Evolving applications for patient-centered health status measures

Quality of life of advanced chronic heart failure: medical care, mechanical circulatory support and transplantation

OBJECTIVES

Advanced chronic heart failure (ACHF) is progressive with poor prognosis and quality of life (QoL). Heart transplantation (HTx) is an effective treatment for ACHF, but is limited by scarcity of donor hearts. Left ventricular assist device (LVAD) support is a useful bridging therapy, and short- and medium-term outcomes have improved. We investigated QoL in patients assessed for HTx, awaiting HTx and after HTx.

METHODS

We carried out a cross-sectional survey across four groups: Group 1-patients assessed for HTx, Group 2-patients listed for HTx on medical therapy, Group 3-patients supported with LVAD and Group 4-patients after HTx. Two questionnaires, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQol dimensions (EQ-5D), were administered in all adult HTx centres in the UK. Scores calculated for the KCCQ and EQ-5D were compared.

RESULTS

Three hundred and eighty-six patients completed questionnaires: 194 in Group 1, 28 in Group 2, 82 in Group 3 and 82 in Group 4. Patients after HTx reported the best QoL [KCCQ overall summary score: mean 73.0 (SD 27.2)]; patients with LVAD reported better QoL than those being assessed for HTx and those listed for HTx on medical therapy [overall summary score; LVAD: 52.6 (22.0), Listed on medical therapy: 33.3 (21.1), ASSESSMENT: 35.5 (21.5)]. Similarly, EQ-5D scores were highest in patients after HTx [HTx: mean 0.74 (0.27); LVAD: 0.58 (0.26), Listed on medical therapy: 0.44 (0.27), ASSESSMENT: 0.50 (SD 0.30)].

CONCLUSIONS

Patients supported with LVAD had a significantly better QoL than those awaiting HTx without LVAD support, although HTx patients reported the best QoL.

Quality of life in patients with coronary heart disease after myocardial infarction and with ischemic heart failure

INTRODUCTION

Quality of life measures are useful when interventions or treatments are indicated for several reasons such as improvement of physical functioning, pain relief, to estimate the effectiveness of therapies or to predict mortality. The aim of the current study was to describe quality of life in patients with stable coronary artery disease, myocardial infarction and heart failure and to evaluate the relationship between depression and health-related quality of life.

MATERIAL AND METHODS

Patients after STEMI, with stable coronary artery disease, and heart failure (n = 332) completed the MacNew Heart Disease Health-related Quality of Life Questionnaire and the Hospital Anxiety and Depression Scale.

RESULTS

Patients with myocardial infarction had significantly higher scores than patients with stable coronary artery disease or heart failure on the MacNew global scale (p < 0.001) and the physical (p < 0.001), emotional (p < 0.001) and social (p < 0.001) subscales. The anxiety scores were significantly higher in the group of patients with stable coronary artery disease than in patients with myocardial infarction (p < 0.05). The depression scores were significantly higher in patients with heart failure (p < 0.01).

CONCLUSIONS

In patients with stable CAD, anxiety correlated mainly with symptoms, i.e. angina, than with the history of MI. Patients with symptoms of angina react to the illness with anxiety more than depression, whereas patients with heart failure with dyspnea react to the illness with depressive symptoms more than anxiety. In patients after MI and with stable CAD, cognitive-behavioral techniques could be useful to quickly reduce the level of anxiety, while patients with heart failure require long-term support therapy to reduce the risk of depressive symptoms.

Quantifying clinical change: discrepancies between patients' and providers' perspectives

PURPOSE

Interpreting the clinical significance of changes in patient-reported outcomes (PROs) is critically important. The most commonly used approach is to anchor mean changes on PRO scores against a global assessment of change. Whether the assessor of global change should be patients or their physicians is unknown. We compared patients' and physicians' assessments of change over time to examine which was more aligned with patients' changes in PRO measures.

METHODS

A total of 459 chronic heart failure patients aged >30 years were enrolled from 13 US centers. Data were obtained by medical record abstraction, physical assessments, and patient interviews at a baseline clinic visit and 6 weeks later. Health status was measured with the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ), and both patients and physicians completed a validated 15-level global assessment of change, ranging from large deterioration to large improvement.

RESULTS

There was substantial variation between physicians/patients' global assessment of clinical change (weighted kappa = 0.36, 95 % CI 0.28, 0.43). Overall, physician assessments were more strongly correlated with change on the KCCQ summary score than were patients' assessments (physician R = 0.37, patient R = 0.29).

CONCLUSION

There was substantial variation between patients' and physicians' global assessment of 6-week change in heart failure status. Physician assessments of the importance of clinical changes were more strongly associated with changes in all domains of patient-reported health status, as assessed by the KCCQ, and may provide a more consistent method for defining the clinical importance of changes in patients' health status.

Patient-reported health status prior to cardiac resynchronisation therapy identifies patients at risk for poor survival and prolonged hospital stays

Background

Patient-reported factors have largely been neglected in search of predictors of response to cardiac resynchronisation therapy (CRT). The current study aimed to examine the independent value of pre-implantation patient-reported health status in predicting four-year survival and cardiac-related hospitalisation of CRT patients.

Methods

Consecutive patients (N = 139) indicated to receive a first-time CRT-defibrillator at the University Medical Center Utrecht were asked to complete a set of questionnaires prior to implantation. The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to assess heart failure-specific health status. Data on patients’ demographic, clinical and psychological characteristics at baseline, and on cardiac-related hospitalisations and all-cause deaths during a median follow-up of 3.9 years were obtained from purpose-designed questionnaires and patients’ medical records.

Results

Results of multivariable Cox regression analyses showed that poor patient-reported health status (KCCQ score < 50) prior to implantation was associated with a 2.5-fold increased risk of cardiac hospitalisation or all-cause death, independent of sociodemographic, clinical and psychological risk factors (adjusted hazard ratio 2.46, 95 % confidence interval (CI) 1.30–4.65). Poor health status was not significantly associated with the absolute number of cardiac-related hospital admissions, but with the total number of days spent in hospital during follow-up (adjusted incidence rate ratio 3.20, 95 % CI 1.88–5.44).

Conclusions

Patient-reported health status assessed prior to CRT identifies patients at risk for poor survival and prolonged hospital stays, independent of traditional risk factors. These results emphasise the importance of incorporating health status measures in cardiovascular research and patient management. Heart failure patients reporting poor health status should be identified and offered appropriate additional treatment programs.

Development and validation of an arrhythmia-specific scale in tachycardia and arrhythmia with focus on health-related quality of life

BACKGROUND

Arrhythmias can cause a profoundly negative impact on a person's daily life, leading to impaired health-related quality of life (HRQOL). Assessment of HRQOL can provide valuable information before, during, and after healthcare interventions for arrhythmias.

OBJECTIVE

The aim was to develop and validate a disease-specific scale evaluating HRQOL in patients with different forms of arrhythmia.

