Supplementing prediction by EuroSCORE with social and patient-reported measures among patients undergoing cardiac surgery.

OBJECTIVES: The risk of poor outcomes is traditionally attributed to biological and physiological processes in cardiac surgery. However, evidence exists that other factors, such as emotional, behavioral, social, and functional, are predictive of poor outcomes. Objectives were to evaluate the predictive value of several emotional, social, functional, and behavioral factors on four outcomes: death within 90 days, prolonged stay in intensive care, prolonged hospital admission, and readmission within 90 days following cardiac surgery. METHODS: This prospective study included adults undergoing cardiac surgery 2013-2014, including information on register-based socioeconomic factors and self-reported health in a nested subsample. Logistic regression analyses to determine the association and incremental value of each candidate predictor variable were conducted. Multiple regression analyses were used to determine the incremental value of each candidate predictor variable, as well as discrimination and calibration based on the area under the curve (AUC) and Brier score. RESULTS: Of 3217 patients, 3% died, 9% had prolonged intensive care stay, 51% had prolonged hospital admission, and 39% were readmitted to hospital. Patients living alone (odds ratio, 1.19; 95% confidence interval, 1.02-1.38), with lower educational levels (1.27; 1.04-1.54) and low health-related quality of life (1.43; 1.02-2.01) had prolonged hospital admission. Analyses revealed living alone as predictive of prolonged intensive care unit (ICU) stay (Brier, 0.08; AUC, 0.68), death (0.03; 0.71), and prolonged hospital admission (0.24; 0.62). CONCLUSION: Living alone was found to supplement EuroSCORE in predicting death, prolonged hospital admission, and prolonged ICU stay following cardiac surgery. Low educational level and impaired health-related quality of life were, furthermore, predictive of prolonged hospital admission.

Educational inequality in patient-reported outcomes but not mortality among cardiac patients: Results from the national DenHeart survey with register follow-up.

Aims: This study aimed to explore whether educational level is associated with mental and physical health status, anxiety and depression symptoms and quality of life at hospital discharge and predicts cardiac events and all-cause mortality 1 year after hospital discharge in patients with ischaemic heart disease, arrhythmias, heart failure or heart valve disease. Methods: The DenHeart survey is cross-sectional and combined with data from national registers. Information on educational level and co-morbidity at hospital discharge and cardiac events and mortality 1-year post-discharge was obtained from registers. Patient-reported outcomes included SF-12, Hospital Anxiety and Depression Scale and HeartQoL. Multivariate linear and logistic regression and Cox proportional hazards regression models were used. Results: A total of 13,145 patients were included. A significant educational gradient was found in patient-reported mental and physical health status, anxiety and depression symptoms and quality of life, with lower educational groups reporting worse outcomes in adjusted analyses. No association was found between educational level and risk of cardiac events or all-cause mortality within 1 year after hospital discharge in adjusted analyses. Conclusions: In a large population of patients with cardiac disease a significant educational gradient was found in mental and physical health and quality of life at hospital discharge. There was, however, no association between educational level and risk of cardiac events or mortality 1 year after hospital discharge.

Sociodemographic, Clinical and Patient-Reported Outcomes and Readmission After Heart Valve Surgery.

BACKGROUND: Readmissions after heart valve surgery represent a significant burden for both the patient and the healthcare system. The study aim was to identify independent predictors of readmission within 180 days after surgery in a population of patients undergoing heart valve surgery. METHODS: Demographic and clinical information was obtained from national registers. Patient-reported outcomes (PROs) including Short Form 12 (SF-12) and EuroQol 5D (EQ-5D) were measured at discharge as part of a national, cross-sectional study (DenHeart). Predictors of first readmission were investigated. RESULTS: Among a total of 1,084 patients (65% men; mean age 68 years; 354 responded to questionnaires), 534 (49%) were readmitted. Responding patients who were readmitted were younger and a greater proportion had undergone mitral valve surgery. A significantly higher proportion of non-responders was readmitted. No significant differences were found in PROs between patients readmitted and those not readmitted, and receiver operating characteristic (ROC) curves showed no predictive effect of SF-12 and EQ-5D. Survival analysis using Cox proportional hazard models showed that prior percutaneous coronary intervention (PCI) (HR 1.50, CI 1.10; 2.05, p = 0.010) and a history of heart failure (HR 1.37, CI 1.10; 1.72, p = 0.006) were predictive of readmission. CONCLUSIONS: Readmission rates after heart valve surgery are high and often seen in patients who have undergone PCI and heart failure before surgery. Predictors for these high readmissions rates are difficult to establish based on medical history and type of surgery. PROs at discharge contribute information regarding a patient's perception of their often poor quality of life, but do not predict readmission.

