Responsiveness of health-related quality of life outcome measures in cardiac rehabilitation: comparison of cardiac rehabilitation outcome measures

Longitudinal association between positive affect and blood lipids in patients following acute myocardial infarction

OBJECTIVE

Unfavorable blood lipid profiles are robust risk factors in predicting atherosclerotic disease. Studies have shown that positive affect (PA) is associated with a favorable lipid profile. However, longitudinal studies regarding the course of PA and lipid profiles in myocardial infarction (MI) patients are lacking. Therefore, the aim of this study was to prospectively explore the association between PA and blood lipid levels across three inv estigations over 12 months following acute MI.

METHODS

Patients following an acute MI were examined at hospital admission (n = 190), and at 3 months (n = 154) and 12 months (n = 106) thereafter. Linear mixed effect regression models were used to evaluate the relation between PA, assessed with the Global Mood Scale, and blood lipid levels. Potential confounding variables were controlled for in the analysis.

RESULTS

Higher PA was significantly associated with higher high-density lipoprotein cholesterol (HDL-C) levels and a lower total cholesterol (TC)/HDL-C ratio over time, independent of demographic factors, indices of cardiac disease severity, comorbidity, medication use, health behaviors, serum cortisol and negative affect (p≤0.040). No association was found between PA and the two blood lipids low-density lipoprotein-cholesterol (LDL-C) and triglycerides (TG).

CONCLUSIONS

Positive affect was independently associated with HDL-C levels and the TC/HDL-C ratio in patients up to 1 year after MI. The findings support a potential role of PA for cardiovascular health through an association with a favorable blood lipid profile.

One-year intensive lifestyle intervention and improvements in health-related quality of life and mental health in persons with type 2 diabetes: a secondary analysis of the U-TURN randomized controlled trial

INTRODUCTION

The effects of lifestyle interventions in persons with type 2 diabetes (T2D) on health-related quality of life (HRQoL) and subjective well-being are ambiguous, and no studies have explored the effect of exercise interventions that meet or exceed current recommended exercise levels. We investigated whether a 1-year intensive lifestyle intervention is superior in improving HRQoL compared with standard care in T2D persons.

RESEARCH DESIGN AND METHODS

We performed secondary analyses of a previously conducted randomized controlled trial (April 2015 to August 2016). Persons with non-insulin-dependent T2D (duration ≤10 years) were randomized to 1-year supervised exercise and individualized dietary counseling (ie, 'U-TURN'), or standard care. The primary HRQoL outcome was change in the 36-item Short Form Health Survey (SF-36) physical component score (PCS) from baseline to 12 months of follow-up, and a key secondary outcome was changes in the SF-36 mental component score (MCS).

RESULTS

We included 98 participants (U-TURN group=64, standard care group=34) with a mean age of 54.6 years (SD 8.9). Between-group analyses at 12-month follow-up showed SF-36 PCS change of 0.8 (95% CI -0.7 to 2.3) in the U-TURN group and deterioration of 2.4 (95% CI -4.6 to -0.1) in the standard care group (difference of 3.2, 95% CI 0.5 to 5.9, p=0.02) while no changes were detected in SF-36 MCS. At 12 months, 19 participants (30%) in the U-TURN group and 6 participants (18%) in the standard care group achieved clinically significant improvement in SF-36 PCS score (adjusted risk ratio 2.6, 95% CI 1.0 to 4.5 corresponding to number needed to treat of 4, 95% CI 1.6 to infinite).

CONCLUSION

In persons with T2D diagnosed for less than 10 years, intensive lifestyle intervention improved the physical component of HRQoL, but not the mental component of HRQoL after 1 year, compared with standard care.

TRIAL REGISTRATION NUMBER

NCT02417012.

A Comparative Effectiveness Review: RESPONSIVENESS OF PATIENT OUTCOME MEASURES IN CARDIAC AND PULMONARY REHABILITATION

BACKGROUND

Cardiac and pulmonary rehabilitation have been shown to reduce the symptoms of disease, as well as reducing health care utilization. To ensure the continuation of these programs, patient outcome measures (POMs) are essential to map treatment effectiveness. This review is a comparative effectiveness literature review of studies with a pre- to post-POM assessment of responsiveness (ie, change in health status over time).

METHODS

A quality review of the literature included not only randomized controlled trials but also parallel studies, as well as all observational and retrospective trials. This review included a list of articles and their characteristics; a quality assessment of the literature and a list of POMs utilized in this setting were assessed for responsiveness.