METHODS

The Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA HRQOL) was developed from a literature review, patient interviews, and expert panel evaluations. This version was then psychometrically evaluated in patients treated with radiofrequency catheter ablation because of different forms of arrhythmias and patients who sought emergency care because of atrial fibrillation. Construct validity was evaluated with item-total correlations, confirmatory factor analyses, and convergent and discriminant validity. Internal consistency was evaluated using Cronbach's α.

RESULTS

All items reached the expected level of item-total correlations of greater than 0.3 for the total scale. The content validity index was sufficient for all items, as was the total scale (0.86-1.0). The 2-factor confirmatory factor analysis model that included the physical and mental factors showed a better fit between model and data than the 1-factor model did (P < .001). Convergent and discriminant validities were evaluated in the correlation analyses between the ASTA HRQOL subscales and SF-36 physical and mental dimensions. A strong correlation was found between the hypothesized physical and mental scales. Internal consistency was satisfactory with a lower bound confidence interval (95%) for Cronbach's α .70 or greater for all the ASTA HRQOL scales.

CONCLUSIONS

The ASTA HRQOL questionnaire can be a valuable contribution to HRQOL assessments in patients with different forms of arrhythmia. Until there is more evidence regarding validity and reliability, using both the total and subscale scores is recommended.

Variation of Quality of Life Data Collection Across INTERMACS Sites

BACKGROUND

Given the importance of patients' health-related quality of life (HRQL) after mechanical circulatory support (MCS) device implantation, the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) collects the Kansas City Cardiomyopathy Questionnaire (KCCQ) before and after MCS. The success of data collection and potential implications of missing data on HRQL analyses are unknown.

METHODS

We examined the frequency and reasons for not collecting baseline and 3-month KCCQ data across INTERMACS sites from May 2012 to December 2013. Hierarchical logistic regression was used to examine site variability (median odds ratios [MOR]) for not collecting KCCQ data to demonstrate the degree to which some sites can collect more complete data than others.

RESULTS

Among 3960 and 3523 patients participating in INTERMACS before and 3 months after left ventricular assist device implantation, the KCCQ was not collected in 43.1% at baseline (range across sites, 0-100%) and 40.9% (range, 0-100%) at follow-up. The most common reasons for incomplete KCCQ data at baseline were that the patient was too sick (13.9%) and consent to participate in research was not obtained (12.4%). Significant variation across sites was observed for missingness because of patient (MOR, 2.8; P < .001) and administrative (MOR, 4.8; P < .001) reasons. The most variable patient reasons were that the patients were too stressed (MOR, 7.2; P < .001) and too busy (MOR, 10.6; P < .001). The most variable administrative reasons were that the coordinator was too busy/forgot (MOR, 7.1; P < .001) and miscellaneous reasons (MOR, 8.7; P < .001). At 3 months, significant variation persisted for both patient (MOR, 2.7; P < .001) and administrative (MOR, 3.5; P < .001) reasons. The most variability across sites was that the patient was too busy (MOR, 6.0, P < .001) and that the coordinator was too busy/forgot (MOR, 5.8; P < .001).

CONCLUSIONS

Sites vary substantially in collecting KCCQ data, and many of these variations seem addressable. Improving the consistency of HRQL data collection can improve the value of INTERMACS in defining the patient-centered benefits of MCS treatment.

The clinical course of health status and association with outcomes in patients hospitalized for heart failure: insights from ASCEND-HF

AIMS

A longitudinal and comprehensive analysis of health-related quality of life (HRQOL) was performed during hospitalization for heart failure (HF) or soon after discharge.

METHODS AND RESULTS

A post-hoc analysis was performed of the ASCEND-HF trial. The EuroQOL five dimensions questionnaire (EQ-5D) was administered to study participants at baseline, 24 h, discharge/day 10, and day 30. EQ-5D includes functional dimensions mapped to corresponding utility scores (i.e. 0 = death and 1 = perfect health), and a visual analogue scale (VAS) ranging from 0 (i.e. 'worst imaginable health state') to 100 (i.e. 'best imaginable health state'). The association between baseline and discharge EQ-5D measurements and subsequent clinical outcomes including death and rehospitalization were assessed using multivariable logistic regression and Cox proportional hazards regression. A total of 6943 patients (97%) had complete EQ-5D data at baseline. Mapped utility and VAS scores (mean ± SD) increased over time, respectively, from 0.56 ± 0.23 and 45 ± 22 at baseline to 0.67 ± 0.26 and 58 ± 22 at 24 h and to 0.79 ± 0.20 and 68 ± 22 at discharge, and remained stable at day 30. Lower mapped utility scores at baseline [odds ratio (OR) per 0.1 decrease in utility score 1.03, 95% confidence interval (CI) 1.00-1.06] and discharge (OR 1.10, 95% CI 1.05-1.15) and VAS scores at baseline (OR per 10 point decrease 1.05, 95% CI 1.01-1.09) were significantly associated with increased risk of 30-day all-cause death or HF rehospitalization.

CONCLUSIONS

Patients hospitalized for HF had severely impaired health status at baseline and, although this improved substantially during admission, health status remained abnormal at discharge.

Interaction between the Kansas City Cardiomyopathy Questionnaire and the Pocock's clinical score in predicting heart failure outcomes

Purpose

Heart failure (HF) is a complex syndrome. Its appropriate management should combine several health measurements. We assessed the relationship between the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Pocock’s clinical score.

Methods

We conducted a prospective registry of HF outpatients. The main outcome was occurrence of death or hospitalization during a 6-month follow-up. A multivariate logistic regression was performed, including the KCCQ overall summary score, the Pocock’s clinical score and their interaction in the model.

Results

From January 2008 to December 2010, 143 patients were involved. Mean age of patients was 68 years, and 74 % were men. KCCQ’s overall summary score and Pocock’s clinical score were inversely correlated (r = −0.24, p = 0.026). A total of 61 (42.7 %) events occurred. There was a high proportion of events (77.8 %) in patients with a Pocock’s clinical score >50 %, whatever the KCCQ score value. When the KCCQ score was ≤50 %, there was a low increase in risk as the Pocock’s clinical score increased (OR 2.0 [0.6; 6.6]). However, when the KCCQ score was between 50 and 75 or ≥75 %, there was a high increase in risk as the Pocock’s clinical score increased (OR 6.9 [1.2; 38.9] and OR 7.4 [0.8; 69.7], respectively).

Conclusions

Patients with a high Pocock’s clinical score are at a high risk of death or hospitalization. For patients with a low Pocock’s clinical score, the KCCQ score can identify those at risk of these events.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-015-1154-9) contains supplementary material, which is available to authorized users.

