Quality of life measured with a generic instrument (Short Form-36) improves following pulmonary rehabilitation in patients with COPD

STUDY OBJECTIVES: The purpose of this study was to evaluate the effects of a 3-week comprehensive pulmonary rehabilitation program on quality of life as measured by the Short Form-36 (SF-36) in patients with COPD. DESIGN AND SETTING: We report on the outcomes of 37 consecutive patients referred for pulmonary rehabilitation at a respiratory specialty medical center. PATIENTS: Thirty-seven patients (mean age, 66 years) with COPD and severe airflow limitation (mean +/- SE FEV(1), 29.6 +/- 1.8% of predicted) were studied. INTERVENTIONS: Rehabilitation consisted of a 3-week pulmonary rehabilitation program incorporating 12 exercise sessions, each of which included bicycle ergometer exercise training, upper-extremity training, strength training, and stretching, along with psychosocial counseling and education. MEASUREMENTS AND RESULTS: The Health Status Index (SF-36) and 6-min walk test were completed before and after rehabilitation. There was an improvement in five of the nine quality-of-life subscales of the SF-36 following pulmonary rehabilitation. Although there was an improvement in functional capacity as measured by the 6-min walk, there was no correlation between improvement in quality of life and improvement in functional capacity. There was no correlation between FEV(1) and improvement in walk distance, but there was a correlation between FEV(1) and improvement in SF-36 physical function and energy/fatigue subscales. CONCLUSION: Health-related quality of life assessed by the SF-36, a general measure of quality of life, improves following an intensive 3-week pulmonary rehabilitation program. Use of the SF-36 allows comparison of the results of pulmonary rehabilitation to therapeutic interventions in patients with other medical disorders.     

Effects of cardiac rehabilitation on self-reported health status after coronary artery bypass surgery

PURPOSE: To examine the effectiveness of cardiac rehabilitation on health status following coronary artery bypass surgery. METHODS: A prospective cohort study of patients having coronary artery bypass surgery at 14 centers in the state of Washington. Baseline clinical and demographic data were collected, as was information from the Rand Short Form, 36 (SF-36), the Seattle Angina Questionnaire, and other questions regarding health status before surgery and at 6 and 12 months after surgery. In the 12-month follow-up survey, subjects were asked to complete questions pertaining to their participation in postdischarge cardiac rehabilitation programs. RESULTS: A total of 947 subjects from 13 centers received 1-year follow-up surveys, with 75% responding. Of these, 691 (95%) answered questions about participation in cardiac rehabilitation programs. SF-36 and Seattle Angina Questionnaire scores improved significantly after surgery for both cardiac rehabilitation participants and nonparticipants. Although more than 90% of subjects who participated in the cardiac rehabilitation programs stated that they were beneficial, for eight SF-36 domains and five Seattle Angina Questionnaire domains, no significant associations were found with participation in cardiac rehabilitation. When the participation status was defined as only those participants who completed at least 8 weeks of cardiac rehabilitation, only 1 of 13 health status domains favored cardiac rehabilitation. Responses to a series of questions about perceptions of change in general and cardiac-specific health did not differ among participants and nonparticipants. CONCLUSIONS: Although patients report favorable impressions of cardiac rehabilitation after coronary artery bypass surgery, it does not appear to provide a measurable benefit in self-reported health status beyond that achieved from the revascularization procedure itself.     

Cardiac rehabilitation to improve physical functioning in refractory angina: a pilot study

Objectives: Refractory angina patients suffer debilitating chest pain despite optimal medical therapy and previous cardiovascular intervention. Cardiac rehabilitation is often not prescribed due to a lack of evidence regarding potential efficacy and patient suitability. A randomised controlled study was undertaken to explore the impact of cardiac rehabilitation on cardiovascular risk factors, physical ability, quality of life and psychological morbidity among refractory angina sufferers. Methods: Forty-two refractory angina patients (65.1 ± 7.3 years) were randomly assigned to an 8-week Phase III cardiac rehabilitation program or symptom diary control. Physical assessment, Progressive Shuttle Walk test, Hospital Anxiety and Depression Scale, Health Anxiety Questionnaire, the York Angina Beliefs scale, ENRICHD Social Support Instrument and SF-36 were completed before and after intervention and at 8-week follow-up. Results: Following cardiac rehabilitation, patients demonstrated improved physical ability compared with controls in Progressive Shuttle Walk level attainment (p = 0.005) and total distance covered (p = 0.015). Angina frequency and severity remained unchanged in both groups, with the control demonstrating worsening SF-36 pain scale (63.43 ± 22.28 vs. 55.46 ± 23.98, p = 0.025). Cardiac rehabilitation participants showed improved Health Anxiety Questionnaire reassurance (1.71 ± 1.72 vs. 1.14 ± 1.23, p = 0.026) and York Beliefs anginal threat perception (12.42 ± 4.58 vs. 14.35 ± 4.73, p = 0.05) after cardiac rehabilitation. Physical measures were broadly unaffected. Conclusions: Cardiac rehabilitation can be prescribed to improve physical ability without affecting angina frequency or severity among patients with refractory angina.     