Hospitalised patients' experiences during Negative Pressure Wound Therapy due to surgical site infection after vascular and cardiac surgery.

Surgical site infections that develop after vascular and cardiac surgery are often treated with Negative Pressure Wound Therapy (NPWT). Due to the severity of the infection and risk of bleeding, this NPWT often requires hospitalisation. Fourteen patients were selected for qualitative interviews to investigate their experiences and the meaning of patient participation during hospitalisation with NPWT. Results show that hospitalisation induces tension between an intrusion of privacy and being part of a community. Patients do not feel ill nor are considered ill. They feel minimised, lack participation and miss continuity, yet they still accept their circumstances by adjusting to hospital routines and treatment. The hospital's organisational framework compromises patient participation, yet patients still participate in supporting their own wound healing. They worry, are bored, lack a clear time horizon, and appear to be in an apathetic mood despite having significant time on their hands. In conclusion, the tension between a patient's privacy and sense of community, as well as involuntary participation in other patients' lives, compromises dignity and increases stress. Wound healing appears to be prolonged due to fasting, inactivity and stress. Self-reliant patients are at risk of being minimised and lack adequate emotional care, and the hospital's organisational framework hampers patient feelings of involvement and participation.

Exercise-based real-time telerehabilitation for older patients recently discharged after transcatheter aortic valve implantation: An extended feasibility study.

OBJECTIVES: To assess the extended feasibility of a telerehabilitation program and its effects on physical performance in older adults who have recently undergone transcatheter aortic valve implantation (TAVI). METHODS: In this single-center feasibility study, patients underwent an eight-week telerehabilitation program, involving web-based home exercise training twice weekly, an activity tracker, access to an informative website, and one online session with a nurse, starting one-week postoperative. Data collection was performed before surgery and three months postoperative. The feasibility of the intervention was based on recruitment and adherence to the program. As a secondary outcome, we evaluated the change in six-minute walk distance from before surgery to three months postoperative. RESULTS: Forty-one patients scheduled for TAVI were assessed for eligibility; 15 patients (37%) were enrolled. Of these, eight were excluded after surgery due to tiredness (n = 2), non-cardiac related hospital readmission (n = 2), fluctuating health (n = 1), death during hospital stay (n = 1), and reduced cognition (n = 2). Seven patients completed the eight-week web-based intervention and were evaluated three months postoperative. Their median (IQR) age was 83 [81, 87] years, and the sample comprised three men and four women. Their walked distance improved from median (IQR) 262 [199, 463] before surgery, to 381 [267, 521] meters three months postoperative. No adverse events were reported. CONCLUSION: Web-based telerehabilitation, including supervised exercise training, in older adults who have recently undergone TAVI was feasible for a small number of patients who completed the eight-week intervention. This was reflected in an improvement in their walked distance three months after the surgery. However, the low recruitment and retention rates do question the overall feasibility of this intervention in a frail, older population of post-TAVI patients.

Patient-reported outcome is associated with health care costs in patients with ischaemic heart disease and arrhythmia.