Development and Validation of a Short Version of the Kansas City Cardiomyopathy Questionnaire

BACKGROUND

There is a growing demand to collect patients' experiences of their health status (their symptoms, function, and quality of life) in clinical trials, quality assessment initiatives, and in routine clinical care. In heart failure, the 23-item, disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ) has been shown to be valid, reliable, sensitive to clinical change, and prognostic of both clinical events and costs. However, its use has been limited, in part, by its length. We sought to develop a shortened version of the instrument that maintains the psychometric properties of the full KCCQ.

METHODS AND RESULTS

Using data from 3 clinical studies incorporating 4168 patients, we derived and validated a 12-item KCCQ, the KCCQ-12, to capture symptom frequency, physical and social limitations, and quality of life impairment as a result of heart failure, as well as an overall summary score. The KCCQ-12 scores had high correlations with the original scales (>0.93 for all scales in all clinical settings), high test–retest reliability (>0.76 for all domains), high responsiveness (16–31 point improvements after discharge from hospitalization; standardized response mean =0.61–1.12), and comparable prognostic significance and interpretation of clinically important differences as compared with the full KCCQ.

CONCLUSIONS

The KCCQ-12 is a shorter version of the original 23-item instrument that should be more feasible to implement while preserving the psychometric properties of the full instrument.

Sex Differences in the Rate, Timing, and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction

BACKGROUND

Young women (<65 years) experience a 2- to 3-fold greater mortality risk than younger men after an acute myocardial infarction. However, it is unknown whether they are at higher risk for 30-day readmission, and if this association varies by age. We examined sex differences in the rate, timing, and principal diagnoses of 30-day readmissions, including the independent effect of sex following adjustment for confounders.

METHODS AND RESULTS

We included patients aged 18 to 64 years with a principal diagnosis of acute myocardial infarction. Data were used from the Healthcare Cost and Utilization Project-State Inpatient Database for California (07-09). Readmission diagnoses were categorized by using an aggregated version of the Centers for Medicare and Medicaid Services' Condition Categories, and readmission timing was determined from the day after discharge. Of 42,518 younger patients with acute myocardial infarction (26.4% female), 4775 (11.2%) had at least 1 readmission. The 30-day all-cause readmission rate was higher for women (15.5% versus 9.7%, P<0.0001). For both sexes, readmission risk was highest on days 2 to 4 after discharge and declined thereafter, and women were more likely to present with noncardiac diagnoses (44.4% versus 40.6%, P=0.01). Female sex was associated with a higher rate of 30-day readmission, which persisted after adjustment (hazard ratio, 1.22; 95% confidence interval, 1.15-1.30). There was no significant interaction between age and sex on readmission.

CONCLUSIONS

In comparison with men, younger women have a higher risk for readmission, even after the adjustment for confounders. The timing of 30-day readmission was similar in women and men, and both sexes were susceptible to a wide range of causes for readmission.

Angina and mental stress-induced myocardial ischemia

OBJECTIVE

Mental stress-induced myocardial ischemia is a common phenomenon in patients with coronary artery disease (CAD) and an emerging prognostic factor. Mental stress ischemia is correlated with ambulatory ischemia. However, whether it is related to angina symptoms during daily life has not been examined.

METHODS

We assessed angina frequency (past month) in 98 post-myocardial infarction (MI) subjects (age 18-60 years) using the Seattle Angina Questionnaire. Patients underwent [(99m)Tc]sestamibi SPECT perfusion imaging at rest, after mental stress, and after exercise/pharmacological stress. Summed scores of perfusion abnormalities were obtained by observer-independent software. A summed difference score (SDS), the difference between stress and rest scores, was used to quantify myocardial ischemia under both stress conditions.

RESULTS

The mean age was 50 years, 50% were female and 60% were non-white. After adjustment for age, sex, smoking, CAD severity, depressive, anger, and anxiety symptoms, each 1-point increase in mental stress-SDS was associated with 1.73-unit increase in the angina frequency score (95% CI: 0.09-3.37) and 17% higher odds of being in a higher angina frequency category (OR: 1.17, 95% CI: 1.00-1.38). Depressive symptoms were associated with 12% higher odds of being in a higher angina frequency category (OR: 1.12, 95% CI: 1.03-1.21). In contrast, exercise/pharmacological stress-induced SDS was not associated with angina frequency.

CONCLUSION

Among young and middle-aged post-MI patients, myocardial ischemia induced by mental stress in the lab, but not by exercise/pharmacological stress, is associated with higher frequency of retrospectively reported angina during the day. Psychosocial stressors related to mental stress ischemia may be important contributory factor to daily angina.

Gender differences in the trajectory of recovery in health status among young patients with acute myocardial infarction: results from the variation in recovery: role of gender on outcomes of young AMI patients (VIRGO) study

BACKGROUND

Despite the excess risk of mortality in young women (≤55 years of age) after acute myocardial infarction (AMI), little is known about young women's health status (symptoms, functioning, quality of life) during the first year of recovery after an AMI. We examined gender differences in health status over time from baseline to 12 months after AMI.

METHODS AND RESULTS

A total of 3501 AMI patients (67% women) 18 to 55 years of age were enrolled from 103 US and 24 Spanish hospitals. Data were obtained by medical record abstraction and patient interviews at baseline hospitalization and 1 and 12 months after AMI. Health status was measured by generic (Short Form-12) and disease-specific (Seattle Angina Questionnaire) measures. We compared health status scores at all 3 time points and used longitudinal linear mixed-effects analyses to examine the independent effect of gender, adjusting for time and selected covariates. Women had significantly lower health status scores than men at each assessment (all P values <0.0001). After adjustment for time and all covariates, women had Short Form-12 physical/mental summary scores that were -0.96 (95% confidence interval [CI], -1.59 to -0.32) and -2.36 points (95% CI, -2.99 to -1.73) lower than those of men, as well as worse Seattle Angina Questionnaire physical limitations (-2.44 points lower; 95% CI, -3.53 to -1.34), more angina (-1.03 points lower; 95% CI, -1.98 to -0.07), and poorer quality of life (-3.51 points lower; 95% CI, -4.80 to -2.22).

CONCLUSION

Although both genders recover similarly after AMI, women have poorer scores than men on all health status measures, a difference that persisted throughout the entire year after discharge.

Gender differences in pre-event health status of young patients with acute myocardial infarction: A VIRGO study analysis

AIMS

We assessed gender differences in pre-event health status (symptoms, functioning, quality of life) in young patients with acute myocardial infarction and whether or not this association persists following sequential adjustment for important covariates. We also evaluated the interaction between gender and prior coronary artery disease, given that aggressive symptom control is a cornerstone of care in those with known coronary disease.

