Health-related quality of life among patients undergoing percutaneous transluminal coronary angioplasty

Relationship between changing patient-reported outcomes and subsequent clinical events in patients with chronic heart failure: insights from HF-ACTION

AIMS

A 5-point change in the Kansas City Cardiomyopathy Questionnaire (KCCQ) is commonly considered to be a clinically significant difference in health status in patients with heart failure. We evaluated how the magnitude of change relates to subsequent clinical outcomes.

METHODS AND RESULTS

Using data from the HF-ACTION trial of exercise training in chronic heart failure (n = 2331), we used multivariable Cox regression with piecewise linear splines to examine the relationship between change in KCCQ overall summary score from baseline to 3 months (range 0-100; higher scores reflect better health status) and subsequent all-cause mortality/hospitalization. Among 2038 patients with KCCQ data at the 3-month visit, KCCQ scores increased from baseline by ≥5 points for 45%, scores decreased by ≥5 points for 23%, and scores changed by <5 points for the remaining 32% of patients. There was a non-linear relationship between change in KCCQ and outcomes. Worsening health status was associated with increased all-cause mortality/hospitalization (adjusted hazard ratio 1.07 per 5-point KCCQ decline; 95% confidence interval 1.03-1.12; P < 0.001). In contrast, improving health status, up to an 8-point increase in KCCQ, was associated with decreased all-cause mortality/hospitalization (adjusted hazard ratio 0.93 per 5-point increase; 95% confidence interval 0.90-0.97; P < 0.001). Additional improvements in health status beyond an 8-point increase in KCCQ was not associated with all-cause death or hospitalization (P = 0.42).

CONCLUSION

In patients with heart failure, small changes in KCCQ are associated with changing future risk, but more research will be necessary to understand how different magnitudes of improving health status affect outcomes.

Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

OBJECTIVES

To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers.

DESIGN

Cross sectional study.

SETTING

10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011.

PARTICIPANTS

991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention.

MAIN OUTCOME MEASURES

Patients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios.

RESULTS

The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site.

CONCLUSION

Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

Quality of life after PCI vs CABG among patients with diabetes and multivessel coronary artery disease: a randomized clinical trial

IMPORTANCE

The FREEDOM trial demonstrated that among patients with diabetes mellitus and multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery resulted in lower rates of death and myocardial infarction but a higher risk of stroke when compared with percutaneous coronary intervention (PCI) using drug-eluting stents. Whether there are treatment differences in health status, as assessed from the patient's perspective, is unknown.

OBJECTIVES

To compare the relative effects of CABG vs PCI using drug-eluting stents on health status among patients with diabetes mellitus and multivessel coronary artery disease.

DESIGN, SETTING, AND PARTICIPANTS

Between 2005 and 2010, 1900 patients from 18 countries with diabetes mellitus and multivessel coronary artery disease were randomized to undergo either CABG surgery (n = 947) or PCI (n = 953) as an initial treatment strategy. Of these, a total of 1880 patients had baseline health status assessed (935 CABG, 945 PCI) and comprised the primary analytic sample.

INTERVENTIONS

Initial revascularization with CABG surgery or PCI.

MAIN OUTCOMES AND MEASURES

Health status was assessed using the angina frequency, physical limitations, and quality-of-life domains of the Seattle Angina Questionnaire at baseline, at 1, 6, and 12 months, and annually thereafter. For each scale, scores range from 0 to 100 with higher scores representing better health. The effect of CABG surgery vs PCI was evaluated using longitudinal mixed-effect models.

RESULTS

At baseline, mean (SD) scores for the angina frequency, physical limitations, and quality-of-life subscales of the Seattle Angina Questionnaire were 70.9 (25.1), 67.3 (24.4), and 47.8 (25.0) for the CABG group and 71.4 (24.7), 69.9 (23.2), and 49.2 (25.7) for the PCI group, respectively. At 2-year follow-up, mean (SD) scores were 96.0 (11.9), 87.8 (18.7), and 82.2 (18.9) after CABG and 94.7 (14.3), 86.0 (19.3), and 80.4 (19.6) after PCI, with significantly greater benefit of CABG on each domain (mean treatment benefit, 1.3 [95% CI, 0.3-2.2], 4.4 [95% CI, 2.7-6.1], and 2.2 [95% CI, 0.7-3.8] points, respectively; P < .01 for each comparison). Beyond 2 years, the 2 revascularization strategies provided generally similar patient-reported outcomes.

CONCLUSIONS AND RELEVANCE

For patients with diabetes and multivessel CAD, CABG surgery provided slightly better intermediate-term health status and quality of life than PCI using drug-eluting stents. The magnitude of benefit was small, without consistent differences beyond 2 years, in part due to the higher rate of repeat revascularization with PCI.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00086450.

Effects of Ranolazine on Disease-Specific Health Status and Quality of Life Among Patients With Acute Coronary Syndromes

Background— Ranolazine has been shown to reduce myocardial ischemia and symptom severity among selected patients with chronic angina. However, data regarding the effect of ranolazine on health status/quality of life (QOL) are limited.

Methods and Results— We performed a prospective QOL analysis alongside the Metabolic Efficiency with Ranolazine for Less Ischemia in Non–ST-elevation acute coronary syndromes (MERLIN)-TIMI 36 trial, a randomized, double-blind, placebo-controlled trial of ranolazine in 6560 patients with non–ST-elevation acute coronary syndromes. Health status/QOL was evaluated at baseline and 4, 8, and 12 months after index hospitalization using the Seattle Angina Questionnaire, Rose dyspnea scale, SF-12, and EuroQol-5D. Health status/QOL scores improved significantly at all follow-up time points for both treatment arms. In the overall population, randomization to ranolazine was associated with minimal 12-month improvements in angina frequency and Seattle Angina Questionnaire-QOL ( P <0.05). In subsequent exploratory analyses, there was a significant interaction between the benefits of ranolazine and anginal status before the index event. Among patients with prior angina (n=3565), treatment with ranolazine was associated with modest benefits across the full range of QOL domains, with the greatest benefits observed in angina frequency (mean effect=3.4; P <0.001) and Seattle Angina Questionnaire-QOL (mean effect=2.7; P <0.001). There were no significant benefits among patients without prior angina, however.