AIMS: Systematic use of patient-reported outcomes (PROs) have the potential to improve quality of care and reduce costs of health care services. We aimed to describe whether PROs in patients diagnosed with heart disease are directly associated with health care costs. METHODS AND RESULTS: A national cross-sectional survey including PROs at discharge from a heart centre with 1-year follow-up using data from national registers. We included patients with either ischaemic heart disease (IHD), arrhythmia, heart failure (HF), or valvular heart disease (VHD). The Hospital Anxiety and Depression Scale, the heart-specific quality of life, the EuroQol five-dimensional questionnaire, and the Edmonton Symptom Assessment Scale were used. The economic analysis was based on direct costs including primary, secondary health care, and medical treatment. Patient-reported outcomes were available from 13 463 eligible patients out of 25.241 [IHD (n = 7179), arrhythmia (n = 4322), HF (n = 987), or VHD (n = 975)]. Mean annual total direct costs in all patients were €23 228 (patients with IHD: €19 479, patients with arrhythmia: €21 076, patients with HF: €34 747, patients with VDH: €48 677). Hospitalizations contributed overall to the highest part of direct costs. For patients discharged with IHD or arrhythmia, symptoms of anxiety or depression, worst heart-specific quality of life or health status, and the highest symptom burden were associated with increased economic expenditure. We found no associations in patients with HF or VHD. CONCLUSION: Patient-reported outcomes at discharge from a heart centre were associated with direct health care costs in patients with IHD and arrhythmia. REGISTRATION: ClinicalTrials.gov: NCT01926145.

Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care.

The aim of the study was to explore nurses' experience of how their own vulnerability and suffering influence their ethical formation and their capacity to provide professional care when they are confronted with the patient's vulnerability and suffering. Care is shaped in the meeting between human beings. Professional care is informed by the patient's appeal for help as it is expressed in the meeting. Ethical formation is understood as a personal ethical and existential process, resulting in the capacity to provide professional care. A nurse must have the sense of being a complete human being with own personal attributes and sensitivity in order to be able to relate to other people. The study is based on qualitative interviews with 23 experienced nurses from Sweden, Finland and Denmark. The analyses and interpretation were carried out in line with Steinar Kvale's three levels of interpretation. The study clarifies that ethical formation is a union of the nurse's personal attributes and professional qualifications and that ethical formation is developed over time. Moreover, it also demonstrates that the nurse's personal and professional life experiences of vulnerability and suffering influence ethical formation. Vulnerability and suffering have proven to be sensitive issues for nurses, like a sore point that either serve as an eye-opener or cause the development of blind spots. Furthermore, vulnerability, suffering and the sore points are seen to shape the nurse's courage in relation to care. Courage appears to be a significant unifying phenomenon that manifests itself as the courage to help patients face their own vulnerability and suffering, to bear witness to patients' vulnerability and suffering and to have faith in oneself in arguing for and providing professional care. Courage thus seems to play a significant role in nurses' ability to engage in care. Nurses' own vulnerability, suffering and sore points seem to shape their courage.

Predictors of patient-reported outcomes at discharge in patients with heart failure.

BACKGROUND: It is well-established that heart failure has a negative impact on quality of life. However, little is known about patient-related predictors of health-related quality of life, anxiety and depression, symptoms and illness perception among patients with heart failure. AIM: To study the association between patient-related predictors and patient-reported outcome measures at discharge from hospital in a cohort of patients with heart failure. METHODS: We used data from 1506 patients with heart failure, participating in the national DenHeart Survey of patient-reported outcome measures in patients with heart disease. The potential patient-related predictors included demographic, administrative, clinical and socioeconomic factors. The patient-reported outcome measures included six questionnaires: the Short Form-12, the Hospital Anxiety and Depression Scale, the EuroQol five-dimensional, five-level questionnaire, the HeartQoL, the Brief Illness Perception Questionnaire and the Edmonton Symptom Assessment Scale. Data were linked to national patient registry data and medical records. We performed multivariable linear and logistic regression analyses. RESULTS: In adjusted linear regression analyses we found that a length of hospital stay of >2 days was associated with worse scores across questionnaires, except for the Brief Illness Perception Questionnaire. Higher comorbidity level was associated with worse scores across all questionnaires, whereas low social support was associated with worse scores across questionnaires, except for the physical domain of the Short Form-12 and the HeartQoL global score. CONCLUSIONS: This study identified length of hospital stay > 2 days, a higher comorbidity level and low social support to be associated with worse scores across questionnaires at discharge from a cardiac-related hospitalisation in patients with heart failure.

Patient-reported outcomes are independent predictors of one-year mortality and cardiac events across cardiac diagnoses: Findings from the national DenHeart survey.

