AJCC
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

American Journal of Critical Care. 2002;11: 211-219
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Respond to This Article
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Right arrow Take the CE Test
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Riedinger, M. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Riedinger, M. S.

Quality of Life in Women With Heart Failure, Normative Groups, and Patients With Other Chronic Conditions

By Mary S. Riedinger, RN, PhD, Kathleen A. Dracup, RN, DNSc, Mary-Lynn Brecht, PhD and for the SOLVD Investigators*. From Cedars-Sinai Medical Center, Los Angeles, Calif (MSR), University of California, Los Angeles, School of Nursing (KAD), and University of California, San Francisco, School of Nursing (MLB).


   Abstract
Top
 Abstract
Study Aims
 Methods
 Results
 Discussion
 Limitations
 Summary
 References
 
• Background In the United States, 2.5 million women have heart failure, yet little is known about their quality of life. Because most studies included small samples of women, the results are not generalizable.

• Objective To compare the quality of life of women with heart failure with that of a normative group and with that of women with other chronic conditions.

• Methods Descriptive techniques were applied to baseline data collected in the Studies of Left Ventricular Dysfunction trials to characterize quality of life in women with heart failure (n = 691). Global quality of life and the quality-of-life dimensions of physical function, emotional distress, social health, and general health were measured by using the Ladder of Life, items from the Profile of Mood States Inventory, the Functional Status Questionnaire, the Beta Blocker Heart Attack Trial instrument, and an item from the RAND Medical Outcomes Study instrument.

• Results Compared with the normative group of women, women with heart failure had significantly lower global quality of life; worse vigor, intermediate activities of daily living, social activity, and general health ratings; and higher ratings for anxiety and depression. Fewer than half of the women with heart failure felt that they were healthy enough to perform normal activities.

• Conclusions Women with heart failure have worse quality of life than do normative populations and patients with other chronic diseases such as hypertension, Parkinson disease, and cancer.

Heart failure is a leading cause of morbidity and mortality in the United States and is a major public health concern. An estimated 5 million persons have heart failure; newly diagnosed cases occur at a rate of 400 000 per year.1 Extended life expectancy, combined with increasingly effective treatments for myocardial infarction, will increase the number of patients with heart failure. Women account for 62% of total deaths due to heart failure; additionally, women have more hospital discharges for heart failure than do men. The total estimated direct and indirect costs of hospitalization, nursing homes, healthcare professionals, medications, lost productivity, morbidity, and mortality are approximately $21 billion.1

The number of patients currently affected, the alarming rate of new cases each year, and the enormous burden this disease places on the healthcare system make treatment of heart failure an important healthcare issue. Disease management programs have been developed to decrease variation in care for patients with heart failure. These programs focus on implementing interventions that standardize care, steps that may result in decreases in signs and symptoms, hospital length of stay, and hospital readmission rates and increases in functioning and survival.2,3 However, if treatment to prolong survival decreases quality of life, patients may decide that the increase in survival has too great a cost. Therefore, understanding the baseline quality of life in women with heart failure is important. Additionally, comparison of the baseline quality of life in women with heart failure with that of normative populations and other groups with chronic conditions offers a reference point from which clinicians can truly understand the impact that heart failure has on quality of life in women.

The concept of quality of life was developed to evaluate the well-being of populations. Quality of life for a specific population of patients may be compared with the quality of life of other populations of patients or with that of the total population, as a whole, in an effort to establish whether aspects of quality of life are similar. Social and health policy may then address obvious inequity.4

To date, much less information is available on women than on men with heart failure. Most research on heart failure has included only small samples of women, making it impossible to make definitive statements about heart failure and women. In a recent study,5 researchers evaluated the enrollment of women with heart failure in 10 large clinical trials done in the 10 years preceding the study. The combined enrollment for the 10 trials was 17 370 patients; of these, approximately 20% were women. These investigators5 thought that the prevalence of diastolic dysfunction might be higher in women than in men, thereby disqualifying women from trials in which systolic dysfunction was the main criterion for enrollment.


   Study Aims
Top
 Abstract
 Study Aims
Methods
 Results
 Discussion
 Limitations
 Summary
 References
 
The purpose of the current study was to describe quality of life in a large sample of women with heart failure and compare it with the quality of life of normative groups and of patients with other chronic diseases. The hypothesis was that women with heart failure have poor quality of life.

A secondary analysis of data collected during the Studies of Left Ventricular Dysfunction (SOLVD) trials6 was done. In the SOLVD trials, data on quality of life were collected for patients with heart failure who were randomized to treatment with either the angiotensin-converting enzyme inhibitor enalapril or placebo.7 These data were not analyzed separately for men and women. Separate analysis of the women’s data would be an important contribution to the knowledge of quality of life in women with heart failure.


   Methods
Top
 Abstract
 Study Aims
 Methods
Results
 Discussion
 Limitations
 Summary
 References
 
SOLVD Trials
The SOLVD studies consisted of 2 distinct sections: a heart failure registry and 2 double-blinded, placebo-controlled, randomized trials of enalapril in patients with either overt or covert heart failure.6 Data on quality of life were collected from patients with heart failure, who were randomized to treatment with either enalapril or placebo, at baseline, 4 to 6 weeks, 1 year, and 2 years after admission into the study.7,8 Clinical data were collected at various intervals throughout the study. In this article, we describe the quality of life of women at the baseline period.

Sample
The inclusionary and exclusionary criteria of the SOLVD trials are given in the Appendix. A total of 691 women from the SOLVD trials were included in this study of baseline quality of life.