Conclusion— Among a broad population of patients with unstable coronary disease, ranolazine had a minimal effect on disease-specific health status and QOL over ≈12 months of follow-up. Posthoc subgroup analysis, however, suggested a modest benefit among the subgroup of patients with angina before their acute coronary syndromes event.

Design of the Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease (FREEDOM) Trial

BACKGROUND

Prior randomized trials suggested that revascularization of diabetic patients by coronary artery bypass grafting (CABG) produced results superior to balloon angioplasty. The introduction of drug-eluting stents (DESs) calls into question the relevance of past studies to the current era. The FREEDOM Trial is designed to determine whether CABG or percutaneous coronary intervention (PCI) is the superior approach for revascularization of diabetic patients.

STUDY DESIGN

The FREEDOM Trial is a multicenter, open-label prospective randomized superiority trial of PCI versus CABG in at least 2000 diabetic patients in whom revascularization is indicated. Consenting diabetic patients with multivessel disease will be randomized on a 1:1 basis to either CABG or multivessel stenting using DESs and observed at 30 days, 1 year, and annually for up to 5 years. At the discretion of the primary physician or interventionalists, patients randomized to the PCI/DES arm will receive any approved DESs. The primary outcome measure is the composite of all-cause mortality, nonfatal myocardial infarction, or stroke. Patients will be observed for a mean of 4 years.

IMPLICATIONS

At present, coronary revascularization with CABG surgery is the treatment of choice in diabetic patients with multivessel coronary artery disease. Drug-eluting stents have shown promising preliminary results in the diabetic population. The FREEDOM Trial is an international study designed to define the optimal revascularization strategy for the diabetic patient with multivessel coronary disease.

The Effect of Depressive Symptoms on the Association Between Functional Status and Social Participation

OBJECTIVES: The aim of the current study was to examine the interactive effects of depressive symptoms and lower extremity functioning on social participation for a group of moderately to severely disabled older women. METHODS: The study used a cross-sectional community based sample, enrolled in the Women's Health and Aging Study I, randomly selected from the Centers for Medicare & Medicaid Services enrollment files for women living in the Baltimore, Maryland area. The participants were women aged 65 or older who completed the in-person interview (n = 999). RESULTS: After adjusting for demographics and risk factors, each unit increase in the Short Physical Performance Battery (SPPB) score was associated with a 0.31 point increase in satisfaction with social participation for the non-depressed group, and 2.04 points for the depressed group. DISCUSSION: Depressive symptoms and lower extremity functioning interact to affect satisfaction with social participation. Among women with high depressive symptoms the gradient of association with social participation increased sharply with better lower extremity function compared with non-depressed women, where the gradient of association was moderate. The findings suggest the potential value of programs that focus on improving lower extremity function among older high risk groups.

Work-related outcomes after a myocardial infarction

STUDY OBJECTIVE

To evaluate work-related outcomes of patients at 7 months after a myocardial infarction and to identify patient, disease, and intervention characteristics associated with these outcomes.

DESIGN

Cross-sectional survey analysis.

SETTING

Large Midwestern academic health system.

PATIENTS

Eighty-nine patients with the discharge diagnosis of acute myocardial infarction during a 1-year index period.

INTERVENTION

Work performance questionnaire administered by telephone, and medical record review.

MEASUREMENTS AND MAIN RESULTS

Seven months after discharge, 232 patients were interviewed by telephone to determine work status before and after myocardial infarction, work-related outcomes (absenteeism and perceived work performance, assessed by the Work Performance Scale [WPS] of the Functional Status Questionnaire), and health-related quality of life. Univariate analyses were used to determine the association between individual characteristics and work-related outcomes. Of the 89 patients who had worked before the index myocardial infarction, 21 (23.6%) did not return to work. Variables associated with the outcome of not returning to work were past myocardial infarction (before the index myocardial infarction), coronary artery bypass graft surgery, heart failure, positive stress test, and low score on the Physical Component Summary (PCS-12) scale of the Short Form-12. Patients who did not return to work also tended to have more comorbidities and take more prescribed drugs than those who returned to work. Median WPS scores were higher for patients who had higher ejection fractions at discharge, had not experienced a myocardial infarction before the index event, underwent a percutaneous revascularization intervention at the time of hospitalization, and had not recently been absent from work. Workers reporting absences had lower PCS-12 scores than their counterparts or reported a rehospitalization before the survey.

CONCLUSION

Preexisting cardiac disease and poorer physical functioning were consistently related to worse work-related outcomes. This small study demonstrates the need for a larger, broader study that includes health beliefs, treatment, and other job and patient factors that may influence work-related outcomes.

Association of changes in health-related quality of life in coronary heart disease with coronary procedures and sociodemographic characteristics

Background

Few studies have focused on the association between the sociodemographic characteristics of a patient with the change in health-related quality of life (HRQOL) following invasive coronary procedures, and the results remain inconclusive. The objective of the present study was to measure the temporal changes in HRQOL of patients with coronary heart disease, and assess how these changes are associated with invasive coronary procedures and sociodemographic characteristics.

Methods

This was a prospective study of 254 patients with angina pectoris and 90 patients with acute coronary syndrome. HRQOL was assessed with the multi-item scales and summary components of the SF-36, both 6 weeks and 2 years after baseline hospitalization in 1998. Paired t-tests and multiple regression analyses were used to assess temporal changes in HRQOL and to identify the associated factors.

