Measuring quality of life in patients with myocardial infarction or stroke: a feasibility study of four questionnaires in The Netherlands

Beyond MACE: a multidimensional approach to outcomes in clinical trials for older adults with stable ischemic heart disease

The global population of older adults is expanding rapidly resulting in a shift towards managing multiple chronic diseases that coexist and may be exacerbated by cardiovascular illness. Stable ischemic heart disease (SIHD) is a predominant contributor to morbidity and mortality in the older adult population. Although results from clinical trials demonstrate that chronological age is a predictor of poor health outcomes, the current management approach remains suboptimal due to insufficient representation of older adults in randomized trials and the inadequate consideration for the interaction between biological aging, concurrent geriatric syndromes, and patient preferences. A shift towards a more patient-centered approach is necessary for appropriately and effectively managing SIHD in the older adult population. In this review, we aim to demonstrate the distinctive needs of older adults who prioritize holistic health outcomes like functional capacity, cognitive abilities, mental health, and quality of life alongside the prevention of major adverse cardiovascular outcomes reported in cardiovascular clinical trials. An individualized, patient-centered approach that involves shared decision-making regarding outcome prioritization is needed when any treatment strategy is being considered. By prioritizing patients and addressing their unique needs for successful aging, we can provide more effective care to a patient population that exhibits the highest cardiovascular risks.

Evaluating the GAD-2 to screen for post-stroke anxiety on an acute stroke unit

Post stroke anxiety is associated with reduced quality of life, worse rehabilitation outcomes and poor social functioning in stroke survivors. Despite its clinical relevance, there are a lack of screening tools to identify post-stroke anxiety. The Hospital Anxiety and Depression Scale (HADS-A) and Geriatric Anxiety Inventory (GAI) are the only self-report screening test for anxiety validated in stroke patients. However, both of these measures have limitations associated with their clinical utility, length of time to administer and cost to purchase. This study aimed to assess the classiciation accuracy of a freely available and shorter alternative, the Generalized Anxiety Disorder 2-item (GAD-2) for use in the acute stroke setting. This study used retrospective analysis of a sequential sample in a clinical database of mood and cognitive scores. Patients' scores on the GAD-2 and HADS-A were compared. The GAD-2 demonstrated strong convergent validity with the HADS-A and good specificity and sensitivity for clinical anxiety. In conclusion, the GAD-2 may be a useful screening assessment of post-stroke anxiety in the acute setting; however, it should be used with due consideration of the methodological limitations of this study.

The Potential Role of Thermography in Determining the Efficacy of Stroke Rehabilitation

INTRODUCTION

Maintaining good physiological circulation in the extremities requires an optimally functioning muscle pump. Stroke symptoms indicate a change in venous circulation. In this study, changes were measured in joint function and microcirculation, and the correlation between them was examined.

SETTING

Physiotherapy Center, Ss. Cosmas and Damian Rehabilitation Institute, Visegrád, Hungary.

METHODOLOGY

Sixteen randomly selected poststroke patients with hemiparesis affecting mainly the upper extremities began undergoing rehabilitation 13 ± 4 days following stroke. Thermograms were taken with a Fluke Ti 20 (Fluke Corporation, WA) pretreatment and post-treatment, and a physiotherapy documentation form was completed. Treatment comprised 15 physiotherapy, massage, and galvanic therapy sessions per patient, with the side exhibiting no neurological symptoms as a control.

RESULTS

Joint function showed significant improvement on the affected side (P < .05). Thermographic examinations revealed microcirculatory dysfunction in the affected extremities in 100% of the cases. Following treatment, temperature increased significantly (P ≥ .5°C) on the affected side. A strong correlation (r) was observed between joint function and temperature change (P < .05).

CONCLUSION

Thermography is shown to be a reliable method for monitoring the effects of stroke rehabilitation treatment. Thermographic testing may enable us to predict the course of the trauma and the efficacy of treatment even at the acute stage.

Being the Next of Kin of an Adult Person With Muscular Dystrophy

A chronic disorder affects all members of the family in various ways. The aim of this study is to elucidate the next of kin's ( N= 36) experiences when an adult family member has muscular dystrophy. The relationships were partner (36%, n= 14), parent (18%, n= 7), child (21%, n= 8), sibling (15%, n= 6), and other relative (3%, n= 1). Latent content analysis is employed and involves an interpretation of the interviewtext. The results showthe meaning of being close to a person with muscular dystrophy through the themes that emerged: exposure of the family; the span between obligation and love; being vigilant, protective, and supportive; and striving for an ordinary life. This study reveals a need for healthcare staff to understand the next of kin's narrated meaning of changes when a family member has a progressive disease.

