الفهرس 
Cardiovascular diseases risk factorsOnly 14 pages are availabe for public view
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Abstract
Cardiac surgery changes the patient’s health condition dramatically. Improvements in survival and quality of life are the primary indications for the operation. 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 patients’ perspective and satisfaction are one of the major indicators of their medical outcome. The outcome of cardiac surgical procedures is traditionally assessed by mortality and morbidity rates, but the present study was conducted in response to a felt need for studying the health related quality of life of patients undergoing cardiac surgery.
Aim of the study
General objective
To study the health-related quality of life of patients undergoing cardiac surgery in Alexandria.
Specific objectives
1- To compare the health related quality of life( HRQOL) before and after cardiac surgery.
2- To identify determinants which could affect the HRQOL of patients undergoing cardiac surgery.
Subjects and methods
Study setting:
The study was conducted at:
1. One of the Ministry of Health hospitals (Shark el Madena) which is dealing with patients sponsored by the Ministry of Health (MOH), Health Insurance and some private cases.
2. The Main University Hospital, which provides services for patients, sponsored by the Ministry of Health and Health Insurance patients.
3. The New University Hospital, which provides services for Health Insurance patients and also private cases.
4. International Cardiac Center (ICC) hospital, which provides services for private cases and Health Insurance patients for some organizations.
- At Shark el Madena hospital, patients prepare all needed investigations and blood bags reservation during their follow up at the cardiothoracic outpatient clinics and when ready, they are admitted to hospital the day before surgery.
- At the Main University Hospital, patients are followed up at the cardiothoracic outpatient clinics till they receive the MOH consent to undergo the operation or bring referral letters from their organization (for Health Insurance cases) at the New University Hospital. Then admission occurs and they wait for their turn on the scheduled operation list.
- On the other hand, private cases mostly follow up with the treating surgeons at their clinics and when the patients become ready for operation, they are admitted on the day of operation or one day before.
Study design:
Intervention study (a pre – post study)
Target population:
Patients undergoing cardiac surgery (coronary artery bypass graft (CABG), mitral valve replacement or repair, double valve replacement or repair, aortic valve replacement (valvular operations) ,closure of atrial or ventricular septal defect (congenital heart operations).
Sample:
Sample size was calculated by MedCalc software to be 250 patients, Eligible participants were enrolled consecutively.
• Eligible participant:
Patients attending the previously mentioned hospitals for cardiac surgery, aged 16 years or older, both sex and willing to participate in the study.
Data collection
Data were collected by reviewing patients’ files available in the cardio- thoracic ward and follow-up cards available at the outpatient clinics. Data were collected by interviewing all the sampled patients attending for cardiac surgery after their informed consent to participate in the study.
It took 4 months to collect the pre-operative data. The follow up, one month and 6 months postoperatively, started for each patient from the operation date.
Each hospital was visited twice /week in order to meet the patients before surgery and to follow up after one month post operatively. On the other hand, Shark el Madena hospital was visited four days/ week for four months because the patients are admitted the day before the surgery only. After completing the baseline data the researcher went to collect the follow up one month data twice/week.
For the follow up after six months post operatively, some of the patients were met in the cardiac outpatient clinics after arrangement of appointment by phone, while the ones who couldn’t be met at the clinics were followed up by phone.
Data collection tools
Two questionnaires were used for collection of data by interviewing the patients undergoing cardiac surgery:
1- A pre-coded structured interview questionnaire
Was designed and used to collect the following data:
Personal data:
Age, sex, residence, phone number, education, type of work, marital status, height, weight, smoking habit.
Medical data:
Diagnosis, time lapse between diagnosis and performing surgery, previous medication taken and its regularity, previous cardiac catheterization and time of last one , family history, previous surgery and concomitant condition.
Operative data:
Name and date of operation, use of CPB (cardio – pulmonary bypass) and presence of any perioperative complications.
2. The health related quality of life (HRQOL) questionnaire short form, SF-36
Health-related quality of life (HRQOL) was measured by the Short Form 36 health survey (SF-36); a generic measure developed to assess HRQOL. The SF-36 has shown satisfactory reliability and validity and is a measure that has been very well tested as to psychometric properties in several countries. It consists of 36 items measuring eight conceptual domains or dimensions of health: self-reported general health, physical functioning, bodily pain, mental health, role limitations due to physical problems, role limitations due to emotional problems, vitality and social functioning .The scores in each domain are transformed into 0-100 scales. For all scales higher scores reflect better health.
Results obtained in the present study could be summarized in the following:
• Description of the study sample. The study started with 250 patients (107 CABG, 108 valvular and 35 congenital heart patients).By the first month 27 patients had dropped from the study, of which 15 patients had died and hence 223 patients were followed up. After six months, 39 patients were lost to follow up 14 had died therefore 184 patients were interviewed. Other reasons for DROP out included: some families refused to continue in the study, some of them did not answer the phone and the rest were living in distant places outside Alexandria, had incomplete address and did not answer the phone despite many calls. About half of the sample (53.6 %) aged 40 - <60 years old, Male patients formed more than half 64.4% of the study sample, , urban dwellers were more than double 71.6% rural. The highest percentage of total study sample was married (67.6%), one third of patients (32%) were below primary education. The highest percentage of patients (44%) were overweight. The highest percentage (63.6 %) of the sample were not current smokers. The highest percentage of total patients (62 .8%) had medication less than one year before surgery and 83.9% had taken it on regular basis. Positive family history was found in 76.8% of the total sample, 18% of the total sample were hypertensive, 16.8% of total sample were diabetic, 11.6% of the total sample had bronchial asthma, 6% of total sample had kidney diseases, 4.8% of total sample had liver diseases, two thirds (69.6 %) of the total sample had previous diagnostic cardiac catheterization and 42.5% had a previous surgery. During the present surgery, only 10.4% of the total sample had complications and 97.2 % used CPB.