METHODS AND RESULTS

A total of 3501 acute myocardial infarction patients (2349 women) aged 18-55 years were enrolled from 103 US/24 Spanish hospitals (2008-2012). Clinical/health status information was obtained by medical record abstraction and patient interviews. Pre-event health status was measured by generic (Short Form-12, EuroQoL) and disease-specific (Seattle Angina Questionnaire) measures. T-test/chi-square and multivariable linear/logistic regression analysis was utilized, sequentially adjusting for covariates. Women had more co-morbidities and significantly lower generic mean health scores than men (Short Form-12 physical health = 43 ± 12 vs. 46 ± 11 and mental health = 44 ± 13 vs. 48 ± 11); EuroQoL utility index = 0.7 ± 0.2 vs. 0.8 ± 0.2 and visual analog scale = 63 ± 22 vs. 67 ± 20, P < 0.0001 for all. Their disease-specific health status was also worse, with more angina (Seattle Angina Questionnaire angina frequency = 83 ± 22 vs. 87 ± 18), worse physical function (physical limitation = 78 ± 27 vs. 87 ± 21) and poorer quality of life (55 ± 25 vs. 60 ± 22, P<0.0001 for all). In multivariable analysis, the association between female gender and worse generic physical/mental health persisted, as well as worse disease-specific physical limitation and quality of life. The interaction between gender and prior coronary artery disease was not significant in any of the health status outcomes.

CONCLUSION

Young women have worse pre-event health status as compared with men, regardless of their coronary artery disease history. While future studies of gender differences should adjust for baseline health status, an opportunity may exist to better address the pre-event health status of women at risk for acute myocardial infarction.

Transitions of care in heart failure: a scientific statement from the American Heart Association

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

Hospital-level variation in angina and mortality at 1 year after myocardial infarction: insights from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) Registry

BACKGROUND

Despite calls to expand measurement of acute myocardial infarction (AMI) outcomes to include symptom burden, little has been done to describe hospital-level variation in this patient-centered outcome, or its association with mortality. Understanding the relationship between symptoms and longer-term mortality could inform the importance of these outcomes for monitoring quality of care.

METHODS AND RESULTS

Among 4316 patients with AMI treated at 24 hospitals participating in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study, we assessed risk-standardized 1-year symptom burden as measured by the Seattle Angina Questionnaire Angina Frequency Score and mortality attributed to the hospital that provided AMI care. Median odds ratios were used to assess outcome variation and reflect the relative odds of an outcome for 2 patients with identical covariates at different, randomly selected, hospitals. We then evaluated the correlation between hospital-level mortality and angina. Finally, we determined the extent to which variation in mortality and angina was explained by achievement of AMI performance measures. We observed hospital variation in risk-adjusted 1-year mortality (range, 4.9%-8.6%; median odds ratio, 1.30; P=0.01) and angina (range, 17.7%-29.4%; median odds ratio, 1.34; P<0.001). At the hospital level, mortality and angina at 1 year were weakly correlated (r=0.40; 95% confidence interval, 0.00-0.68; P=0.05). Accounting for the quality of AMI care did not attenuate variation in risk-adjusted 1-year mortality or angina.

CONCLUSIONS

Symptom burden and mortality vary at the hospital level after AMI and are only weakly correlated. These findings suggest that symptom burden should be considered a separate quality domain that is not well captured by current quality metrics.

Are all outcomes in chronic heart failure rated equally? An argument for a patient-centred approach to outcome assessment

Chronic heart failure (CHF) is a multi-dimensional and complex syndrome. Outcome measures are important for determining both the efficacy and quality of care and capturing the patient's perspective in evaluating the outcomes of health care delivery. Capturing the patient's perspective via patient-reported outcomes is increasingly important; however, including objective measures such as mortality would provide more complete account of outcomes important to patients. Currently, no single measure for CHF outcomes captures all dimensions of the quality of care from the patient's perspective. To describe the role of outcome measures in CHF from the perspective of patients, a structured literature review was undertaken. This review discusses the concepts and methodological issues related to measurement of CHF outcomes. Outcome assessment at the level of the patient, provider and health care system were identified as being important. The perspectives of all stakeholders should be considered when developing an outcomes measurement suite to inform CHF health care. This paper recommends that choice of outcome measures should depend on their ability to provide a comprehensive, comparable, meaningful and accurate assessment that are important to patient.

Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: a randomized trial

BACKGROUND

The STICH (Surgical Treatment for Ischemic Heart Failure) trial compared a strategy of routine coronary artery bypass grafting (CABG) with guideline-based medical therapy for patients with ischemic left ventricular dysfunction.

OBJECTIVE

To describe treatment-related quality-of-life (QOL) outcomes, a major prespecified secondary end point in the STICH trial.

DESIGN

Randomized trial. (ClinicalTrials.gov: NCT00023595).

SETTING

99 clinical sites in 22 countries.

PATIENTS

1212 patients with a left ventricular ejection fraction of 0.35 or less and coronary artery disease.

INTERVENTION

Random assignment to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients).

MEASUREMENTS

A battery of QOL instruments at baseline (98.9% complete) and 4, 12, 24, and 36 months after randomization (collection rates were 80% to 89% of those eligible). The principal prespecified QOL measure was the Kansas City Cardiomyopathy Questionnaire, which assesses the effect of heart failure on patients' symptoms, physical function, social limitations, and QOL.

RESULTS

The Kansas City Cardiomyopathy Questionnaire overall summary score was consistently higher (more favorable) in the CABG group than in the medical therapy group by 4.4 points (95% CI, 1.8 to 7.0 points) at 4 months, 5.8 points (CI, 3.1 to 8.6 points) at 12 months, 4.1 points (CI, 1.2 to 7.1 points) at 24 months, and 3.2 points (CI, 0.2 to 6.3 points) at 36 months. Sensitivity analyses to account for the effect of mortality on follow-up QOL measurement were consistent with the primary findings.

LIMITATION

Therapy was not masked.

CONCLUSION

In this cohort of symptomatic high-risk patients with ischemic left ventricular dysfunction and multivessel coronary artery disease, CABG plus medical therapy produced clinically important improvements in quality of life compared with medical therapy alone over 36 months.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Development and validation of a short version of the Seattle angina questionnaire

BACKGROUND

Clinical trials and national performance measures increasingly mandate reporting patients' perspectives of their health status: their symptoms, function, and quality of life. Although the Seattle Angina Questionnaire (SAQ) is a validated disease-specific health status instrument for coronary artery disease (CAD) with high test-retest reliability, predictive power, and responsiveness, its use in routine clinical practice has been limited, in part, by its length (19 items).

METHODS AND RESULTS

Using data from 10 408 patients with CAD from 5 multicenter registries, we derived and validated a shortened version of the SAQ (SAQ-7) among patients presenting with stable CAD, undergoing percutaneous coronary intervention, and after acute myocardial infarction. We examined the psychometric properties of the SAQ-7 as compared with the full SAQ. Seven items from the Physical Limitation, Angina Frequency, and Quality of Life domains were identified for the SAQ-7, with high levels of concordance (0.88-1.00) with each original SAQ domain. The SAQ-7 demonstrated good construct validity (compared with Canadian Cardiovascular Society class for angina), with a correlation of 0.62 and 0.38 for patients with stable CAD and undergoing percutaneous coronary intervention, respectively. It was highly reproducible in patients with stable CAD (intraclass correlation, ≥0.78) and exhibited excellent responsiveness in patients after percutaneous coronary intervention (≥18 points in each SAQ domain). Finally, the SAQ-7 was predictive of 1-year mortality and readmission.

