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Eur J Cardiothorac Surg 2008;33:72-76. doi:10.1016/j.ejcts.2007.09.023
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Health related quality of life following cardiac surgery — correlation with EuroSCORE

Zeljko Colak*, Iva Segotic, Sandra Uzun, Mirabel Mazar, Visnja Ivancan, Visnja Majeric-Kogler

Department of Anesthesiology, Reanimatology and Intensive Care, Clinical Hospital Center Zagreb, Kispaticeva 12, Zagreb, Croatia

Received 23 July 2007; received in revised form 22 September 2007; accepted 25 September 2007.

* Corresponding author. Address: Kispaticeva 12, 10000 Zagreb, Croatia. Tel.: +385 12388235; fax: +385 12388235. (Email: zcolak2000{at}yahoo.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: To explore differences in the health-related quality of life (HRQOL) of patients before and after cardiac surgery, to compare the results with norms of Croatian population and to correlate the results with values of EuroSCORE. Methods: This was a prospective observational study with repeated measurements using the Short Form SF-36 health survey before surgery and 1 year after discharge, to assess changes in quality of life. Results: A total number of 111 patients were included in the study. Seventy-one patients (64%) responded to second measurement of HRQOL 1 year after surgery. The mean age was 61 years, patients were predominantly male and the majority of patients were admitted for coronary artery bypass graft. The prevalence of comorbidity was relatively high. Preoperative mean values of study population were statistically lower than those representing Croatian general population in five out of eight health domains: physical functioning (p < 0.001), role physical (p < 0.001), bodily pain (p < 0.001), social functioning (p < 0.001) and mental health (p < 0.001). Data show significant improvement 1 year after discharge in four out of eight health domains: physical functioning (p = 0.02), role physical (p < 0.001), social functioning (p = 0.004) and mental health (p = 0.03). A subgroup of 30 patients with EuroSCORE ≥6 shows postdischarge improvements in the majority of scales: role physical (p < 0.001), bodily pain (p < 0.001), vitality (p = 0.03), social functioning (p = 0.01), role emotional (p = 0.03) and mental health (p = 0.002), and group with EuroSCORE <6 shows postdischarge improvement only in one health domain – role physical (p < 0.001). Conclusions: The health status of patients one year after hospital discharge shows a statistically significant improvement in half of the domains of physical and mental health compared with presurgery status. The high-risk group of patients (EuroSCORE ≥6) were likely to have significant improvement in greater number of health domains following surgery than the low- and medium-risk group (EuroSCORE <6).

Key Words: Cardiac surgery • Health-related quality of life • SF-36 • Risk factors • EuroSCORE


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
According to Croatian health service yearbook 2005, ischemic heart diseases sit in first place and heart failure in third place on the rank of the 10 leading causes of death in Croatia [1]. Primary treatment option for these diseases is cardiac surgery (coronary artery bypass graft and valve surgery) and improvements in survival and quality of life are the primary indications for the operation [2]. Factors associated with survival following cardiac surgery have been well defined and risk indices for the prediction of postoperative mortality and morbidity have been developed [3–5]. However, it is important to consider that although the operation relieves the symptoms of cardiac disease, this reduction does not directly translate into quality of life improvement following surgery. The operation has an impact on overall physical and mental health status and health-related quality of life (HRQOL); the patient's perspective and satisfaction are one of the major indicators of their medical outcome. In recent years, several studies have been undertaken to evaluate the patient's assessment of their general health status following cardiac surgery in order to help clinicians identify which patients are likely to have an improvement or decrement in their overall quality of life following surgery [6–16]. Most of these studies had reported an improvement in general health status, but there were some diversities related to age, different dimensions of health, preoperative functional status, etc.

In this study, we wanted to assess the profile of changes in HRQOL in Croatian patients undergoing cardiac surgery and a contribution of patient's preoperative EuroSCORE on postoperative health status. We assumed that patients with higher preoperative EuroSCORE are more likely to have an improvement in quality of life following cardiac surgery.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1 Study population
The data were obtained from Clinical Hospital Center Zagreb during 2004. The total number of adult patients undergoing cardiac surgery was 158 during the 6 month period (January 2004–June 2004) and 111 patients were included in the study. Some of the patients declined to complete the survey and some could not complete the survey as a result of the emergent nature of their condition. All patients who participated in the study agreed to take part and written informed consent was provided. HRQOL was assessed using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) before surgery and 1 year after surgery. In all, 71 patient (64%) completed surveys at both time points, 10 patients (9%) had died during this postoperative period and 30 patients (27%) completed a survey at only one of the time points.