The Assessment of Poststroke Depression

Poststroke depression (PSD) is a common clinical consequence of stroke. PSD is associated with poor functional and social outcomes, reduced quality of life, the presence of cognitive impairment, and increased mortality. Despite the potential benefit associated with the identification and treatment of PSD, it often remains unrecognized and undertreated. The present study provides a critical review and synthesis of measurement properties for 10 instruments used in the assessment of depression following stroke. Assessment considerations specific to PSD are addressed, and tools are reviewed within the context of stroke. To facilitate the timely detection, diagnosis, and initiation of treatment for PSD, a two-step assessment process is recommended, thereby taking strategic advantage of the strengths and limitations associated with self-report and observer-rating assessment tools.

Quality-of-Life measures for cardiac surgery practice and research: a review and primer

Declining mortality and major morbidity rates after cardiac surgery have led to increasing focus on patient quality of life (QOL). Beyond longevity, the impact of cardiac surgery on day-to-day functioning is incredibly salient to patients, their spouses, and families. As such, QOL measures are a welcome and sometimes necessary addition to clinical trials. However, how does one navigate the expansive market of QOL questionnaires, which QOL measures are applicable to cardiac surgery units, and how can they be used meaningfully in clinical practice? Because nearly two decades have passed since QOL measures were reviewed for relevance to cardiac surgery settings, an overview is provided of various generic (Short Form Health Survey [SF-36], Sickness Impact Profile, Nottingham Health Profile) and disease-specific QOL measures (Duke Activity Status Index, Seattle Angina Questionnaire, MN Living with Heart Failure Questionnaire; Heart-QOL) with examples from cardiac surgery studies. Recommendations are provided for the application of QOL measures to clinical trials and the impact on clinical decision-making is discussed. The paucity of methodologically sound QOL studies highlights the necessity for further rigorous empirical data to better inform treatment efficacy studies and clinical decision-making.

Development and validation of participation and positive psychologic function measures for stroke survivors

OBJECTIVE

To evaluate the reliability and validity of Neurologic Quality of Life (NeuroQOL) item banks that assess quality-of-life (QOL) domains not typically included in poststroke measures.

DESIGN

Secondary analysis of item responses to selected NeuroQOL domains.

SETTING

Community.

PARTICIPANTS

Community-dwelling stroke survivors (n=111) who were at least 12 months poststroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Five measures developed for 3 NeuroQoL domains: ability to participate in social activities, satisfaction with participation in social activities, and positive psychologic function.

RESULTS

A single bank was developed for the positive psychologic function domain, but 2 banks each were developed for the ability-to-participate and satisfaction-with-participation domains. The resulting item banks showed good psychometric properties and external construct validity with correlations with the legacy instruments, ranging from .53 to .71. Using these measures, stroke survivors in this sample reported an overall high level of QOL.

CONCLUSIONS

The NeuroQoL-derived measures are promising and valid methods for assessing aspects of QOL not typically measured in this population.

Temporal trends in patient-reported angina at 1 year after percutaneous coronary revascularization in the stent era: a report from the National Heart, Lung, and Blood Institute-sponsored 1997-2006 dynamic registry

BACKGROUND

Percutaneous coronary intervention (PCI) has witnessed rapid technological advancements, resulting in improved safety and effectiveness over time. Little, however, is known about the temporal impact on patient-reported symptoms and quality of life after PCI.

METHODS AND RESULTS

Temporal trends in post-PCI symptoms were analyzed using 8879 consecutive patients enrolled in the National Heart, Lung, and Blood Institute-sponsored Dynamic Registry (wave 1: 1997 [bare metal stents], wave 2: 1999 [uniform use of stents], wave 3: 2001 [brachytherapy], wave 4, 5: 2004, 2006 [drug eluting stents]). Patients undergoing PCI in the recent waves were older and more often reported comorbidities. However, fewer patients across the waves reported post-PCI angina at one year (wave 1 to 5: 24%, 23%, 18%, 20%, 20%; P(trend)<0.001). The lower risk of angina in recent waves was explained by patient characteristics including use of antianginal medications at discharge (relative risk [95% CI] for waves 2, 3, 4 versus 1: 1.0 [0.9 to 1.2], 0.9 [0.7 to 1.1], 1.0 [0.8 to 1.3], 0.9 [0.7 to 1.1]). Similar trend was seen in the average quality of life scores over time (adjusted mean score for waves 1 to 5: 6.2, 6.5, 6.6 and 6.6; P(trend)=0.01). Other factors associated with angina at 1 year included younger age, female gender, prior revascularization, need for repeat PCI, and hospitalization for myocardial infarction over 1 year.

CONCLUSIONS

Favorable temporal trends are seen in patient-reported symptoms after PCI in routine clinical practice. Specific subgroups, however, remain at risk for symptoms at 1 year and thus warrant closer attention.

