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Improved health-related quality of life 12 months after bypass or angioplasty for peripheral arterial disease
Vol. XVIII No. 3
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Improved health-related quality of life 12 months after bypass or angioplasty for peripheral arterial disease Carol C. Donaghue, RN, BSN, RVT, Richard W. Bohannon, EdD, PT, NCS, Rose Maljanian, RN, MBA, Linda Frigon, RN, MSN, Sheryl Horowitz, PhD, and Angela McGovern, RN, BSN, CVN
Revascularization procedures are known to have a favorable influence on multiple outcomes for patients with peripheral arterial disease. Their affect on health-related quality of life (HRQOL) is less certain. This study was conducted to document changes in HRQOL associated with revascularization procedures and to identify variables associated with HRQOL and changes in HRQOL 12 months after revascularization. Forty-four patients undergoing arterial bypass or angioplasty improved significantly in their HRQOL as measured by the physical component summary (PCS) and mental component summary (MCS)scales of the SF-12. These measurements of HRQOL at 12 months were most highly correlated with the same measures at baseline. For the 12-month PCS, regression analysis showed that a higher baseline PCS, a greater improvement in vascular status, and a higher baseline MCS were predictive of higher scores. For the change in PCS, regression analysis revealed that men with lower baseline PCS scores showed the greatest improvements. Higher 12-month MCS but lesser changes in MCS were shown by regression analysis to be predicted by a higher baseline MCS. Obesity contributed positively to 12-month MCS but negatively to MCS change. In conclusion, the results of this study verify that HRQOL can be improved by revascularization procedures, but that HRQOL at 12 months and improvement in HRQOL are determined by baseline measures. (J Vasc Nurs 2000;18:75-82)
Carol C. Donaghue, RN, BSN, RVT, is the technical director, Noninvasive Vascular Laboratory Section, Jefferson X-Ray; formerly, nurse manager, Vascular Laboratory, Hartford Hospital. Richard W. Bohannon, EdD, PT, NCS, is a senior scientist, Institute of Outcomes Research, Hartford Hospital, and professor, School of Allied Health, University of Connecticut. Rose Maljanian, RN, MBA, is director, Institute of Outcomes Research, Hartford Hospital. Linda Frigon, RN, MSN, is the director of Surgical Nursing, Hartford Hospital. Sheryl Horowitz, PhD, is a senior scientist, Institute of Outcomes Research, Hartford Hospital. Angela McGovern, RN, BSN, CVN, is a surgical nurse, Hartford Hospital. Supported in part by a small grant from the Hartford Hospital Research Committee. Address reprint requests to Dr Richard W Bohannon, PT, NCS, Institute of Outcomes Research and Evaluation, Hartford Hospital, 80 Seymour St, Hartford, CT 06102. Copyright © 2000 by the Society for Vascular Nursing, Inc. 1062-0303/2000/$12.00 + 0 40/1/109329 doi:10.1067/mvn.2000.109329
Peripheral arterial disease (PAD) is a serious problem with consequences in the lower extremities, which range from intermittent claudication to ulceration, gangrene, and amputation. A PAD of sufficient severity to result in intermittent claudication affects about 1.8% of the population younger than 60 years, 3.7% of the population of age 60 to 70 years, and 5.2% of the population older than 70 years.1 Early in its course, PAD can be treated by lifestyle changes (principally smoking cessation by cigarette smokers and weight reduction by persons who are overweight),2,3 exercise,4-7 and pharmocologic therapy.8,9 As PAD progresses, invasive vascular procedures are often warranted. Primary among these procedures are arterial bypass and angioplasty. The outcomes of both procedures have been studied extensively, most often by using survival, limb salvage, ulcer healing, and arterial or bypass patency as outcome variables.10-28 Measures of pain, function, or health-related quality of life (HRQOL) have been used also, but less often.10,11,14,16,28,29 Because they are based on patients’ perspectives of their own health, HRQOL measures characterize an important outcome and are well suited for patients with PAD.30 However, little is known about the effects of vascular procedures on HRQOL among patients with PAD. Therefore, the purposes of this study were to (1) determine whether HRQOL measured 12 months after bypass or angioplasty is significantly greater than at baseline (preoperatively), and (2) discover which selected variables predict HRQOL and improvements in HRQOL at 12 months. METHODS
Subjects Patients with chronic limb ischemia were eligible to participate in this study if they provided informed consent, received vascular studies, completed a baseline HRQOL questionnaire, and underwent subsequent bypass or angioplasty for PAD at Hartford Hospital. Of 111 eligible patients, 44 also completed a HRQOL questionnaire 12 months after the vascular procedure and are included as subjects in this study. These subjects had ages of 55 to 88 (71 ± 9.1) years. Thirty-nine (79.6%) were white. Twenty-two (50.0 %) were men. Nine (20.5%) underwent angioplasty and 35 (79.5%) underwent bypass.
Instrumentation and Procedures The outcome variable in this study, HRQOL 12 months after vascular procedure, was quantified by using the SF-12.31 The SF-12 was also used to quantify HRQOL at baseline. Physical component summary (PCS) and mental component summary
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TABLE I.
TABLE II.
SUMMARY OF HRQOL (SF-12) OUTCOME MEASUREMENTS
NUMBER OF PATIENTS (OF 44) WHO POSSESSED DOCUMENTED COMORBIDITIES/RISK FACTORS AND AHCORS CATEGORY SCORES
Measurement PCS norm (65-74)* PCS norm (75+)* PCS baseline PCS 12 month PCS change† MCS norm(65-74)* MCS norm (75+)* MCS baseline MCS 12 month MCS change‡
Mean 43.6 38.7 32.7 37.3 4.6 52.1 50.1 45.8 50.8 5.0
Median
32.1 36.3 4.2
45.3 51.6 5.0
SD 11.0 11.0 9.5 11.0 9.7 9.5 10.9 13.2 11.1 13.9
Range 13.0-59.0 17.0-57.0 15.6-56.1 18.8-56.6 –18.5-31.1 19.0-70.0 22.0-69.0 13.9-66.4 31.0-69.4 –24.0-47.3
*Normative values are for the general United States population (age ranges in parentheses) and are taken from Ware et al.31 †The change between baseline and 12 months is significant (t = 3.074, P = .004). ‡The change between baseline and 12 months is significant (t = 2.387, P = .021).