2.2 SF-36
The SF-36 Health Survey is one of the most extensive standardized, self-administered, generic questionnaires for measuring both the physical and mental health of a patient [17,18]. It was developed to assess the functional status and well-being of patients. SF-36 consists of 36 questions in eight areas: physical functioning (physical limitations in performance of daily living), role-physical (problems encountered with daily activities or work as a result of physical health), bodily pain (overall pain severity), general health perception (overall general health), vitality (frequency of feeling full of energy vs tired), social functioning (performing normal social activities or not), role-emotional (problems with work or daily activities as a result of emotional problems) and mental health (degree of nervousness or depression). Higher values on the transformed 0–100 scale for each health domain indicate better health status.

2.3 EuroSCORE
EuroSCORE is a simple, objective and up-to-date scoring system for assessing heart surgery, soundly based on one of the largest, most complete and accurate databases in European cardiac surgical history [3]. The scoring system identifies three groups of risk factors (patient-related, cardiac and operation-related) with their weights (additive %predicted mortality). In this study, we used additive EuroSCORE model.

2.4 Statistical analyses
Descriptive statistics were calculated for patient's preoperative characteristics. The differences between the study group and the group with incomplete data were compared by t-test and chi-square ({chi} 2) test. We compared the study group with the general Croatian population by using a test of means against reference constant (value). Differences in SF-36 scores obtained from the pre- and postoperative assessments were compared by Wilcoxon matched-pairs rank-sum test. For both subgroups confidence intervals are presented. p-Values of 0.05 or less were considered statistically significant. All statistical analyses were performed using STATISTICA 7.1 software.1 Data are presented as mean ± standard deviation.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
3.1 Patient characteristics
A summary of the patient's preoperative data are shown in Table 1 . The mean age was 61.1 ± 9 years and the majority of the patients were male (57 out of 71). Patients were admitted primarily for coronary artery bypass graft (CABG) surgery (more than two thirds of the patients). More than half of patients had left ventricular ejection fraction (LVEF) greater than 0.5 but there was a relatively high prevalence of comorbidity. The high cardiac operative risk group (EuroSCORE ≥6) consisted of 30 patients. Compared with the 71 patient in the final study population, the patients who did not complete both a baseline and follow-up SF-36 survey had no significant differences in the majority of variables including age, gender, type of surgery, prevalence of comorbidities and LVEF. Our study population had a statistically lower preoperative mean values for five out of the eight health domains assessed by SF-36, compared with the general Croatian population means (Table 2 ) [19].


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  		Table 1 Preoperative clinical characteristics of the study population
 

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  		Table 2 Comparison of the study group with the general Croatian population
 
3.2 Changes in SF-36 scores
The results of changes in pre- and postoperative SF-36 scores are presented in Fig. 1 . Postoperative SF-36 scores of the study population significantly improved in four health domains: physical functioning (p = 0.02), role-physical (p < 0.001), social functioning (p = 0.004) and mental health (p = 0.03). When we analyzed individual pre- and postoperative SF-36 scores for each patient, we saw that more than half of them experienced improvement in the following health domains: physical functioning, role-physical, vitality, social functioning and mental health. In domains bodily pain, general health and role-emotional less than half the patients experienced improvement.


Figure 1
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  		Fig. 1. SF-36 scores of the study population before and 1 year after cardiac surgery. (PF: physical functioning (p = 0.02), RP: role physical (p < 0.001), BP: bodily pain, GH: general health, VT: vitality, SF: social functioning (p = 0.004), RE: role emotional, MH: mental health (p = 0.03)).

 
Next, patients were divided in two subgroups according to their EuroSCORE values. Group I consisted of patients whose EuroSCORE was less than 6 (low- and medium-risk group), while Group II were patients whose EuroSCORE was greater than or equal to 6 (high-risk group). Comparison of pre- and postoperative SF-36 results between these two subgroups is presented in Table 3 . Subgroup analysis revealed that patients in Group I experienced statistically significant improvement in only one health domain – role-physical (p < 0.001), while Group II patients experienced improvement in majority of health domains: role-physical (p < 0.001), bodily pain (p < 0.001), vitality (p = 0.03), social functioning (p = 0.01), role emotional (p = 0.03) and mental health (p = 0.002).


