Quality of life in women with heart failure, normative groups, and patients with other chronic conditions

Quality of life in women with heart failure, normative groups, and patients with other chronic conditions – Cardiology Critical Care

Mary S. Riedinger

* BACKGROUND In the United States, 2.5 million women have heart failure, yet little is known about their quality of life. Because most studies included small samples of women, the results are not generalizable.

* OBJECTIVE To compare the quality of life of women with heart failure with that of a normative group and with that of women with other chronic conditions.

* METHODS Descriptive techniques were applied to baseline data collected in the Studies of Left Ventricular Dysfunction trials to characterize quality of life in women with heart failure (n = 691). Global quality of life and the quality of-life dimensions of physical function, emotional distress, social health, and general health were measured by using the Ladder of Life, items from the Profile of Mood States Inventory, the Functional Status Questionnaire, the Beta Blocker Heart Attack Trial instrument, and an item from the RAND Medical Outcomes Study instrument.

* RESULTS Compared with the normative group of women, women with heart failure had significantly lower global quality of life; worse vigor, intermediate activities of daily living, social activity, and general health ratings; and higher ratings for anxiety and depression. Fewer than half of the women with heart failure felt that they were healthy enough to perform normal activities.

* CONCLUSIONS Women with heart failure have worse quality of life than do normative populations and patients with other chronic diseases such as hypertension, Parkinson disease, and cancer.

**********

Heart failure is a leading cause of morbidity and mortality in the United States and is a major public health concern. An estimated 5 million persons have heart failure; newly diagnosed cases occur at a rate of 400 000 per year. (1) Extended life expectancy, combined with increasingly effective treatments for myocardial infarction, will increase the number of patients with heart failure. Women account for 62% of total deaths due to heart failure; additionally, women have more hospital discharges for heart failure than do men. The total estimated direct and indirect costs of hospitalization, nursing homes, healthcare professionals, medications, lost productivity, morbidity, and mortality are approximately $21 billion. (1)

The number of patients currently affected, the alarming rate of new cases each year, and the enormous burden this disease places on the healthcare system make treatment of heart failure an important healthcare issue. Disease management programs have been developed to decrease variation in care for patients with heart failure. These programs focus on implementing interventions that standardize care, steps that may result in decreases in signs and symptoms, hospital length of stay, and hospital readmission rates and increases in functioning and survival. (2,3) However, if treatment to prolong survival decreases quality of life, patients may decide that the increase in survival has too great a cost. Therefore, understanding the baseline quality of life in women with heart failure is important. Additionally, comparison of the baseline quality of life in women with heart failure with that of normative populations and other groups with chronic conditions offers a reference point from which clinicians can truly understand the impact that heart failure has on quality of life in women.

The concept of quality of life was developed to evaluate the well-being of populations. Quality of life for a specific population of patients may be compared with the quality of life of other populations of patients or with that of the total population, as a whole, in an effort to establish whether aspects of quality of life are similar. Social and health policy may then address obvious inequity. (4)

To date, much less information is available on women than on men with heart failure. Most research on heart failure has included only small samples of women, making it impossible to make definitive statements about heart failure and women. In a recent study, (5) researchers evaluated the enrollment of women with heart failure in 10 large clinical trials done in the 10 years preceding the study. The combined enrollment for the 10 trials was 17 370 patients; of these, approximately 20% were women. These investigators (5) thought that the prevalence of diastolic dysfunction might be higher in women than in men, thereby disqualifying women from trials in which systolic dysfunction was the main criterion for enrollment.

Study Aims

The purpose of the current study was to describe quality of life in a large sample of women with heart failure and compare it with the quality of life of normative groups and of patients with other chronic diseases. The hypothesis was that women with heart failure have poor quality of life.

A secondary analysis of data collected during the Studies of Left Ventricular Dysfunction (SOLVD) trials (6) was done. In the SOLVD trials, data on quality of life were collected for patients with heart failure who were randomized to treatment with either the angiotensin-converting enzyme inhibitor enalapril or placebo. (7) These data were not analyzed separately for men and women. Separate analysis of the women’s data would be an important contribution to the knowledge of quality of life in women with heart failure.