Results

Physical components of HRQOL had improved most during the 2 years following invasive coronary procedures. Our findings indicated that patients with angina pectoris who were younger, male, and more educated were most likely to increase their HRQOL following invasive coronary procedures. When adjusting for baseline HRQOL scores, invasive coronary procedures and sociodemographic characteristics did not explain temporal changes in patients with acute coronary syndrome, possibly due to higher comorbidity.

Conclusion

Sociodemographic characteristics should be taken into account when comparing and interpreting changes in HRQOL scores in patients with and without invasive coronary procedures.

Assessing risk for major depression on patients selected for percutaneous transluminal coronary angioplasty: is it a worthwhile venture?

We hypothesized that a prior history of a major depressive disorder would not compromise the efficacy of percutaneous transluminal coronary angioplasty (PTCA), a coronary revascularization procedure, in improving quality of life and health status when comparing patients with no previous history. To determine the utility of screening for risk for depression in heart patients scheduled for PTCA, 190 patients were administered a two-item depressive disorders screener prior to PTCA and the SF-36 and Seattle Angina Questionnaire prior to and 6 months post procedure. Results reveal that while those with no prior history of depression had statistically better quality of life and health status outcomes than those with a probable past depression, (P <.05), the clinically meaningful differences as determined by effect size scores showed that those susceptible to recurrent depression benefited from PTCA as well as, and on some measures better than those with no previous history. Prescreening patients at probable risk for a depression is not a valid or helpful enterprise if the purpose is to develop intervention strategies for improving outcome post PTCA. Screening out patients based on history of depression may in fact lead to an inequitable allocation of resources and have no major benefit in enhancing quality of life and improving health status.

Factors influencing health-related quality of life in cardiac rehabilitation patients

Associations of age, gender, cardiac procedure (coronary artery bypass grafting or percutaneous transluminal coronary angioplasty), risk stratification, and number of comorbidities with health-related quality of life (HRQL) were examined among 217 men and 84 women (mean age, 63+/-11 years) consecutively enrolled in a phase II cardiac rehabilitation program. Female gender and high-risk stratification were independently associated with impaired treatment gains in most areas of HRQL. Older age and having a greater number of comorbidities were also associated with impaired gains in specific areas. HRQL was generally lower at baseline but not post-treatment in coronary artery bypass grafting vs. percutaneous transluminal coronary angioplasty patients. Cardiac rehabilitation patients also had lower HRQL scores than an age-matched, normative sample at baseline (most areas) and post-treatment (mainly on role physical). Findings reinforce the need for cardiac rehabilitation programs to tailor assessments and risk factor modification strategies to patient characteristics associated with low levels of HRQL, especially in women and those with higher risk stratification.

Quality of life of patients with chronic stable angina before and four years after coronary revascularisation compared with a normal population

OBJECTIVE

To assess the impact of coronary revascularisation on the health related quality of life (HRQOL) of patients with chronic stable angina compared with data from "community" norms four years following revascularisation.

DESIGN

Prospective survey and review of medical records.

SETTING

Seven of the eight public Swedish heart centres that performed coronary artery interventions.

SUBJECTS

827 patients aged 55-79 years with chronic stable angina who underwent coronary artery revascularisation in 1994 or 1995 and completed the four year HRQOL survey.

MAIN OUTCOME MEASURES

Five components of the Swedish quality of life survey.

RESULTS

Compared with age and sex adjusted population norms, patients at baseline had significantly lower mean scores on all five functioning and wellbeing scales (p < 0.001). Four years after revascularisation, the mean levels of functioning and wellbeing were similar to those in the normative population (p > 0.05) except for quality of sleep (p < 0.001). The improvements were the same across age groups and for men and women. However, 36% of men and 55% of women were not completely free from angina by four years (p < 0.001). Men without angina after four years had better HRQOL than their community norms (p < 0.001) on all dimensions except quality of sleep (p > 0.05). Women without angina had less pain (p < 0.01) and better general health perception (p < 0.05) but similar physical functioning, quality of sleep, and emotional wellbeing compared with their community counterparts. Both men and women who had suffered at least one anginal attack during the preceding four weeks had significantly worse HRQOL by four years than their community norms (p < 0.01).

CONCLUSIONS

By four years following revascularisation, three fifths of patients with chronic stable angina were free of angina and their HRQOL was the same as or better than that of the general Swedish population. However, fewer than half of all women and two thirds of men who underwent revascularisation were angina-free after four years. Among patients with new or persistent angina, the HRQOL was worse than that in community norms.

[Psychometric properties of a psychological well-being test for people with physical impairments]

Measuring the psychological well-being of people with physical impairments could provide relevant information to occupational therapists. The aim of this study was to verify psychometric properties of a psychological well-being test called Test de personnalité PER (PER). This test was administered to two samples of people with physical impairments. Two time measurements were collected within a group of 36 individuals and one single measure within another group of 79 individuals. Comparisons between time measurements, between groups and with the normative group of the PER were performed in an attempt to verify the sensitivity, the capacity to discriminate between known groups, and the construct validity of the PER. One section of the Sickness Impact Profile measuring psychological well-being was administered to the same groups to verify the concurrent criterion validity of the PER. The results indicate that the PER has sufficient psychometric qualities.

Sociodemographic and clinical factors associated with low quality of life one year after coronary bypass operations: the Israeli coronary artery bypass study (ISCAB)

OBJECTIVES

We sought to examine the effect of sociodemographic characteristics and perioperative clinical factors 1 year after coronary bypass operations on low health-related quality of life. We also sought to assess the usefulness of an additional single question on overall health for identifying patients with low health-related quality of life.

