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Ann Thorac Surg 2003;76:1598-1604
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Open heart surgery: one-year self-assessment of quality of life and functional outcome

^a Department of Thoracic and Cardiovascular Surgery, Hôpital Jean-Minjoz,, Besançon, France
^b Department of Biostatistics and Epidemiology, Faculté de Médecine et de Pharmacie, Besançon, France

Accepted for publication April 21, 2003.

^* Address reprint requests to Dr Falcoz, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean-Minjoz, Boulevard Fleming, 25000 Besançon, France
e-mail: pierre-emmanuel.falcoz{at}wanadoo.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
BACKGROUND: The aim of this prospective study, based on the completion of the short form health survey questionnaire (SF36) before and 1-year after open heart surgery, was threefold: to evaluate the changes in quality of life (QOL) after open heart surgery, to determine the factors influencing QOL, and to assess the relation between preoperative QOL and 1-year cardiac functional status.

METHODS: Logistic regression was used to determine factors that influence patients’ QOL scores and their 1-year cardiac functional status. Different groups were constituted in terms of 1-year cardiac functional status by means of an arborescent classification.

RESULTS: Comparison of preoperative and postoperative mean scores in the 293 patients included in the study revealed an improvement in all but three dimensions of the SF36 scale. Quality of life improved after operation in an average of 50% of patients. The most frequently found independent predictors of impairment after surgery were NYHA functional class III or IV and angina class III or IV. At 1 year, 64% of patients had satisfactory cardiac functional status. Independent predictive factors of 1-year cardiac functional status were: physical functioning, pain, general health problems, and coronary artery bypass graft. The arborescent classification indicated that the probability of having a "satisfactory" 1-year cardiac functional status was greater than 75% for patients with at least one preoperative QOL dimension above 75 on the scale.

CONCLUSIONS: Preoperative QOL determined by the SF36 is predictive of 1-year cardiac functional status. Coronary artery bypass patients do not recover as well as patients having undergone heart valve surgery.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Advances in cardiopulmonary bypass techniques, myocardial perfusion, and perioperative care have resulted in marked reductions in mortality and morbidity rates [1] for coronary artery bypass graft (CABG) and heart valve surgery (HVS). Health-related quality of life has come to be recognized as being of major importance following cardiac surgery [2, 3]. Improvement in physical, psychologic, and social functioning as well as an overall sense of well-being are related to the relief from the main cardiac symptoms (angina pectoris and dyspnea) and the improvement in physical functioning that typically follow cardiac surgery [4, 5].

Quality of life (QOL) is a multidimensional concept that is based on the patient’s own perception of his or her health and integrates not only the functional and physical dimensions of the disease, but also the psychologic and social dimensions [6]. It can play a role in the clinical management of patients with cardiac disorders by extending the assessment process beyond traditional clinical factors and tracking the global impact of the cardiac surgical procedure over time [7, 8].

In a previous study [9] we compared two QOL questionnaires, the Nottingham health profile (NHP) and the short form health survey questionnaire (SF36), in patients undergoing open heart operations. We concluded that the SF36 seemed more suitable than the NHP for evaluating QOL in cardiac surgery. In designing the present study, we felt it would be of interest to describe the relation between preoperative clinical data, QOL, and the main cardiac functional symptoms (angina pectoris and dyspnea).

The aim of this prospective study, based on the completion of the SF36 questionnaire before and 1-year after open heart surgery was threefold: to evaluate the changes in QOL after open heart surgery, to determine the factors influencing QOL, and to assess the relation between preoperative QOL and 1-year cardiac functional status in this sample of patients.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Sample and questionnaires
From July 2000 to May 2001, a total of 452 patients underwent open heart surgery in the Department of Thoracic and Cardiovascular Surgery at the University Hospital of Besançon (France). In all, 159 (35.2%) of 452 operated patients did not fill in the preoperative questionnaires: 12 patients (2.6%) neither spoke nor read French and were excluded, 4 patients (0.9%) refused, and 143 patients (31.7%) required unscheduled surgery. Hence, 293 patients (64.8%) gave their written informed consent and were enrolled in the study. A data manager proposed the SF36 questionnaire to the patients the day before their open heart operation. Patients were also given self-administered questionnaires about angina pectoris and dyspnea. One-year later the patients were contacted by mail. They were sent a cover letter, the SF36 questionnaire, a self-administered questionnaire about angina pectoris and dyspnea, and a stamped self-addressed return envelope.