Methods

SOLVD Trials

The SOLVD studies consisted of 2 distinct sections: a heart failure registry and 2 double-blinded, placebo-controlled, randomized trials of enalapril in patients with either overt or covert heart failure. (6) Data on quality of life were collected from patients with heart failure, who were randomized to treatment with either enalapril or placebo, at baseline, 4 to 6 weeks, 1 year, and 2 years after admission into the study. (7,8) Clinical data were collected at various intervals throughout the study. In this article, we describe the quality of life of women at the baseline period.

Sample

The inclusionary and exclusionary criteria of the SOLVD trials are given in the Appendix. A total of 691 women from the SOLVD trials were included in this study of baseline quality of life.

Quality-of-Life Definition

The SOLVD investigators included 2 global measures of the quality of life (current life and general life satisfaction) and 4 dimensions (physical functioning, emotional distress, social health, and perceived health) in their definition of quality of life. Physical functioning included the concepts of vigor, activities of daily living (ADL), and health that interfered with activities. Emotional distress included anxiety and depression. Social health included social function, social life satisfaction, and intimacy. Finally, perceived health included general health. Because our analysis is a secondary analysis of the SOLVD data, we are limited to the quality-of-life definition of the SOLVD investigators.

Instruments

The quality-of-life instrument consisted of 90 items drawn from a number of instruments: the Profile of Mood States Inventory (POMS), Functional Status Questionnaire (FSQ), the Beta Blocker Heart Attack Trial instrument, Symptoms Scale, Ladder of Life, and an item from the RAND Medical Outcomes Study instrument. All of the parent instruments have been used extensively in patients with heart failure and other clinical populations. The psychometric properties have been tested, and the instruments are considered valid and reliable. The items used in this study were subjected to additional testing for internal consistency and validity with this sample of patients.

The multi-item scales used in the SOLVD battery were tested for reliability by using a Cronbach [alpha] test; every scale exceeded the 0.70 [alpha] coefficient level. Therefore, the SOLVD multi-item scales were considered reliable.

Discriminate validity of the SOLVD battery was tested by using a correlation matrix to determine the degree of independence between constructs. Second, the ability of the constructs to differentiate between patients on the basis of the severity of heart failure was tested. The second method of discrimination has been used in other populations with heart disease. (9) The calculated correlations indicated that most constructs of the SOLVD quality-of-life battery fell below the 0.50 level of discrimination. This level has been used by other investigators and is thought to be discriminative enough that constructs can be considered different from each other. (10) Basic and intermediate ADL scores had a correlation of 0.58; basic ADL scores and intermediate ADL scores had correlations with social activities of 0.53 and 0.75, respectively. The correlation between anxiety and depression was 0.74. The correlation between social and general life satisfaction was 0.63.

After patients were grouped according the New York Heart Association (NYHA) classification, t tests revealed significant differences between the NYHA severity groups for all quality-of-life dimensions except anxiety and depression. This finding indicates that most dimensions in the SOLVD battery can be used to discriminate severity of illness.

Data Analysis

Descriptive statistical techniques were used. Additionally, when comparative data were available, t tests were used to test for differences between the mean scores of the study group and those of the comparative populations.

Frequencies were calculated to determine the amount of missing data. Depending on the type of data and the quantity of missing data, data were either eliminated from the analyses or were estimated (imputed). If a scale had less than 50% of the data missing, then missing values were imputed. The subject’s mean score for valid items was used in place of missing items. Imputation was considered solely for those scales for which the items were similar and the responses were similar.

The study was considered exempt from review by the human subject protection committee. The data were existing, and the data set contained no information on patients’ identity. Therefore, patients’ confidentiality was maintained.

Results

Demographic Data

The demographic data are presented in Table 1. As stated, the sample size for the demographic data was 691 unless otherwise noted.