Outcomes of Perioperative β-Blockade in Patients Undergoing Noncardiac Surgery: A Meta-Analysis

Background:

Several studies have evaluated the impact on myocardial infarction (MI), stroke, and overall mortality of perioperative β-blocker use in patients undergoing noncardiac surgery (NCS). However, most studies did not have adequate sample size and statistical power and were therefore underpowered to adequately evaluate these end points.

Objective:

To conduct a meta-analysis to determine the balance of benefits and harms associated with perioperative β-blocker use in NCS.

Methods:

A systematic literature search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted from January 1960 through February 2009. Manual reference search was performed to identify additional relevant trials. Randomized, double-blinded, placebo-controlled trials comparing the use of β-blockars with placebo; using β-blockers perioperatively in β-blocker–naïve patients undergoing NCS; and evaluating endpoints of Ml, stroke, or all-cause mortality were included.

Results:

Six trials (N = 10,183) met our inclusion criteria. Perioperative β-blocker use was associated with a significant reduction in patients' odds of developing Ml (OR 0.74, 95% CI 0.61 to 0.89) but a significant increase in odds of developing stroke (OR 1.98, 95% CI 1.23 to 3.20) and also a nonsignificant increase in mortality (OR 1.21, 95% CI 0.98 to 1.49) versus placebo. Control-rate meta-regression determined that patients with highest baseline odds of stroke had decreased relative odds of having a stroke with a β-blocker versus placebo (β coefficient –0.97; 95% credible interval –1.04 to –0.90).

Conclusions:

When perioperative β-blockers are used in NCS patients, there is a trade-off between reduction in MI and increase in stroke, with a troubling trend toward an increase in mortality. Patients with lower baseline odds of developing stroke appear to be at greater risk of β-blockgr–induced stroke.

Content comparison of health-related quality of life measures used in stroke based on the international classification of functioning, disability and health (ICF): a systematic review

OBJECTIVE

To examine and compare the contents of health-related quality of life (HRQoL) measures used in stroke, based on the ICF as the frame of reference.

DESIGN

We conducted a systematic literature review to select current generic and condition-specific HRQoL measures applied in stroke. We examined the contents of the selected measures by linking the concepts within the instruments' items to the ICF.

RESULTS

The systematic literature review resulted in the selection of six generic and seven stroke-specific HRQoL measures. Within the selected instruments we identified 979 concepts. To map these concepts, we used 200 different ICF categories. None of the ICF categories is contained in all of the instruments. The most frequently used category is 'b152 Emotional functions' contained in 53 items from 10 instruments. Stroke-specific measures more often address 'Mental functions', while the selected generic instruments more often include Environmental Factors.

DISCUSSION

The present study provides an overview on current HRQoL measures in stroke with respect to their covered contents and provides valuable information to facilitate the selection of appropriate instruments for specific purposes in clinical as well as research settings.

Feelings of being disabled as a risk factor for mortality up to 8 years after acute myocardial infarction

OBJECTIVE

We examined the independent prognostic value of the four subscales of the Heart Patients Psychological Questionnaire (HPPQ) on mortality in acute myocardial infarction (AMI) survivors up to 8 years after the event.

METHODS

The HPPQ, which measures well-being, feelings of being disabled, despondency and social inhibition, was administered to 567 AMI patients during hospitalisation and at 3 months follow-up. The patients were followed for 8 years.

RESULTS

During follow-up, 157 patients (28%) died. Forty-one percent of the patients had a score indicating at least mild to moderate feelings of being disabled. Patients with feelings of being disabled were at increased risk of mortality compared with those having a low score, adjusted for other cardiac risk factors [hazard ratio (HR)=1.8, 95% confidence interval (CI)=1.3-2.5]. There was no interaction between feelings of being disabled and gender. None of the other HPPQ subscales were related to mortality or recurrent myocardial infarction (MI). When the study population was stratified by low and high clinical risk (43% vs. 57%, respectively), feelings of being disabled was the most prominent predictor of mortality in the low-risk group (HR=3.5, 95% CI=1.4-8.8).

CONCLUSION

Feelings of being disabled measured at baseline and at 3 months was the most prominent predictor of mortality in low-risk patients 8 years post-MI. This finding adds to the existing knowledge that psychosocial variables influence morbidity and mortality in cardiac patients.

Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke

OBJECTIVES

To determine the effect of two different community-based group exercise programs on functional balance, mobility, postural reflexes, and falls in older adults with chronic stroke.

DESIGN

A randomized, clinical trial.

SETTING

Community center.

PARTICIPANTS

Sixty-one community-dwelling older adults with chronic stroke.