RESULTS

There was inconsistency in the literature with the measurement of responsiveness or effect size. The most commonly used POM was the SF-36; however, it was found to be less responsive to change in health status pre- to post-rehabilitation, particularly in the mental domain of this instrument. The most responsive POM in this setting was the Global Mood Scale.

CONCLUSION

The surveyed literature found no "gold standard" POM for either cardiac rehabilitation or pulmonary rehabilitation but there was some preference for the disease-specific POMs; however, some of these instruments lose their discriminatory power at the end of the rehabilitation period. This literature review found that a Likert scale is more responsive than a dichotomous scale and that a simple questionnaire is more responsive in a pre- to post-setting than a complex questionnaire.

Shared care versus hospital-based cardiac rehabilitation: a cost-utility analysis based on a randomised controlled trial

Background

Changes in the organisation of chronic healthcare, an increased awareness of costs and challenges of low adherence in cardiac rehabilitation (CR) call for the exploration of more flexible CR programmes as alternatives to hospital-based CR (H-CR). A model of shared care cardiac rehabilitation (SC-CR) that included general practitioners and the municipality was developed. The aim of this study was to analyse the cost utility of SC-CR versus H-CR.

Methods

The cost-utility analysis was based on a randomised controlled trial of 212 patients who were allocated to SC-CR or H-CR and followed up for 12 months. A societal cost perspective was applied that included the cost of intervention, informal time, healthcare and productivity loss. Costing was based on a microcosting approach for the intervention and on national administrative registries for the other cost categories. Quality-adjusted life years (QALYs) were based on the EuroQol 5-Dimensions measurements at baseline, after 4 months and after 12 months. Conventional cost-effectiveness methodology was employed to estimate the net benefit of SC-CR.

Results

The average cost of SC-CR was 165.5 kDKK and H-CR 163 kDKK. Productivity loss comprised 74.1kDKK and 65.9 kDKK. SC-CR cost was an additional 2.5 kDKK (95% CI −38.1 to 43.1) ≈ (0.33; −5.1 to 5.8 k€) and a QALY gain of 0.02 (95% CI −0.03 to 0.06). The probability that SC-CR would be cost-effective was 59% for a threshold value of willingness to pay of 300 kDKK (k€40.3).

Conclusion

CR after shared care model and H-CR are comparable and similar in socioeconomic terms.

Trial registration number

NCT01522001; Results.

Heart Rate Recovery After Exercise in Outpatients with Coronary Heart Disease: Role of Depressive Symptoms and Positive Affect

Heart rate recovery after 1 min of exercise cessation (HRR-1) is an important prognostic factor in patients with cardiovascular disease (CVD). We aimed to further elucidate the association between HRR-1 and known psychosocial risk factors in patients referred for comprehensive cardiac rehabilitation. We examined 521 patients with coronary heart disease in the first week of an outpatient cardiac rehabilitation program. Depressive and anxiety symptoms were measured with the Hospital Anxiety and Depression Scale, and positive (PA) and negative affect were rated with the Global Mood Scale. Depressive symptoms showed a significant inverse relationship with HRR-1 (p < .05), controlling for sociodemographic and medical covariates, whereas anxiety symptoms did not show a significant association. PA made a significant contribution to HRR-1 as well (p < .05). Our findings suggest an independent association between HRR-1 and psychosocial risk factors of CVD.

Internet-delivered treatment: its potential as a low-intensity community intervention for adults with symptoms of depression: protocol for a randomized controlled trial

BACKGROUND

Depression is a high prevalence disorder, displaying high rates of lifetime incidence, early age onset, high chronicity, and role impairment. In Ireland 12-month prevalence of depression has been reported to be 10.3%. A large percentage of affected individuals have no medical diagnosis nor seek treatment. Cognitive Behavior Therapy (CBT) has established itself as an option for the treatment of depression. Many Irish adults with depression find it difficult to access evidence-based CBT, this is due to several factors, like stigma and costs. However, systematic factors including the shortage of trained professionals and the relative underdevelopment of services also make access difficult.Stepped-care can increase access to evidence-based CBT. One option is tailored internet-delivered treatment programs. Preliminary research from Ireland needs now to include large-scale studies on effectiveness. Thus the current study seeks to examine the potential of an internet-delivered low-intensity treatment for symptoms of depression in an Irish adult community sample.