The majority of women were white and 21 to 80 years old. Fifty-three percent had completed 12 years or more of education. Ejection fractions ranged from 0.60 to 0.35. More than half had a history of smoking; 18% were smokers at the time of entry into the study. Because of strict exclusion criteria, few of the women had comorbid conditions. The majority of women had disease of NYHA class II or class III. In the month before collection of baseline data, the most frequent symptoms, in order, were dyspnea, chest pain, and dizziness.

Quality of Life of Women With Heart Failure

The research hypothesis was that women with heart failure have a poor quality of life. Results of the analysis of baseline quality of life in women are presented in Table 2. Where normative data or information from other populations of chronically ill women were available, the data were compared with the data of the women with heart failure (Table 3). Unfortunately, most comparative data include values for men; available studies in which data on women only were compared are scarce. Therefore, comparative data that included values for men are presented when comparative data exclusive to women were not available.

Global Quality of Life. Although the women with heart failure rated their overall current life situation significantly lower than did men and women in a nationwide study, (11) the majority of the women with heart failure were extremely, very, or generally satisfied with their lives.

Physical Functioning. Vigor was measured by using a subscale of the POMS instrument, with higher scores signifying greater vigor. Most available normative data for the POMS measure were based on an aggregated or “Total Mood” score from all subscales and therefore were unusable as comparative data in this study. However, in a study (12) of 250 normative healthy women, the POMS instrument was used to collect mood data 4 times during a 1-year period. The mean vigor score of these women was significantly higher (P<.001) than the vigor score for women with heart failure. In another study, (13) the effects of antihypertensive treatments on quality of life were compared in men and women. This group of patients also had significantly higher vigor scores than did the women with heart failure. Finally, the vigor scores of patients with various types of cancer (14) did not differ significantly from the scores of the women with heart failure. In summary, the vigor scores of women with heart failure were significantly lower than the scores of a normative female group and of a group of patients with hypertension and were similar to the scores of elderly cancer patients.

The developers of the FSQ scales created a computerized program used to score the FSQ survey and provided “warning-zone” information. The warning-zone ranges were determined through consultation with a panel of experienced clinicians: 5 physicians, a social worker, and a psychologist. (24) The panel reviewed the survey items and judged the degree of impairment that would justify clinical concern. The warning-zone ranges were used as markers of decreased function in our study. The women with heart failure were within the normal range for basic ADL, but the mean intermediate ADL score was in the warning-zone range (0-88). Comparative data were available from a study (15) in which researchers evaluated 2 groups of community-dwelling subjects, geriatric and nongeriatric. The basic ADL scores of the geriatric and nongeriatric groups did not differ significantly from the basic ADL scores of the women with heart failure. However, the women with heart failure had significantly lower intermediate ADL scores than did the 2 normative groups.

The basic ADL scores of the women with heart failure were significantly better than the basic scores of frail hospitalized older adults, (16) outpatients who had Parkinson disease, (17) and outpatients who had chronic obstructive pulmonary disease (COPD). (18) However, the intermediate scores of the women with heart failure were significantly worse than the intermediate scores of the other 3 groups.

These data suggest that women with heart failure can perform basic ADL, such as taking care of themselves (bathing, eating, dressing) and moving in and out of bed, within normal ranges and have better basic ADL functioning than do patients with COPD or Parkinson disease or elderly hospitalized patients. However, women with heart failure are quite limited in their ability to perform intermediate ADL tasks; their scores were significantly lower than those of normative subjects, hospitalized older adults, patients with Parkinson disease, and patients with COPD.

More than half of the women with heart failure felt that their health limited their ability to perform their daily activities. We had no comparative data for analyses.

Emotional Distress. Anxiety and depression were measured by using subscales of the POMS instrument, with higher scores signifying more mood disturbance. Women with heart failure had significantly worse anxiety (P<.001) and depression (P<.001) scores than did the normative sample from the vitamin D study (12) and patients in the antihypertensive study (12) Additionally, women with heart failure had a worse mean anxiety score than did the geriatric subjects in a study (19) of the use of over-the-counter medications; the mean depression score of the women with heart failure, however, was similar to that of the geriatric subjects.