INTERVENTION

Participants were randomly assigned to an agility (n=30) or stretching/weight-shifting (n=31) exercise group. Both groups exercised three times a week for 10 weeks.

MEASUREMENTS

Participants were assessed before, immediately after, and 1 month after the intervention for Berg Balance, Timed Up and Go, step reaction time, Activities-specific Balance Confidence, and Nottingham Health Profile. Testing of standing postural reflexes and induced falls evoked by a translating platform was also performed. In addition, falls in the community were tracked for 1 year from the start of the interventions.

RESULTS

Although exercise led to improvements in all clinical outcome measures for both groups, the agility group demonstrated greater improvement in step reaction time and paretic rectus femoris postural reflex onset latency than the stretching/weight-shifting group. In addition, the agility group experienced fewer induced falls on the platform.

CONCLUSION

Group exercise programs that include agility or stretching/weight shifting exercises improve postural reflexes, functional balance, and mobility and may lead to a reduction of falls in older adults with stroke.

A comparison of 4 questionnaires to measure fatigue in postpoliomyelitis syndrome

OBJECTIVE

To assess the comparability and reproducibility of 4 questionnaires used to measure fatigue in postpoliomyelitis syndrome (PPS).

DESIGN

Repeated-measures at a 3-week interval.

SETTING

University hospital.

PARTICIPANTS

Convenience sample of 65 patients with PPS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Fatigue Severity Scale (FSS), the Nottingham Health Profile (NHP) energy category, the Polio Problem List (PPL) fatigue item, and the Dutch Short Fatigue Questionnaire (SFQ).

RESULTS

Correlations of scores between questionnaires were all significant (P<.01) and ranged from.43 (between the NHP energy category and the PPL fatigue item) to.68 (between the PPL fatigue item and the SFQ). Scores on the second visit, normalized to a 0 to 100 scale, were: FSS, 78+/-15; NHP energy category, 47+/-35; PPL fatigue item, 81+/-17; and SFQ, 65+/-22. Except for the difference between the FSS and the PPL fatigue item, the differences in scores between the questionnaires were significant (P<.01). Scale analysis indicated that all questionnaires measured the same unidimensional construct. The reproducibility of the FSS, the PPL fatigue item, and the SFQ was moderate. The smallest detectable change was 1.5 points for the FSS, 2.0 points for the PPL fatigue item, and 1.9 points for the SFQ.

CONCLUSIONS

Although the questionnaires measure the same fatigue construct in PPS, the results are not interchangeable because the ranges of measurement differ. The NHP energy category, in particular, appeared to have a high detection threshold. The moderate reproducibility of the questionnaires indicates a lack of precision, especially when applied at the individual patient level.

Two Short Instruments Measuring Quality of Life in Survivors of a Myocardial Infarction

Summary: The aim of this study was to validate the use of short, generic, quality-of-life (QoL) questionnaires in a population of myocardial infarction survivors. The feasibility, reliability, and validity of two short questionnaires (the MOS-24 and the COOP/WONCA charts) were evaluated and compared with a long questionnaire (the Sickness Impact Profile). The study population consisted of 99 myocardial infarction survivors some years after the event and 101 referents without a history of heart or brain infarction. The feasibility of the short questionnaires was good. Both instruments covered the most important domains of QoL, similar to the Sickness Impact Profile. In addition, the two short questionnaires measured “pain” and the MOS-24 also covered “vitality.” The MOS-24 had a smaller floor effect than the COOP/WONCA charts. The MOS-24 was shown to be a reliable test. Both short instruments were able to detect between-group differences (especially MOS-24) although at different rates. Convergent validity of the MOS-24 was high compared with the COOP/WONCA charts. In contrast, the discriminant validity of the COOP/WONCA charts was better. The discriminant validity of the MOS-24 was, nevertheless, reasonable. In conclusion, both instruments are suitable for measuring the QoL of myocardial infarction survivors. The multi-item MOS-24 questionnaire however, is slightly preferable.

Quality of life in patients with coronary heart disease-I: assessment tools

Health-related quality of life (HRQL) assessment is an important measure of the impact of the disease, effect of treatment and other variables affecting people's lives. The review focused on the assessment of HRQL in patient with coronary heart disease (CHD) by appropriate tools. Although no consensus exists about the precise definition of HRQL, a plethora of instruments have been developed to assess it. Two broad types – generic and disease-specific – have been developed but there is some debate about their relative merits. There is a wide selection of instruments available but choice should be based on a careful consideration of an instrument's psychometric properties, the breadth and depth with which it addresses relevant health domains and the specific clinical or research purpose for which it is intended.

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care

BACKGROUND

Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates.

AIMS

To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months.

METHOD

The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial.

RESULTS

One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024).