The SF36 is a self-administered 36-item tool that covers eight dimensions of health including: limitations in physical functioning, usual role activities, social functioning related to health problems, and vitality. It also includes a global evaluation of health. Each dimension is scored on a scale from 0 to 100, with higher scores indicating better health. The number of possible responses per item varies from 2 to 6. Two summary scores are also calculated to summarize the patient’s physical and mental state of health [10]: the physical component summary scores (PCS) and the mental component summary scores (MCS). The SF36 has received wide validation in English [11, 12]. The French version, used here, was adapted by forward and back translation, iterative revision, and consensus by experts [13].

The assessment of angina pectoris and dyspnea, done by self-administered questionnaires given the day before open heart surgery and 1-year afterward, was considered valid due to the fact that the agreement between the coding of the patient and the medical coding (New York Heart Association [NYHA] and Canadian Cardiovascular Society classification [CCS] [14]) were judged very satisfactory (kappa = 0.816 for angina pectoris and kappa = 0.768 for dyspnea).

The variables recorded were: sociodemographic (age, sex, family situation, level of study), angina pectoris status according to the CCS, dyspnea class according to the NYHA classification (class II was divided into two subgroups: II-mild for patients not troubled by shortness of breath when walking up a slight hill at a normal pace, and II-severe for patients who had to stop for breath when walking up a slight hill at their own pace), ejection fraction, left ventricular wall motion, surgical preoperative risk estimation scores (Parsonnet score [15] and Euroscore [16]), comorbid diseases, type of heart operation, and operative complications.

Statistical analysis
After having described the sample and its main characteristics, we explored the variations in QOL subsequent to open heart surgery and the predictors of these variations. Qualitative variables were expressed in percentage and quantitative variables and QOL scores as mean ± standard error of the mean. All tests were two sided. The SF36 scoring rules were applied for the questionnaire [17].

The preoperative and postoperative scores for each QOL section were compared using the Wilcoxon matched-pairs rank test. For each section of QOL, the preoperative and postoperative scores of each patient were compared to determine which patients had improved and which patients were impaired after surgery. To determine independent predictive factors influencing the QOL status of a patient, with the dependent variable being binary (improved or impaired), we first performed a univariate analysis with the Fischer’s exact test and then a multivariate analysis by logistic regression. Variables with a level of significance less than or equal to 0.20 in the univariate analysis were included in the multivariate model, which was analyzed using a stepwise logistic regression.

To assess the 1-year cardiac functional status, patients were divided into two groups: "satisfactory" when the classification of angina pectoris was I and dyspnea was I or II-mild, and "unsatisfactory" for all others patients. For each dimension of preoperative QOL, we transformed the continuous scale into several classes. The choice of the most relevant classes, with regard to the 1-year cardiac functional status, was done thanks to receiver operating characteristic (ROC) curves that revealed the discriminate cut points [18]. We performed logistic regression, adjusted on the preoperative status of angina pectoris and dyspnea, first by univariate analysis and then by multivariate analysis. Variables with a level of significance less than or equal to 0.20 in the univariate analysis were included in the multivariate model, which was analyzed using a stepwise logistic regression. From the variables selected in this multivariate model, an arborescent classification was used to identify different groups in terms of 1-year cardiac functional status, which were then compared by ² test.

Data analysis was anonymous, and data collection and processing were approved by the institutional review board of our hospital. All statistical analyses were performed with SAS software, version 8.02 (SAS Institute Inc, Cary, NC).