Compared with elderly patients with cancer, (14) the women with heart failure had significantly better mean depression scores (P<.001) but significantly worse mean anxiety scores (P<.001). Women with heart failure also had significantly lower depression scores than did cancer patients enrolled in a brief weekend psychoeducational program. (20) However, the anxiety scores of the cancer patients were significantly better than the anxiety scores for the women with heart failure (8.50 [+ or -] 7.66 vs 9.14[+ or -]6.65, P=.02).

In a study (21) of 32 women, mood disturbance was evaluated 1 and 4 months after acute myocardial infarction. The mean anxiety (P=.20) and depression (P=.50) scores of these women 4 months after myocardial infarction did not differ significantly from the scores of the women with heart failure. However, mean anxiety (P<.001) and depression (P<.001) scores 1 month after myocardial infarction as well as the mean scores of subjects with COPD who were not receiving oxygen therapy at home (22) were significantly worse than the mean scores for the women with heart failure.

Overall, women with heart failure had worse feelings of anxiety than did the normative group of women in the vitamin D study, both cancer patient cohorts, the geriatric subjects, and the patients in the antihypertensive study. Women with heart failure did have better anxiety scores than did patients with COPD and patients 1 month after acute myocardial infarction. Feelings of depression were higher in the women with myocardial infarction at 1 month, the cancer patients (both groups), and the COPD cohort. The depression scores of the women with heart failure were worse than those of the geriatric patients, the normative women in the vitamin D trial, and the patients in the antihypertensive study.

Social Health. The FSQ expert panel defined a normal range for the social activity scale as a score between 79 and 100. The mean social activity score for the women with heart failure was below this normal range. The women had statistically lower mean social activity scores than did frail hospitalized older adults (16) (P<.05); however, women with heart failure had significantly better social activity scores than did patients with Parkinson disease (17) (P<.001) and COPD (18) (P<.001).

Among the women with heart failure, 66% were very or fairly satisfied with their social life, 19% had mixed feelings, and 15% felt some degree of dissatisfaction.

General Health. Fewer than half of the women with heart failure felt that their general health was excellent, very good, or good. Forty-five percent felt that their general health was fair, and 9% thought that their general health was poor. After this item was converted to a 100-point scaled score, (23) the mean score for the women with heart failure was significantly lower than the mean score of a normative population of women (P<.001) and the mean scores of groups of men and women with heart failure (P<.001), diabetes (P<.001), Parkinson disease (P<.001), COPD (P<.001), recent myocardial infarction (P<.001), and hypertension (P<.001). The women with heart failure had significantly worse general health than did patients with other chronic and acute diseases. (17,23)

Discussion

The hypothesis that women with heart failure have poor quality of life was mostly supported. With regards to global quality of life, the women with heart failure had significantly lower current life situation scores than did the normative group of women. Normative data were not available for the life satisfaction item, but 65% of the women with heart failure had some degree of satisfaction with their lives.

For the quality-of-life dimensions, when comparative data were available, women with heart failure had worse vigor, intermediate ADL, anxiety, depression, social activity, and general health ratings. Women with heart failure had scores consistent with normative populations for basic ADL dimensions. Fewer than half of the women with heart failure felt that they were healthy enough to perform normal activities.

Heart failure is a devastating condition that produces fatigue, dyspnea, and limitations in exercise capacity, all of which severely affect the quality of life. (25) Patients with heart failure report high anxiety and score low for general health and functioning. (26) The morbidity that accompanies heart failure results in increases in the number of hospital readmissions, early retirement, loss of income, and the inability to perform physical activities–all of which can lead to depression. (2,27)

Our results indicate that heart failure places a tremendous burden on quality of life in women with heart failure; this burden is greater than in most other chronic conditions. These findings are consistent with those of Bennett et al, (28) who found that women with heart failure (n = 30) had high physical symptom impact and poor perceived physical health status. In another study, Chin and Goldman, (27) using the Medical Outcomes Short Form 36, found that quality of life was low in patients with heart failure. Additionally, despite controls for socioeconomic and clinical variables, women with heart failure (n = 90) bad significantly lower scores for physical function and vitality than did men. These findings persisted even after 1 year.