METHODS

This report is part of the Israeli coronary artery bypass study of 1994, in which every patient undergoing isolated coronary bypass grafting in Israel was included. The target population for this report comprised all survivors beyond 1 year who were 45 to 65 years of age. Patients were interviewed before the operations. Self-administered questionnaires regarding health-related quality of life (SF-36) were sent to 1724 patients who were successfully located 1 year postoperatively, and 1270 questionnaires were completed. Low health-related quality of life was defined as the lowest tertile of the distribution of scores for the 2 summary components of the SF-36 and the single question on overall health. Logistic models were constructed for each of the 3 outcomes.

RESULTS

Female sex and low socioeconomic background were associated with low health-related quality of life in the logistic models. Other significant factors were symptoms of angina, sleep disturbances, hypertension, high severity of illness scores, hospital readmission, no rehabilitation, and hospitals with high perioperative mortality. Of the 3 study outcomes, the model for the single question on overall health was the most discriminating (C statistic = 0.76 vs 0.70 and 0.70, respectively).

CONCLUSIONS

The study identifies patients who would most benefit from posthospitalization community support after bypass operations. Under circumstances of limited resources, these disadvantaged groups should be targeted as a priority. Encouraging participation in existing rehabilitation programs or introducing telephone hotlines could improve health-related quality of life after coronary bypass grafting without large investments.

Predictors of patient-reported physical and mental health 6 months after percutaneous coronary revascularization

BACKGROUND

There is interest in measuring and comparing outcomes of percutaneous transluminal coronary angioplasty (PTCA) other than death, but there are no accepted methods for adjusting these outcomes for preprocedure differences in populations. We sought to identify independent predictors of functional outcome after PTCA.

METHODS AND RESULTS

We developed multivariate risk adjustment models for the 6-month postprocedure physical and mental health summary scores of the MOS SF-36. Complete data were available on 1182 patients undergoing PTCA at 12 institutions. The mean physical component score (PCS) of the SF-36 rose from 36.6 before PTCA to 43. 4 at 6 months after PTCA (P <.0001). Independent predictors of follow-up PCS were baseline PCS, a composite index of comorbidities, prior coronary bypass surgery, baseline MOS SF-36 mental component score (MCS), age, and recent thrombolysis. The model had an adjusted R(2) value of 0.357. The mean MCS rose from 48.5 before PTCA to 50.5 at 6 months after PTCA (P <.0001). Independent predictors of postprocedure mental health were baseline MCS, age, and heart failure. The predictive model for MCS had an adjusted R(2) value of 0.235.

CONCLUSIONS

Preprocedure patient-reported functional status and select clinical variables are significantly associated with physical functioning and mental health 6 months after PTCA. The predictive power of these models, however, is probably insufficient to allow their use for comparisons among institutions or providers.

Perceived health over 3 years after percutaneous coronary balloon angioplasty

The magnitude of the benefit of percutaneous transluminal coronary angioplasty (PTCA) in terms of quality of life depending on baseline and outcome clinical variables is not sufficiently understood because of the restrictive inclusion criteria of randomized clinical trials. The present study was designed to assess perceived health outcome at 3 years and its association with clinical variables after successful elective PTCA in a tertiary hospital throughout a prospective cohort study. Questionnaires were administered on the day before the procedure and 1 month and 3.4 years later (as mean follow-up) to 106 patients recruited during a 15-month period. Mean perceived health scores improved significantly for the population as a whole 1 month after PTCA, and improvement was maintained at the end of follow-up. The magnitude of the effect was different depending on clinical subgroups: (a) It was greatest in patients free from angina, myocardial infarction, or new revascularization procedures at the end of follow-up; (b) It was moderately reduced in patients with comorbidity; (c) Patients who reported to have dyspnea or angina at rest after the latest revascularization procedure did not improve, with poor final perceived health scores. Elective PTCA is associated with a significant improvement in perceived health, which varies depending on the clinical outcome. Comorbidity and initial perceived health influence outcome but do not preclude improvement.

Prediction of functional and psychological status after percutaneous transluminal coronary angioplasty

OBJECTIVE

To examine symptom, functional status, and psychological status profiles after percutaneous transluminal coronary angioplasty (PTCA) and determine indicators of outcome.

DESIGN

Descriptive and correlational with repeated measures.

SETTING

Hospital or home (2.1 days before PTCA) and home (3.9 and 10.2 months after discharge).

MEASURES

Self-administered questionnaires (developed for study) for functional status (personal and instrumental activities of daily living), and cardiac symptoms (chest pain and shortness of breath at rest and on exertion). General Health Questionnaire(16) for psychological status.

PATIENTS

One hundred thirty with PTCA (mean age 57 years, 84% male, 15% with prior PTCA).

RESULTS

Chest pain and shortness of breath at rest and on exertion decreased and functional and psychological status improved 3.9 months after PTCA, with measures maintained at 10.2 months. At 3.9 months after PTCA, poorer psychological status was predicted by having had a longer duration of coronary artery disease before PTCA. Post-PTCA indicators of poor psychological status were continued chest pain and shortness of breath on exertion and not working. The presence of post-PTCA chest pain on exertion and not working were also correlated with reduced functional status.

CONCLUSIONS

Although pre-PTCA variables such as duration of coronary artery disease can predict post-PTCA outcome, the use of variables measured after PTCA may also provide clinicians with accurate estimates of functional and psychological status after PTCA.

Quality of life of low-vision patients and the impact of low-vision services

PURPOSE

To investigate the functional status and quality of life of patients at a low-vision clinic and to evaluate the impact of low-vision services.

METHODS

Interviews, including the Medical Outcomes Study 36-Item Short Form (SF-36), the Visual Function-14 (VF-14), and the 51-item Field Test Version of the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ), were administered to 156 consecutive patients 1 week before and 3 months after their low-vision clinic visit.