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  		Table 3 Comparison of pre and postoperative SF-36 scores for Group 1 (EuroSCORE <6) and Group 2 (EuroSCORE ≥6)
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The outcome of cardiac surgical procedures is traditionally assessed by mortality and morbidity rates, but the aim of this study was to evaluate the benefits from cardiac surgery in terms of changes in HRQOL. Patient's perspectives on outcome of surgical procedure and their satisfaction with it have a great impact on their quality of life and physical, social and mental well-being. Earlier studies have demonstrated that the most appropriate method to achieve our aim is to assess our patient's HRQOL by using the SF-36 survey [18,20].

Some of the earlier studies presented only summary SF-36 scores as changes in physical health status (physical component score – PCS, derived from physical functioning, role-physical, bodily pain and general health) and mental health status (mental component score – MCS, derived from vitality, social functioning, role-emotional and mental health) [6,10]. We presented changes in pre- and postoperative scores in each one of the eight domains of HRQOL.

The Croatian version of SF-36 survey was done after a standard procedure of translation coordinated under International Quality of Life Assessment (IQOLA) Project [21]. In the year 2000, the first Croatian SF-36 study provided preliminary results on metric characteristics of the Croatian version of the SF-36 survey [22]. One of the recent studies presented population norms for the Croatian version of SF-36 survey that can be used as a valid and reliable instrument in research in subjective health of the Croatian population [19]. In recent years, several demographic studies in Croatia used SF-36 survey [23,24] but, according to our knowledge, this is the first Croatian clinical study using SF-36 survey.

The findings of our study are consistent with findings of some of the earlier studies that reported a general improvement in HRQOL following cardiac surgery [6,9,14]. Our results show a statistically significant improvement for the whole study population in 4 domains of HRQOL: physical functioning, role-physical, social functioning and mental health. We also explored individual changes in HRQOL for each of our patients and discovered that HRQOL improved in all health domains except role-emotional in approximately half of our patients. In role-emotional only one third of patients experienced improvement. These findings are consistent with study of Falcoz et al. [11].

We also wanted to explore whether cardiac operation risk factors correlate with postoperative improvement in HRQOL and therefore we divided patients into two subgroups according to EuroSCORE values. Patients with high operative risk (EuroSCORE greater than or equal to 6) had lower preoperative SF-36 scores and were likely to experience significant improvement in a greater number of health domains compared to patients with low and medium risk (EuroSCORE less than 6). Those patients with low and medium operative risk had a postoperative deterioration in some of the health domains of SF-36 survey. HRQOL can deteriorate postoperatively for several reasons: surgical complications, progression of non-cardiac diseases, neurological and psychological complications after cardiopulmonary bypass, etc.

According to these findings, we can conclude that patients with high cardiac operative risk often have lower preoperative HRQOL and are more likely to have significant improvement postoperatively if their surgical outcome is satisfactory. SF-36 scores do not show significant changes postoperatively in patients with low and medium cardiac operative risk. These findings are consistent with some of the earlier studies [6] but there are some, which revealed the opposite results [8,11].

In order to help identify which patients are likely to have an improvement in their overall quality of life following cardiac surgery, we conclude that patient's cardiac operative risk (EuroSCORE) as well as SF-36 score should be assessed. According to findings of this study, clinicians can easier identify patients likely to experience postoperative improvement in HRQOL.

We also have to discuss the limitations of this study. Major limitations are size of the study population and bias that probably arises from the large number of patients who did not complete either baseline or follow-up SF-36 survey. Because of the rather small study population, it was difficult to determine the exact combination of preoperative SF-36 scores and EuroSCORE that can be considered as reference points for expected postoperative HRQOL improvement. We believe that our study could be the basis for further research that can verify the validity of our findings in a greater number of cardiac surgery patients, and perhaps produce guidelines for identification of patients who are likely to experience improvement in HRQOL following cardiac surgery.


   Footnotes
 
1 (Electronic Version): StatSoft, Inc. (2007). Electronic Statistics Textbook. Tulsa, OK: StatSoft. WEB: http://www.statsoft.com/textbook/stathome.html. Back


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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