(MCS) scale scores were calculated for the SF-12 at both baseline and 12 months31; improvement scores were derived by subtracting baseline from 12-month summary scale scores. Previous research has shown that both the PCS and MCS scores possess test-retest reliability. Test-retest reliability coefficients for the PCS have been reported to be .89 and .88 for samples of subjects in the United States and the United Kingdom, respectively. Corresponding reliability coefficients for the MCS have been reported to be .76 and .78, respectively.31 Discriminant construct and criterion validity have also been claimed for the PCS and MCS summary scale scores of the SF-12.31 Predictor variables other than demographics and type of procedure that were measured included comorbidities/risk factors, baseline class of limb ischemia, and change in vascular status and patency at 12 months. Comorbidities/risk factors documented (present [coded –1]/absent [coded 0]) were cigarette smoking, morbid obesity, chronic lung disease, diabetes status (noninsulin dependent/insulin dependent), hypertension, congestive heart failure, and myocardial infarction within 1 year. Limb ischemia, change in vascular status, and patency were measured in accordance with the recommendations of the Ad Hoc Committee on Reporting Standards (AHCORS) of the Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery.32 Specifically, limb ischemia was quantified as follows: 0 (asymptomatic), 1 (mild claudication), 2 (moderate claudication), 3 (severe claudication), 4 (ischemic rest pain), 5 (minor tissue loss), and 6 (major tissue loss). Change in vascular status was rated on the basis of another 7-level ordinal scale: 1 (markedly improved), 2 (moderately improved), 3 (minimally improved), 4 (no change), 5 (mildly worse), 6 (moderately
Variable Smoking Morbid obesity Lung disease NIDDM IDDM NIDDM or IDDM Hypertension Congestive heart failure Myocardial infarction Ischemia classification 2 (moderate claudication) 3 (severe claudication) 4 (ischemic rest pain) 5 (minor tissue loss) Graft patency Vascular improvement 1 (improved) 2 (little change) 3 (worse)
Number 18 6 4 12 12 24 39 1 1
Percentage 40.9 13.6 9.1 27.3 27.3 54.5 88.7 2.3 2.3
9 10 10 15 35
20.5 22.7 22.7 34.1 79.5
19 10 15
43.2 22.7 34.1
NIDDM, Non–insulin-dependent diabetes mellitus; IDDM, insulin-dependent diabetes mellitus.
worse), and 7 (markedly worse). However, these categories were collapsed into 3: improved (1-2), little change (3-5), and worse (6-7). Patency was judged on the basis of the 5 AHCORS criteria.
Statistical Analysis Statistical analysis was conducted by using the SPSS (10.0) and Systat (8.0) statistical programs (SPSS, Chicago, Ill). After the calculation of descriptive statistics, paired t tests were used to determine if there was a significant difference between baseline and 12-month PCS summary scale scores and between baseline and 12-month MCS summary scale scores. Zero order correlations (Pearson and Spearman) were used initially to examine the relationships between the outcome and predictor variables. Because the magnitude of these correlations did not differ appreciably, only Pearson correlations are reported. Multiple regression was used to determine whether multiple independent variables might be superior to individual independent variables for predicting outcome. Dichotomous variables with fewer than 6
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cases in a category (eg, congestive heart failure) were excluded from the multiple regression analysis. RESULTS Table I summarizes the HRQOL measurements. The mean PCS and MCS summary scale scores increased 4.6 and 5.0 points, respectively, between baseline and 12 months. These increases represent improvements of approximately 13.8% and 10.9%, respectively, between baseline and 12 months. Both of these increases were significant (P < .05). The effect sizes associated with these increases were small to medium (PCS = .47, MCS = .38). Table II summarizes the proportion of subjects with comorbidities/risk factors and the distribution of their AHCORS measurements. Few of the selected predictor variables were correlated significantly with HRQOL outcomes (Table III). For the PCS scores at 12 months, the PCS baseline score was most highly correlated (r = 0.547, P < .001), but baseline ischemia class and improvement in vascular status at 12 months were also correlated significantly. These correlations indicate that patients with higher PCS scale scores at 12 months tended to be those with higher PCS scores at baseline, less ischemia at baseline, and improved vascular status at 12 months. For the MCS scores at 12 months, only the MCS baseline scores were significant predictors. For the improvement in PCS score, the PCS baseline score was correlated most strongly, but gender was also a significant predictor. These correlations indicate that patients improving the most in their PCS scores were men who had lower PCS scores at baseline. For the change in MCS, only the MCS baseline and obesity scores were correlated significantly. Table IV summarizes the results of the regression analyses. For the PCS score at 12 months and the PCS improvement score, multiple regression demonstrated that multiple independent variables provided a better prediction than did any single independent variable. Specifically, the regression analysis indicated that higher PCS scores were realized at 12 months by patients with higher PCS baseline scores, higher MCS baseline scores, and more vascular improvement. Together, these variables explained 41.8% of the variance in the 12-month PCS score. Regression analysis demonstrated the greatest improvements in PCS scores occurred in male patients who had lower baseline PCS scores. Together, these variables explained 23.9% of the variance in the improvement in the PCS score. Multiple regression found MCS outcome scores to be predicted best by a combination of MCS baseline scores and obesity. Higher baseline MCS scores had a positive influence on 12-month MCS scores but a negative influence on MCS change scores. Obesity negatively influenced both 12month MCS scores and MCS change scores. DISCUSSION Although HRQOL measures have been advocated for use with patients with PAD who undergo revascularization procedures,30 we know of no previously published studies addressing HRQOL both before and after revascularization. Studies addressing the HRQOL of patients with PAD have typically been limited to patients who have not yet undergone revasculariza-
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TABLE III. PEARSON CORRELATIONS BETWEEN SELECTED PREDICTOR VARIABLES* AND HRQOL (SF-12) OUTCOME VARIABLES Predictor variable Age Sex Race† Smoking Morbid obesity Lung disease† NIDDM IDDM NIDDM or IDDM Hypertension† Congestive heart failure† Myocardial infarction (recent)† Ischemia classification Procedure PCS baseline MCS baseline Patency Vascular improvement
PCS 12 –0.120 –0.256 –0.065 –0.023 0.171 –0.016 0.084 0.208 –0.226
MCS 12 0.073 –0.103 0.141 –0.154 –0.267 –0.060 0.162 –0.214 0.020
PCS change –0.010 –0.352 –0.062 –0.017 0.021 –0.186 0.070 –0.247 –0.186
MCS change –0.228 –0.292
0.257 –0.216
–0.148 –0.162
0.211 –0.061 –0.124 –0.089
–0.043
–0.173
–0.076 –0.150
–0.386 0.058 0.547 0.166 0.171 –0.390
–0.037 0.273 0.002 0.354 0.010 0.041
–0.217 –0.083 0.172 0.116 –0.353 0.038 0.226 -0.664 0.042 –0.025 –0.194 –0.146
0.255 –0.130 –0.323 0.045 –0.078 –0.166 0.173
*Correlations significant at P < .05 are underlined (for 80% power a correlation must be ≥.400), correlations significant at P < .01 are in italics, correlations significant at P < .001 are in bold. †The
small number of cases (≤5) falling into one category of these dichotomous vari-
ables render correlations suspect.