Patient preferences for cardiac rehabilitation and desired program elements

BACKGROUND: Data evaluating the efficacy of traditional cardiac rehabilitation programs to meet patient needs are limited. The authors studied patient-perceived preferences in cardiac rehabilitation programs and desired program elements to evaluate differences by gender or age. METHODS: The authors surveyed 199 patients (136 men, 60.0 +/- 11.6 years; 63 women, 63.7 +/- 12.7 years; P = 0.045) discharged from a tertiary referral hospital with acute myocardial infarction. Participants completed a standardized questionnaire regarding enrollment in rehabilitation and preferences for six program types on a 10-point scale (1 = little or no agreement, 10 = strongly agree). RESULTS: In this study, 54.3% of subjects enrolled in cardiac rehabilitation. Older patients (> or = 65 years) were more likely to enroll in home-based programs compared with younger patients (< 65 years) (11.8% versus 1.4%, P = 0.02). Younger patients preferred a short-term rehabilitation facility more than older patients (7.4 +/- 3.5 versus 5.1 +/- 4.1 units on the 10-point scale, P = 0.001), and rated the following more favorably than older patients: local health club programs (6.2 +/- 3.7 versus 4.5 +/- 4.0, P = 0.01), long-term programs (6.5 +/- 3.8 versus 4.9 +/- 4.2, P = 0.02), and comprehensive programs (6.6 +/- 3.7 versus 4.9 +/- 2.2, P = 0.02). Younger patients rated the following program elements more favorably compared with older patients: stress management (7.0 +/- 3.5 versus 5.7 +/- 4.1, P = 0.04), vocational counseling (5.1 +/- 3.9 versus 1.9 +/- 2.4, P = 0.001), and smoking cessation (4.9 +/- 4.4 versus 2.7 +/- 3.4, P = 0.001). CONCLUSIONS: Program preferences differed significantly by age, but not gender. Older patients enrolled in home-based programs over clinic-based programs. Younger patients rated stress management, vocational counseling, and smoking cessation more favorably than older patients. Strategies to enhance patient participation in cardiac rehabilitation should incorporate patient age and preferences for program types and elements.     

Impact of pulmonary rehabilitation on quality of life and functional capacity in patients on waiting lists for lung transplantation

OBJECTIVE:

To investigate the impact of a pulmonary rehabilitation program on the functional capacity and on the quality of life of patients on waiting lists for lung transplantation.

METHODS:

Patients on lung transplant waiting lists were referred to a pulmonary rehabilitation program consisting of 36 sessions. Before and after the program, participating patients were evaluated with the six-minute walk test and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The pulmonary rehabilitation program involved muscle strengthening exercises, aerobic training, clinical evaluation, psychiatric evaluation, nutritional counseling, social assistance, and educational lectures.

RESULTS:

Of the 112 patients initially referred to the program, 58 completed it. The mean age of the participants was 46 ± 14 years, and females accounted for 52%. Of those 58 patients, 37 (47%) had pulmonary fibrosis, 13 (22%) had pulmonary emphysema, and 18 (31%) had other types of advanced lung disease. The six-minute walk distance was significantly greater after the program than before (439 ± 114 m vs. 367 ± 136 m, p = 0.001), the mean increase being 72 m. There were significant point increases in the scores on the following SF-36 domains: physical functioning, up 22 (p = 0.001), role-physical, up 10 (p = 0.045); vitality, up 10 (p < 0.001); social functioning, up 15 (p = 0.001); and mental health, up 8 (p = 0.001).

CONCLUSIONS:

Pulmonary rehabilitation had a positive impact on exercise capacity and quality of life in patients on lung transplant waiting lists.     