• Reliability of the different domains of SF- 36 HRQOL among cardiac surgery patients (Cronbach’s alpha). Reliability was high for some domains namely: role limitations due to emotional problems (0.989), role limitations due to physical health (0.972), pain (0.870), physical function (0.772) and social functioning (0.721). Yet, reliability was less for emotional wellbeing (0.614) and was weak for energy/fatigue and general health domains (0.376 and 0.215 respectively).
• The median scores for HRQOL physical and mental components domains. Scores were increased one month post operatively but the scores increased more at six months for the three operations (the difference between preoperative, one month and six months postoperative was statistically significant p<0.05 for the three operations), with higher score in valvular and CABG operations, followed by congenital heart operations . At six months, the difference between the three operations was not statistically significant.
• Scores of SF-36 HRQOL domains preoperatively and postoperatively (one month & six months). The current study demonstrated substantial deterioration in physical function domain at one month postoperatively, when compared with preoperative status, but no changes occurred from the preoperative period in role limitation due to physical health, role limitation due to emotional problems and social function domains. At 6months, there was a statistically significant improvement for the whole study population in the eight domains of health related quality of life but no difference in median score at the three times for role limitation due to emotional problems domain.
• The time lapse between diagnosis till surgery ranged from 1 to 216 months with average of 9 months. There was a significant weak indirect correlation between time lapse and emotional wellbeing, social functioning and pain but it was intermediate indirectly with general health i:e the longer the time lapse the less the improvement in those domains. There was a weak direct correlation between time lapse and role limitation due to emotional problems. There was a weak indirect correlation with physical functioning, role limitation due to physical health and energy/fatigue. Yet, those correlations were not statistically significant
• PCS and MCS of SF-36 HRQOL domains from pre-operative to 6 months postoperatively and their improvement in relation to personal factors (age, sex, residence, marital status, educational level, type of work, BMI and smoking).In general all scores increased one month post operatively but the scores increased more at six months for all the factors mentioned before. At six months, it was found that mental component scores were higher than physical component scores in relation to all the mentioned factors.
Personal characteristics that significantly affected cardiac surgery patients’ scores improvement were sex (in MCS only), residence, marital status (in PCS only), education (in MCS only) and BMI.
Medical history factors that significantly affected cardiac surgery patients’ scores were those patients compliant with medication before surgery and family history of heart disease (MCS only).
Surgical history factors. At six months, it was found that mental component scores were higher than physical component scores for all surgical history factors. Patients who had previous cardiac catheterization (in MCS only) significantly affected the improvement in cardiac surgery patients’ scores.
Conclusions
Heart surgery improves HRQOL. PCS and MCS median scores were higher for patients, undergoing CABG and valvular operations than congenital heart operations. All domains improved after 6 months, except for the median score for role limitation due to emotional problems. Factors significantly related with improvement were sex, residence, marital status, education, BMI, pre-surgical compliance with medication, family history and previous cardiac catheterization.
Recommendations
1. Appropriate management should also cover prevention, screening and early detection, diagnosis, treatment, rehabilitation, and palliative care.
2. Integrated prevention involves interventions that simultaneously prevent and reduce a set of common modifiable risk factors. The management of cardiac diseases requires integration of services through strengthened referrals and relationships among primary, secondary, and tertiary levels of care.
3. Implementation of a preadmission clinic, a change in the planning and waiting list system and support via follow-up telephone calls or internet-based support system to help decrease waiting time till surgery and improve the HRQOL after surgery.
4. Implementation of additional clinical services that address post hospital discharge management for cardiac surgery patients should be evaluated formally and include the regular and repeated measurement of health status to monitor patient recovery for at least 6 months.
5. The importance of a rehabilitation program for better improvement after surgery is emphasized.
6. Attention should be given to specific areas of patient orientation, education and support to facilitate realistic expectations of recovery. In addition, some form of systematic follow-up that focuses on patient recovery in terms of both physical and psychological function is important.
7. Further in-depth research studies are required to explore the impact of cardiac surgery on individuals’ different HRQOL domains in Egypt. And also research studies for HRQOL domains for each type of cardiac surgery separately in depth.
8. Additional studies need to be conducted to test the reliability and validity of the Arabic version of the SF-36 using a well-designed sampling frame from the general Egyptian population. Studies also are needed to evaluate the sensitivity of the Arabic version to variation in disease severity as well as its responsiveness to the effects of medical treatments.
Health care policy recommendations
1. National plans should be designed to guarantee the availability of accessible, affordable and effective services for the prevention, early detection and treatment of cardiac diseases and their risk factors. Special emphasis is placed on access and universal coverage to essential technology and medication, which are cost-effective for the treatment of cardiac patients or decrease the cost to enable patients to do screening early.
2. Revolutionization of the bureaucratic procedures in the MOH system to considerably decrease the time and steps needed by patients to be ready for surgery.
3. Education and training to health professionals regarding the comprehensive treatment of cardiac surgeries.