tion33 or to patients who have already undergone revascularization.13,16,24,34 We sought in this study to address HRQOL both before and after angioplasty or bypass by using a quickly administered measure of HRQOL, that is, the SF-12. The mean PCS and MCS baseline scores of the patients of this study were lower than those of the general elderly population of the United States (Table I).31 The mean PCS and MCS baseline scores were also lower than those of patients with other chronic conditions (hypertension, congestive heart failure, myocardial infarction, type II diabetes).31 Whereas this difference may mean that PAD has a greater influence on HRQOL than do other chronic conditions, the nature and size of our sample preclude definitive conclusions. This study showed that patients’ HRQOL improved 12 months after, compared with before, bypass or angioplasty. It is
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TABLE IV. RESULTS OF REGRESSION ANALYSIS MODELS BEST PREDICTING HRQOL (SF-12) OUTCOMES Outcome variable PCS 12 month
Predictor variable PCS baseline Vascular improvement MCS baseline
R 0.547 0.601 0.646
R2 0.299 0.361 0.418
PCS change
PCS baseline Sex
0.353 0.489
0.125 0.239
MCS 12 month
MCS baseline Obesity
0.354 0.471
MCS change
MCS baseline Obesity
0.664 0.709
interesting that these improvements were not limited to the PCS, which might be expected to be affected more by a procedure aimed at a physiologic problem. Whereas HRQOL has been shown to improve in other diagnostic groups after interventions,35,36 our review of the literature did not reveal any studies showing such improvement in patients with PAD who underwent revascularization procedures. The detection by the SF-12 of improvements in HRQOL after revascularization supports both the value of the bypass and angioplasty procedures and the responsiveness of the SF-12 for patients undergoing revascularization procedures. Not all patients undergoing revascularization procedures ended up the same in regard to HRQOL. Whether on the basis of zero order correlations or regression analysis, patients with the highest HRQOL at 12 months were those with the highest HRQOL before revascularization. This finding is consistent with other studies showing that other measures of status 6 months after arterial bypass are predicted by status before bypass.10,11 However, other variables also contributed to the prediction of physical aspects of HRQOL. It is logical that ischemia classification and vascular improvement would be related to the PCS scores of the HRQOL. The physical burden associated with obesity would explain its having an influence on the 12-month PCS scores (but it did not); the basis of its measurable affect on the MCS scores of the HRQOL is unclear. Whereas knowing if and how much patients improve is important, knowing what contributes to their improvement can also be important. Here again, HRQOL at baseline was important. However, in this case patients with lower HRQOL improved more. This finding is important. It indicates that even if patients with lower HRQOL do not end up with as high a HRQOL after revascularization, they do realize a greater benefit. The finding that improved vascular status predicted improved HRQOL is encouraging. It indicates that the benefits of revascularization procedures are not limited to the physiologic; they
Adjusted R2 0.283 0.330 0.374
F change 17.944 3.940 3.905
F (prob) <.001 .054 .055
0.104 0.202
5.985 6.150
.019 .017
0.125 0.222
0.104 0.184
6.017 5.066
.018 .030
0.441 0.502
0.427 0.478
33.069 5.066
.001 .030
generalize to more global indicators of patients’ health status. Studies of the general population of the United States reveal that men tend to have slightly higher PCS and MCS scores than women,31 but this finding does not address “improvements” in HRQOL. Perhaps men and women also view changes in HRQOL differently. The reason obesity contributed negatively to changes in the MCS but not the PCS cannot be discerned from the study data. This study supports the usefulness of the SF-12 for monitoring HRQOL in patients undergoing revascularization procedures for PAD. The HRQOL instrument was shown to be useful for predicting outcome in spite of the small sample. This sample’s nonrandom representation of only 39.6% of the eligible patients is a weakness. It must be acknowledged that the mean baseline PCS score of the 44 subjects in the sample studied (32.7) differed from that of the 67 excluded subjects (28.2). The PCS of the sample subjects was significantly higher (P = .007). That this may have influenced the results cannot be discounted. On the other hand, the mean baseline MCS score did not differ significantly (45.7 vs 48.7, P = .231). The baseline ischemia classification of the 44 subjects also did not differ significantly (P =.124) from that of the other 67 patients. The small sample also limited the number of potential predictor variables that were found to be significantly correlated with HRQOL outcome variables. Countering this fact was the large number of correlations calculated, which increased the likelihood of finding a correlation that was significant at P < .05. (With 72 correlations, 3.6 [72 × .05] might be significant by chance.) The aforementioned notwithstanding, correlations that were not significant were not of great magnitude and would not have explained much variance. The correlations that were significant had acceptable power and explained a notable amount of variance in outcome. Thus whereas a larger and more complete sample and use of a stricter α (eg, P < .01) might be preferable, we believe our results are instructive to clinicians involved with patients undergoing revascularization for