RESULTS

Low-vision patients scored lower (P < .001) in physical functioning and role limitations caused by physical and emotional health problems than published SF-36 scores of the age-appropriate United States normal population, patients with congestive heart failure, and clinically depressed patients. Low-vision services were associated with improvement in the subjective functional status of 150 patients (98.7%) and were rated "very useful" by 82 (53.9%) patients. The SF-36 scores did not change significantly after low-vision services. The VF-14 mean score improved from 35.8 to 41.2 (P < .001). Four NEI-VFQ subscale scores improved significantly (P < .001): general vision, near activities, distance activities, and peripheral vision.

CONCLUSIONS

The SF-36, VF-14, and NEI-VFQ demonstrate that low-vision clinic patients perceive marked impairment of functional status and quality of life. Low-vision services are associated with high patient satisfaction. Vision-targeted questionnaires are more sensitive than general health-related quality of life questionnaires to changes in functional status and quality of life after low-vision services, and they may help elucidate the outcomes of low-vision services.

HEALTH STATUS ASSESSMENT METHODS FOR ADULTS: Past Accomplishments and Future Challenges

Over the past 30 years, health status assessment methods for adults have proliferated. Numerous generic, disease-specific, and preference-based measures now exist that tap diverse aspects of functioning, well-being, symptom states, and subjective perceptions of health. The evolution of the state of the art in adult health status assessment is reviewed. Applications of these tools in health services research, health policy, and clinical practice are discussed. Recommendations are offered for selecting among the armamentaria of tools. Conceptual and methodological challenges that confront instrument users and developers alike are identified and discussed.

Quality of life in coronary artery disease

BACKGROUND

Coronary artery disease (CAD) constitutes a considerable financial burden on society in Finland; it is the cause of death of approximately 7,500 men and 6,500 women annually in a population of 5 million.

OBJECTIVES

The purpose of this study was to assess the changes in the quality of life (QOL) of patients with CAD treated by medication, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass surgery (CABS) during 1 year.

METHOD

The study population consisted of 280 patients with CAD. One hundred patients had been referred to CABS and another 100 to PTCA, whereas 80 patients were on drug therapy. The patients assessed their health status and QOL in terms of functional capacity and aspects of distress using self-completed questionnaires with the Nottingham Health Profile (NHP) instrument before the operation and 6and 12 months afterwards.

RESULTS

The QOL of the patients who had undergone CABS and PTCA was significantly better on the dimensions of energy, pain, and mobility 1 year after the intervention. In the medication group, the only improvement took place on the dimension of social isolation, whereas both energy and mobility deteriorated.

CONCLUSIONS

The results on QOL obtained in this study support the notion that patients continue to have many problems even after medical treatment with a good outcome. The problems occur in different areas compared with the pretreatment situation as on the dimensions of social isolation and emotional reaction. The rehabilitation of CAD patients is therefore important because the new problems are manifested differently from those seen before the illness or the treatment. The patient's QOL and personal preference for a treatment modality should be important criteria in the choice of treatment.

A population-based perspective of changes in health-related quality of life after myocardial infarction in older men and women

This study analyzes changes in health-related quality-of-life (HQL) outcomes following myocardial infarction (MI) from a population-based perspective. Data came from a representative sample of 2812 men and women 65 years and older living in New Haven, CT. All subjects were interviewed at baseline in 1982, and again in 1985 and 1988. HQL outcomes included self-rated health, depressive symptoms, and physical and social functioning. Pooled logistic regression models were used to estimate the risk for decline in HQL outcomes due to MI. Of the 203 MIs during follow-up, 111 (55%) survived until the next interview to provide post-MI data on outcomes. In bivariate analysis, MI patients were more likely than subjects without MI to show a decline in physical functioning (26.4% vs. 11.9%, P = .001) and social functioning (31.4% vs. 20.8%), P = .06). There were no differences in self-rated health (26.3% vs. 26.9%), but MI patients were less likely to show an increase in depression (9.1%) vs. 15.8%, P = .08). These associations remained mostly unchanged after adjustment for CHD risk factors. The effect of MI on physical and social functioning was much stronger among patients with a recent MI (<1 year ago) than those whose MI had occurred more than a year before post-MI assessment. While a substantial proportion of MI patients experience a significant decline in quality of life-related outcomes, only some of these declines occur more frequently among MI patients than in the population at large. This effect may also be limited to the immediate post-MI period. Results from this analysis are discussed in terms of the "burden of illness" within a defined population due to MI.

Assessment of quality of life with the Nottingham Health Profile among women with coronary artery disease

OBJECTIVE

To examine the differences in the health-related quality of life (HRQOL) of Finnish women with coronary artery disease (CAD) (n = 91) in comparison with Finnish men with CAD (n = 189). Healthy women (n = 990) served as a control group.

DESIGN

Prospective, cross-sectional survey.

SETTING

Surgical and medical clinics at the University of Oulu, Finland.

PATIENTS

Twenty-one women underwent coronary artery bypass grafting (CABG), 40 women underwent percutaneous transluminal coronary angioplasty (PTCA), and 30 women received medication for treatment of CAD. The patients in the medication group were taking beta blockers (81%), long-acting nitrates (86%), calcium channel blockers (43%), aspirin (79%), and lipid-lowering drugs (18%).

OUTCOME MEASURES

The Nottingham Health Profile (NHP), which consists of six dimensions: energy, sleep, pain, emotional reactions, social isolation, and physical mobility. Higher mean indexes signify lower HRQOL.

INTERVENTION

The patients referred to CABG and PTCA procedures were interviewed and asked to fill in the questionnaire on the day before the operation. They were instructed to describe their HRQOL over the preceding 3 months. The patients in the medication group were mailed the NHP questionnaire.

RESULTS

Women with CAD reported significantly poorer HRQOL than age-matched women in the healthy sample, as measured by the following dimensions of the NHP: energy, sleep, pain, emotional reactions, and physical mobility. This indicates the NHP dimensions affected by CAD among women. HRQOL for women with CAD was lower than that of men with CAD. The mean indexes of four of the six NHP dimensions, energy, sleep, emotional reactions, and physical mobility were higher for women with CAD than men with CAD in the two youngest age groups. Social isolation was most common in the youngest age group among both women and men with CAD. In women with CAD, emotional reactions and social isolation were most clearly related to demographic characteristics such as traumatic life experiences, depression, financial situation, and smoking.