CONCLUSION

Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.

Evaluation of the hospital anxiety and depression scale in patients with Parkinson's disease

The purpose of this study was to evaluate the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in patients with Parkinson's disease (PD) and to assess the prevalence of symptoms of anxiety and depression in this population. The HADS was sent to 205 patients with PD, together with three quality-of-life (QoL) instruments, i.e. the Parkinson's Disease Questionnaire (PDQ-39), the EQ-5D, and a visual analogue scale (VAS). Hospital Anxiety and Depression Scale scores were also compared with Hoehn-Yahr (H&Y) scores. Eighty-six percent of the patients returned the questionnaires. The quality of the data was good. Cronbach alpha for the HADS was 0.88. Test-retest reliability over 2 weeks was 0.84 for the sum score of the HADS (intraclass correlation coefficient) and ranged from 0.42-0.76 for individual items (weighted kappa). Factor analysis revealed two factors, accounting for 51.9% of the variance. One factor represented anxiety, the other depression. Correlations with PDQ-39, EQ-5D, VAS, and H&Y were 0.72, -0.59, -0.59, and 0.32, respectively (p values < 0.001). Depression scores accounted for 52% of the variance in QoL, whereas disease severity explained 24%. Using the cut-off values proposed by the developers indicated that possible and probable anxiety were present in 29.4% and 19.8% of the patients, respectively. Percentages for possible and probable depression were 21.5 and 16.9. The psychometric performance of the HADS in patients with PD is satisfactory. In addition, almost 50% of the patients displayed symptoms of anxiety, whereas nearly 40% showed signs of depression.

Development and validation of a short measure of health status for individuals with acute myocardial infarction: the myocardial infarction dimensional assessment scale (MIDAS)

The purpose of this study was to develop and validate a disease-specific health status measure for individuals with myocardial infarction (MI). The development of the myocardial infarction dimensional assessment scale (MIDAS) followed three main stages. Stage 1 consisted of in-depth, semi-structured, exploratory interviews conducted on a sample of 31 patients to identify areas of salience and concern to patients with MI. These interviews generated 48 candidate questions. In stage 2 the 48-item questionnaire was used in a postal survey to identify appropriate rephrasing/shortening, to determine acceptability and to help identify sub-scales of the instrument addressing different dimensions of MI. Finally, in stage 3 the construct validity of MIDAS subscales was examined in relation to clinical and other health outcomes. A single centre (district general hospital) in England was used for stages 1 and 3 and a national postal survey was conducted for stage 2. A total of 410 patients were recruited for the national survey (stage 2). Full data were available on 348 (85%) patients. One hundred and fifty-five patients were recruited to test construct validity (stage 3). The MIDAS contains 35 questions measuring seven areas of health status: physical activity, insecurity, emotional reaction, dependency, diet, concerns over medication and side effects. The measure has high face, internal and construct validity and is likely to prove useful in the evaluation of treatment regimes for MI.

Smallest real difference, a link between reproducibility and responsiveness

The aim of this study is to show the relationship between test-retest reproducibility and responsiveness and to introduce the smallest real difference (SRD) approach, using the sickness impact profile (SIP) in chronic stroke patients as an example. Forty chronic stroke patients were interviewed twice by the same examiner, with a 1-week interval. All patients were interviewed during the qualification period preceding a randomized clinical trial. Test-retest reproducibility has been quantified by the intraclass correlation coefficient (ICC). the standard error of measurement (SEM) and the related smallest real difference (SRD). Responsiveness was defined as the ratio of the clinically relevant change to the SD of the within-stable-subject test-retest differences. The ICC for the total SIP was 0.92, whereas the ICCs for the specified SIP categories varied from 0.63 for the category 'recreation and pastime' to 0.88 for the category 'work'. However, both the SEM and the SRD far more capture the essence of the reproducibility of a measurement instrument. For instance, a total SIP score of an individual patient of 28.3% (which is taken as an example, being the mean score in the study population) should decrease by at least 9.26% or approximately 13 items, before any improvement beyond reproducibility noise can be detected. The responsiveness to change of a health status measurement instrument is closely related to its test-retest reproducibility. This relationship becomes more evident when the SEM and the SRD are used to quantify reproducibility, than when ICC or other correlation coefficients are used.

Changes in functional outcome and quality of life in patients and caregivers after aneurysmal subarachnoid hemorrhage

OBJECT

Although the case-fatality rate after subarachnoid hemorrhage (SAH) does not change considerably after the first 4 weeks, functional outcome and the quality of life (QOL) may. To assess the extent of changes in functional outcome and QOL after SAH, the authors conducted a follow-up study at 18 months in patients and caregivers who had participated in a previous study of QOL 4 months after SAH.