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PAD. As a result of this study, nurses working with patients can have some confidence that the benefits of revascularization procedures are not solely physiologic; they extend to HRQOL. However, nurses’ expectations may require adjustment on the basis of patient specifics. The SF-12 appears to have sufficient responsiveness to recommend it as an outcome measure among such patients. We gratefully acknowledge the assistance of Louise Reagan, APRN, in the early design phase of the study. REFERENCES 1. McDaniel MD, Cronenwett JL. Basic data related to the natural history of intermittent claudication. Ann Vasc Surg 1989;3:273-7. 2. Quick CRG, Cotton LT. The measured effect of stopping smoking on claudication. Br J Surg 1982;69:524-6. 3. Wyatt MG, Scott PMJ, Scott OJA, et al. Effect of weight on claudication distance. Br J Surg 1991;78:1386-8. 4. Perkins JMT, Collin J, Creasy TS, et al. Eur J Vasc Endovasc Surg 1996;11:409-13. 5. Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg 1996;23:104-15. 6. Womack CJ, Sieminski DJ, Katzel LI, et al. Improved walking economy in patients with peripheral arterial disease. Med Sci Sports Exerc 1997;29:1286-90. 7. Patterson RB, Pinto B, Marcus B, et al. Value of a supervised exercise program for the therapy of arterial claudication. J Vasc Surg 1997;25:312-9. 8. Hood SC, Moher D, Barber GG. Management of intermittent claudication with pentoxi-fyeline: meta analysis of randomized controlled trials. Can Med Assoc J 1996;155:1053-9. 9. Money SR, Herd JA, Isaacsohn JL, et al. Effect of cilostazol on walking distances in patients with intermittent claudication caused by peripheral vascular disease. J Vasc Surg 1998;27:267-75. 10. Abou-Zamzam AM, Lee RW, Moneta GL, et al. Functional outcome after infrainguinal bypass for limb salvage. J Vasc Surg 1997;25:287-97. 11. Gibbons GW, Burgess AM, Guadagnoli E, et al. Return to well-being and function after infrainguinal revascularization. J Vasc Surg 1995;21:35-45. 12. Pomposelli FB, Arara S, Gibbons GW, et al. Lower extremity arterial reconstruction in very elderly: successful outcome preserves not only the limb but also residential status and ambulatory function. J Vasc Surg 1998;28:215-25. 13. Schieder JR, McHorney CA, Malenka DJ, et al. Functional health and well-being in patients with severe atherosclerotic peripheral vascular occlusive disease. Ann Vasc Surg 1993;7:419-26. 14. Nicoloff AD, Taylor LM, McLafferty RB, et al. Patient recovery after infrainguinal bypass grafting for limb salvage. J Vasc Surg 1998;27:256-66. 15. Reifsnyder T, Grossman JP, Leers SA. Limb loss after lower
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extremity bypass. Am J Surg 1997;174:149-51. 16. Holtzman J, Caldwell M, Walvatre C, et al. Long-term functional status and quality of life after lower extremity revascularization. J Vasc Surg 1999;29:395-402. 17. Watelet J, Soury P, Menard J-F, et al. Femoropopliteal bypass: insitu or reversed vein grafts? Ten year results of a randomized prospective study. Ann Vasc Surg 1997;11:510-9. 18. Debus ES, Timmermann W, Sailer M, et al. Arterial reconstruction on diabetes and peripheral arterial occlusive disease: results in 192 patients. Vasa 1998;27:240-3. 19. Biancari F, Alback A, Ihlberg L, et al. Angiographic run off score as a predictor of outcome following femoromural bypass surgery. Eur J Vasc Surg 1999;17:480-5. 20. Watson HR, Schrooder TV, Simms MH, et al. Relationship of femorodistal bypass patency to clinical outcome. Eur J Vasc Endovasc Surg 1999;17:77-83. 21. Martin DR, Katz SG, Kohl RD, et al. Percutaneous transluminal angioplasty of infrainguinal vessels. Ann Vasc Surg 1999;13:184-7. 22. Spence LD, Hartnelln GG, Reinking G, et al. Diabetic versus nondiabetic limb threatening ischemia: outcome of percutaneous iliac intervention. Am J Radiology 1999;172: 1335-41. 23. Hakaim AG, Gordon JK, Scott TE. Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end stage renal failure: analysis of 83 limbs. J Vasc Surg 1998;27:1049-55. 24. Cavillon A, Melliere D, Allaire E, et al. Are femoroinfrapopliteal bypasses worthwhile for limb salvage. J Cardio Vasc Surg 1998;39:267-72. 25. Peltoner S, Biancari F, Lindgren L, et al. Outcome of infrainguinal bypass surgery for critical leg ischaemia in patients with chronic renal failure. Eur J Vasc Endovasc Surg 1998;15:122-7. 26. Wilson SE, Wolf GL, Cross AP. Percutaneous transluminal angioplasty versus operation for peripheral arteriosclerosis. J Vasc Surg 1989;9:1-9. 27. Matsi PJ, Manniner HI, Suhoner MT, et al. Chronic critical lower-limb ischemia: prospective trial of angioplasty with 136 months follow-up. Radiology 1993;188:381-7. 28. Seabrook GR, Cambria RA, Freischlag JA, et al. Healthrelated quality of life and functional outcome following arterial reconstruction for limb salvage. Cardiovasc Surg 1999;7:279-86. 29. Reifler DR, Feinglass J, Slavensky R, et al. Functional outcomes for patients with intermittent claudication: bypass surgery versus angioplasty versus noninvasive management. J Vasc Med Biol 1994;5:203-11. 30. Murphy TP. Medical outcomes studies in peripheral vascular disease. J Vasc Intervent Radiol 1998;9:879-89. 31. Ware JE, Kosinski M, Keller SD. SF-12: how to score the SF12 physical and mental health summary scales. 2nd ed. Boston (MA): The Health Institute, New England Medical Center; 1995. 32. Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society
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for Cardiovascular Surgery. Suggested standards for reports dealing with lower extremity ischemia. J Vasc Surg 1986;4: 80-94. 33. Feinglass J, McCarthy WJ, Slavensky R, et al. Effect of lower extremity blood pressure on physical functioning in patients who have intermittent claudication. J Vasc Surg 1996;24:503-12. 34. Bruni KR, Hoosier-Paty DM, Hoffman GT. The quality of life of the limb threatened patient after lower-extremity
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revascularization. J Vasc Nurs 1996;14:99-103. 35. Engebretson TO, Clark MM, Niaura RS, et al. Quality of life and anxiety in a phase II cardiac rehabilitation program. Med Sci Sports Exerc 1999;31:216-33. 36. Cambach W, Chadwick-Straver RVM, Wagennar RC, et al. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Resp J 1997;10:104-13.
WRITING AWARD The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to create a publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascular nursing practice, and excellence of writing style. All feature articles published in the Journal of Vascular Nursing during the calendar year will be considered for the JVN Article Award. The award recipient will be given a plaque commemorating the award and a cash prize donated by Mosby. The award and cash prize will presented at the annual symposium. Annoucement of the award recipient will appear in the Journal of Vascular Nursing and in SVN...prn.
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Improved health-related quality of life 12 months after bypass or angioplasty for peripheral arterial disease Contact Hours: 1.0 Test Processing Fee: $10.00
Minimum Passing Score: 70% Test ID: JVN09
OBJECTIVES:
1. Identify changes in health-related quality of life (HRQOL) after revascularization procedures. 2. Identify variables that affect HRQOL after revascularization. 3. Discuss the impact of revascularization on HLQOL.