METHOD/DESIGN

The study is a randomized controlled trial of an online CBT (iCBT) program for the treatment of adults with depressive symptoms. The trial will include an active treatment group and a waiting-list control group. The active condition will consist of 8 weekly modules of iCBT, with post-session feedback support. Participants in the waiting list will receive access to the treatment at week 8. Participants will complete the Beck Depression Inventory (BDI-II) and eligibility criteria will also apply. Primary outcomes are depressive symptoms. Secondary outcomes include quality of life indicators, significant events and satisfaction with online treatment. Data will be collected at baseline and at post-treatment, week 8, and at follow-up week 20 (3-months) and week 32 (6-months). Analysis will be conducted on the intention-to-treat basis.

DISCUSSION

The study seeks to evaluate the effectiveness of an online delivered treatment for depression in a community sample of Irish adults with symptoms of depression. The study will be a first contribution and depending on the sample recruited the results may be generalizable to people with similar difficulties in Ireland and may therefore give insight into the potential of low-intensity interventions for Irish people with depressive symptoms.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN03704676. DOI: 10.1186/ISRCTN03704676.

Exercise Mediates the Association Between Positive Affect and 5-Year Mortality in Patients With Ischemic Heart Disease

Background—

Positive affect has been associated with better prognosis in patients with ischemic heart disease, but the underlying mechanisms remain unclear. We examined whether positive affect predicted time to first cardiac-related hospitalization and all-cause mortality, and whether exercise mediated this relationship in patients with established ischemic heart disease.

Methods and Results—

The sample comprised 607 patients with ischemic heart disease from Holbæk Hospital, Denmark. In 2005, patients completed the Global Mood Scale (GMS) to assess positive affect and a purpose-designed question on exercise. Data on mortality and hospitalization were collected from Danish national registers for the period 2006–2010. Adjusted Cox and logistic regression were used to analyze the mediation model. Because no significant association between positive affect and cardiac-related hospitalization was found, we constructed no mediation model for hospitalization. Importantly, patients with high positive affect had a significantly reduced risk of all-cause mortality (hazard ratio, 0.58; 95% confidence interval, 0.37–0.92; unadjusted analysis) and were more likely to exercise (odds ratio, 1.99; 95% confidence interval, 1.44–2.76; unadjusted analysis; odds ratio, 1.48; 95% confidence interval, 1.03–2.13; adjusted analysis). When controlling for positive affect and other relevant variables, patients engaged in exercise were less likely to die during follow-up (hazard ratio, 0.50; 95% confidence interval, 0.31–0.80; P =0.004). Importantly, exercise acted as a mediator in the relationship between positive affect and mortality.

Conclusions—

Patients with higher levels of positive affect were more likely to exercise and had a lower risk of dying during 5-year follow-up, with exercise mediating the relationship between positive affect and mortality. Interventions aimed at increasing both positive affect and exercise may have better results with respect to patients’ prognosis and psychological well-being than interventions focusing on 1 of these factors alone.

Evaluating the responsiveness of the Warwick Edinburgh Mental Well-Being Scale (WEMWBS): group and individual level analysis

Background

Mental well-being now features prominently in UK and international health policy. However, progress has been hampered by lack of valid measures that are responsive to change. The objective of this study was to evaluate the responsiveness of the Warwick Edinburgh Mental Well-being Scale (WEMWBS) at both the individual and group level.

Methods

Secondary analysis of twelve different interventional studies undertaken in different populations using WEMWBS as an outcome measure. Standardised response mean (SRM), probability of change statistic (P̂) and standard error of measurement (SEM) were used to evaluate whether WEMWBS detected statistically important changes at the group and individual level, respectively.

Results

Mean change in WEMWBS score ranged from −0.6 to 10.6. SRM ranged from −0.10 (95% CI: -0.35, 0.15) to 1.35 (95% CI: 1.06, 1.64). In 9/12 studies the lower limit of the 95% CI for P̂ was greater than 0.5, denoting responsiveness. SEM ranged from 2.4 to 3.1 units, and at the threshold 2.77 SEM, WEMWBS detected important improvement in at least 12.8% to 45.7% of participants (lower limit of 95% CI>5.0%).

Conclusions

WEMWBS is responsive to changes occurring in a wide range of mental health interventions undertaken in different populations. It offers a secure base for research and development in this rapidly evolving field. Further research using external criteria of change is warranted.