METHODS

In a consecutive series of 98 patients admitted with SAH, 68 had survived until 4 months postbleed, at which time an initial outcome assessment had been performed in 64 of them. This series of 64 patients was contacted again at a median of 18 months after SAH. In all patients, functional outcome was assessed by means of the modified Rankin Scale (mRS). In 48 patients and 35 caregivers QOL was assessed using the SF-36, the Sickness Impact Profile (SIP), and a visual analog scale. The results were compared with the scores that had been obtained at 4 months after SAH. Thirty-two patients (50%) had improved at least one point on the mRS, in 23 patients functional outcome had remained unchanged, six patients had deteriorated one point on the mRS, and three had died. No major changes in the QOL of patients and caregivers could be found on the SIP, but on the SF-36 an improved QOL was detected in patients with better Rankin grades. On both instruments, the QOL at 18 months was still reduced compared with the reference population in all patients.

CONCLUSIONS

Functional outcome improves significantly between 4 months and 18 months post-SAH; studies on functional outcome after SAH can be compared only if outcome is assessed at the same time interval. The improved functional outcome seems to be accompanied by an improved QOL.

Adverse psychological outcome in women with coronary artery disease

OBJECTIVES

To investigate gender differences on psychological outcome following cardiac disease, and to identify predictors of psychological distress.

METHODS

In total, 536 consecutive cardiac patients ≤70 years were identified from medical records to participate in the study: 36 of them proved to have died since the index event. The mean time since the index event was one year and seven months. Of the 500 patients, 357 (71%) agreed to attend an interview on biomedical risk factors and fill in a psychological questionnaire. Complete psychological data were available for 287 (80%) patients.

RESULTS

Women scored significantly higher on anxiety, depression, vital exhaustion and social inhibition, and lower on wellbeing compared with men. Gender, age, percutaneous transluminal coronary angioplasty, smoking and admission for a recurrent event since the index event were independent predictors of psychological outcome.

CONCLUSION

These results add to current knowledge on gender differences and show that women have an adverse outcome on a range of psychological variables. This has implications for secondary prevention and rehabilitation. Longitudinal studies are needed to assess the implications of adverse psychological outcome in women on prognosis.

Psychological status and the role of coping style after coronary artery bypass graft surgery. Results of a prospective study

The results of a prospective study in patients who underwent a first coronary artery bypass graft operation are presented. The goals of this project consisted in assessing the psychological changes during the first year after surgery. For that purpose, 330 consecutive patients were recruited. They were assessed by means of several psychological scales before and on three occasions after surgery. These scales were: the Heart Patients' Psychological Questionnaire (HPPQ), the State-Trait Anxiety Scale (STAI), the Symptom Check List (SCL-90), the Maastricht Questionnaire (MQ) and the Marlowe Crowne Desirability Scale. Furthermore, the study focused on the differential influence of three coping styles. The data demonstrate a clear overall improvement in psychological status over the first year, more specifically during the first 6 months after CABG. Patients were less anxious, less depressed, less exhausted and experienced more subjective well-being. However, almost 30% of all patients did not experience that average favourable evolution. The final psychological end-state was predicted by psychological variables, measured pre-operatively (somatic complaints, hostility and dysphoria) and short-term post-operatively (anxiety). No single medical variable could predict patients' psychological end-state. Finally, the most favourable change was made by patients who display the sensitising coping style, resulting in lower anxiety and depression. Health care providers, physicians as well as nursing staff and psychologists, should therefore use psychodiagnostic tools in order to identify patients at risk for negative psychological outcome. Appropriate therapeutic interventions may consequently be developed and evaluated in future research.

Feelings of being disabled as a predictor of mortality in men 10 years after percutaneous coronary transluminal angioplasty

OBJECTIVE

To examine the independent prognostic value of the four subscales of the Heart Patients Psychological Questionnaire (HPPQ) on mortality in male and female patients 10 years following percutaneous transluminal coronary angioplasty (PTCA).

METHODS

The HPPQ, which measures well-being, feelings of being disabled, despondency, and social inhibition, was administered to 356 patients (23% women) post-PTCA. The patients were followed for a median of 10 years. Clinical and demographic variables were sampled from medical records.

RESULTS

During the follow-up period, 104 patients (29%) had died. Women scored significantly worse on all psychological subscales compared with men. Fifty-nine (72%) women and 92 (34%) men had a score indicating at least mild to moderate feelings of being disabled. Men scoring high on feelings of being disabled were at increased risk of mortality compared with men having a low score, adjusted for other cardiac risk factors (chi(2)=7; P=.008). No differences were found between women with low or high scores on feelings of being disabled (relative risk (RR): 1.2; 95% confidence interval (CI): 0.5-3.3). None of the other HPPQ subscales were related to mortality.

