB according to (1) anatomy and (2) predicted risk. Anatomic factors against OPCAB were target vessel size less than 1.25 mm, calcification, poor quality, intramyocardial location, and multiple stenoses. Given that OPCAB could be performed safely, patients in the moderate risk range, ie, those elderly with multiple comorbidities, were preferentially treated using OPCAB.

RESULTS

The OPCAB group had higher predicted 30-day mortality compared with the on-pump CABG group, consistent with the protocol's intent. However, morbidity and mortality were similar between on-pump CABG and OPCAB. The OPCAB patients received the same number of internal mammary artery grafts but fewer distal grafts. Mortality and observed to expected ratios were favorable for both groups and below those The Society of Thoracic Surgeons' predicted for OPCAB.

CONCLUSIONS

Matching surgical strategy to patient-related factors and needs resulted in excellent outcomes. Our data support the use of a protocol based on patient characteristics to drive the surgeon's choice between an on-pump CABG or OPCAB approach. As such, OPCAB can be viewed as a tool to be used by the surgeon developing a best practice in treating coronary artery disease.