In a study (29) of the same SOLVD cohort (691 women) as the one in our study, women had significantly worse general life satisfaction, physical function, social health, and general health scores than did men. The differences between men and women for current life situation and emotional distress were not significant. After the researchers controlled for NYHA classification, women still had significantly worse ratings for intermediate ADL and social activity. In a study (30) of gender and quality of life in patients with heart failure (n = 191), quality of life was significantly more impaired in women than in men. In another investigation, (31) patients with advanced heart failure (111 men and 23 women) felt that their quality of life was significantly compromised. Although they had a wide range of physical abilities, the patients rated themselves as moderately anxious and hostile and moderately to severely depressed.

Compared with normative populations, the women with heart failure who participated in the SOLVD trials had worse overall quality-of-life scores and worse scores for vigor, intermediate ADL, general health, anxiety, and depression; they had similar scores for basic ADL. Women with heart failure also had a quality of life that was worse than that of patients with other chronic diseases, including cancer and Parkinson disease. This finding is significant because of the increasing prevalence of heart failure. Although the basic ADL scores of the women with heart failure were normal, their scores for intermediate ADL functioning such as grocery shopping climbing stairs, and walking several blocks were poor.

The majority of the women with heart failure reported that their health interfered with the performance of normal activities; overall, general health ratings were also lower for the women with heart failure than for the other groups. Despite these findings, the majority of the women with heart failure were satisfied with their lives in general. This satisfaction may be a result of effective coping behavior and needs further exploration.

Heart failure disease management programs have been developed to reduce variation in care. (2,32-38) Goals include decreasing heart failure symptoms, decreasing hospital length of stay and hospital readmissions, and increasing physical functioning. Many clinicians equate quality of life with physical functioning, which is an important dimension of quality of life; however, other dimensions are equally important and need attention, including, but not limited to, emotional and social function.

In elderly patients, higher levels of quality of life are related to fewer readmissions and thus decreases in cost. (39) It may be cost-effective to include interventions that improve quality of life in patients with heart failure. The programs for managing patients with heart failure may not be reducing cost as much as possible because of the lack of interventions that focus on quality of life. Programs may be able to include interventions that improve on other dimensions of quality of life, thereby improving the overall health-related quality of life of women with heart failure and reducing costs by decreasing readmission rates.

Limitations

This study has several limitations. First, generalizability is a potential limitation, because the subjects were participants in a randomized clinical trial. Results may not be generalizable to the general female population with heart failure. Second, the research was limited to the data collected in the SOLVD trials and the variables contained therein. All data were taken at face value and were considered accurate; this assumption may not have been the case in all instances.

Summary

Heart failure imposes a great burden on quality of life. Women, as indicated by our findings, tend to have a poor quality of life in most dimensions. Further research is needed to determine why women with heart failure have such poor quality of life compared with that of other populations and to test interventions to improve quality of life. Quality of life may be less valued by clinicians who focus more heavily on improving survival in patients with heart failure. However, Rector et al (40) found that a substantial number of patients with heart failure were willing to accept a risk of drug-induced death for improved quality of life. Clinicians and those who design disease management programs need to focus not only on reducing the number of hospital readmissions and increasing physical functioning and survival but also on improving the psychosocial aspects of quality of life in women with heart failure.

Table 1 Sociodemographics and clinical data of women in

this study (N=691) *

No. of

Characteristics patients % Mean SD

Age, years 691 60.65 10.48

Ethnic background

African American 144 20.84

Asian 1 0.14

White 521 75.40

Hispanic 21 3.04

Native American 2 0.29

Other 2 0.29

Education, years 10.86 3.02

History of smoking 402 58.18

Smoker at a time of 124 17.94

entry in study

Severity of heart

failure

Ejection fraction 691 0.27 0.72

New York Heart 691 1.97 0.72

Association class

Cause of ischemia 453 65.66

Comorbid conditions

Comorbidity score 691 0.98 0.70

History of myocardial 423 61.22

infarction

History of diabetes 180 26.05

mellitus

History of chronic 49 7.09

obstructive

pulmonary disease

History of stroke 51 7.38

Symptomatic 437 63.24

congestive heart

failure

Symptoms

Chest pain 308 44.60

Dyspnea 480 69.50

Dizziness 305 44.10

Medications at

baseline

Taking vasolidators 365 52.82

Taking diuretics 447 64.69

Taking digitalis 302 43.70

Taking other 6 0.87

inotropic agents

Taking [beta]-blockers 87 12.59

* Empty cells indicate not applicable.