CONCLUSIONS

To increase the feasibility of measuring patient-reported outcomes in patients with CAD, we developed and validated a shortened 7-item SAQ instrument for use in clinical trials and routine care.

Correlates of quality of life in rural patients with heart failure

BACKGROUND

There is abundant research indicating poor physical, psychological, and social functioning of patients with chronic heart failure (HF), a reality that can lead to poor health-related quality of life (QoL). Little is known about the experience of rural patients with HF.

METHODS AND RESULTS

This study was part of a randomized clinical trial titled Rural Education to Improve Outcomes in Heart Failure (REMOTE-HF) designed to test an education and counseling intervention to improve self-care in patients with HF. We evaluated 612 rural patients. Multiple validated questionnaires were administered to assess patient perceptions of health and health literacy. Baseline factors were collected and compared with baseline QoL measures only. Patients' health-related QoL was assessed using the Minnesota Living with Heart Failure scale. The data were analyzed using a general linear model to test the association of various patient characteristics with QoL in rural patients with HF. Patients were 65.8 (+12.9) years of age. The majority were men (58.7%), married (56.4%), and had completed a high-school education (80.9%). Factors associated with reduced QoL among this population include geographic location, younger age, male sex, higher New York Heart Association class, worse HF knowledge, poorer perceived control, and symptoms of depression or anxiety. The data provided no evidence of an association between left ventricular ejection fraction and QoL.

CONCLUSIONS

This study of rural patients with HF confirms previously identified factors associated with perceptions of QoL. However, further study is warranted with an urban control group.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00415545.

Decreased physical effort, fatigue, and mental distress in patients with coronary artery disease: importance of personality-related differences

BACKGROUND

Identification of cardio-toxic psychological symptoms in coronary artery disease (CAD) patients is important.

PURPOSE

We examined the association of negative affectivity (NA), social inhibition (SI), and their combination in the distressed (Type D) personality with functional status, fatigue, and mental distress in CAD patients.

METHOD

Following acute coronary syndrome, 690 consecutive CAD patients agreed to participate in this cross-sectional study and were evaluated for clinical characteristics, including left ventricular ejection fraction (LVEF), and for NA, SI, and Type D personality (i.e., NA and SI; DS14 scale) when they entered a cardiac rehabilitation program in Lithuania. Patient-centered outcomes included functional status (bicycle ergometer), symptoms of fatigue (Multidimensional Fatigue Inventory-20), and mental distress (Beck Depression Inventory-II and Hospital Anxiety and Depression Scale).

RESULTS

The reference subgroup (neither NA nor SI) included 34 % of patients; 13 % had NA only, 19 % had SI only, and 34 % had Type D profile. Type D patients had worse functional status, and Type D patients and NA-only patients had higher symptom levels of fatigue and mental distress. In multivariate regression models that included LVEF, clinical characteristics, and depressive symptoms, Type D personality was an independent predictor of decreased exercise capacity (OR = 1.77, 95 % CI 1.06-2.95, p = .03) and decreased motivation for activity (OR = 3.14, 95 % CI 1.73-5.73, p < .001). Type D, NA, and SI were also independent predictors of mental distress.

CONCLUSIONS

Type D personality traits independently predicted poor functional status and worse patient-centered outcomes independently from LVEF and depression. Further studies exploring personality-related differences in cardiovascular outcomes are needed.

Systematic review of health-related quality of life in older people following percutaneous coronary intervention

People aged over 60 years represent an increasingly high proportion of the population undergoing percutaneous coronary intervention. While risks are greater for older people in terms of major adverse cardiovascular events and higher mortality for this treatment, it is unclear if the benefits of health-related quality of life outcomes may outweigh risks. A search of the PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica, and Cochrane databases was conducted for the period from January 1999 to June 2012 using key words "percutaneous coronary intervention"/"angioplasty," "older," "elderly," and "quality of life"/"health-related quality of life." Using a systematic review approach, data from 18 studies were extracted for description and synthesis. Findings revealed that everyone regardless of age reported better health-related quality of life, primarily from the relief of angina and improved physical and mental function. Age itself did not have an independent predictive effect when other factors such as comorbid conditions were taken into account. Assessment of older peoples' health status following percutaneous coronary intervention by nurses and other health professionals is therefore important for the provision of quality care.

Predictors of changes in health status between and within patients 12 months post left ventricular assist device implantation

BACKGROUND

Improving patient-reported outcomes (e.g. health status) has become an important goal in left ventricular assist device (LVAD) therapy, in addition to reducing mortality and morbidity. We examined predictors of changes in health status scores between and within patients 12 months post LVAD implantation.

METHODS

Health status [Kansas City Cardiomyopathy Questionnaire (KCCQ); Short-Form 12 (SF-12)] were assessed at 3-4 weeks after implantation, and at 3, 6 and 12 months follow up in 54 LVAD patients (74% men; mean age 54 ± 9 years).

RESULTS

Patients experienced significant improvements in health status between baseline and 3 months follow-up as assessed by the KCCQ (clinical summary score: F = 33.49, P < 0.001; overall summary score: F = 31.13, P < 0.001) and the SF-12 (physical component score: F = 31.59, P < 0.001; mental component score: F = 21.77, P < 0.001), but not between 3 months and 12 months follow-up (P > 0.05 for all). Higher scores on anxiety and depression over time, older age, lower ejection fraction, and more co-morbidity were associated with poorer health status scores on one or both of the KCCQ and SF-12 subscales. The majority of the between-patient variance of the mental component summary scores (82.6%), but not the KCCQ overall summary score (41.9%), KCCQ clinical summary score (36.2%) and physical component summary scores (23.2%), was explained by the sociodemographic, clinical and psychological factors.

CONCLUSION

The majority of LVAD patients show a significant improvement in health status after LVAD implantation. However, there are large differences in individual health status score trajectories which are only partly explained by measures of disease severity pre-LVAD, co-morbidity and psychological stress.