CONCLUSION

Feelings of being disabled measured at least 1 year after hospital discharge is a significant predictor of mortality in men 10 years post-PTCA, but not in women. This finding adds to the increasing knowledge that psychosocial variables influence morbidity and mortality in cardiac patients.

Evaluation of measures used to assess quality of life after stroke

BACKGROUND AND PURPOSE

Assessment of quality of life (QOL) after stroke is becoming common with the recognition that evaluation of treatment should include quality as well as quantity of survival. This article will outline the main conceptual and methodological issues in QOL assessment, highlight advantages and disadvantages of measures used in stroke QOL research, and discuss some unresolved issues.

SUMMARY OF REVIEW

We undertook a MEDLINE search using the keywords "stroke" and "quality of life" and reviewed 3 key texts on QOL measurement in stroke. Fifteen generic and 10 condition-specific measures used to assess QOL in stroke were identified and evaluated with the following criteria: reliability, validity, responsiveness, precision, acceptability, suitability for proxy respondents, mode of administration, and use of patient-centered approaches in development. Domains covered and level of comprehensiveness varied widely between generic and stroke-specific measures. No stroke-specific instruments used patient-centered approaches in their development. Four stroke-specific measures (Frenchay Activities Index, Niemi QOL scale, Ferrans and Powers QOL Index-Stroke Version, and Stroke-Adapted Sickness Impact Profile [SA-SIP30]) provided evidence of reliability and validity.

CONCLUSIONS

The need remains for a patient-centered, psychometrically robust, stroke-specific QOL measure. Patients should be involved in each stage of instrument development. Caution is needed in the selection of an instrument to measure QOL after stroke. Although the Ferrans and Powers QOL Index-Stroke Version, Niemi QOL scale, SA-SIP30, and Sickness Impact Profile come closest to satisfying many of the criteria outlined in this article, the selection of any individual instrument depends on the specific goals and constraints of a particular study.

Measuring the health related quality of life of people with ischaemic heart disease

OBJECTIVES

To inform researchers and clinicians about the most appropriate generic and disease specific measures of health related quality of life for use among people with ischaemic heart disease.

METHODS

MEDLINE and BIDS were searched for research papers which contained a report of at least one of the three most common generic instruments or at least one of the five disease specific instruments used with ischaemic heart disease patients. Evidence for the validity, reliability, and sensitivity of these instruments was critically appraised.

RESULTS

Of the three generic measures-the Nottingham health profile, sickness impact profile, and short form 36 (SF-36)-the SF-36 appears to offer the most reliable, valid, and sensitive assessment of quality of life. However, a few of the SF-36 subscales lack a sufficient degree of sensitivity to detect change in a patient's clinical condition. According to the best available evidence, the quality of life after myocardial infarction questionnaire should be preferred to the Seattle angina questionnaire, the quality of life index cardiac version, the angina pectoris quality of life questionnaire, and the summary index. Overall, research on disease specific measures is sparse compared to the number of studies which have investigated generic measures.

CONCLUSIONS

An assessment of the quality of life of people with ischaemic heart disease should comprise a disease specific measure in addition to a generic measure. The SF-36 and the quality of life after myocardial infarction questionnaire (version 2) are the most appropriate currently available generic and disease specific measures of health related quality of life, respectively. Further research into the measurement of health related quality of life of people with ischaemic heart disease is required in order to address the problems (such as lack of sensitivity to detect change) identified by the review.

Quality of life and neurological illness: a review of the literature

This article highlights some of the conceptual and methodological problems associated with quality of life (QoL) measurement in individuals with neurological illness. It is suggested that these problems have contributed to the underdeveloped status of QoL research in neurological settings. Many of the existing QoL measures that have been used, or show potential for use with individuals with neurological illness, are reviewed in terms of their theoretical basis, content, and practicality. A large proportion of these measures fail to meet adequate psychometric standards and/or have rarely been psychometrically tested. The confusion that surrounds adequate psychometric standards is discussed, and the dynamic nature of QoL is highlighted as a factor that requires further attention. Research addressing the discrepancies between proxy and patient ratings of patient QoL is also warranted. More focused research in these areas may contribute to a clearer understanding of how to assess QoL in individuals with neurological illness.

Quality of life after a first ischemic stroke. Long-term developments and correlations with changes in neurological deficit, mood and cognitive impairment

BACKGROUND

Studies on determinants of quality of life (QOL) after a stroke focus on one aspect (most important: neurological deficit, mood disorders or cognitive failure) and as such provide no insight in the relative contribution of each factor on QOL. The groups of patients studied often contain victims of different types of stroke. This inhomogenity in patients leads to further confusion about QOL after stroke.