Table 2 Quality of life of women with heart failure (N = 691) *

No. of Score

Dependent variables patients Mean SD %

Current life situation 663 6.36 2.35

Life satisfaction, 689

general

Extremely satisfied 72 10.45

Very satisfied most of 157 22.79

the time

Generally satisfied 221 32.08

Mixed 186 27.00

Generally dissatisfied 38 5.52

Extremely dissatisfied 15 2.18

Physical functioning

Vigor 673 14.30 6.62

Activities of daily

living

Basic 684 91.90 14.41

Intermediate 673 30.77 13.52

Interference with 683

activities

Yes, definitely so 107 15.67

For the most part 215 31.48

Health problems 249 36.46

limited me

Can only take care 47 6.88

of self

Need help taking 30 4.39

care of self

Need help with 35 5.12

most or all

Emotional distress

Anxiety 670 9.13 6.65

Depression 667 7.05 9.57

Social health

Social activity 601 77.72 29.47

Social life satisfaction 688

Very satisfied 168 24.42

Fairly satisfied 286 41.57

Neutral or mixed 133 19.33

feelings

Somewhat dissatisfied 64 9.30

Very dissatisfied 37 5.38

Perceived health, 688 3.45 0.92

general

* Empty cells indicate no data or not applicable.

Table 3 Comparisons of quality of life of women with heart failure

with that other populations *

Age,

Women mean,

Dependent variables, quality of life domains n % years

Current life situation

SOLVD trials, women 663 – –

Ladder of Life norm, women (11) 1406 100 –

Physical Functioning, vigor ([dagger])

SOLVD trials, women 673 – –

Normative women (12) 250 100 62

Patients in antihypertensive study (13) 540 43 54

Elderly cancer patients (14) 100 67 73

Physical functioning, basic ADL

SOLVD Trials, women 684 – –

Geriatric subjects, community dwelling (15) 40 83 73

Nongeriatric subjects, community dwelling (15) 40 72 42

Hospitalized older adults (16) 1889 57 76

Patients with Parkinson disease (17) 193 42 68

Patients with COPD (18) 154 64 59

Physical functioning, intermediate ADL

SOLVD Trials, women 673 – –

Geriatric subjects, community dwelling (15) 40 83 73

Nongeriatric subjects, community dwelling (15) 40 72 42

Hospitalized older adults (16) 1889 57 76

Patients with Parkinson disease (17) 193 42 68

Patients with COPD (18) 154 64 59

Emotional distress, anxiety

SOLVD trials, women 670 – –

Normative women (12) 250 100 62

Geriatric subjects (19) 186 69 76

Patients in antihypertensive study (13) 540 43 54

Elderly cancer patients (14) 100 67 73

Cancer patients enrolled in a brief 156 71 49

psychoeducational program (20)

Women, 1 month after acute myocardial

infarction (21) 32 100 –

Women, 4 months after acute myocardial

infarction (21) 32 100 –

Patients with COPD (22) 143 38 68

Emotional distress, depression

SOLVD trials, women 667 – –

Normative women (12) 250 100 62

Geriatric subjects (19) 186 69 76

Patients in antihypertensive study (13) 540 43 54

Elderly cancer patients (14) 100 67 73

Cancer patients enrolled in a brief 156 71 49

psychoeducational program (20)