Psychometric characteristics of health-related quality-of-life questionnaires in oropharyngeal dysphagia

Dysphagia can have severe consequences for the patient's health, influencing health-related quality of life (HRQoL). Sound psychometric properties of HRQoL questionnaires are a precondition for assessing the impact of dysphagia, the focus of this study, resulting in recommendations for the appropriate use of these questionnaires in both clinical practice and research contexts. We performed a systematic review starting with a search for and retrieval of all full-text articles on the development of HRQoL questionnaires related to oropharyngeal dysphagia and/or their psychometric validation from the electronic databases PubMed and Embase published up to June 2011. Psychometric properties were judged according to quality criteria proposed for health status questionnaires. Eight questionnaires were included in this study. Four are aimed solely at HRQoL in oropharyngeal dysphagia: the deglutition handicap index (DHI), dysphagia handicap index (DHI'), M.D. Anderson Dysphagia Inventory (MDADI), and SWAL-QOL, while the EDGQ, EORTC QLQ-STO 22, EORTC QLQ-OG 25 and EORTC QLQ-H&N35 focus on other primary diseases resulting in dysphagia. The psychometric properties of the DHI, DHI', MDADI, and SWAL-QOL were evaluated. For appropriate applicability of HRQoL questionnaires, strong scores on the psychometric criteria face validity, criterion validity, and interpretability are prerequisites. The SWAL-QOL has the strongest ratings for these criteria, while the DHI' is the most easy to apply given its 25 items and the use of a uniform scoring format. For optimal use of HRQoL questionnaires in diverse settings, it is necessary to combine psychometric and utility approaches.

Comparable performance of the Kansas City Cardiomyopathy Questionnaire in patients with heart failure with preserved and reduced ejection fraction

BACKGROUND

Despite the growing epidemic of heart failure with preserved ejection fraction (HFpEF), no valid measure of patients' health status (symptoms, function, and quality of life) exists. We evaluated the Kansas City Cardiomyopathy Questionnaire (KCCQ), a validated measure of HF with reduced EF, in patients with HFpEF.

METHODS AND RESULTS

Using a prospective HF registry, we dichotomized patients into HF with reduced EF (EF≤ 40) and HFpEF (EF≥50). The associations between New York Heart Association class, a commonly used criterion standard, and KCCQ Overall Summary and Total Symptom domains were evaluated using Spearman correlations and 2-way ANOVA with differences between patients with HF with reduced EF and HFpEF tested with interaction terms. Predictive validity of the KCCQ Overall Summary scores was assessed with Kaplan-Meier curves for death and all-cause hospitalization. Covariate adjustment was made using Cox proportional hazards models. Internal reliability was assessed with Cronbach's α. Among 849 patients, 200 (24%) had HFpEF. KCCQ summary scores were strongly associated with New York Heart Association class in both patients with HFpEF (r=-0.62; P<0.001) and HF with reduced EF (r=-0.55; P=0.27 for interaction). One-year event-free rates by KCCQ category among patients with HFpEF were 0 to 25=13.8%, 26 to 50=59.1%, 51 to 75=73.8%, and 76 to 100=77.8% (log rank P<0.001), with no significant interaction by EF (P=0.37). The KCCQ domains demonstrated high internal consistency among patients with HFpEF (Cronbach's α=0.96 for overall summary and ≥0.69 in all subdomains).

CONCLUSIONS

Among patients with HFpEF, the KCCQ seems to be a valid and reliable measure of health status and offers excellent prognostic ability. Future studies should extend and replicate our findings, including the establishment of its responsiveness to clinical change.

Cross-cultural translation and measurement properties of the Polish version of the Knee injury and Osteoarthritis Outcome Score (KOOS) following anterior cruciate ligament reconstruction

Background

Knee Injury and Osteoarthritis Outcome Score (KOOS) is available in over 30 languages and a commonly used Patient-Reported Outcome (PRO) for assessment of treatment effects following knee surgery. The aim of the study was to report the linguistic translational process and evaluate the psychometric properties of the Polish version of the KOOS questionnaire.

Methods

We translated and culturally adapted the KOOS according to current guidelines for use in Poland. Patients who had undergone anterior cruciate ligament reconstruction (ACLR) completed the KOOS and Short Form 36 Health Survey (SF-36). We evaluated floor/ceiling effects, reliability (using Cronbach’s alpha, intraclass correlation coefficients (ICC) and measurement error), convergent and divergent construct validity (using four a priori stated hypotheses) and responsiveness (using data obtained prior to and one year after ACLR and described by both effect size (ES) and standardized response mean (SRM)).

Results

The clinical study population consisted of 72 subjects (mean age 29.8, 28% women). We did not observe floor effects in any KOOS subscales neither pre- nor postoperatively. As expected, ceiling effects were found postoperatively for the subscales Pain and ADL in this cohort assessed on average 1.3 year after surgery as more than 15% reported no pain or limitations in daily activities. The Cronbach’s alpha was above 0.9 for all subscales indicating excellent internal consistency. The test-retest reliability of all KOOS subscales at one-year postoperatively was excellent with ICCs exceeding 0.86 for all subscales. The minimal detectable change on group level ranged from 1.3 to 2.4, and on an individual level from 10.9 to 20.2. Responsiveness was demonstrated since the expected pattern of effect sizes between subscales following ACLR was found.

Conclusions

We found the Polish version of the KOOS to be a valid and reliable instrument for use in patient groups having ACLR. We caution against monitoring individual patients since the smallest change considered clinically relevant cannot reliably be detected.

End points for comparative effectiveness research in heart failure

CER for heart failure continues to evolve, including its assessment of end points. Reliance on surrogate end points is unacceptable as a means of definitively establishing comparisons of clinical effectiveness. CER needs to focus on measures that clearly reflect clinical effectiveness and safety, not just survival but also standardized assessments of health status and detailed resource utilization, and it must do so in a standardized way to allow for comparison. This strategy almost certainly requires increased reliance on prospective studies with proactive end-point capture, preferably in the setting of randomized allocation of the interventions being compared.

Cardiac resynchronization and quality of life in patients with minimally symptomatic heart failure

OBJECTIVES

This study compared the quality of life (QOL) of patients with cardiac resynchronization therapy (CRT) and an implantable cardioverter-defibrillator (ICD) to patients with an ICD only.

BACKGROUND

CRT with ICD is associated with a reduction in heart failure risk among minimally symptomatic patients. It is unknown whether this improves QOL.

METHODS

This study uses the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) data. The MADIT-CRT enrolled 1,820 patients at 110 centers across 14 countries. Patients had ischemic cardiomyopathy (New York Heart Association [NYHA] functional class I or II) or nonischemic cardiomyopathy (NYHA functional class II only), sinus rhythm, an ejection fraction of 30% or less, and prolonged intraventricular conduction with a QRS duration of 130 ms or more. QOL was evaluated on the 1,699 patients with baseline and follow-up measures using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Six dimensions (Physical Limitation, Symptom Stability, Symptom Frequency, Symptom Burden, Quality of Life, and Social Limitations) and 3 summary scores (Total Symptom, Clinical Summary, and Overall Summary) were analyzed.

RESULTS

During an average follow-up of 2.4 years, the CRT-ICD group had greater improvement than the ICD-only group on all KCCQ measures (p < 0.05 on each scale). These differences were significant among patients with left bundle branch block conduction disturbance (n = 1,204, p < 0.01 on each scale), but not among patients without left bundle branch block (n = 494).