CONCLUSIONS

These findings suggest that the subjective HRQOL should be considered along with the clinical severity of the disease in the evaluation of CAD. The findings further shed light on the HRQOL of especially young women with CAD, the female and male patients' referral for treatment, and the use of the NHP instrument among patients with CAD.

Does transplantation produce quality of life benefits? A quantitative analysis of the literature

BACKGROUND

Despite numerous reports published since the early 1970s, it is frequently asserted that quality of life (QOL) outcomes of transplantation have seldom been investigated and/or that little is known about QOL. This view may have persisted due to lack of adequate cumulation and synthesis of existing data. We performed an exhaustive, quantitative literature review to determine the nature and degree of any QOL benefits associated with transplantation in adults.

METHODS

All independent, peer-reviewed empirical, English-language QOL studies were retrieved for six areas of transplantation: kidney, pancreas/combined kidney-pancreas, heart, lung/combined heart-lung, liver, and bone marrow. Studies' findings were analyzed to determine whether the weight of evidence suggested that (a) QOL improved from pre- to posttransplant, (b) transplant recipient QOL was better than that of patient comparison groups, and (c) recipient QOL equaled that of healthy nonpatient samples.

RESULTS

A total of 218 independent studies, evaluating a total of approximately 14,750 patients, were identified. The majority of studies demonstrated statistically significant (P<0.05) pre- to posttransplant improvements in physical functional QOL, mental health/cognitive status, social functioning, and overall QOL perceptions. The majority documented physical functional and global QOL advantages for transplant recipients relative to ill comparison groups. The studies did not indicate that recipient QOL in specific functional areas equaled that of healthy, nonpatient cohorts, although global QOL perceptions were often high.

CONCLUSIONS

Although transplantation may not restore to the patient the "normal" life he/she may once have had, convergent evidence from six areas of transplantation, a variety of study designs, and demographically diverse study cohorts suggests that there are distinct QOL benefits of transplantation. Future work is required to identify background and personal factors that influence the degree of QOL benefits that any individual patient realizes from transplantation.

Quality of life and social production functions: a framework for understanding health effects

Quality of life (QofL) has emerged as a new outcome paradigm. It is now the endpoint in various taxonomies of patient outcomes, in which relationships are modeled amongst biological abnormalities, symptom status, functional status, disability, health perceptions and quality of life. Although current models and taxonomies point at important determinants of QofL, they do not provide a heuristic that guides the conceptualization of QofL and the systematic development of an explanatory theory of how ill health affects QofL. General mechanisms linking ill health, behavior, and QofL are lacking. In this paper we propose social production function (SPF) theory as providing such a heuristic, relating the effects of ill health, the activities that patients engage in to maintain QofL, and QofL itself. This theory basically asserts that people produce their own well-being by trying to optimize achievement of universal human goals via six instrumental goals within the environmental and functional limitations they are facing. Three important notions of SPF theory are: (1) the linkages between goals, needs, and well-being; (2) the distinction between universal needs and instrumental goals; and (3) substitution among instrumental goals, activities and endowments according to cost-benefit considerations, whereby costs refer to scarce resources such as functional capacity, time, effort and money. We will argue that SPF theory meaningfully relates the "biomedical model"-with its focus on pathological processes and biological, physiological and clinical outcomes-to the "quality of life" model, with its focus on functioning and well-being. We describe SPF theory and how SPF theory can be used to: (1) operationally define and measure QofL; (2) clarify persistent measurement problems; and (3) develop an explanatory framework of the effects of disease on QofL. In the discussion section, we address the limitations of the SPF approach of QofL and its relationship with personality.

Outcome after total hip arthroplasty. Comparison of a traditional disease-specific and a quality-of-life measurement of outcome

The purpose of this study was to examine the relationship between the Harris Hip Score (HHS), a traditional method of patient assessment of a total hip arthroplasty (THA), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), a commonly used health-related quality-of-life survey. One hundred forty patients returning for routine clinical follow-up evaluation of a primary THA were asked to fill out the SF-36 quality-of-life survey, as well as questions concerning their perceptions of their THA. The patient's surgeon assessed the THA with the traditional HHS. The correlations between the HHS and the SF-36 domains were highest in the physical component summary scores for male patients of all ages and female patients 65 years of age or older. The correlations were lower for the mental component summary scores of all patients, but particularly in female patients younger than 65. When the SF-36 scores were compared with age and sex-matched population norms, both age and sex were found to be important. Men younger than 65 had scores lower than norms in the physical function domains, but were comparable in the mental health domains. The older men had scores comparable to the norms in all domains. Female patients of all ages, however, had lower scores in the physical function domains. The greatest differences were noted in the female patients younger than 65. The HHS is commonly used to assess disease-specific pain and function in THA patients; however, the results of this study suggest that the SF-36 health survey can capture additional important quality-of-life domains that are influenced by a THA and that these domains are influenced by the age and sex of the patient. The combination of a disease-specific scoring system and a quality-of-life survey would allow a more global assessment of a THA in all patients. Studies evaluating the results of THAs should either assess the results of male and female patients separately when sample size is sufficiently large or use sex as a possible covariate in a multivariate analysis.