1. Peripheral artery disease can be treated by changes that include the following EXCEPT: a. smoking cessation b. social standing c. weight reduction d. pharmacologic therapy 2. Predictor variables used in this study did NOT include: a. risk factors b. classification of limb ischemia c. changes in vascular status and patency d. compliance with healthy behaviors 3. Comorbid risk factors used in this study were the following EXCEPT: a. chronic lung disease b. exercise patterns c. hypertension d. diabetes 4. Improved PCS scores were correlated with: a. gender b. obesity c. smoking d. congestive heart failure 5. Changes to MCS were correlated with: a. gender b. obesity c. smoking d. congestive heart failure 6. The greatest improvement in PCS scores using regression analysis was found in which group: a. females with improved vascular status at 12 months
b. females with lower ischemia at baseline c. males with lower baseline PCS scores d. males with lower ischemia at baseline 7. The greatest prediction in MCS outcome using regression analysis was: a. obesity negatively influenced baseline MCS scores b. low baseline MCS scores had a positive influ ence in 12 month MCS scores c. obesity positively influenced MCS change scores d. high baseline MCS scores had a negative influ ence on MCS change scores 8. Results of this study yielded: a. revascularization procedures provide only physiologic benefits b. the use of SF-12 to monitor HRQOL is not recommended c. the small sample size is a weakness to this study d. obesity does not affect outcome 9. Nearly 89% of the patients studied had which comorbid factor: a. smoking b. lung disease c. congestive heart failure d. hypertension 10. The comorbid variable that was the smallest in this study group was: a. hypertension b. diabetes c. myocardial infarction d. lung disease
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Improved health-related quality of life 12 months after bypass or angioplasty for peripheral arterial disease Carol C. Donaghue, RN, BSN, RVT, Richard W. Bohannon, EdD, PT, NCS, Rose Maljanian, RN, MBA, Linda Frigon, RN, MSN, Sheryl Horowitz, PhD, and Angela McGovern, RN, BSN, CVN
Revascularization procedures are known to have a favorable influence on multiple outcomes for patients with peripheral arterial disease. Their affect on health-related quality of life (HRQOL) is less certain. This study was conducted to document changes in HRQOL associated with revascularization procedures and to identify variables associated with HRQOL and changes in HRQOL 12 months after revascularization. Forty-four patients undergoing arterial bypass or angioplasty improved significantly in their HRQOL as measured by the physical component summary (PCS) and mental component summary (MCS)scales of the SF-12. These measurements of HRQOL at 12 months were most highly correlated with the same measures at baseline. For the 12-month PCS, regression analysis showed that a higher baseline PCS, a greater improvement in vascular status, and a higher baseline MCS were predictive of higher scores. For the change in PCS, regression analysis revealed that men with lower baseline PCS scores showed the greatest improvements. Higher 12-month MCS but lesser changes in MCS were shown by regression analysis to be predicted by a higher baseline MCS. Obesity contributed positively to 12-month MCS but negatively to MCS change. In conclusion, the results of this study verify that HRQOL can be improved by revascularization procedures, but that HRQOL at 12 months and improvement in HRQOL are determined by baseline measures. (J Vasc Nurs 2000;18:75-82)
Carol C. Donaghue, RN, BSN, RVT, is the technical director, Noninvasive Vascular Laboratory Section, Jefferson X-Ray; formerly, nurse manager, Vascular Laboratory, Hartford Hospital. Richard W. Bohannon, EdD, PT, NCS, is a senior scientist, Institute of Outcomes Research, Hartford Hospital, and professor, School of Allied Health, University of Connecticut. Rose Maljanian, RN, MBA, is director, Institute of Outcomes Research, Hartford Hospital. Linda Frigon, RN, MSN, is the director of Surgical Nursing, Hartford Hospital. Sheryl Horowitz, PhD, is a senior scientist, Institute of Outcomes Research, Hartford Hospital. Angela McGovern, RN, BSN, CVN, is a surgical nurse, Hartford Hospital. Supported in part by a small grant from the Hartford Hospital Research Committee. Address reprint requests to Dr Richard W Bohannon, PT, NCS, Institute of Outcomes Research and Evaluation, Hartford Hospital, 80 Seymour St, Hartford, CT 06102. Copyright © 2000 by the Society for Vascular Nursing, Inc. 1062-0303/2000/$12.00 + 0 40/1/109329 doi:10.1067/mvn.2000.109329
Peripheral arterial disease (PAD) is a serious problem with consequences in the lower extremities, which range from intermittent claudication to ulceration, gangrene, and amputation. A PAD of sufficient severity to result in intermittent claudication affects about 1.8% of the population younger than 60 years, 3.7% of the population of age 60 to 70 years, and 5.2% of the population older than 70 years.1 Early in its course, PAD can be treated by lifestyle changes (principally smoking cessation by cigarette smokers and weight reduction by persons who are overweight),2,3 exercise,4-7 and pharmocologic therapy.8,9 As PAD progresses, invasive vascular procedures are often warranted. Primary among these procedures are arterial bypass and angioplasty. The outcomes of both procedures have been studied extensively, most often by using survival, limb salvage, ulcer healing, and arterial or bypass patency as outcome variables.10-28 Measures of pain, function, or health-related quality of life (HRQOL) have been used also, but less often.10,11,14,16,28,29 Because they are based on patients’ perspectives of their own health, HRQOL measures characterize an important outcome and are well suited for patients with PAD.30 However, little is known about the effects of vascular procedures on HRQOL among patients with PAD. Therefore, the purposes of this study were to (1) determine whether HRQOL measured 12 months after bypass or angioplasty is significantly greater than at baseline (preoperatively), and (2) discover which selected variables predict HRQOL and improvements in HRQOL at 12 months. METHODS
Subjects Patients with chronic limb ischemia were eligible to participate in this study if they provided informed consent, received vascular studies, completed a baseline HRQOL questionnaire, and underwent subsequent bypass or angioplasty for PAD at Hartford Hospital. Of 111 eligible patients, 44 also completed a HRQOL questionnaire 12 months after the vascular procedure and are included as subjects in this study. These subjects had ages of 55 to 88 (71 ± 9.1) years. Thirty-nine (79.6%) were white. Twenty-two (50.0 %) were men. Nine (20.5%) underwent angioplasty and 35 (79.5%) underwent bypass.
Instrumentation and Procedures The outcome variable in this study, HRQOL 12 months after vascular procedure, was quantified by using the SF-12.31 The SF-12 was also used to quantify HRQOL at baseline. Physical component summary (PCS) and mental component summary
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TABLE I.
TABLE II.
SUMMARY OF HRQOL (SF-12) OUTCOME MEASUREMENTS
NUMBER OF PATIENTS (OF 44) WHO POSSESSED DOCUMENTED COMORBIDITIES/RISK FACTORS AND AHCORS CATEGORY SCORES
Measurement PCS norm (65-74)* PCS norm (75+)* PCS baseline PCS 12 month PCS change† MCS norm(65-74)* MCS norm (75+)* MCS baseline MCS 12 month MCS change‡
Mean 43.6 38.7 32.7 37.3 4.6 52.1 50.1 45.8 50.8 5.0
Median
32.1 36.3 4.2
45.3 51.6 5.0
SD 11.0 11.0 9.5 11.0 9.7 9.5 10.9 13.2 11.1 13.9
Range 13.0-59.0 17.0-57.0 15.6-56.1 18.8-56.6 –18.5-31.1 19.0-70.0 22.0-69.0 13.9-66.4 31.0-69.4 –24.0-47.3
*Normative values are for the general United States population (age ranges in parentheses) and are taken from Ware et al.31 †The change between baseline and 12 months is significant (t = 3.074, P = .004). ‡The change between baseline and 12 months is significant (t = 2.387, P = .021).