The efficacy and applicability of a pulmonary rehabilitation programme for patients with COPD in a secondary-care community hospital

Background and objective:   Pulmonary rehabilitation is known to have beneficial effects in COPD patients. This study aimed to assess the applicability and efficacy of a pulmonary rehabilitation programme in a community hospital lacking specialist pulmonary rehabilitation services.
Methods:   This randomized, controlled, prospective study included a total of 78 patients. Questionnaires were used to collect data on sociodemographic characteristics, respiratory function tests, the Modified Medical Research Council dyspnoea scale, 6MWD, the Short Form-36 (SF-36) quality of life scale, the Hospital Anxiety and Depression Scale (HADS) and the St George's Respiratory Questionnaire (SGRQ). The experimental group underwent a pulmonary rehabilitation programme while the control group did not participate. The first, second and third month measurements for all parameters were compared between the two groups.
Results:   No significant differences in pulmonary function tests or dyspnoea scale ( P  > 0.05) were observed between the two groups. Significant differences were observed in the 6MWD measurements at the third month ( P  < 0.05), as well as in the SF-36 quality of life scale, SGRQ and HADS measurements at the second and third months ( P  < 0.01).
Conclusions:   Short-term pulmonary rehabilitation had a positive impact on exercise capacity and quality of life of patients with COPD, irrespective of FEV₁. This study demonstrated the efficacy of a pulmonary rehabilitation programme in a secondary care hospital not staffed by a specialist pulmonary rehabilitation group.     

Effect of pulmonary rehabilitation on quality of life in patients with COPD: the use of SF-36 summary scores as outcomes measures

PURPOSE: Pulmonary rehabilitation (PR) is an accepted therapy for patients with chronic obstructive pulmonary disease (COPD), improving both exercise capacity and quality of life (QOL). Generic measures of QOL have been criticized as being insensitive to detecting the improvement in QOL after PR in contrast to disease-specific instruments. The authors looked at the Medical Outcomes Survey Short Form 36-item questionnaire (SF-36), a generic QOL measure, to detect changes in QOL in COPD patients after completion of PR. METHODS: Patients with COPD who participated in a PR program completed the QOL questionnaire before and after completion of PR. Exercise tolerance was assessed by the 6-minute walking test. Quality of life was assessed by the SF-36; the authors calculated its eight dimensions as well as mental (MCS) and physical (PCS) component summary scores. RESULTS: The patients realized a significant improvement in exercise tolerance; 6-minute walking test distance increased from 470 +/- 104 m (mean +/- standard deviation) to 536 +/- 133 m (P = 0.0006) after PR. Quality of life also improved in nearly all dimensions and in both summary scores; PCS improved from 26.1 +/- 8.0 before PR to 30.5 +/- 9.0 after PR (P = 0.008) and MCS improved from 27.9 +/- 7.0 before PR to 34.1 +/- 5.0 after PR (P = 0.0002). CONCLUSION: The SF-36 and its summary scores are sensitive instruments to detect improvement in QOL in COPD patients after PR.     

Long-term effectiveness of an inpatient pulmonary rehabilitation program for elderly COPD patients: comparison between young-elderly and old-elderly groups

OBJECTIVE: To evaluate the long-term effects of pulmonary rehabilitation in elderly COPD patients, we monitored patients for 1 year after they completed a 2-week inpatient pulmonary rehabilitation program. We also compared the effects of pulmonary rehabilitation on young-elderly (age 65-74 years) and old-elderly (age 75 years or over) COPD patients. METHODOLOGY: Fifty-nine elderly COPD patients (mean age 72.8 years) were studied. They underwent a comprehensive 2-week inpatient pulmonary rehabilitation program incorporating 10 exercise sessions, each of which included endurance training of the lower extremities, peripheral muscle conditioning training of the upper and lower extremities, and stretching, along with various education sessions. The effects of pulmonary rehabilitation were evaluated at 3, 6, and 12 months after completion of the program. RESULTS: Overall, patient health-related quality of life (HRQoL) as assessed by a QoL scale, and dyspnoea as assessed by an oxygen cost diagram, improved significantly over the 12-month period. Exercise capacity assessed by a 6-min walking distance test (6MWD) was similarly significantly improved. However, there was some fall-off in terms of the distance walked 12 months after pulmonary rehabilitation. The improvements in exercise capacity, dyspnoea, and HRQoL did not differ between the two groups, with the exception that the 6MWD (P < 0.01) and the QoL scale (P < 0.05) at 3 months post-pulmonary rehabilitation were significantly higher in the old-elderly group. CONCLUSIONS: Pulmonary rehabilitation is an effective treatment in terms of improving dyspnoea, exercise capacity and HRQoL in elderly COPD patients, and the benefits are almost comparable for young-elderly and old-elderly patients.     