Positive affect dimensions and their association with inflammatory biomarkers in patients with chronic heart failure

BACKGROUND

In cardiac patients positive affect has found to be associated with improved clinical outcomes, with reduced inflammation being one of the potential mechanisms responsible.

METHODS

Positive affect was assessed using The Global Mood Scale (GMS), Positive and Negative Affect Schedule (PANAS), and Hospital Anxiety and Depression Scale (HADS) in patient with chronic heart failure (N=210; 67 ± 9 years, 79% men). Markers of inflammation (TNFα, sTNFr1, sTNFr2, IL-6 and CRP) were measured and averaged at three consecutive time points.

RESULTS

The positive affect dimensions of the GMS and PANAS were significantly associated with lower averaged levels of sTNFr2, TNFα and IL-6 (p<.1), even after adjustment for clinical and lifestyle confounders. Positive affect of the HADS was significantly associated with lower averaged levels of hsCRP (p<.1), but was no longer significant after correction for lifestyle confounders and depressive symptoms.

CONCLUSION

Positive affect is associated with reduced inflammation in patients with heart failure.

Psychological well-being in obese inpatients with ischemic heart disease at entry and at discharge from a four-week cardiac rehabilitation program

The purposes of this observational pre-post study were twofold: 1- to evaluate psychological health in obese patients with ischemic heart disease at admission to cardiac rehabilitation (CR) and 2 – to examine the effectiveness of a 4-week CR residential program in improving obese patients’ psychological well-being at discharge from CR. A sample of 177 obese patients completed the Psychological General Well-Being Inventory (PGWBI) at admission to the CR program and at discharge. The equivalence testing method with normative comparisons was used to determine the clinical significance of improvements after having established that baseline mean scores on the PGWBI scales were significantly lower than normal means. Results show that patients scored equally or better than norms on many PGWBI dimensions at admission to CR but scored significantly worse on Global Score, Vitality and Self-control. At discharge, mean scores that were impaired at baseline returned to normal levels at the more conservative equivalence interval. A 4-week CR program was thus effective in improving obese patients’ psychological well-being. The equivalence testing method allowed to establish the clinical significance of such improvement.

Type D personality is a predictor of poor emotional quality of life in primary care heart failure patients independent of depressive symptoms and New York Heart Association functional class

Quality of life is an important patient-centered outcome and predictor of mortality in heart failure, but little is known about the role of personality as a determinant of quality of life in this patient group. We examined the influence of Type D personality (i.e., increased negative emotions paired with emotional non-expression) on quality of life in primary care heart failure patients, using a prospective study design. Heart failure patients (n = 251) recruited from 44 primary care practices in Germany completed standardized questionnaires at baseline and 9 months. The prevalence of Type D was 31.9%. Type D patients experienced poorer emotional (P < .001) and physical quality of life (P = .01) at baseline and 9 months compared to non-Type D patients. There was no significant change in emotional (P = .78) nor physical quality of life (P = .74) over time; neither the interaction for time by Type D for emotional (P = .31) nor physical quality of life (P = .91) was significant, indicating that Type D exerted a stable effect on quality of life over time. Adjusting for demographics, New York Heart Association functional class, and depressive symptoms, Type D remained an independent determinant of emotional (P = .03) but not physical quality of life (P = .29). Primary care heart failure patients with a Type D personality experienced poorer emotional but not physical quality of life compared to non-Type D patients. Patients with this personality profile should be identified in primary care to see if their treatment is optimal, as both Type D and poor quality of life have been associated with increased morbidity and mortality.

Negative and positive affect are independently associated with patient-reported health status following percutaneous coronary intervention

PURPOSE

We examined the association between negative and positive affect and 12-month health status in patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents.

METHODS

Consecutive PCI patients (n = 562) completed the Global Mood Scale at baseline to assess affect and the EuroQoL-5D (EQ-5D) at baseline and 12-month follow-up to assess health status.

RESULTS

Negative affect [F(1, 522) = 17.14, P < .001] and positive affect [F(1, 522) = 5.11, P = .02] at baseline were independent associates of overall health status at 12-month follow-up, adjusting for demographic and clinical factors. Moreover, there was a significant interaction for negative by positive affect [F(1, 522) = 6.11, P = .01]. In domain-specific analyses, high negative affect was associated with problems in mobility, self-care, usual activities, pain/discomfort, and anxiety/depression with the risk being two to fivefold. Low positive affect was only associated with problems in self-care (OR: 8.14; 95% CI: 1.85-35.9; P = .006) and usual activities (OR: 1.87; 95% CI: 1.17-3.00; P = .009).

