Changes in Health-Related Quality of Life in Off-Pump Versus On-Pump Cardiac Surgery: Veterans Affairs Randomized On/Off Bypass Trial

Health-related quality of life impacts upon 5-year survival after coronary artery bypass surgery

BACKGROUND

Poor preoperative health-related quality of life (HRQoL) has been associated with reduced short-term survival after coronary artery bypass graft (CABG) surgery; however, its impact on long-term mortality is unknown. This study's objective was to determine if baseline HRQoL status predicts 5-year post-CABG mortality.

METHODS

This prespecified, randomized on/off bypass follow-up study (ROOBY-FS) subanalysis compared baseline patient characteristics and HRQoL scores, obtained from the Seattle Angina Questionnaire (SAQ) and Veterans RAND Short Form-36 (VR-36), between 5-year post-CABG survivors and nonsurvivors. Standardized subscores were calculated for each questionnaire. Multivariable logistic regression assessed whether HRQoL survey subcomponents independently predicted 5-year mortality (p ≤ .05).

RESULTS

Of the 2203 ROOBY-FS enrollees, 2104 (95.5%) completed baseline surveys. Significant differences between 5-year post-CABG deaths (n = 286) and survivors (n = 1818) included age, history of chronic obstructive pulmonary disease, stroke, peripheral vascular disease, renal dysfunction, diabetes, lower left ventricular ejection fraction, atrial fibrillation, depression, non-White race/ethnicity, lower education status, and off-pump CABG. Adjusting for these factors, baseline VR-36 physical component summary score (p = .01), VR-36 mental component summary score (p < .001), and SAQ physical limitation score (p = .003) were all associated with 5-year all-cause mortality.

CONCLUSIONS

Pre-CABG HRQoL scores may provide clinically relevant prognostic information beyond traditional risk models and prove useful for patient-provider shared decision-making and enhancing pre-CABG informed consent.

Does the technique used in coronary artery bypass graft surgery affect patients' anxiety, depression, mental and physical health? First 3-month outcomes

PURPOSE

This study was aimed at investigating the effect of coronary artery bypass graft surgery conducted with different techniques on patients' anxiety, depression, mental and physical health.

DESIGN AND METHODS

This cross-sectional study included 60 patients who completed the Beck Anxiety Inventory, the Beck Depression Inventory, and the 36-Item Short-Form Health Survey.

FINDINGS

Anxiety, depression, and mental health showed significant differences in different time measurements, and combined effects of surgical technique and time factor.

PRACTICE IMPLICATIONS

Preoperative routine evaluations can speed up recovery, reduce cost, and improve quality of life by preventing the possible negative effects of anxiety and depression.

Effect of coronary artery bypass grafting on quality of life: a meta-analysis of randomized trials

AIMS

We conducted a systematic review and meta-analysis to evaluate temporal trends in quality of life (QoL) after coronary artery bypass grafting (CABG) surgery in randomized clinical trials, and a quantitative comparison from before surgery to up to 5 years after surgery.

METHODS AND RESULTS

We searched MEDLINE, CINAHL, EMBASE, Cochrane Library, and PsycINFO from 2010 to 2020 to identify studies that included the measurement of QoL in patients undergoing CABG. The primary outcome was the Seattle Angina Questionnaire (SAQ), and secondary outcomes were the 36-item Short Form Health Survey (SF-36) and EuroQol Questionnaire (EQ-5D). We pooled the means and the weighted mean differences over the follow-up period. In the meta-analysis, 2586 studies were screened and 18 full-text studies were included. There was a significant trend towards higher QoL scores from before surgery to 1 year post-operatively for the SAQ angina frequency (AF), SAQ QoL, SF-36 physical component (PC), and EQ-5D, whereas the SF-36 mental component (MC) did not improve significantly. The weighted mean differences from before surgery to 1 year after was 24 [95% confidence interval (CI): 21.6-26.4] for the SAQ AF, 31 (95% CI: 27.5-34.6) for the SAQ QoL, 9.8 (95% CI: 7.1-12.8) for the SF-36 PC, 7.1 (95% CI: 4.2-10.0) for the SF-36 MC, and 0.1 (95% CI: 0.06-0.14) for the EQ-5D. There was no evidence of publication bias or small-study effect.

CONCLUSION

CABG had both short- and long-term improvements in disease-specific QoL and generic QoL, with the largest improvement in angina frequency.

Patient-Reported Outcomes in Cardiothoracic Surgery

BACKGROUND

Current studies in cardiothoracic clinical research frequently fail to use end points that are most meaningful to patients, including measures associated with quality of life. Patient-reported outcomes (PROs) represent an underused but important component of high-quality patient-centered care. Our objective was to highlight important principles of PRO measurement, describe current use in cardiothoracic operations, and discuss the potential for and challenges associated with integration of PROs into large clinical databases.

METHODS

We performed a literature review by using the PubMed/EMBASE databases. Clinical articles that focused on the use of PROs in cardiothoracic surgical outcomes measurement or clinical research were included in this review.