CONCLUSIONS

Compared with patients with ICD only, CRT-ICD is associated with greater improvement in QOL among relatively asymptomatic patients, specifically among those with left bundle branch conduction disturbance.

Comparison of frail patients versus nonfrail patients ≥65 years of age undergoing percutaneous coronary intervention

Frailty is a geriatric syndrome characterized by functional impairments and is associated with poor outcomes; however, the prevalence of frailty and its association with health status in patients treated with percutaneous coronary intervention (PCI) are unknown. To assess the prevalence of frailty and its association with health status in PCI-treated patients, we studied 629 patients ≥65 years old undergoing PCI from October 2005 through September 2008. Frailty was characterized using the Fried criteria: weight loss >10 lbs. in previous 1 year, exhaustion, low physical activity, poor gait speed, and poor grip strength (3 features = frail; 1 feature to 2 features = intermediate frailty; 0 feature = not frail). Health status was assessed using the Short-Form 36 and the Seattle Angina Questionnaire (SAQ). Multivariable linear regression models were used to estimate the independent association between frailty and health status. Complete data on 545 patients demonstrated that 19% (n = 117) were frail, 47% (n = 298) had intermediate frailty, and 21% (n = 130) were not frail. Frail patients had more co-morbidities and more frequent left main coronary artery or multivessel disease after adjusting for age and gender (p <0.05 across groups). Multivariable linear regression demonstrated poorer health status in frail patients compared to nonfrail patients as evidenced by lower Short-Form 36 scores, lower SAQ scores for physical limitation, and lower SAQ scores for quality of life (p <0.001 for each health status domain). In conclusion, 1/5 of older patients are frail at the time of PCI and have greater comorbid burden, angiographic disease severity, and poorer health status than nonfrail adults.

Cross-cultural adaptation and validation of the Peripheral Artery Questionnaire: Korean version for patients with peripheral vascular diseases

The Peripheral Artery Questionnaire (PAQ), as developed in US English, is a validated scale to evaluate the health status of patients with peripheral artery disease (PAD). The aim of this study was to translate the PAQ into Korean and to evaluate its reliability and validity. A multi-step process of forward-translation, reconciliation, consultation with the developer, back-translation and proofreading was conducted. The test-retest reliability was evaluated at a 2-week interval using the intra-class correlation coefficient (ICC). The validity was assessed by identifying associations between Korean PAQ (KPAQ) scores and Korean Health Assessment Questionnaire (KHAQ) scores. A total of 100 PAD patients were enrolled: 63 without and 37 with severe claudication. The reliability of the KPAQ was adequate, with an ICC of 0.71. There were strong correlations between KPAQ's subscales. Cronbach's alpha for the summary score was 0.94, indicating good internal consistency and congruence with the original US version. The validity was supported by a significant correlation between the total KHAQ score and KPAQ physical function, stability, symptom, social limitation and quality of life scores (r = -0.24 to -0.90; p < 0.001) as well as between the KHAQ walking subscale and the KPAQ physical function score (r = -0.55, p < 0.001). Our results indicate that the KPAQ is a reliable, valid instrument to evaluate the health status of Korean patients with PAD.

High nutritional risk is associated with worse health-related quality of life in patients with heart failure beyond sodium intake

BACKGROUND

The most desirable outcome in heart failure (HF) management is to improve health-related quality of life (HRQoL) as a patient-centred health outcome. Nutrition is assumed to be important in HF management, whereas there is little evidence that nutritional risk affects HRQoL, except for sodium.

PURPOSE

We aimed to determine whether nutritional risk is associated with worse HRQoL after controlling for daily sodium intake.

METHODS

A total of 134 consecutive patients with HF [age 63 ± 11 years, 35% female, 45% New York Heart Association (NYHA) class III/IV, ejection fraction (EF) 33 ± 13%] completed the Nutrition Screening Initiative (NSI) to assess nutritional risk and a 24-h urine sodium excretion assessment to estimate daily sodium intake at baseline. The Minnesota Living with HF Questionnaire was used to evaluate HRQoL at baseline and 6 months later. Hierarchical linear regressions were used to determine whether nutritional risk predicted HRQoL at baseline and 6 months later.

RESULTS

Seventy-eight (58.2%) patients had high nutritional risk as indicated by a total NSI score ≥ 6. Increased nutritional risk was independently associated with worse HRQoL at baseline and 6 months later (β = 0.33, p < 0.001; β = 0.35, p < 0.001, respectively), after controlling for age, gender, aetiology, body mass index, NYHA class, EF, total comorbidity score, prescribed medications, and daily sodium intake.

CONCLUSION

These findings show that higher nutritional risk beyond sodium intake affects worse HRQoL in patients with HF. Further work is required to provide specific dietary guidelines to improve health outcomes for patients with HF.

Hemoglobin A1c improvements and better diabetes-specific quality of life among participants completing diabetes self-management programs: a nested cohort study

BACKGROUND

Numerous primary care innovations emphasize patient-centered processes of care. Within the context of these innovations, greater understanding is needed of the relationship between improvements in clinical endpoints and patient-centered outcomes. To address this gap, we evaluated the association between glycosylated hemoglobin (HbA1c) and diabetes-specific quality of life among patients completing diabetes self-management programs.

METHODS

We conducted a retrospective cohort study nested within a randomized comparative effectiveness trial of diabetes self-management interventions in 75 diabetic patients. Multiple linear regression models were developed to examine the relationship between change in HbA1c from baseline to one-year follow-up and Diabetes-39 (a diabetes-specific quality of life measure) at one year.

RESULTS

HbA1c levels improved for the overall cohort from baseline to one-year follow-up (t (74) = 3.09, p = .0029). One-year follow up HbA1c was correlated with worse overall quality of life (r = 0.33, p = 0.004). Improvements in HbA1c from baseline to one-year follow-up were associated with greater D-39 diabetes control (β = 0.23, p = .04) and D-39 sexual functioning (β = 0.25, p = .03) quality of life subscales.

CONCLUSIONS

Improvements in HbA1c among participants completing a diabetes self-management program were associated with better diabetes-specific quality of life. Innovations in primary care that engage patients in self-management and improve clinical biomarkers, such as HbA1c, may also be associated with better quality of life, a key outcome from the patient perspective.

Physical function and independence 1 year after myocardial infarction: observations from the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status registry

BACKGROUND

Acute myocardial infarction (AMI) may contribute to health status declines including "independence loss" and "physical function decline." Despite the importance of these outcomes for prognosis and quality of life, their incidence and predictors have not been well described.

METHODS

We studied 2,002 patients with AMI enrolled across 24 sites in the TRIUMPH registry who completed assessments of independence and physical function at the time of AMI and 1 year later. Independence was evaluated by the EuroQol-5D (mobility, self-care, and usual activities), and physical function was assessed with the Short Form-12 physical component score. Declines in ≥1 level on EuroQol-5D and >5 points in PCS were considered clinically significant changes. Hierarchical, multivariable, modified Poisson regression models accounting for within-site variability were used to identify predictors of independence loss and physical function decline.