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Characteristics of study population
Of the original 293 patients, 264 were available for follow-up at 1 year and completed the SF36 and the self-administered questionnaires. Twenty-nine patients did not fill in the postoperative questionnaires: 22 patients (7.5%) had died during the year, and 7 patients (2.4%) would not answer despite numerous calls. Comparison of the characteristics of the 264 patients with those of the 29 without postoperative questionnaires indicated that the latter were similar (data not shown), except for postoperative complications (p < 0.0001), which were more numerous.

The main characteristics of the study population are summarized in Table 1. The sample was 70% male and 30% female, aged 14 to 87 years old (mean 65.3 years old; SD 11 years). As for the subdivision of the class II for dyspnea, 78 patients (29.5%) were in class II-mild and 72 patients (27.3%) in class II-severe. A large majority of the patients (83%) were married or cohabited, and 54% lived in a rural area. More than half were white-collar (27%) or blue-collar (35%) workers. At the time of surgery, 190 patients (72%) were retired. The predominant heart valve disease was calcified aortic stenosis (44%). Beating heart surgery was performed in 23 patients (17% of the coronary artery bypass grafts). In terms of preoperative scores, the patients were divided as follows: 234 patients were Parsonnet A or B (88.6%) and 30 patients were C or D (11.4%), whereas 186 patients were Euroscore A or B (71.5%) and 74 patients were C or D (28.5%).

View larger version (29K): [in this window] [in a new window]   Fig 1. Mean scores for each section of quality of life before and one year after surgery (n = 264); data are mean ± standard error of the mean. For quality of life dimensions, see footnote in Table 2 for complete labels. Comparison of the scores before and one year after the operation demonstrates an improvement in quality of life in all but three dimensions of the SF36 scales. **p < 0.001; *p < 0.05. Open bars = preoperative; shaded bars = postoperative. (MCS = mental component summary scores; PCS = physical component summary scores).

The univariate analysis highlighted seven different clinical variables statistically linked to the 1-year status: CABG, obesity, comorbid disease, chronic pulmonary obstructive disease, cerebral or peripheral vascular disease, dyspnea, and angina pectoris. As for the QOL dimensions (eight baseline dimensions and the two summary scores), each one was statistically linked to the 1-year status. ROC curves permitted determination of the following cut-point values: 75 for physical functioning, social functioning, pain, and mental health; 50 for general health problems, role limitation due to physical health problems, and energy; 33 for role limitation due to mental health problems (data not shown).

The multivariate model, which combined clinical variables and QOL dimensions, isolated the four following predictive variables of 1-year status (Table 4): three of the QOL dimensions (physical functioning, pain, and general health problems) and one of the clinical variables (CABG).

View larger version (17K): [in this window] [in a new window]   Fig 2. Patient classification according to the two main quality of life dimensions illustrated by multivariate analysis: physical functioning and pain. In group 1 the positive predictive value for the 1-year "satisfactory" status was 88%; it was 75% in group 2 and 50% in group 3.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

Measures of morbidity and mortality do not provide complete information about physical, functional, emotional, and mental well-being and can be supplemented by patients’ perceptions of their recovery. The use of QOL measures in clinical practice is a way of focusing treatment on the patient rather than on the disease. Our choice of the SF36 questionnaire was based on the results of a previous study [9], in which we found it more suitable than the NHP for evaluating QOL in cardiac surgery. The SF36 questionnaire is a generic scale and was not originally designed for patients undergoing cardiac operations. It explores eight dimensions of health and the preoperative and postoperative scores are easily compared. Our results, a 2.3% loss of follow-up, are in line with previous findings that the SF36 questionnaire is used and accepted easily by patients [9, 19].

Comparison between preoperative and postoperative QOL
In the field of cardiac surgery, most of the recent studies on QOL deal with coronary artery bypass grafting [7, 8], elderly patients [20–22], or intensive care treatment [23]. However, there are limited data available to help clinicians identify patients that are likely to show improvement or impairment in their overall QOL following open heart surgery (CABG and HVS). The comparison between mean preoperative and postoperative scores demonstrated an improvement in all but three dimensions of the SF36 scale. In an average of 50% of patients, QOL improved after surgery. These results do not confirm the findings of previous studies done with the NHP questionnaire, which indicated QOL to improve in all sections [3, 5], with an average improvement of 80% after operation [5]. We suggest that the considerable difference in these results is due principally to the different psychometric properties of the two questionnaires. The SF36 has been described as more responsive than the NHP, hence more useful in the assessment of QOL, whereas the NHP has been criticized as having a low sensitivity to change, probably due to its use of binary responses (0 or 1) and its propensity towards a ceiling effect [19, 24].