RESULTS

PROs measure the outcomes that matter most to patients and facilitate the delivery of patient-centered care. When effectively used, PRO measures have provided detailed and nuanced quality-of-life data for comparative effectiveness research. However, further steps are needed to better integrate PROs into routine clinical care.

CONCLUSIONS

Incorporation of PROs into routine clinical practice is essential for delivering high-quality patient-centered care. Future integration of PROs into prospectively collected registries and databases, including that The Society of Thoracic Surgeons National Database, has the potential to enrich comparative effectiveness research in cardiothoracic surgery.

Feasibility of Distinguishing Performance Among Provider Groups Using Patient-reported Outcome Measures in Older Adults With Multiple Chronic Conditions

OBJECTIVE

To examine minimum sample sizes and follow-up times required for patient-reported outcome-based performance measures (PMs) to achieve acceptable reliability as PMs.

PARTICIPANTS

We used 2 groups of patients age 65+ with at least 2 of 13 chronic conditions. The first was a sample of Medicare Advantage beneficiaries, who reported health-related quality of life (HRQoL) at baseline and 2 years. The second was a sample of primary care patients, who reported HRQoL at baseline and 6 months.

MEASURES

Medicare Advantage beneficiaries completed the Veterans RAND 12-Item Short Form (VR-12), while the primary care sample completed the Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure (PROMIS-29). We constructed binary candidate PMs indicating stable or improved physical or mental HRQoL at follow-up, and continuous PMs measuring mean change over time.

RESULTS

In the Medicare Advantage sample, with a sample size per entity profiled of 160, the most promising PM achieved a reliability of 0.32 as a PM. A sample size of 882 per entity would have been needed for this PM to achieve an acceptable reliability of 0.7. In the prospective sample, with a sample size of 27 per clinic, the most promising PM achieved a reliability of 0.16 as a PM. A sample size of 341 patients (at the clinic level) would have been needed for this PM to achieve a reliability of 0.7.

CONCLUSIONS

Achieving acceptable reliability for these PMs and conditions would have required minimum sample sizes of 341 at the clinic level or 880 at the health plan level. These estimates can guide the design of future patient-reported outcome-based PMs.

Evaluating the PROMIS-29 v2.0 for use among older adults with multiple chronic conditions

PURPOSE

The Patient-Reported Outcomes Measurement Information System 29-item profile (PROMIS-29 v2.0), which measures health-related quality of life (HRQoL), has had limited evaluation among older adults (age 65+) with multiple chronic conditions. Our purpose was to establish convergent validity for PROMIS-29 in this population.

METHODS

We collected the PROMIS-29 v2.0 and the Veterans RAND 36 (VR-36) for 1359 primary care patients aged 65 + with at least 2 of 13 chronic conditions, oversampling those aged 80+. We conducted multiple analyses to examine score differences across subgroups, differential item functioning (DIF), and comparisons of PROMIS-29 v2.0 and VR-36 scores.

RESULTS

The mean age was 80.7, and all patients had at least 2 of 13 chronic conditions. Older age, female sex, Hispanic ethnicity, and more chronic conditions were associated with worse physical health scores (PHS) and mental health scores (MHS) on the PROMIS-29 v2.0-findings which are in the expected direction. None of the 700 pairs of items met criteria for DIF. PHS and MHS were highly intercorrelated (r = 0.74, p < 0.001 for this and all other findings). PHS was more highly correlated with the VR-36 Physical Component Score (PCS) than the Mental Component Score (MCS) (r = 0.85 and 0.32, respectively), while MHS was highly correlated with both (r = 0.70 and 0.64, respectively).

CONCLUSIONS

PROMIS-29 v2.0 demonstrates expected bivariate relationships with key person-level characteristics and does not show DIF. PROMIS-29 v2.0 scores are highly correlated with VR-36 scores. These results provide support for the validity of PROMIS-29 v2.0 as a measure of HRQoL among older adults with multiple chronic conditions.

Preoperative factors associated with worsening in health-related quality of life following coronary artery bypass grafting in the Randomized On/Off Bypass (ROOBY) trial

For advanced coronary disease, coronary artery bypass graft (CABG) surgery generally improves patients' symptoms and long-term survival. Unfortunately, some patients experience worse health-related quality of life (HRQL) after CABG. The objective of this study is to report the frequency and risk factors associated with 1-year post-CABG HRQL deterioration.

METHODS

From 2002 to 2007, 2203 "Randomized On/Off Bypass" (ROOBY) trial patients randomly received either off-pump or on-pump CABG at 18 VA medical centers. Subjects completed both baseline and 1-year Seattle Angina Questionnaire (SAQ) and the Veterans Rand 36 (VR-36) questionnaires to assess HRQL. Using previously published criteria, the rates of clinically significant changes were determined for the SAQ [angina frequency (AF), physical limitation (PL), and quality of life (QoL)] and VR36 [mental component score (MCS) and physical component score (PCS)] subscales. Multivariate regression models were then used to identify pre-CABG patient characteristics associated with worsened 1-year HRQL status for each subscale.