CONCLUSIONS

Baseline negative and positive affect contribute independently to patient-reported health status 12 months post PCI. Positive affect moderated the detrimental effects of negative affect on overall health status. Enhancing positive affect might be an important target to improve patient-centered outcomes in coronary artery disease.

Positive affect and negative affect correlate differently with distress and health-related quality of life in patients with cardiac conditions: validation of the Danish Global Mood Scale

OBJECTIVE

The Global Mood Scale (GMS), assessing negative affect (NA) and positive affect (PA), is sensitive to tapping treatment-related changes in patients with cardiac conditions. We examined the psychometric properties of the Danish GMS and the influence of NA and PA on distress and health-related quality of life (HRQL).

METHOD

A mixed group of patients with cardiac conditions (n=502) completed the GMS, the Hospital Anxiety and Depression Scale, the Type D Scale, and the 36-item Short-Form Health Survey.

RESULTS

The two-factor model of the Danish GMS was confirmed, and the scale was shown to be valid, internally consistent (Cronbach's alpha NA/PA=.93/.85), and stable over 3 weeks (Pearson's r NA/PA=.82/.80). Unadjusted multiple linear regression analyses showed NA (beta=0.67, P<.001), PA (beta=-0.17, P=.001), and the interaction effect NA x PA (beta=-0.17, P=.015) to be associated with anxiety and depressive symptoms (NA:beta=0.99, P<.001; PA:beta=-0.12, P=.004; NA x PA:beta=-0.43, P<.001), as well as with physical HRQL (NA:beta=-0.37, P<.001; PA:beta=0.17, P=.001; NA x PA: beta=-0.27, P<.001) and mental HRQL (NA:beta=-0.72, P<.001; PA:beta=0.27, P=.004; NA x PA:beta=0.23, P<.001). When adjusting for demographic and clinical characteristics, only NA (beta=0.26, P=.003) was associated with anxiety, whereas NA (beta=0.75, P<.001) and NA x PA (beta=-0.34, P=.002) were associated with depressive symptoms. For physical HRQL, PA (beta=0.21, P=.03) and NA x PA (beta=-0.36, P=.005) remained significant, whereas NA (beta=-0.38, P<.001) and PA (beta=0.21, P=.002) remained significant for mental HRQL.

CONCLUSION

The Danish GMS is a psychometrically sound measure of affect in patients with cardiac conditions. Future studies should examine changes in both PA and NA and their impact on health outcomes.

Preliminary evidence for the cross-cultural utility of the type D personality construct in the Ukraine

Background

Type D personality is a risk indicator in cardiac patients. The validity and reliability of the Type D Scale (DS14) have been confirmed in Western Europe but not outside this context.

Purpose

We examined the structural, convergent, and divergent validity and the reliability of the DS14 in the Ukrainian setting.

Method

Healthy Ukrainian respondents (n = 250) completed the DS14, the Eysenck Personality Questionnaire, the State Trait Anxiety Inventory, and the Beck Depression Inventory. A subsample (n = 57) completed the DS14 again after 4 weeks.

Results

The prevalence of Type D personality was 22.4%. The two-factor structure and the validity of the DS14 were confirmed. The DS14 subscales were internally consistent (Cronbach’s α = 0.86/0.71; mean inter-item correlation = 0.48/0.27) and stable over a 4-week period (r = 0.85/0.63). Type D individuals had significantly higher mean scores on anxiety (p < 0.001), depressive symptoms (p < 0.001), and negative affect (p < 0.001), and lower scores on positive affect (p < 0.001) compared to non-Type D individuals.

Conclusion

Preliminary evidence suggests that the Ukrainian DS14 is a valid and reliable measure. Future studies are warranted to test the utility of the scale in cardiac patients in the Ukraine, including whether Type D also predicts adverse health outcomes beyond the boundaries of Western Europe.

Correlates of patient acceptance of the cardioverter defibrillator: cross-validation of the Florida Patient Acceptance Survey in Danish patients

BACKGROUND

Device acceptance may comprise one of the keys to identifying implantable cardioverter defibrillator (ICD) patients at risk for adverse health outcomes in clinical practice. We examined (1) the validity and reliability of the Florida Patient Acceptance Survey (FPAS) and (2) correlates of device acceptance in a large sample of Danish patients.