Assessment of quality of life with the Nottingham Health Profile among patients with coronary heart disease

The aim was to describe the quality of life of people suffering from coronary artery disease. The patients had been treated with medication (n = 80), percutaneous transluminal coronary angioplasty (n = 100) and coronary artery bypass surgery (n = 100). Of the 280 patients, 189 were men and 91 women. The patients who participated in this study were seriously ill, as nearly half of them had three or more stenosed coronary arteries. Male patients were most numerous in the bypass surgery group and female patients in the angioplasty group. The quality of life was evaluated using the Nottingham Health Profile (NHP) instrument relation to an age- and sex-matched general population, the background factors and the severity of the coronary disease. The NHP questionnaire consists of 38 statements on health problems, making up six dimensions of subjective health: physical mobility, pain, sleep, energy, emotional reactions and social isolation. The health-related quality of life of coronary patients before the invasive procedures was significantly poorer on all the six dimensions than the quality of life in an age- and sex-matched general population. The most obvious differences were seen on the following dimensions: energy, pain, emotional reactions, sleep and physical mobility. The smallest differences occurred in social isolation. Both males and females had the lowest value for energy and social isolation in the youngest age group (35-54 years). The index values of emotional reactions in the two youngest groups were significantly higher among females than males, which reflects poor quality of life. The women in the age group of 35-54 years found the manifestation of a serious disease extremely hard to face. Our findings clearly suggest that while choosing the mode of treatment, the patient's quality of life should be considered along with the clinical severity of the disease, especially in the case of young women. From the societal and social points of view, the patient's symptoms and quality of life are even more important than the objective medical outcome. In clinical decision-making, the goal is to integrate the results of health-related quality of life assessments with clinical decisions, and this underlines the need to evaluate whether the treatment given is congruent with the patient's quality of life. On the basis of the present findings, the NHP instrument seems to be applicable to quality of life measurements among coronary patients. It does not, however, necessarily give an accurate and profound view of an individual's overall quality of life.

Changes in health after elective percutaneous coronary revascularization. A comparison of generic and specific measures

OBJECTIVES

This study determines changes in health-related quality of life after elective percutaneous transluminal coronary angioplasty and compares generic and specific measures.

METHODS

Changes in health-related quality of life were measured in consecutive, symptomatic patients undergoing elective percutaneous coronary revascularization using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Specific Activity Scale (SAS), and the Canadian Cardiovascular Society Classification (CCSC). The patients were interviewed as outpatients before admission and at least 6 months later.

RESULTS

There were significant changes in the following SF-36 measures: physical functioning (postscore minus prescore = 19.1 +/- 24.1), role limitations due to physical-health problems (40.4 +/- 47.2), bodily pain (19.9 +/- 29.3), vitality (12.9 +/- 25.1), social functioning (20.0 +/- 33.1), role limitations due to emotional-health problems (26.7 +/- 49.0), and general mental health (7.1 +/- 21.2). General health perceptions did not change significantly. Internal-consistency reliability coefficients for these measures ranged from 0.73 to 0.91. There also was significant improvement in the CCSC class, but the SAS class did not change significantly. Overall, the SF-36 role-physical scale was the most responsive to changes after elective percutaneous coronary revascularization, followed by the CCSC and the SF-36 physical functioning scale.

CONCLUSIONS

Although this study cannot determine the causal role of elective percutaneous coronary revascularization in these changes, it provides support for the usefulness of these measures in future evaluations of this intervention.

A comparison of quality of life scores in patients with angina pectoris after angioplasty compared with after medical therapy. Outcomes of a randomized clinical trial. Veterans Affairs Study of Angioplasty Compared to Medical Therapy Investigators

BACKGROUND

Evaluations of therapy for the treatment of angina have traditionally consisted of a combination of objective measures, such as exercise tolerance, and subjective markers, such as angina attack rate. Recently, the need to assess "how patients feel"--their quality of life (QOL)--has been regarded with increasing importance. Standard instruments are available to assess QOL and its change after therapeutic intervention. Although QOL instruments have been used to assess the efficacy of percutaneous transluminal coronary angioplasty (PTCA), they have not been used previously to compare the impact of PTCA with that of medical therapy in patients with angina pectoris. We report on the changes in self-assessed QOL among patients randomly assigned to treatment by PTCA or medical therapy and relate these measurements to changes in exercise performance and coronary angiograms.

METHODS AND RESULTS

Patients with stable angina, a positive exercise tolerance test, and at least 70% stenosis (index lesion) in the proximal two thirds of one major coronary artery were randomly assigned to receive PTCA or medical therapy. Six months after randomization, each patient underwent repeat exercise testing and coronary angiography. Before randomization and at the 6-month visit, patients completed a self-administered QOL questionnaire that measured physical functioning and psychological well-being. We compared the changes in QOL with changes between the baseline and 6-month exercise tests, stratified by terciles (decrease in duration, 0- to 2-minute increase, and > 2-minute improvement). We also stratified patients by whether there was more or less than 2 SD change (18.8%) in diameter stenosis of the index lesion (initial minus follow-up angiogram), and we related these to changes in QOL measures. One hundred eighty-two patients with one-vessel disease completed baseline and 6-month questionnaires. At baseline, there were no differences in any QOL measurements between treatment groups. At the 6-month follow-up visit, there was greater improvement in both physical functioning and psychological well-being scores for patients receiving PTCA (+7.36 +/- 15.6, PTCA; +1.98 +/- 14.7, medical therapy; P < .02). Improvement in QOL variables was noted only in patients demonstrating an increase in exercise performance. Also, patients assigned to either treatment whose angiograms demonstrated more than 18.8% improvement in index lesion percent stenosis experienced a significant increase in their QOL scores.

CONCLUSIONS

This was the first study of the relative changes in QOL measures assessed with the use of previously validated and standardized instruments in patients randomly assigned to treatment with PTCA or medical therapy. Patients assigned to PTCA demonstrated a significantly greater improvement in both physical and psychological measures. This improvement was noted in patients whose exercise performance improved and whose angiograms demonstrated an improvement in lesion severity.

Variation in the use of cardiac procedures after acute myocardial infarction

BACKGROUND

There are large geographic differences in the frequency with which coronary angiography and revascularization are performed. We attempted to assess whether differences in case mix or in the treatment of specific groups of patients may explain this variability. We also assessed the consequences of various patterns of treatment.