(MCS) scale scores were calculated for the SF-12 at both baseline and 12 months31; improvement scores were derived by subtracting baseline from 12-month summary scale scores. Previous research has shown that both the PCS and MCS scores possess test-retest reliability. Test-retest reliability coefficients for the PCS have been reported to be .89 and .88 for samples of subjects in the United States and the United Kingdom, respectively. Corresponding reliability coefficients for the MCS have been reported to be .76 and .78, respectively.31 Discriminant construct and criterion validity have also been claimed for the PCS and MCS summary scale scores of the SF-12.31 Predictor variables other than demographics and type of procedure that were measured included comorbidities/risk factors, baseline class of limb ischemia, and change in vascular status and patency at 12 months. Comorbidities/risk factors documented (present [coded –1]/absent [coded 0]) were cigarette smoking, morbid obesity, chronic lung disease, diabetes status (noninsulin dependent/insulin dependent), hypertension, congestive heart failure, and myocardial infarction within 1 year. Limb ischemia, change in vascular status, and patency were measured in accordance with the recommendations of the Ad Hoc Committee on Reporting Standards (AHCORS) of the Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery.32 Specifically, limb ischemia was quantified as follows: 0 (asymptomatic), 1 (mild claudication), 2 (moderate claudication), 3 (severe claudication), 4 (ischemic rest pain), 5 (minor tissue loss), and 6 (major tissue loss). Change in vascular status was rated on the basis of another 7-level ordinal scale: 1 (markedly improved), 2 (moderately improved), 3 (minimally improved), 4 (no change), 5 (mildly worse), 6 (moderately
Variable Smoking Morbid obesity Lung disease NIDDM IDDM NIDDM or IDDM Hypertension Congestive heart failure Myocardial infarction Ischemia classification 2 (moderate claudication) 3 (severe claudication) 4 (ischemic rest pain) 5 (minor tissue loss) Graft patency Vascular improvement 1 (improved) 2 (little change) 3 (worse)
Number 18 6 4 12 12 24 39 1 1
Percentage 40.9 13.6 9.1 27.3 27.3 54.5 88.7 2.3 2.3
9 10 10 15 35
20.5 22.7 22.7 34.1 79.5
19 10 15
43.2 22.7 34.1
NIDDM, Non–insulin-dependent diabetes mellitus; IDDM, insulin-dependent diabetes mellitus.
worse), and 7 (markedly worse). However, these categories were collapsed into 3: improved (1-2), little change (3-5), and worse (6-7). Patency was judged on the basis of the 5 AHCORS criteria.
Statistical Analysis Statistical analysis was conducted by using the SPSS (10.0) and Systat (8.0) statistical programs (SPSS, Chicago, Ill). After the calculation of descriptive statistics, paired t tests were used to determine if there was a significant difference between baseline and 12-month PCS summary scale scores and between baseline and 12-month MCS summary scale scores. Zero order correlations (Pearson and Spearman) were used initially to examine the relationships between the outcome and predictor variables. Because the magnitude of these correlations did not differ appreciably, only Pearson correlations are reported. Multiple regression was used to determine whether multiple independent variables might be superior to individual independent variables for predicting outcome. Dichotomous variables with fewer than 6
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cases in a category (eg, congestive heart failure) were excluded from the multiple regression analysis. RESULTS Table I summarizes the HRQOL measurements. The mean PCS and MCS summary scale scores increased 4.6 and 5.0 points, respectively, between baseline and 12 months. These increases represent improvements of approximately 13.8% and 10.9%, respectively, between baseline and 12 months. Both of these increases were significant (P < .05). The effect sizes associated with these increases were small to medium (PCS = .47, MCS = .38). Table II summarizes the proportion of subjects with comorbidities/risk factors and the distribution of their AHCORS measurements. Few of the selected predictor variables were correlated significantly with HRQOL outcomes (Table III). For the PCS scores at 12 months, the PCS baseline score was most highly correlated (r = 0.547, P < .001), but baseline ischemia class and improvement in vascular status at 12 months were also correlated significantly. These correlations indicate that patients with higher PCS scale scores at 12 months tended to be those with higher PCS scores at baseline, less ischemia at baseline, and improved vascular status at 12 months. For the MCS scores at 12 months, only the MCS baseline scores were significant predictors. For the improvement in PCS score, the PCS baseline score was correlated most strongly, but gender was also a significant predictor. These correlations indicate that patients improving the most in their PCS scores were men who had lower PCS scores at baseline. For the change in MCS, only the MCS baseline and obesity scores were correlated significantly. Table IV summarizes the results of the regression analyses. For the PCS score at 12 months and the PCS improvement score, multiple regression demonstrated that multiple independent variables provided a better prediction than did any single independent variable. Specifically, the regression analysis indicated that higher PCS scores were realized at 12 months by patients with higher PCS baseline scores, higher MCS baseline scores, and more vascular improvement. Together, these variables explained 41.8% of the variance in the 12-month PCS score. Regression analysis demonstrated the greatest improvements in PCS scores occurred in male patients who had lower baseline PCS scores. Together, these variables explained 23.9% of the variance in the improvement in the PCS score. Multiple regression found MCS outcome scores to be predicted best by a combination of MCS baseline scores and obesity. Higher baseline MCS scores had a positive influence on 12-month MCS scores but a negative influence on MCS change scores. Obesity negatively influenced both 12month MCS scores and MCS change scores. DISCUSSION Although HRQOL measures have been advocated for use with patients with PAD who undergo revascularization procedures,30 we know of no previously published studies addressing HRQOL both before and after revascularization. Studies addressing the HRQOL of patients with PAD have typically been limited to patients who have not yet undergone revasculariza-
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TABLE III. PEARSON CORRELATIONS BETWEEN SELECTED PREDICTOR VARIABLES* AND HRQOL (SF-12) OUTCOME VARIABLES Predictor variable Age Sex Race† Smoking Morbid obesity Lung disease† NIDDM IDDM NIDDM or IDDM Hypertension† Congestive heart failure† Myocardial infarction (recent)† Ischemia classification Procedure PCS baseline MCS baseline Patency Vascular improvement
PCS 12 –0.120 –0.256 –0.065 –0.023 0.171 –0.016 0.084 0.208 –0.226
MCS 12 0.073 –0.103 0.141 –0.154 –0.267 –0.060 0.162 –0.214 0.020
PCS change –0.010 –0.352 –0.062 –0.017 0.021 –0.186 0.070 –0.247 –0.186
MCS change –0.228 –0.292
0.257 –0.216
–0.148 –0.162
0.211 –0.061 –0.124 –0.089
–0.043
–0.173
–0.076 –0.150
–0.386 0.058 0.547 0.166 0.171 –0.390
–0.037 0.273 0.002 0.354 0.010 0.041
–0.217 –0.083 0.172 0.116 –0.353 0.038 0.226 -0.664 0.042 –0.025 –0.194 –0.146
0.255 –0.130 –0.323 0.045 –0.078 –0.166 0.173
*Correlations significant at P < .05 are underlined (for 80% power a correlation must be ≥.400), correlations significant at P < .01 are in italics, correlations significant at P < .001 are in bold. †The
small number of cases (≤5) falling into one category of these dichotomous vari-
ables render correlations suspect.