METHODS

A cohort of consecutive patients (N = 566; 82.2% males; mean age = 61.9 +/- 14.3) implanted with an ICD since 1989 and still alive on November 1, 2006, completed a set of psychological questionnaires.

RESULTS

The four-factor structure and the validity of the FPAS were confirmed, with the four factors accounting for 64.3% of the variance. The reliability, measured by Cronbach's alpha, was acceptable for the total scale and all subscales, ranging from 0.73 to 0.85. Correlates of poor device acceptance included older age (OR: 1.03; 95% CI: 1.01-1.05), symptomatic heart failure (OR: 3.59; 95% CI: 2.12-6.08), Type D personality (OR: 3.51; 95% CI: 1.95-6.30), anxiety (OR: 2.33; 95% CI: 1.24-4.38), depressive symptoms (OR: 2.24; 95% CI: 1.00-5.00), and ICD concerns (OR: 4.16; 95% CI: 2.55-6.80); having a partner was associated with better acceptance (OR: 0.53; 95% CI: 0.31-0.91), adjusting for demographic and clinical factors including shocks. Shocks were not associated with outcome (P = 0.59).

CONCLUSIONS

The FPAS was shown to be a valid and reliable measure of device acceptance in a large sample of Danish ICD patients. Psychological factors rather than clinical factors were the primary correlates of poor device acceptance, whereas having a partner was associated with better acceptance. These preliminary findings suggest that screening for psychological factors may aid clinicians in identifying patients at risk of poor device acceptance.

Type D patients report poorer health status prior to and after cardiac rehabilitation compared to non-type D patients

BACKGROUND

Type D personality is an emerging risk factor in coronary artery disease (CAD). Cardiac rehabilitation (CR) improves outcomes, but little is known about the effects of CR on Type D patients.

PURPOSE

We examined (1) variability in Type D caseness following CR, (2) Type D as a determinant of health status, and (3) the clinical relevance of Type D as a determinant of health status compared to cardiac history.

METHODS

CAD patients (n = 368) participating in CR completed the Type D Scale, the Short-Form Health Survey 36 pre- and post-CR, and the Hospital Anxiety and Depression Scale pre-CR, to assess health status and depressive and anxious symptomatology, respectively.

RESULTS

The prevalence of Type D decreased from 26.6% to 20.7% (p = 0.012) following CR, but Type D caseness remained stable in 81% of patients. Health status significantly improved following CR [F(1,359) = 17.48, p < 0.001], adjusting for demographic and clinical factors and anxious and depressive symptoms. Type D patients reported poorer health status [F(1,359) = 10.40, p = 0.001], with the effect of Type D being stable over time [F(1,359) = 0.49, p = 0.48]. Patients with a cardiac history benefited less from CR [F(1,359) = 5.76, p = 0.02]. The influence of Type D on health status was larger compared to that for cardiac history, as indicated by Cohen's effect size index.

CONCLUSIONS

Type D patients reported poorer health status compared to non-Type D patients pre- and post-CR. In the majority of patients, CR did not change Type D caseness, with Type D being associated with a stable and clinically relevant effect on outcome. These high-risk patients should be identified in clinical practice and may require adjunctive interventions.

Are there meaningful longitudinal changes in health related quality of life--SF36, in cardiac rehabilitation patients?

BACKGROUND

This study aimed to observe changes in quality of life and minimal clinical important differences of quality of life over time in cardiac rehabilitation patients and to compare these with published normal data.

METHODS

In this non-randomised study, SF36 questionnaires were completed by 187 patients recruited to a Phase III cardiac rehabilitation multidisciplinary outpatient programme. Data was collected at beginning, end and six months after Phase III cardiac rehabilitation programme.

RESULTS

There were significant improvements in physical functioning, role limitation due to physical function, pain and general health perception scales, over the above time frame, from both a statistically and a mean clinical important difference point of view. These improvements occurred mainly during the cardiac rehabilitation programme phase.

CONCLUSIONS

These improvements meant that patients six months post-cardiac rehabilitation were only 5% below the quality of life for an aged matched normal group. However patients still had significant deficits in physical role and emotional role limitations. Suitable measurement of quality of life on an individual basis, supported by normal values is needed. This would facilitate the identification of shortfalls in patient quality of life and the subsequent tailoring of care to address these individualised patient needs.