Health outcomes of patients undergoing cardiac surgery: repeated measures using Short Form-36 and 15 Dimensions of Quality of Life questionnaire

OBJECTIVE: The study assessed health-related quality of life (HRQOL) of patients before and after cardiac surgery. DESIGN: This was a prospective repeated-measures observational study. SETTING: The study took place in a 650-bed tertiary referral hospital in Sydney, Australia. METHODS: HRQOL was measured using the Medical Outcomes Study Short Form 36-item health survey (SF-36) and the 15 Dimensions of Quality of Life questionnaire before surgery, at hospital discharge, and 6 months postdischarge. RESULTS: Participants were representative of the cardiac surgery population. Scores for several concepts deteriorated at hospital discharge when compared with presurgery. There were significant improvements in health status at 6 months postdischarge when compared with previous measures for the majority of SF-36 and 15 Dimensions of Quality of Life questionnaire concepts, although mental health and social functioning demonstrated significant deterioration. SF-36 scores were substantially lower than population norms, but similar to previous studies of patients undergoing cardiac surgery except for mental health. CONCLUSION: Deterioration in health status at hospital discharge when compared with presurgery status reinforces the need for further patient care and support after discharge. All dimensions improved after 6 months, except mental health. This information can guide patient expectations regarding rehabilitation posthospitalization, and cardiac surgical services should implement and evaluate formal "outreach programs" for these patients.     

Functional status outcomes of patients with a coronary artery bypass graft over time

OBJECTIVE: To examine functional status outcomes among patients with a coronary artery bypass graft (CABG) over time (ie, at baseline; 3 months, 6 months, and 12 months after surgery) and the impact of selected patient characteristics (ie, age, sex, comorbidities, and cardiac rehabilitation participation) on functional outcomes. DESIGN: A prospective, repeated-measures design was used to examine functional status in patients with a CABG over time. SETTING: A midwestern community hospital and regional cardiac referral center was the setting for enrolling patients with a CABG.Outcome Measures: Functional status outcomes were measured by using the Medical Outcomes Study (MOS) Short Form 36 (SF-36) and Modified 7-Day Activity instruments. METHODS: Baseline data were obtained by patient interview in the hospital setting after CABG surgery. At 3 months, 6 months, and 12 months after surgery, telephone interviews were conducted to administer research instruments. RESULTS: Baseline scores on 7 of the 8 subscales of the MOS SF-36 were significantly lower than at 3 months, 6 months, or 12 months after surgery. Role-emotional functioning baseline scores were not significantly lower than 3-month scores; however, baseline scores were significantly lower than 6-month and 12-month scores. Three-month subscale scores were also significantly lower than 6-month or 12-month scores except for the subscales measuring social and general health functioning. Functional status as measured by the Modified 7-Day Activity tool did not demonstrate any significant differences between 3-month, 6-month, or 12-month activity levels. There were no significant differences by age group on any of the 8 subscales of the MOS SF-36 instrument. Women and subjects with more than 1 comorbidity had a significantly lower preoperative level of physical functioning. Cardiac rehabilitation participants had lower preoperative scores on role-emotional functioning than subjects who were not in rehabilitation. CONCLUSION: Findings from this study can assist nurses and other health care workers to gain a perspective of the recovery and rehabilitation trajectory of patients with a CABG. The results of the study provide a basis for determining areas of functional limitations during recovery from CABG surgery. Study results can also be the foundation for evaluating outcomes of patients with a CABG when specific interventions (eg, pain management, psychosocial support, physical strengthening, fatigue management) are implemented during hospitalization, home recovery, and rehabilitation to target optimal psychosocial and physiologic functioning of patients with a CABG.     