Women, 1 month after acute myocardial

infarction (21) 32 100 –

Women, 4 months after acute myocardial

infarction (21) 32 100 –

Patients with COPD (22) 143 38 68

Functional status questionnaire, social activity

SOLVD trials, women 601

Patients with Parkinson disease (17) 193 42 68

Patients with COPD (18) 154 64 59

Hospitalized older adults (16) 1889 57 76

Perceived health, general health

SOLVD trials, women 688 – –

Medical Outcomes Study, norms for men and

women (23) 2474 53 58

Medical Outcomes Study, norms for

women (23) 1412 100 58

Medical Outcomes Study, patients with CHF (23) 216 52 67

Medical Outcomes Study, patients with

hypertension (23) 2089 59 59

Medical Outcomes Study, patients with type 2 541 42 68

diabetes mellitus (23)

Medical Outcomes Study, patients with recent acute 107 31 59

myocardial infarction (23)

Medical Outcomes Study, patients with COPD (23) 85 64 62

Patients with Parkinson disease (17) 193 42 68

Score

Dependent variables, quality of life domains Mean SD

Current life situation

SOLVD trials, women 6.35 2.35

Ladder of Life norm, women (11) 7.64 2.05

Physical Functioning, vigor ([dagger])

SOLVD trials, women 14.31 6.62

Normative women (12) 19.50 5.95

Patients in antihypertensive study (13) 18.67 5.80

Elderly cancer patients (14) 13.55 6.94

Physical functioning, basic ADL

SOLVD Trials, women 91.84 14.47

Geriatric subjects, community dwelling (15) 93.80 11.10

Nongeriatric subjects, community dwelling (15) 93.80 12.60

Hospitalized older adults (16) 89.00 18.40

Patients with Parkinson disease (17) 71.50 1.70

Patients with COPD (18) 83.30 18.0

Physical functioning, intermediate ADL

SOLVD Trials, women 30.73 13.50

Geriatric subjects, community dwelling (15) 77.9 21.5

Nongeriatric subjects, community dwelling (15) 83.80 23.40

Hospitalized older adults (16) 63.60 31.40

Patients with Parkinson disease (17) 64.50 2.00

Patients with COPD (18) 56.20 24.40

Emotional distress, anxiety

SOLVD trials, women 9.12 6.65

Normative women (12) 3.13 5.78

Geriatric subjects (19) 7.05 5.24

Patients in antihypertensive study (13) 6.77 5.47

Elderly cancer patients (14) 7.39 5.96

Cancer patients enrolled in a brief 8.50 7.66

psychoeducational program (20)

Women, 1 month after acute myocardial

infarction (21) 11.80 7.20

Women, 4 months after acute myocardial

infarction (21) 8.40 6.60

Patients with COPD (22) 34.53 21.30

Emotional distress, depression

SOLVD trials, women 7.05 9.57

Normative women (12) 4.80 6.10

Geriatric subjects (19) 6.89 8.29

Patients in antihypertensive study (13) 4.47 6.57

Elderly cancer patients (14) 12.45 11.19

Cancer patients enrolled in a brief 12.31 10.38

psychoeducational program (20)

Women, 1 month after acute myocardial

infarction (21) 10.60 9.30

Women, 4 months after acute myocardial

infarction (21) 8.10 9.10

Patients with COPD (22) 19.92 18.68

Functional status questionnaire, social activity

SOLVD trials, women 77.16 29.46

Patients with Parkinson disease (17) 73.40 2.10

Patients with COPD (18) 64.80 32.80

Hospitalized older adults (16) 79.70 31.30

Perceived health, general health

SOLVD trials, women 38.84 22.93

Medical Outcomes Study, norms for men and

women (23) 71.95 20.34

Medical Outcomes Study, norms for women (23) 70.61 21.50

Medical Outcomes Study, patients with CHF (23) 47.05 24.17

Medical Outcomes Study, patients with

hypertension (23) 63.30 19.69

Medical Outcomes Study, patients with type 2 56.11 21.12

diabetes mellitus (23)

Medical Outcomes Study, patients with recent acute 59.17 19.34

myocardial infarction (23)