Factors influencing QOL
In the present study, we also focused on the main two cardiac functional symptoms: dyspnea and angina pectoris. Contrary to comorbid diseases or age, these two criteria may vary between the preoperative and postoperative periods. Therefore, it was not very surprising to find that the NYHA and angina pectoris functional classes were the two most frequently quoted independent predictors of variation in QOL. Our study demonstrates a higher preoperative NYHA or CCS class to be a predictive factor of impaired postoperative QOL. One might have expected the patients who were the most symptomatic before surgery to derive the greatest benefit in QOL from a successful operation. In fact, this is not the case, probably because a higher NYHA or CCS class indicates a more advanced stage of disease. Perhaps a 1-year follow-up is not sufficient to ascertain the real recovery of these patients.

Factors influencing One-Year cardiac functional status
Quality of life has been assessed in various groups of patients. It has been reported to be a predictive factor of mortality within 180 days after CABG surgery [7] and of 3-year survival after open heart operations [25]. To date, very little is known about the value of preoperative QOL as a predictor of cardiac functional status (physical limitation due to angina and dyspnea) following cardiac surgery; it may add to the understanding of how the outcome of a given health care episode is influenced by a patient’s preoperative health status. In our study, 64% of the patients were considered to have a "satisfactory" cardiac functional status at the 1-year evaluation versus 36% "unsatisfactory." Multivariate analysis after adjustment on preoperative status illustrated four independent predictive variables to influence the 1-year cardiac functional status: physical functioning, pain, general health problems, and CABG. The fact that CABG was selected in the multivariate analysis as an independent variable highlights the fact that patients requiring HVS or CABG do not react the same way. HVS patients recover better than CABG patients. Two of the three selected preoperative QOL dimensions, physical functioning and pain, were more powerful than clinical variables in predicting 1-year cardiac functional status (Table 4).

The identification of prognostic factors of cardiac functional status allows a stratification of patients and an a priori distinction of different groups. In the present study, groups were defined by the two most relevant QOL dimensions that had emerged from analysis: physical functioning and pain. For patients belonging to Groups 1 and 2 (127 patients), the probability of having a "satisfactory" 1-year cardiac functional status in terms of cardiac functional outcome was greater than 75%. Therefore, we can say that a noninvasive self-reported measurement tool (the SF36 questionnaire) is able to predict postoperative cardiac functional status with a positive predictive value greater than 75% for patients having at least one preoperative QOL dimension above 75 on the scale. Hence, preoperative QOL assessment with the SF36 may be useful in identifying those patients most likely to have satisfactory (or unsatisfactory) 1-year cardiac functional status outcomes. These findings require confirmation in further studies by external validation. The two summary scores (PCS and MCS) were not selected in the final analysis. It was somewhat surprising and disappointing, as several advantages of these scores over the original eight dimensions of the SF36 have been reported [10]. However, the analysis done in the present work found them to be less effective than the two baseline dimensions, physical functioning and pain, in identifying cardiac functional status.

Study limitations
Two limitations need to be mentioned. First, the study population comes from a single institution study. Second, 32% of the patients operated on during the study period were not included; these were patients who required unscheduled operations (urgent or emergent). This restricted the scope of the results to scheduled patients.

In conclusion, as preoperative QOL determined by SF36 is predictive of 1-year cardiac functional status, the authors suggest using the SF36 questionnaire before open heart operations, thereby placing its dimensions within the context of traditional clinical variables.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The authors thank Nancy Richardson-Peuteuil for her editorial assistance and Francis Guillemin for his helpful comments.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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