RESULTS

Over 80% of patients had an improvement or no change in SAQ and VR-36 subscale scores 1 year after CABG. The HRQL scale-specific deterioration rates were 4.5% SAQ-AF, 16.8% SAQ-PL, 4.9% SAQ-QoL, 19.4% VR36-MCS, and 13.5% VR36-PCS. Predictors of 1-year HRQL deterioration were diabetes and smoking for the SAQ-AF; diabetes, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD) for SAQ-PL; COPD and depression for the SAQ-QoL; diabetes for VR36-PCS, and history of stroke and depression for VR36-MCS. The baseline score was an independent predictor for worsening in all the subscales studied.

CONCLUSIONS

Among VA patients, less than 20% experienced worse HRQL 1 year after CABG. For patients with low symptom burden at baseline, diabetes, smoking, depression, PVD, COPD, and a prior stroke, clinicians should be more cautious in pre-CABG counseling as to their anticipated HRQL improvements.

Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass

BACKGROUND

Coronary-artery bypass grafting (CABG) surgery may be performed either with cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump). We report the 5-year clinical outcomes in patients who had been included in the Veterans Affairs trial of on-pump versus off-pump CABG.

METHODS

From February 2002 through June 2007, we randomly assigned 2203 patients at 18 medical centers to undergo either on-pump or off-pump CABG, with 1-year assessments completed by May 2008. The two primary 5-year outcomes were death from any cause and a composite outcome of major adverse cardiovascular events, defined as death from any cause, repeat revascularization (CABG or percutaneous coronary intervention), or nonfatal myocardial infarction. Secondary 5-year outcomes included death from cardiac causes, repeat revascularization, and nonfatal myocardial infarction. Primary outcomes were assessed at a P value of 0.05 or less, and secondary outcomes at a P value of 0.01 or less.

RESULTS

The rate of death at 5 years was 15.2% in the off-pump group versus 11.9% in the on-pump group (relative risk, 1.28; 95% confidence interval [CI], 1.03 to 1.58; P=0.02). The rate of major adverse cardiovascular events at 5 years was 31.0% in the off-pump group versus 27.1% in the on-pump group (relative risk, 1.14; 95% CI, 1.00 to 1.30; P=0.046). For the 5-year secondary outcomes, no significant differences were observed: for nonfatal myocardial infarction, the rate was 12.1% in the off-pump group and 9.6% in the on-pump group (P=0.05); for death from cardiac causes, the rate was 6.3% and 5.3%, respectively (P=0.29); for repeat revascularization, the rate was 13.1% and 11.9%, respectively (P=0.39); and for repeat CABG, the rate was 1.4% and 0.5%, respectively (P=0.02).

CONCLUSIONS

In this randomized trial, off-pump CABG led to lower rates of 5-year survival and event-free survival than on-pump CABG. (Funded by the Department of Veterans Affairs Office of Research and Development Cooperative Studies Program and others; ROOBY-FS ClinicalTrials.gov number, NCT01924442 .).

Postoperative atrial fibrillation impacts on costs and one-year clinical outcomes: the Veterans Affairs Randomized On/Off Bypass Trial

BACKGROUND

New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass graft surgery (CABG) is associated with worse in-hospital morbidity and mortality, extended hospital stays, and higher costs. Beyond the initial hospital discharge, the cost and outcomes of POAF have not been well studied.

METHODS

For CABG patients with and without new-onset POAF, a retrospective propensity-matched, multivariable regression analysis was performed to compare 1-year outcomes (including health-related quality of life [HRQoL] scores and mortality rates) and costs (standardized to 2010 dollars). Regression models controlled for site and patient factors, with propensity matching used to adjust for differences in POAF versus no-POAF patients' risk profiles.

RESULTS

Using the existing CABG trial database, 2,096 patient records were analyzed, including POAF patients (n = 549) versus no-POAF patients (n = 1,547). For the index CABG hospitalization, POAF patients had longer postoperative length of stay (+3.9 days) and higher discharge costs (+$13,993) than no-POAF patients. At 1 year, POAF patients had more than twice the adjusted odds of dying (p < 0.01), with higher 1-year total cumulative costs. This 1-year cost difference (+$15,593) was largely attributable to hospital-based costs during the index surgery hospitalization. There was no difference in 1-year HRQoL scores (or HRQoL score changes) between POAF patients and no-POAF patients.

CONCLUSIONS

Compared with no-POAF patients, POAF patients had higher discharge and 1-year costs along with higher 1-year mortality rates, but no differences were observed in 1-year HRQoL scores. Additional research appears warranted to improve the longer-term survival rates for POAF CABG patients, targeting future POAF-specific postdischarge interventions.

Coronary artery bypass grafting: Part 1--the evolution over the first 50 years

Surgical treatment for angina pectoris was first proposed in 1899. Decades of experimental surgery for coronary artery disease finally led to the introduction of coronary artery bypass grafting (CABG) in 1964. Now that we are approaching 50 years of CABG experience, it is appropriate to summarize the advancement of CABG into a procedure that is safe and efficient. This review provides a historical recapitulation of experimental surgery, the evolution of the surgical techniques and the utilization of CABG. Furthermore, data on contemporary clinical outcomes are discussed.