Comparison of Two Different Levels of Physical Training in Patients with Moderate to Severe COPD

Our objective was to compare the effect of a 4−week homebased low and middle intensity and frequency training program in patients with moderate to severe chronic obstructive pulmonary disease. From 124 patients hospitalized with chronic obstructive lung disease (COPD) in an 18-month period 65 fulfilled the inclusion criteria and were invited to participate. Only 31 (48%) accepted and among these only 20 patients (31% of invited) completed the 4-week study period. The walking time in seconds in a standardized treadmill walking test was unchanged after 4 weeks of low intensity training 60 minutes per week for two weekly training sessions. In contrast, the walking time in seconds increased 55% (p < 0.001) from 321 seconds to 499 seconds in 9 patients who completed 4 weeks of middle intensity training which comprised 21/2 hours of training per week for 5 weekly training sessions. There was no change in lung function over the 4 weeks but the combined score for physical quality of life (physical component summary) measured by SF-36 increased (p < 0.05) with both low intensity and middle intensity physical training. In conclusion, homebased physical training, which aims at improvements in patient performance and quality of life as part of pulmonary rehabilitation programs, is only accepted by about one-third of unselected patients with moderate to severe COPD. The minimum training time necessary to improve physical performance is 2–3 hours per week of middle intensity training.     

Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias

BACKGROUND: Clinical practice guidelines have been published for cardiac rehabilitation, directing programs to address secondary risk-reduction issues. The role of risk factor profiles in the referral of patients to cardiac rehabilitation programs has not been evaluated. METHODS: Patients from the Cardiovascular Information Registry at the Cleveland Clinic Foundation (CCF) who entered the CCF hospital-based cardiac rehabilitation program (n = 371) were compared with those who did not participate in the CCF program (n = 2960) with respect to gender, demographics, and risk factor profile for CAD. A random subset of those who did not participate in the CCF program (n = 100) was interviewed by phone to determine participation patterns in other rehabilitation programs. RESULTS: Only 11% of patients participated in CCF-based program. Standard risk factors were similar between participants and nonparticipants. Rehabilitation patients were younger (63 +/- 10 versus 66 +/- 10, P < 0.01) and as a group had better left ventricular function (moderate-severe left ventricle: 16% versus 23%, P < 0.01) than nonparticipants. Women were underrepresented in the CCF rehabilitation population (20% versus 30%, P < 0.01). Of the phone survey sample, 21% of patients entered other community-based rehabilitation programs. Similar trends with respect to risk factors, younger age, and better left ventricular function were noted for the community subset. However, women accounted for a greater percentage of the participants in the community programs than the CCF-based program (42.8% versus 19.7%, P < 0.03). CONCLUSIONS: Conclusions based on institution-specific programs likely underestimate overall participation in cardiac rehabilitation. Traditional risk factors apparently are not considered when referring patients to cardiac rehabilitation programs. Younger patients with lower mortality risks preferentially participate in rehabilitation programs. Women are more likely to participate in community-based programs. Overall use of cardiac rehabilitation programs remains low.     

Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life

BACKGROUND: The authors examined the importance of the frequency of aerobic exercise training in multidisciplinary rehabilitation in improving health-related quality of life in the short run in patients with documented coronary artery disease. METHODS: Patients (114 males and 16 females; age range, 32-70 years) were randomized into either a high-frequency or a low-frequency exercise training program (10 versus 2 sessions per week, respectively) as part of a 6-week multidisciplinary cardiac rehabilitation program. The General Health Questionnaire and the RAND-36 were used to assess changes in psychological distress and subjective health status. RESULTS: After 6 weeks, high-frequency patients reported significantly more positive, change in "psychological distress" (P < 0.05), "mental health" (P = 0.05), and "health change" (P < 0.01), than low-frequency patients. Apart from changes in mean scores, individual effect sizes indicated that a significantly greater percentage of high-frequency patients experienced substantial improvements in "psychological distress" (P < 0.01), "physical functioning" (P < 0.05), and "health change" (P < 0.05), compared with low-frequency patients. In addition, deterioration of quality of life was observed in a considerable number of high-frequency patients (ranging from 1.7% to 25.8% on the various measures). CONCLUSIONS: The frequency of aerobic exercise has a positive, independent effect on psychological outcomes after cardiac rehabilitation. However, this benefit after high-frequency rehabilitation appears to be limited to a subgroup of patients. Further investigation is required to identify these patients. Results provide input into recent controversies regarding the role of exercise training in cardiac rehabilitation.     