METHODS

We studied patients covered by Medicare who were 65 to 79 years of age and were admitted to 478 hospitals with acute myocardial infarctions during 1990 in New York (1852 patients), where the rate of use of cardiac procedures is low, and in Texas (1837 patients), where the rate of use of such procedures is high. We compared the patterns of treatment of clinically similar groups of patients in the two states. We also compared mortality rates and measures of the health-related quality of life.

RESULTS

Coronary angiography was performed more often in Texas than in New York (45 percent vs. 30 percent, P < 0.001). The frequency of use in Texas was significantly higher than that in New York for all the clinical subgroups of patients analyzed except those at greatest risk for reinfarction. Over a two-year period, the adjusted likelihood of death was lower in New York than in Texas (hazard ratio, 0.87; 95 percent confidence interval, 0.78 to 0.98). Patients from Texas were 41 percent more likely to report angina (P = 0.002) and 62 percent more likely to say they could not perform activities requiring energy expenditure of 5 or more metabolic equivalents than patients from New York approximately two years after infarction (P < 0.001).

CONCLUSIONS

Physicians in Texas were more likely to perform angiography than physicians in New York for patients whose conditions allowed more discretion in the use of cardiac procedures. On average, there appears to be no advantage with respect to mortality or health-related quality of life to performing the procedures at the higher rate used in Texas.

Health-related quality of life in patients with advanced prostate cancer: a multinational perspective

To explore the value of antiandrogen therapy for advanced prostate cancer, two clinical trials of similar design were recently conducted in six countries throughout Europe. A total of 550 patients with previously untreated metastatic prostate cancer were randomized either to treatment with an antiandrogen or castration. While time to treatment failure, objective tumour response and survival were expected to be similar between study treatments, their effects on health-related quality of life (HRQOL) were expected to differ and were therefore a focus of concern in this trial. To assess these effects, we developed a brief self-administered patient questionnaire covering 10 domains of HRQOL (general health perceptions, pain, emotional well-being, vitality, social functioning, physical capacity, sexual interest, sexual functioning, activity limitation and bed disability), which we translated from English into several other languages. In this paper, we describe the development, content and translation of this survey instrument and report on its reliability and validity in six countries based on data collected for the first 487 patients to complete questionnaires at study entry.

Techniques for outcomes research in chronic sinusitis

Accurate assessment of patient outcome after sinus surgery requires the collection of valid and reliable data. Symptom-based surveys were administered in a prospective manner to 104 patients with chronic sinusitis. Test-retest reliability for the Chronic Sinusitis Survey based on duration of symptoms (0.86, P < .0001) was superior to that for a similar survey based on severity of symptoms (0.57, P < .0001). Results of the Chronic Sinusitis Survey also correlated significantly with subscales of a general health assessment in the extent to which chronic sinusitis limits physical activity (0.40, P < .01), interferes with work or other activities (0.36, P < .01), and affects patient perception of bodily pain (0.46, P < .001). The Chronic Sinusitis Survey is an efficient and reliable method to follow health status and health-related quality of life outcomes in patients with chronic sinusitis.

A self-administered quality-of-life questionnaire after acute myocardial infarction

A slightly modified version of the Quality-of-Life after Myocardial Infarction (QLMI) questionnaire developed by Oldridge and colleagues was applied in a self-administered mode to patients with suspected acute myocardial infarction (AMI) in a randomized controlled trial of secondary prevention. Acceptability of the questionnaire was good, with 93% of responders answering all items. Factor analysis suggested three quality-of-life (QL) dimensions which we called "emotional", "physical" and "social". These differed somewhat from the dimensions proposed by Oldridge and colleagues. However, a sensitivity analysis showed relative invariance of results to weighting schemes. Scores on our three dimensions were responsive to differences between the treatment groups, and demonstrated construct validity based on associations between the measured QL and variables expected to affect QL. We conclude that the QLMI questionnaire has good potential as an instrument for assessing QL in post-AMI patients and that it can be successfully self-administered.

Functional health and well-being in patients with severe atherosclerotic peripheral vascular occlusive disease

Functional health and sense of well-being are known to be adversely affected by chronic illness. The extent to which peripheral vascular occlusive disease (PVOD) alters these factors independent of other comorbid conditions is unknown. Sixty patients with PVOD severe enough to have required aortobifemoral bypass (AFB) between 1985 and 1990 were selected for evaluation. Although all were heavy smokers and 20% had suffered previous myocardial infarction, all had adequate cardiopulmonary function to survive AFB. The SF-20 questionnaire, validated in the Medical Outcomes Study (MOS), was used to evaluate patients' functional health and well-being at least 6 months after AFB. All grafts were patent at the time of questionnaire completion. Three measures of functional health (physical function, role function, and bodily pain) and three measures of well-being (mental health, health perception, and social function) were scored from SF-20 responses using the MOS protocol. These PVOD patients were then compared to MOS norms for patients without any chronic disease, to MOS norms adjusted for age and other comorbidities of the PVOD patients sampled, and to patients with congestive heart failure or recent myocardial infarction. Physical function, role function, and health perception were worse and bodily pain greater in patients with severe PVOD after surgical treatment as compared with MOS patients even after adjustment for comorbidities. Decrements in physical function, role function, and health perception for PVOD patients were comparable to MOS patients with congestive heart failure or recent myocardial infarction, whereas level of bodily pain was worse in PVOD patients than in these other groups. After adjustment for comorbidities, social function and mental health were not independently affected by PVOD. Functional health and well-being were not significantly different when PVOD patients with limb threat were compared to those with claudication. Severe PVOD is associated with decrements in functional health and well-being comparable to or greater than other severe chronic illness, even after successful revascularization. Further study is needed to examine the effect of revascularization on functional health.