Medical Outcomes Study, patients with COPD (23) 45.29 18.94

Patients with Parkinson disease (17) 52.90 1.50

Dependent variables, quality of life domains t P

Current life situation

SOLVD trials, women – –

Ladder of Life norm, women (11) -12.13 <.001

Physical Functioning, vigor ([dagger])

SOLVD trials, women – –

Normative women (12) -1.85 <.05

Patients in antihypertensive study (13) -12.21 <.001

Elderly cancer patients (14) 1.03 .20

Physical functioning, basic ADL

SOLVD Trials, women – –

Geriatric subjects, community dwelling (15) -1.07 .15

Nongeriatric subjects, community dwelling (15) -0.95 .20

Hospitalized older adults (16) 4.08 <.001

Patients with Parkinson disease (17) 35.90 <.001

Patients with COPD (18) 5.50 <.001

Physical functioning, intermediate ADL

SOLVD Trials, women – –

Geriatric subjects, community dwelling (15) 13.72 <.001

Nongeriatric subjects, community dwelling (15) -14.20 <.001

Hospitalized older adults (16) -36.92 <.001

Patients with Parkinson disease (17) -62.55 <.001

Patients with COPD (18) -12.52 <.001

Emotional distress, anxiety

SOLVD trials, women – –

Normative women (12) 13.41 <.001

Geriatric subjects (19) 4.47 <.001

Patients in antihypertensive study (13) 6.74 <.001

Elderly cancer patients (14) 2.67 <.001

Cancer patients enrolled in a brief 0.93 <.005

psychoeducational program (20)

Women, 1 month after acute myocardial

infarction (21) -2.06 <.02

Women, 4 months after acute myocardial

infarction (21) 0.60 .20

Patients with COPD (22) -14.12 <.001

Emotional distress, depression

SOLVD trials, women – –

Normative women (12) 4.85 <.001

Geriatric subjects (19) 0.51 .50

Patients in antihypertensive study (13) -0.90 .20

Elderly cancer patients (14) -4.58 <.001

Cancer patients enrolled in a brief -5.78 <.001

psychoeducational program (20)

Women, 1 month after acute myocardial

infarction (21) -2.11 <.02

Women, 4 months after acute myocardial

infarction (21) -0.64 .50

Patients with COPD (22) -8.02 <.001

Functional status questionnaire, social activity

SOLVD trials, women – –

Patients with Parkinson disease (17) 3.10 <.001

Patients with COPD (18) 4.26 <.001

Hospitalized older adults (16) -1.81 <.05

Perceived health, general health –

SOLVD trials, women – –

Medical Outcomes Study, norms for men and

women (23) -26.14 <.001

Medical Outcomes Study, norms for women (23) -23.40 <.001

Medical Outcomes Study, patients with CHF (23) -1.90 <.05

Medical Outcomes Study, patients with

hypertension (23) -18.08 <.001

Medical Outcomes Study, patients with type 2 -9.35 <.001

diabetes mellitus (23)

Medical Outcomes Study, patients with recent acute -7.42 <.001

myocardial infarction (23)

Medical Outcomes Study, patients with COPD (23) -0.83 .20

Patients with Parkinson disease (17) -9.33 <.001

* Dashes indicate not applicable or no data.

([dagger]) With the exception of vigor, the higher the score, the

greater was mood disturbance or distress.

ADL indicates activities of daily living; CHF, congestive heart

failure; COPD, chronic obstructive pulmonary disease.

Reprint requests: Dr Mary S. Riedinger, Cedars-Sinai Medical Center, 8631 W Third St, Suite 800E, Los Angeles, CA 90048.

* A complete list of the SOLVD investigators has been published (N Engl J Med. 1992;327:685-691).

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By Mary S. Riedinger, RN. PhD, Kathleen A. Dracup, RN. DNSc, and Mary-Lynn Brecht, PhD, for the SOLVD Investigators. * From Cedars-Sinai Medical Center, Los Angeles, Calif (MSR), University of California, Los Angeles, School of Nursing (FAD), and University of California, San Francisco, School of Nursing (MLB).

COPYRIGHT 2002 American Association of Critical-Care Nurses

COPYRIGHT 2003 Gale Group