Impact of duration in a cardiac rehabilitation program on coronary risk profile and health-related quality of life outcomes

BACKGROUND: Optimal cardiac rehabilitation (CR) program length and the time course of changes in relevant outcomes are unknown. The purpose of this study was to assess changes in coronary risk factors and health-related quality of life (HRQoL) after 3 months and 6 months of cardiac rehabilitation. METHODS: This is an observational study of a cohort of 126 consecutive cardiac rehabilitation patients who completed baseline, 3-month, and 6-month evaluations of coronary risk factors and HRQoL. The coronary risk factors included lipid profile, blood pressure, body mass index (BMI), and physical activity level. HRQoL was assessed using the Short Form-36 questionnaire (SF-36) comprising eight health concepts and two component scales (physical [PCS] and mental [MCS]). RESULTS: There was significant improvement in all coronary risk factors and HRQoL measures, except BMI, over the 6-month period (P < 0.001). Significant changes in blood pressure, physical activity, PCS, and high-density lipoprotein cholesterol (HDL-C) were apparent at 3 months, and no additional significant changes in these variables occurred between 3 and 6 months. For total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and MCS, significant change was achieved between 3 and 6 months but not between baseline and 3 months. CONCLUSIONS: Secondary prevention and HRQoL outcomes improved at variable rates. Physical activity and physical function peaked at 3 months and were maintained at program completion. Significant improvements occurred in mental health recovery beyond the traditional 12-week CR program length. Outcomes furthest from normative values showed the most rapid improvement. Optimal duration of participation may vary according to the outcome of interest.     

Disparate effects of improving aerobic exercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients

PURPOSE: Although cardiopulmonary exercise variables predict prognosis, functional capacity, and quality of life (QoL) in patients with coronary artery disease (CAD), these variables have not been assessed fully before and after exercise training in elderly with CAD. Therefore, the purpose of this study was to determine the impact of formal Phase II cardiac rehabilitation and exercise training programs on cardiopulmonary variables and QoL in elderly and younger CAD patients. METHODS: The authors analyzed consecutive patients before and after Phase II cardiac rehabilitation and exercise training programs, and compared exercise cardiopulmonary data and data from validated questionnaires assessing QoL (MOS SF-36) and function in 125 younger patients (< 55 years; mean 48 +/- 6 years) and 57 elderly (> 70 years; mean 78 +/- 3 years). RESULTS: At baseline, elderly patients had lower estimated aerobic exercise capacity (-27%; P < 0.001), peak oxygen consumption (VO2) (-19%; P < 0.01), and anaerobic threshold (-10%; P < 0.05), as well as total function scores (-11%; P < 0.01) and total QoL scores (-5%; P = 0.06). Commonly used prediction equations greatly overestimated aerobic exercise capacity compared with precise measurements using cardiopulmonary testing both before (+23% and +12% in younger and elderly patients, respectively) and after the exercise training programs (+51% and +31% in younger and elderly patients, respectively), and more so in younger compared with older patients. After rehabilitation, the elderly had significant improvements in estimated aerobic exercise capacity (+32%; P < 0.0001), peak VO2 (+13%; P < 0.0001), anaerobic threshold (+11%; P = 0.03), total function scores (+27%; P < 0.0001), and total QoL scores (+20%; P < 0.0001). Although younger patients had greater improvements in estimated aerobic exercise capacity (+44% versus +32%; P = 0.08), peak VO2 (+18% versus +13%; P < 0.01), and anaerobic threshold (+17% versus +11%; P = 0.07), the elderly had statistically greater improvements in both function scores (+27% versus +20%; P = 0.02), and total QoL scores (+20% versus +14%; P = 0.03). CONCLUSIONS: These data confirm the benefits of precisely determining aerobic exercise capacity by cardiopulmonary function, especially to determine the benefits of an exercise training program. In addition, these data using cardiopulmonary exercise tests and validated assessments of quality of life demonstrate the disparate effects of cardiac rehabilitation programs on improvements in aerobic exercise capacity and QoL in young and elderly with CAD.     