Reduced positive affect (anhedonia) predicts major clinical events following implantation of coronary-artery stents

OBJECTIVE

Emotional distress has been related to clinical events in patients with coronary artery disease, but the influence of positive affect (i.e. mood states such as activity, joy and cheerfulness) has received little attention. Therefore, we wanted to investigate the role of positive affect on clinical outcome after percutaneous coronary intervention (PCI) with stent implantation in these patients.

DESIGN

Prospective follow-up study. At baseline, patients from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed measures of positive affect, depression and anxiety post-PCI. Patients with reduced positive affect scored 1 SD below the mean score.

SETTING

University Hospital; Thoraxcenter of the Department of Cardiology.

SUBJECTS

874 patients (72% men; 62.2 +/- 10.9 years) from the RESEARCH registry. Main outcome measure. Death or myocardial infarction (MI) 2 years post-PCI.

RESULTS

At follow-up, there were 52 clinical events (deaths n = 27, MIs n = 25). Reduced positive affect and depression/anxiety were associated with poor prognosis, but reduced positive affect was the only independent predictor of events. The incidence of death/MI in adequate versus reduced positive affect patients was 4% (29/663) vs. 11% (23/211); HR = 2.55 (95% CI 1.46-4.34, P = 0.001), adjusting for clinical variables. Reduced positive affect and diabetes were independent prognostic factors, and patients with one (HR = 2.84, 95% CI 1.58-5.10) or both (HR = 5.61, 95% CI 2.25-13.99) of these factors had a higher risk when compared with nondiabetic patients with adequate positive affect, P < or = 0.003.

CONCLUSIONS

Reduced positive affect independently predicted death/MI following stent implantation, and improved risk stratification above and beyond diabetes.

Psychological symptom clusters, psychiatric comorbidity and poor self-reported health status following myocardial infarction

BACKGROUND

Depression is a risk factor for adverse outcomes following myocardial infarction (MI). However, the importance of various other psychological factors is less well established.

PURPOSE

The purpose is (a) explore the degree to which self-reported psychological symptoms in post-MI patients represent one or more underlying dimensions and (b) examine whether psychological symptom profiles based on these dimensions are differentially associated with major depressive disorder (MDD) and anxiety disorder (AD), and impaired health status.

METHODS

Two months post-MI, the Beck Depression Inventory, State-Trait Anxiety Inventory, and Global Mood Scale were used to measure symptoms of depression, anxiety, and mood status in 324 patients. The Composite International Diagnostic Interview was administered to diagnose DSM-IV MDD and AD. Health status was assessed by the Seattle Angina Questionnaire.

RESULTS

Principal component analysis revealed 4 essential features of post-MI distress: depressed affect, anxious apprehension, positive affect, and emotional exhaustion. Cluster analysis using these components identified 3 subgroups with different symptom profiles: A no distress subgroup (high positive affect, low on the remaining components), a first increased distress subgroup (ID1; elevated anxious apprehension/emotional exhaustion scores and decreased positive affect, p<.001, but absence of depressed affect, p=.56), and a second increased distress subgroup (ID2; decreased positive affect and elevated scores on the other components, all p<.001). Both increased distress subgroups were more likely to have psychiatric disorder (ID1: odds ratio [OR]=5.4, 95% confidence interval [CI]=1.3-22.1, p=.018; ID2: OR=27.1, 95% CI=6.4-114.7, p<.0001) and worse health status (ID1: -.38<B<-.12; all p<.05; ID2: -.48<B<-.20; all p<.05).

CONCLUSIONS

In addition to standard depressive symptoms, other affective components are important in understanding emotional adjustment in post-MI patients. These components are closely related to psychiatric comorbidity and poor health status post-MI.

Issues associated with the measurement of psychosocial benefits of group audiologic rehabilitation programs

The purpose of this review is to describe the psychosocial effects of hearing loss, review the literature that has attempted to measure the psychosocial benefits of group audiologic rehabilitation programs, and offer suggestions for the design of future studies. The psychosocial aspects of hearing loss are multidimensional and may include the emotional, cognitive, interpersonal, behavioral, and physical responses to hearing loss. As a result of the stigma of hearing loss, individuals may isolate themselves, avoid social interactions, and/or bluff their way through communication breakdowns. Participation in group audiologic rehabilitation programs is a straightforward way to deal with the stigma and the loss of social identity associated with hearing loss, and these groups are an ideal forum for teaching communication strategies. Yet, the literature on the efficacy of group audiologic rehabilitation has produced equivocal results. Several factors may have contributed to the lack of psychosocial benefits reported in the literature, including the theoretical framework upon which the program was designed, the actual class content, the effectiveness of the outcome measures, and the demographic characteristics of the participants in the programs. Future research should determine (1) if the theoretical framework and/or the content covered in group audiologic rehabilitation programs influences the psychosocial outcomes, (2) if instructor training influences psychosocial outcomes, (3) the ideal test battery to assess the psychosocial benefits of group audiologic rehabilitation programs, (4) the participant demographic and personality characteristics that influence psychosocial outcomes, and (5) whether experienced hearing aid users have different hearing-loss related psychosocial needs than new hearing aid users.