OBJECTIVE

To evaluate in one study factors important for QOL in the period 3-12 months after a first one-sided ischemic stroke in the region of the middle cerebral artery.

DESIGN

Measures for QOL (Sickness Impact Profile, SIP), cognitive status (Wechsler Adult Intelligence Scale revised), mood and neurological deficit were scored 3. 6 and 12 months after the stroke.

SETTING

Successive patients admitted to a general hospital and rehabilitation clinic in The Hague, The Netherlands.

PATIENTS

A complete examination was performed three times in 35 patients. The results were compared to those of 20 controls matched for age, last occupation and educational level.

RESULTS

There was no significant neurological improvement between 3 and 12 months after the stroke. Cognition was impaired when compared to the estimated premorbid level and to the controls. There was incomplete recovery over the study interval. The patients as a group were depressed and remained so over the period of the study. The resulting quality of life scores were abnormal at 3 months and improved only slightly. Stepwise regression analysis revealed that depression and degree of paresis were the most important variables for the SIPtotal outcome.

CONCLUSIONS

In a homogenous group of stroke patients the QOL improved somewhat in the period 3 to 12 months after the stroke but was still highly abnormal after 1 year. The decrease in QOL was correlated with depression and - to some degree - with neurological deficit, but not to cognitive disturbances.

Quality of life measurements in patients with Parkinson's disease: A community-based study

The objective of this paper is to evaluate the health-related quality of life in a community-based population of patients with Parkinson's disease (PD). The PD population consisted of 233 patients and was derived from a wider prevalence study in the county of Rogaland, Norway. The quality of life was measured by the Nottingham Health Profile (NHP) and four general health and well-being questions. The results were compared with quality of life measurements in 100 patients with diabetes mellitus (DM) and 100 healthy elderly people. The control groups had the same age and sex distribution as the patients with PD. This study showed that PD has a substantial impact on the health-related quality of life. Patients with PD had higher distress scores in all measured dimensions of the NHP than the two control groups. The negative impact of PD was highest for physical mobility, emotional reactions, social isolation and energy. Correlation analysis of the quality of life showed that age, duration of levodopa therapy, higher levodopa doses, depression, cognitive impairment and more advanced disease correlated with higher distress scores in patients with PD. The results of this study showed that PD had a broad impact on well-being, more so than DM. The distress related to the severity of the disease, as well as to depressive symptoms and cognitive impairment. An important finding was the underestimated distress related to lack of energy. Copyright 1998 Lippincott Williams & Wilkins

Quality of life in patients and partners after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Outcome after subarachnoid hemorrhage (SAH) is often graded as "poor," "fair," or "good." Such categories are usually based on physicians' assessments of physical abilities of patients rather than on how patients themselves perceive their physical, psychological, and social well-being. We assessed functional outcome and quality of life (QoL) in patients with SAH and their partners.

METHODS

In a consecutive series of 64 patients and 51 partners studied 4 months after the SAH, we assessed functional outcome by means of the Rankin Scale, and QoL by means of the SF-36, the Sickness Impact Profile (SIP), and a visual analogue scale. Additionally, we asked two "simple questions" about dependency and recovery. All questionnaires were completed in an interview setting. The scores on the QoL instruments from patients and partners were stratified according to the Rankin grades of the patients and were compared with data from a Dutch reference population.

RESULTS

Only patients who had no symptoms at all (Rankin grade 0) had no reduction in QoL compared with the reference population; some of these patients even indicated an improvement in QoL from before the SAH according to the visual analogue scale. Patients who had symptoms but were independent (Rankin grades 1 to 3) and therefore usually designated as having "good outcome" often had reductions in QoL, on both the physical and psychosocial subscores of the SIP and SF-36. The QoL of partners was considerably reduced in several psychosocial domains.

CONCLUSIONS

SAH has a considerable impact on the QoL of patients and their partners. Only patients without residual symptoms (Rankin grade 0) have a good outcome in terms of physical performance and QoL.

International experiences with the Hospital Anxiety and Depression Scale--a review of validation data and clinical results

More than 200 published studies from most medical settings worldwide have reported experiences with the Hospital Anxiety and Depression Scale (HADS) which was specifically developed by Zigmond and Snaith for use with physically ill patients. Although introduced in 1983, there is still no comprehensive documentation of its psychometric properties. The present review summarizes available data on reliability and validity and gives an overview of clinical studies conducted with this instrument and their most important findings. The HADS gives clinically meaningful results as a psychological screening tool, in clinical group comparisons and in correlational studies with several aspects of disease and quality of life. It is sensitive to changes both during the course of diseases and in response to psychotherapeutic and psychopharmacological intervention. Finally, HADS scores predict psychosocial and possibly also physical outcome.