Usefulness of a linear analog scale questionnaire to measure health-related quality of life in elderly patients with chronic obstructive pulmonary disease

OBJECTIVES: To examine the validity, discriminatory ability, and responsiveness of health-related quality-of-life (HRQoL) questionnaires using a linear analog scale (Quality of Life (QOL) scale) for chronic obstructive pulmonary disease (COPD). DESIGN: Cross-sectional and longitudinal. SETTING: Outpatient. PARTICIPANTS: One hundred two elderly subjects with mild to severe COPD. MEASUREMENTS: Scores on the QOL scale, the St. George's Respiratory Questionnaire (SGRQ), and the 36-item Short-Form Health Survey questionnaire (SF-36) and various clinical parameters were recorded. The correlations between these QOL questionnaires and various clinical parameters were then examined. The responses of 31 elderly COPD patients to the QOL scale and the SGRQ before and 3 months after the completion of a comprehensive pulmonary rehabilitation program were compared longitudinally. RESULTS: On cross-sectional study, the QOL scale showed a significant correlation with the total score and three components of the SGRQ. The QOL scale correlated significantly with all components of the SF-36, but the total SGRQ score correlated with only six components of the SF-36, excluding vitality and the mental health index. Both the QOL scale and the total score of the SGRQ correlated significantly with the oxygen cost diagram (OCD), Morale scale, 6-minute walking distance (6MWD), forced expiratory volume in 1 second, and instrumental activities of daily living (IADL) score. When subjects were divided into three groups according to disease severity (mild, moderate, severe) using American Thoracic Society guidelines, the total SGRQ score discriminated between the three groups. The QOL scale could not discriminate between mild and moderate or moderate and severe. On longitudinal study, 3 months after finishing the comprehensive pulmonary rehabilitation program, the QOL scale, the SGRQ, 6MWD, and OCD all showed significant improvement. The difference in the QOL scale after the comprehensive pulmonary rehabilitation program showed a significant correlation with changes in the SGRQ total score and the OCD but not with the 6MWD. CONCLUSION: The QOL scale is similar to more-complex questionnaires such as the SGRQ in terms of validity and responsiveness for evaluating disease-specific HRQoL in elderly COPD patients. In clinical settings, the QOL scale, as a simple questionnaire, may be useful for disease-specific HRQoL assessments in elderly COPD patients.     

Barriers to outpatient cardiac rehabilitation participation and adherence

BACKGROUND: A significant proportion of eligible patients do not participate in outpatient cardiac rehabilitation. The purpose of this study was to identify barriers to participation and adherence to outpatient cardiac rehabilitation by querying program staff. METHODS: In January 1999, a survey was mailed to all North Carolina program directors of outpatient cardiac rehabilitation programs. The response rate was 85% (61/72). RESULTS: Across programs, the most common barrier to participation in outpatient cardiac rehabilitation was financial. Other barriers identified by program directors included lack of patient motivation, patient work or time conflicts, and lack of physician support or referral. When program directors were asked to cite reasons that referred patients provided for not participating in rehabilitation, the most common answer was financial or lack of motivation or commitment. The most common reason cited for dropping out of the rehabilitation program was work, followed by financial reasons and lack of motivation or commitment. CONCLUSIONS: The results of this statewide survey of program directors indicated a common set of barriers that many patients currently face to begin and continue participating in outpatient cardiac rehabilitation.     

Effects of sustained audit/feedback on self-reported health status of primary care patients

PURPOSE: Because limited audit/feedback of health status information has yielded mixed results, we evaluated the effects of a sustained program of audit/feedback on patient health and satisfaction. METHODS: We conducted a group-randomized effectiveness trial in which firms within Veterans Administration general internal medicine clinics served as units of randomization, intervention, and analysis. Respondents to a baseline health inventory were regularly mailed the 36-Item Short Form (SF-36) and, as relevant, questionnaires about six chronic conditions (ischemic heart disease, diabetes, chronic obstructive pulmonary disease, depression, alcohol use, and hypertension) and satisfaction with care. Data were reported to primary providers at individual patient visits and in aggregate during a 2-year period. RESULTS: Baseline forms were mailed to 34,050 patients; of the 22,413 respondents, 15,346 completed and returned follow-up surveys. Over the 2-year study, the difference between intervention and control groups (as measured by difference in average slope) was -0.26 (95% confidence interval [CI]: -0.79 to 0.27; P=0.28) for the SF-36 Physical Component Summary score and -0.53 (95% CI: -1.09 to 0.03; P=0.06) for the SF-36 Mental Component Summary score. No significant differences emerged after adjusting for deaths. There were no significant differences in condition-specific measures or satisfaction between groups after adjustment for provider type, panel size, and number of intervention visits, or after analysis of patients who completed all forms. CONCLUSION: An elaborate, sustained audit/feedback program of general and condition-specific measures of health/satisfaction did not improve outcomes. To be effective, such data probably should be incorporated into a comprehensive chronic disease management program.