tion33 or to patients who have already undergone revascularization.13,16,24,34 We sought in this study to address HRQOL both before and after angioplasty or bypass by using a quickly administered measure of HRQOL, that is, the SF-12. The mean PCS and MCS baseline scores of the patients of this study were lower than those of the general elderly population of the United States (Table I).31 The mean PCS and MCS baseline scores were also lower than those of patients with other chronic conditions (hypertension, congestive heart failure, myocardial infarction, type II diabetes).31 Whereas this difference may mean that PAD has a greater influence on HRQOL than do other chronic conditions, the nature and size of our sample preclude definitive conclusions. This study showed that patients’ HRQOL improved 12 months after, compared with before, bypass or angioplasty. It is
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TABLE IV. RESULTS OF REGRESSION ANALYSIS MODELS BEST PREDICTING HRQOL (SF-12) OUTCOMES Outcome variable PCS 12 month
Predictor variable PCS baseline Vascular improvement MCS baseline
R 0.547 0.601 0.646
R2 0.299 0.361 0.418
PCS change
PCS baseline Sex
0.353 0.489
0.125 0.239
MCS 12 month
MCS baseline Obesity
0.354 0.471
MCS change
MCS baseline Obesity
0.664 0.709
interesting that these improvements were not limited to the PCS, which might be expected to be affected more by a procedure aimed at a physiologic problem. Whereas HRQOL has been shown to improve in other diagnostic groups after interventions,35,36 our review of the literature did not reveal any studies showing such improvement in patients with PAD who underwent revascularization procedures. The detection by the SF-12 of improvements in HRQOL after revascularization supports both the value of the bypass and angioplasty procedures and the responsiveness of the SF-12 for patients undergoing revascularization procedures. Not all patients undergoing revascularization procedures ended up the same in regard to HRQOL. Whether on the basis of zero order correlations or regression analysis, patients with the highest HRQOL at 12 months were those with the highest HRQOL before revascularization. This finding is consistent with other studies showing that other measures of status 6 months after arterial bypass are predicted by status before bypass.10,11 However, other variables also contributed to the prediction of physical aspects of HRQOL. It is logical that ischemia classification and vascular improvement would be related to the PCS scores of the HRQOL. The physical burden associated with obesity would explain its having an influence on the 12-month PCS scores (but it did not); the basis of its measurable affect on the MCS scores of the HRQOL is unclear. Whereas knowing if and how much patients improve is important, knowing what contributes to their improvement can also be important. Here again, HRQOL at baseline was important. However, in this case patients with lower HRQOL improved more. This finding is important. It indicates that even if patients with lower HRQOL do not end up with as high a HRQOL after revascularization, they do realize a greater benefit. The finding that improved vascular status predicted improved HRQOL is encouraging. It indicates that the benefits of revascularization procedures are not limited to the physiologic; they
Adjusted R2 0.283 0.330 0.374
F change 17.944 3.940 3.905
F (prob) <.001 .054 .055
0.104 0.202
5.985 6.150
.019 .017
0.125 0.222
0.104 0.184
6.017 5.066
.018 .030
0.441 0.502
0.427 0.478
33.069 5.066
.001 .030
generalize to more global indicators of patients’ health status. Studies of the general population of the United States reveal that men tend to have slightly higher PCS and MCS scores than women,31 but this finding does not address “improvements” in HRQOL. Perhaps men and women also view changes in HRQOL differently. The reason obesity contributed negatively to changes in the MCS but not the PCS cannot be discerned from the study data. This study supports the usefulness of the SF-12 for monitoring HRQOL in patients undergoing revascularization procedures for PAD. The HRQOL instrument was shown to be useful for predicting outcome in spite of the small sample. This sample’s nonrandom representation of only 39.6% of the eligible patients is a weakness. It must be acknowledged that the mean baseline PCS score of the 44 subjects in the sample studied (32.7) differed from that of the 67 excluded subjects (28.2). The PCS of the sample subjects was significantly higher (P = .007). That this may have influenced the results cannot be discounted. On the other hand, the mean baseline MCS score did not differ significantly (45.7 vs 48.7, P = .231). The baseline ischemia classification of the 44 subjects also did not differ significantly (P =.124) from that of the other 67 patients. The small sample also limited the number of potential predictor variables that were found to be significantly correlated with HRQOL outcome variables. Countering this fact was the large number of correlations calculated, which increased the likelihood of finding a correlation that was significant at P < .05. (With 72 correlations, 3.6 [72 × .05] might be significant by chance.) The aforementioned notwithstanding, correlations that were not significant were not of great magnitude and would not have explained much variance. The correlations that were significant had acceptable power and explained a notable amount of variance in outcome. Thus whereas a larger and more complete sample and use of a stricter α (eg, P < .01) might be preferable, we believe our results are instructive to clinicians involved with patients undergoing revascularization for
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PAD. As a result of this study, nurses working with patients can have some confidence that the benefits of revascularization procedures are not solely physiologic; they extend to HRQOL. However, nurses’ expectations may require adjustment on the basis of patient specifics. The SF-12 appears to have sufficient responsiveness to recommend it as an outcome measure among such patients. We gratefully acknowledge the assistance of Louise Reagan, APRN, in the early design phase of the study. REFERENCES 1. McDaniel MD, Cronenwett JL. Basic data related to the natural history of intermittent claudication. Ann Vasc Surg 1989;3:273-7. 2. Quick CRG, Cotton LT. The measured effect of stopping smoking on claudication. Br J Surg 1982;69:524-6. 3. Wyatt MG, Scott PMJ, Scott OJA, et al. Effect of weight on claudication distance. Br J Surg 1991;78:1386-8. 4. Perkins JMT, Collin J, Creasy TS, et al. Eur J Vasc Endovasc Surg 1996;11:409-13. 5. Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg 1996;23:104-15. 6. Womack CJ, Sieminski DJ, Katzel LI, et al. Improved walking economy in patients with peripheral arterial disease. Med Sci Sports Exerc 1997;29:1286-90. 7. Patterson RB, Pinto B, Marcus B, et al. Value of a supervised exercise program for the therapy of arterial claudication. J Vasc Surg 1997;25:312-9. 8. Hood SC, Moher D, Barber GG. Management of intermittent claudication with pentoxi-fyeline: meta analysis of randomized controlled trials. Can Med Assoc J 1996;155:1053-9. 9. Money SR, Herd JA, Isaacsohn JL, et al. Effect of cilostazol on walking distances in patients with intermittent claudication caused by peripheral vascular disease. J Vasc Surg 1998;27:267-75. 10. Abou-Zamzam AM, Lee RW, Moneta GL, et al. Functional outcome after infrainguinal bypass for limb salvage. J Vasc Surg 1997;25:287-97. 11. Gibbons GW, Burgess AM, Guadagnoli E, et al. Return to well-being and function after infrainguinal revascularization. J Vasc Surg 1995;21:35-45. 12. Pomposelli FB, Arara S, Gibbons GW, et al. Lower extremity arterial reconstruction in very elderly: successful outcome preserves not only the limb but also residential status and ambulatory function. J Vasc Surg 1998;28:215-25. 13. Schieder JR, McHorney CA, Malenka DJ, et al. Functional health and well-being in patients with severe atherosclerotic peripheral vascular occlusive disease. Ann Vasc Surg 1993;7:419-26. 14. Nicoloff AD, Taylor LM, McLafferty RB, et al. Patient recovery after infrainguinal bypass grafting for limb salvage. J Vasc Surg 1998;27:256-66. 15. Reifsnyder T, Grossman JP, Leers SA. Limb loss after lower