RESULTS

One-year post AMI, 43.0% of patients experienced health status declines: 12.8% independence loss alone, 15.2% physical function decline alone, and 15.0% both. After adjustment, variables that predicted independence loss included female sex, nonwhite race, unmarried status, uninsured status, end-stage renal disease, and depression. Variables that predicted physical function decline were uninsured status, lack of cardiac rehabilitation referral, and absence of pre-AMI angina. Age was not predictive of either outcome after adjustment.

CONCLUSIONS

>40% of patients experience independence loss or physical function decline 1 year after AMI. These changes are distinct but can occur simultaneously. Although some risk factors are not modifiable, others suggest potential targets for strategies to preserve patients' health status.

Psychometric properties of the Kansas City Cardiomyopathy Questionnaire (KCCQ)

BACKGROUND

The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a well-established instrument used to evaluate the health status of heart failure (HF) patients. There has been a lack of clarity about the best way to conceptualize the KCCQ. The purpose of this investigation of the KCCQ was to: (1) explore the factor structure with an exploratory factor analyses; (2) perform reliability and validity testing to determine the best factor solution for item groupings; and (3) determine the most meaningful components of health status captured by the KCCQ.

METHODS AND RESULTS

A secondary analysis of data from 280 adults with stage-C HF enrolled from three US northeastern sites was conducted to test the KCCQ subscale structure. Criterion-related validity for the Self-efficacy subscale was tested with the Dutch Heart Failure Knowledge Scale and the Self-care of Heart Failure Index Self-care Confidence Scale. Overall, internal consistency reliability (Cronbach's alpha) for the KCCQ and subscales was 0.92, social interference (seven items, 0.90), physical limitation (four items, 0.84), symptoms (eight items, 0.86), independent care (two items, 0.80), and self-efficacy (two items, 0.63). Two items failed to correspond to a previously identified factor so the independent care subscale was added. Items intending to measure quality of life were loaded in the social interference subscale.

CONCLUSIONS

We recommend eliminating the quality of life subscale and including those items in the social interference subscale, and eliminating the self-efficacy items and re-evaluating the items related to independent care.

Symptoms of anxiety and cardiac hospitalizations at 12 months in patients with heart failure

OBJECTIVE

Heart failure (HF) is a leading cause of hospitalization. Clinical and socio-demographic factors have been associated with cardiac admissions, but little is known about the role of anxiety. We examined whether symptoms of anxiety were associated with cardiac hospitalizations at 12 months in HF patients.

METHODS

HF outpatients (N = 237) completed the Hospital Anxiety and Depression Scale (HADS) at baseline (i.e., inclusion into the study). A cutoff ≥8 was used to indicate probable clinical levels of anxiety and depression. At 12 months, a medical chart abstraction was performed to obtain information on cardiac hospitalizations.

RESULTS

The prevalence of symptoms of anxiety was 24.9% (59/237), and 27.0% (64/237) of patients were admitted for cardiac reasons at least once during the 12-month follow-up period. Symptoms of anxiety were neither significantly associated with cardiac hospitalizations in univariable logistic analysis [OR = 1.13, 95% CI (0.59-2.17), p = 0.72] nor in multivariable analysis [OR = 0.94, 95% CI (0.38-2.31), p = 0.89]. New York Heart Association (NYHA) functional class III [OR = 3.00, 95% CI (1.08-8.12), p = 0.04] and a history of HF-related hospitalizations [OR = 1.18, 95% CI (1.01-1.38), p = 0.03] were independently associated with 12-month cardiac admissions.

CONCLUSIONS

The current study found no significant association between symptoms of anxiety and cardiac hospitalizations at 12 months in HF patients. In contrast, clinical indicators (i.e., NYHA class III and a history of HF-related hospitalizations) were significantly associated with admissions due to a cardiac cause. Future studies are warranted to investigate the importance of symptoms of anxiety in HF using a larger sample size and a longer follow-up duration.

What is the methodological and reporting quality of health related quality of life in chronic heart failure clinical trials?

BACKGROUND

Although the number of clinical trials assessing health related quality of life (HRQoL) in chronic heart failure (CHF) has increased exponentially over the last decade, little is known about the quality of reporting. The purpose of this review was to assess the methodological and reporting rigor of HRQoL in RCTs of pharmacological therapy in CHF.

METHODS

The electronic data bases, Medline and EMBASE were searched from 1990 to 2009 using the key search terms 'heart failure' combined with 'quality of life', 'pharmacological therapy' and 'randomized controlled trials'. A total of 136 articles were identified and evaluated according to the "Minimum Standard Checklist (MSC) for Evaluating HRQoL Outcomes".

RESULTS

According to the MSC criteria, 26 (19.1%) studies were considered 'very limited', 91 (66.9%) were 'limited' and only 19 (14.0%) studies were considered to be of a 'probably robust' in terms of methodological and reporting rigor. In fact, the quality of HRQoL reporting has not improved over time.

CONCLUSION

HRQoL is a critical consideration in CHF management, yet reporting is highly variable. There is a need to develop a standardized method for measuring and reporting HRQoL measures in clinical trials to aid in the interpretation and application of findings.

Type D personality and course of health status over 18 months in outpatients with heart failure: multiple mediating inflammatory biomarkers

BACKGROUND

The distressed (Type D) personality is associated with poor health status (HS) and increased inflammatory activation in heart failure (HF). We tested whether multiple inflammatory biomarkers mediated the association between Type D personality and the course of self-reported HS over 18 months.

METHODS

HF outpatients (n=228, 80% male, mean age 67.0±8.7 years), filled out the Type D questionnaire (DS14) at inclusion and the Short Form-12 (SF12) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) at 0, 6, 12, and 18 months. Blood samples at inclusion were analyzed for high sensitive C-reactive protein (hsCRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α, and its soluble receptors (sTNFr1, sTNFr2). A multiple mediation latent growth model was tested using structural equation modeling.

RESULTS

Type D personality (prevalence=21%) was associated with poorer HS (all scales p<0.001), deterioration of mental HS (p<0.001), and higher TNF-α and sTNFr2 levels in the full mediation model. A higher inflammatory burden was associated with a poorer baseline level and a deterioration of generic physical, mental and disease-specific HS. No mediating effects were found for the multiple inflammatory biomarkers on the association between Type D and baseline self-reported HS, whereas change in physical HS was significantly mediated by the group of five inflammatory biomarkers (p=0.026).

CONCLUSIONS

Only the association between Type D personality and change in self-reported physical health status was significantly mediated by inflammatory biomarkers. Future research should investigate whether the association between Type D personality and poor health status may be explained by other biological or behavioral factors.