Home-based cardiac rehabilitation versus hospital-based rehabilitation: A cost effectiveness analysis

BACKGROUND

Home-based cardiac rehabilitation offers an alternative to traditional, hospital-based cardiac rehabilitation.

AIM

To compare the cost effectiveness of home-based cardiac rehabilitation and hospital-based cardiac rehabilitation.

METHODS

104 patients with an uncomplicated acute myocardial infarction and without major comorbidity were randomized to receive home-based rehabilitation (n=60) i.e. nurse facilitated, self-help package of 6 weeks' duration (the Heart Manual) or hospital-based rehabilitation for 8-10 weeks (n=44). Complete economic data were available in 80 patients (48 who received home-based rehabilitation and 32 who received hospital-based rehabilitation). Healthcare costs, patient costs, and quality of life (EQ-5D4.13) were assessed over the 9 months of the study.

RESULTS

The cost of running the home-based rehabilitation programme was slightly lower than that of the hospital-based programme (mean (95% confidence interval) difference - 30 pounds sterling (- 45 pounds sterling to - 12 pounds sterling) [-44 euro, -67 euro to -18 euro] per patient. The cost difference was largely the result of reduced personnel costs. Over the 9 months of the study, no significant difference was seen between the two groups in overall healthcare costs (78 pounds sterling, - 1102 pounds sterling to 1191 pounds sterling [-115 euro, -1631 euro to -1763 euro] per patient) or quality adjusted life-years (-0.06 (-0.15 to 0.02)). The lack of significant difference between home-based rehabilitation and hospital-based rehabilitation did not alter when different costs and different methods of analysis were used.

CONCLUSIONS

The health gain and total healthcare costs of the present hospital-based and home-based cardiac rehabilitation programmes for patients after myocardial infarction appear to be similar. These initial results require affirmation by further economic evaluations of cardiac rehabilitation in different settings.

Positive and negative affect within the realm of depression, stress and fatigue: the two-factor distress model of the Global Mood Scale (GMS)

BACKGROUND

The Global Mood Scale (GMS; [Denollet, J., 1993a. Emotional distress and fatigue in coronary heart disease: the Global Mood Scale (GMS). Psychol Med 23, 111-121., Denollet, J., 1993b. The sensitivity of outcome assessment in cardiac rehabilitation. J Consult Clin Psychol 61, 686-695.]) was originally developed as a measure of positive affect (PA) and negative affect (NA) in cardiac patients. The purpose of this study was to examine its two-factor affect model in the realm of stress, depression, and fatigue in working adults.

METHODS

Affect, stress, depression, and fatigue were assessed with validated questionnaires in a sample of 228 adults (49.6% male; mean = 41.4 +/- 9 years) from the working population.

RESULTS

The GMS PA and NA scales were internally consistent (Cronbach's alpha = .94 and alpha = .93, respectively), and correlated in the expected direction with their corresponding mood scales from the Positive and Negative Affect Schedule (PANAS). Factor analyses of the 40 mood terms comprising the GMS and PANAS yielded one common PA-dimension, but two NA-dimensions reflecting emotional exhaustion (GMS) and anxious apprehension (PANAS) as different components of the stress process. A relatively high mean NA score of the GMS suggested that these working adults perceived terms that refer to malaise/deactivation as being relevant to describe their negative affective status. The GSM-NA scale was related to stress, depression and fatigue while the GMS-PA scale was positively associated with quality of life.

LIMITATIONS

This study is based on a cross-sectional design.

CONCLUSIONS

The association between the PA (negative correlation) and NA (positive correlation) scales of the GMS and perceived stress, depressive symptoms, and fatigue supports the validity of its two-factor model. Assessment of both PA and NA may benefit a better understanding of emotional distress in adults from the working population.