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extremity bypass. Am J Surg 1997;174:149-51. 16. Holtzman J, Caldwell M, Walvatre C, et al. Long-term functional status and quality of life after lower extremity revascularization. J Vasc Surg 1999;29:395-402. 17. Watelet J, Soury P, Menard J-F, et al. Femoropopliteal bypass: insitu or reversed vein grafts? Ten year results of a randomized prospective study. Ann Vasc Surg 1997;11:510-9. 18. Debus ES, Timmermann W, Sailer M, et al. Arterial reconstruction on diabetes and peripheral arterial occlusive disease: results in 192 patients. Vasa 1998;27:240-3. 19. Biancari F, Alback A, Ihlberg L, et al. Angiographic run off score as a predictor of outcome following femoromural bypass surgery. Eur J Vasc Surg 1999;17:480-5. 20. Watson HR, Schrooder TV, Simms MH, et al. Relationship of femorodistal bypass patency to clinical outcome. Eur J Vasc Endovasc Surg 1999;17:77-83. 21. Martin DR, Katz SG, Kohl RD, et al. Percutaneous transluminal angioplasty of infrainguinal vessels. Ann Vasc Surg 1999;13:184-7. 22. Spence LD, Hartnelln GG, Reinking G, et al. Diabetic versus nondiabetic limb threatening ischemia: outcome of percutaneous iliac intervention. Am J Radiology 1999;172: 1335-41. 23. Hakaim AG, Gordon JK, Scott TE. Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end stage renal failure: analysis of 83 limbs. J Vasc Surg 1998;27:1049-55. 24. Cavillon A, Melliere D, Allaire E, et al. Are femoroinfrapopliteal bypasses worthwhile for limb salvage. J Cardio Vasc Surg 1998;39:267-72. 25. Peltoner S, Biancari F, Lindgren L, et al. Outcome of infrainguinal bypass surgery for critical leg ischaemia in patients with chronic renal failure. Eur J Vasc Endovasc Surg 1998;15:122-7. 26. Wilson SE, Wolf GL, Cross AP. Percutaneous transluminal angioplasty versus operation for peripheral arteriosclerosis. J Vasc Surg 1989;9:1-9. 27. Matsi PJ, Manniner HI, Suhoner MT, et al. Chronic critical lower-limb ischemia: prospective trial of angioplasty with 136 months follow-up. Radiology 1993;188:381-7. 28. Seabrook GR, Cambria RA, Freischlag JA, et al. Healthrelated quality of life and functional outcome following arterial reconstruction for limb salvage. Cardiovasc Surg 1999;7:279-86. 29. Reifler DR, Feinglass J, Slavensky R, et al. Functional outcomes for patients with intermittent claudication: bypass surgery versus angioplasty versus noninvasive management. J Vasc Med Biol 1994;5:203-11. 30. Murphy TP. Medical outcomes studies in peripheral vascular disease. J Vasc Intervent Radiol 1998;9:879-89. 31. Ware JE, Kosinski M, Keller SD. SF-12: how to score the SF12 physical and mental health summary scales. 2nd ed. Boston (MA): The Health Institute, New England Medical Center; 1995. 32. Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society
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for Cardiovascular Surgery. Suggested standards for reports dealing with lower extremity ischemia. J Vasc Surg 1986;4: 80-94. 33. Feinglass J, McCarthy WJ, Slavensky R, et al. Effect of lower extremity blood pressure on physical functioning in patients who have intermittent claudication. J Vasc Surg 1996;24:503-12. 34. Bruni KR, Hoosier-Paty DM, Hoffman GT. The quality of life of the limb threatened patient after lower-extremity
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revascularization. J Vasc Nurs 1996;14:99-103. 35. Engebretson TO, Clark MM, Niaura RS, et al. Quality of life and anxiety in a phase II cardiac rehabilitation program. Med Sci Sports Exerc 1999;31:216-33. 36. Cambach W, Chadwick-Straver RVM, Wagennar RC, et al. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Resp J 1997;10:104-13.
WRITING AWARD The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to create a publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascular nursing practice, and excellence of writing style. All feature articles published in the Journal of Vascular Nursing during the calendar year will be considered for the JVN Article Award. The award recipient will be given a plaque commemorating the award and a cash prize donated by Mosby. The award and cash prize will presented at the annual symposium. Annoucement of the award recipient will appear in the Journal of Vascular Nursing and in SVN...prn.
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Improved health-related quality of life 12 months after bypass or angioplasty for peripheral arterial disease Contact Hours: 1.0 Test Processing Fee: $10.00
Minimum Passing Score: 70% Test ID: JVN09
OBJECTIVES:
1. Identify changes in health-related quality of life (HRQOL) after revascularization procedures. 2. Identify variables that affect HRQOL after revascularization. 3. Discuss the impact of revascularization on HLQOL.
1. Peripheral artery disease can be treated by changes that include the following EXCEPT: a. smoking cessation b. social standing c. weight reduction d. pharmacologic therapy 2. Predictor variables used in this study did NOT include: a. risk factors b. classification of limb ischemia c. changes in vascular status and patency d. compliance with healthy behaviors 3. Comorbid risk factors used in this study were the following EXCEPT: a. chronic lung disease b. exercise patterns c. hypertension d. diabetes 4. Improved PCS scores were correlated with: a. gender b. obesity c. smoking d. congestive heart failure 5. Changes to MCS were correlated with: a. gender b. obesity c. smoking d. congestive heart failure 6. The greatest improvement in PCS scores using regression analysis was found in which group: a. females with improved vascular status at 12 months
b. females with lower ischemia at baseline c. males with lower baseline PCS scores d. males with lower ischemia at baseline 7. The greatest prediction in MCS outcome using regression analysis was: a. obesity negatively influenced baseline MCS scores b. low baseline MCS scores had a positive influ ence in 12 month MCS scores c. obesity positively influenced MCS change scores d. high baseline MCS scores had a negative influ ence on MCS change scores 8. Results of this study yielded: a. revascularization procedures provide only physiologic benefits b. the use of SF-12 to monitor HRQOL is not recommended c. the small sample size is a weakness to this study d. obesity does not affect outcome 9. Nearly 89% of the patients studied had which comorbid factor: a. smoking b. lung disease c. congestive heart failure d. hypertension 10. The comorbid variable that was the smallest in this study group was: a. hypertension b. diabetes c. myocardial infarction d. lung disease
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