AIMS: Patient-reported quality of life and anxiety/depression scores provide important prognostic information independently of traditional clinical data. The aims of this study were to describe: (a) mortality and cardiac events one year after hospital discharge across cardiac diagnoses; (b) patient-reported outcomes at hospital discharge as a predictor of mortality and cardiac events. DESIGN: A cross-sectional survey with register follow-up. METHODS: Participants: All patients discharged from April 2013 to April 2014 from five national heart centres in Denmark. MAIN OUTCOMES: Patient-reported outcomes: anxiety and depression (Hospital Anxiety and Depression Scale); perceived health (Short Form-12); quality of life (HeartQoL and EQ-5D); symptom burden (Edmonton Symptom Assessment Scale). Register data: mortality and cardiac events within one year following discharge. RESULTS: There were 471 deaths among the 16,689 respondents in the first year after discharge. Across diagnostic groups, patients reporting symptoms of anxiety had a two-fold greater mortality risk when adjusted for age, sex, marital status, educational level, comorbidity, smoking, body mass index and alcohol intake (hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.52-2.42). Similar increased mortality risks were found for patients reporting symptoms of depression (HR 2.29, 95% CI 1.81-2.90), poor quality of life (HR 0.46, 95% CI 0.39-0.54) and severe symptom distress (HR 2.47, 95% CI 1.92-3.19). Cardiac events were predicted by poor quality of life (HR 0.71, 95% CI 0.65-0.77) and severe symptom distress (HR 1.58, 95% CI 1.35-1.85). CONCLUSIONS: Patient-reported mental and physical health outcomes are independent predictors of one-year mortality and cardiac events across cardiac diagnoses.

Patient-reported outcomes after aortic and mitral valve surgery - results from the DenHeart Study.

BACKGROUND: Clinical course, co-morbidity and age often differs between patients undergoing aortic and mitral valve surgery and this might affect patient-reported outcomes. AIMS: The purpose of this study was to describe differences in patient-reported physical and mental health and health-related quality of life after aortic valve or mitral valve surgery, and to identify demographic and clinical characteristics associated with worse patient-reported physical and mental health, and health-related quality of life. METHODS: Patient-reported outcomes were measured at discharge as a part of a national, cross-sectional study (DenHeart). Patient-reported outcome measures included: Short-Form-12, Hospital Anxiety and Depression Scale, EuroQol-5D-5L, HeartQol and Edmonton Symptom Assessment System. Demographic and clinical information was obtained from national registers. RESULTS: Of 354 patients (65% men, mean age: 68 years), 79% underwent aortic valve surgery. Patients who had undergone aortic valve surgery had more symptoms of anxiety compared with patients who had undergone mitral valve surgery (34% vs 17%, p=0.003, Hospital Anxiety and Depression Scale anxiety cut-off score of eight). Being female was associated with worse patient-reported outcomes on all measures, whereas being unmarried was associated with worse physical health (Physical Component Score Short-Form-12) and symptom burden (Edmonton Symptom Assessment System). Length of stay was associated with worse symptoms on EuroQol-5D-5L Visual Analogue Scale. Age and comorbidity were not associated with patient-reported outcomes. CONCLUSION: Patients who had undergone aortic valve and mitral valve surgery did not significantly differ in patient-reported health at discharge, except for symptoms of anxiety. Being female was the only characteristic associated with overall worse patient-reported outcomes at discharge.

Precautions related to midline sternotomy in cardiac surgery: a review of mechanical stress factors leading to sternal complications.

BACKGROUND: After midline sternotomy patients are instructed on activity precautions to avoid sternal wound complications. We questioned how restrictive these precautions must be, since they can lead to a postoperative decrease in quality of life. AIMS: To identify mechanical stress factors causing sternal instability and infection in order to create evidence based guidelines for activity following sternotomy. METHODS: Literature review. RESULTS: No evidence was found to support weight limitation regarding activity, as long as the upper arms are kept close to the body and activity is within a pain-free range. RECOMMENDATIONS: Avoid stretching both arms backwards at the same time (10 days); loaded activities should be done with the elbows close to the body (eight weeks); only move arms within a pain-free range; use leg rolling with counterweighing when getting in and out of bed; when coughing cross the arms in a "self-hugging" posture; supportive bra or vest is recommended when breast cup>or=D, body mass index>or=35 or frequent cough. CONCLUSION: This study provides insights into mechanical stress factors acting upon sternum and the overlying skin. RECOMMENDATIONS on activity precautions based on these finding have a patient supportive approach focusing on possibilities and not restrictions.