Quality-of-Life Definition
The SOLVD investigators included 2 global measures of the quality of life (current life and general life satisfaction) and 4 dimensions (physical functioning, emotional distress, social health, and perceived health) in their definition of quality of life. Physical functioning included the concepts of vigor, activities of daily living (ADL), and health that interfered with activities. Emotional distress included anxiety and depression. Social health included social function, social life satisfaction, and intimacy. Finally, perceived health included general health. Because our analysis is a secondary analysis of the SOLVD data, we are limited to the quality-of-life definition of the SOLVD investigators.

Instruments
The quality-of-life instrument consisted of 90 items drawn from a number of instruments: the Profile of Mood States Inventory (POMS), Functional Status Questionnaire (FSQ), the Beta Blocker Heart Attack Trial instrument, Symptoms Scale, Ladder of Life, and an item from the RAND Medical Outcomes Study instrument. All of the parent instruments have been used extensively in patients with heart failure and other clinical populations. The psychometric properties have been tested, and the instruments are considered valid and reliable. The items used in this study were subjected to additional testing for internal consistency and validity with this sample of patients.

The multi-item scales used in the SOLVD battery were tested for reliability by using a Cronbach {alpha}test; every scale exceeded the 0.70 {alpha}coefficient level. Therefore, the SOLVD multi-item scales were considered reliable.

Discriminate validity of the SOLVD battery was tested by using a correlation matrix to determine the degree of independence between constructs. Second, the ability of the constructs to differentiate between patients on the basis of the severity of heart failure was tested. The second method of discrimination has been used in other populations with heart disease.9 The calculated correlations indicated that most constructs of the SOLVD quality-of-life battery fell below the 0.50 level of discrimination. This level has been used by other investigators and is thought to be discriminative enough that constructs can be considered different from each other.10 Basic and intermediate ADL scores had a correlation of 0.58; basic ADL scores and intermediate ADL scores had correlations with social activities of 0.53 and 0.75, respectively. The correlation between anxiety and depression was 0.74. The correlation between social and general life satisfaction was 0.63.

After patients were grouped according the New York Heart Association (NYHA) classification, t tests revealed significant differences between the NYHA severity groups for all quality-of-life dimensions except anxiety and depression. This finding indicates that most dimensions in the SOLVD battery can be used to discriminate severity of illness.

Data Analysis
Descriptive statistical techniques were used. Additionally, when comparative data were available, t tests were used to test for differences between the mean scores of the study group and those of the comparative populations.

Frequencies were calculated to determine the amount of missing data. Depending on the type of data and the quantity of missing data, data were either eliminated from the analyses or were estimated (imputed). If a scale had less than 50% of the data missing, then missing values were imputed. The subject’s mean score for valid items was used in place of missing items. Imputation was considered solely for those scales for which the items were similar and the responses were similar.

The study was considered exempt from review by the human subject protection committee. The data were existing, and the data set contained no information on patients’ identity. Therefore, patients’ confidentiality was maintained.


   Results
Top
 Abstract
 Study Aims
 Methods
 Results
Discussion
 Limitations
 Summary
 References
 
Demographic Data
The demographic data are presented in Table 1Go. As stated, the sample size for the demographic data was 691 unless otherwise noted.


View this table:
[in this window]
[in a new window]
  		Table 1 Sociodemographics and clinical data of women in this study (N=691)*

 
The majority of women were white and 21 to 80 years old. Fifty-three percent had completed 12 years or more of education. Ejection fractions ranged from 0.60 to 0.35. More than half had a history of smoking; 18% were smokers at the time of entry into the study. Because of strict exclusion criteria, few of the women had comorbid conditions. The majority of women had disease of NYHA class II or class III. In the month before collection of baseline data, the most frequent symptoms, in order, were dyspnea, chest pain, and dizziness.

Quality of Life of Women With Heart Failure
The research hypothesis was that women with heart failure have a poor quality of life. Results of the analysis of baseline quality of life in women are presented in Table 2Go. Where normative data or information from other populations of chronically ill women were available, the data were compared with the data of the women with heart failure (Table 3Go). Unfortunately, most comparative data include values for men; available studies in which data on women only were compared are scarce. Therefore, comparative data that included values for men are presented when comparative data exclusive to women were not available.


View this table:
[in this window]
[in a new window]
  		Table 2 Quality of life of women with heart failure (N=691)*

 

View this table:
[in this window]
[in a new window]
  		Table 3 Comparisons of quality of life of women with heart failure with that of other populations*

 
  Global Quality of Life.   Although the women with heart failure rated their overall current life situation significantly lower than did men and women in a nationwide study,11 the majority of the women with heart failure were extremely, very, or generally satisfied with their lives.

  Physical Functioning.   Vigor was measured by using a subscale of the POMS instrument, with higher scores signifying greater vigor. Most available normative data for the POMS measure were based on an aggregated or "Total Mood" score from all subscales and therefore were unusable as comparative data in this study. However, in a study12 of 250 normative healthy women, the POMS instrument was used to collect mood data 4 times during a 1-year period. The mean vigor score of these women was significantly higher (P<.001) than the vigor score for women with heart failure. In another study,13 the effects of antihypertensive treatments on quality of life were compared in men and women. This group of patients also had significantly higher vigor scores than did the women with heart failure. Finally, the vigor scores of patients with various types of cancer14 did not differ significantly from the scores of the women with heart failure. In summary, the vigor scores of women with heart failure were significantly lower than the scores of a normative female group and of a group of patients with hypertension and were similar to the scores of elderly cancer patients.

The developers of the FSQ scales created a computerized program used to score the FSQ survey and provided "warning-zone" information. The warning-zone ranges were determined through consultation with a panel of experienced clinicians: 5 physicians, a social worker, and a psychologist.24 The panel reviewed the survey items and judged the degree of impairment that would justify clinical concern. The warning-zone ranges were used as markers of decreased function in our study. The women with heart failure were within the normal range for basic ADL, but the mean intermediate ADL score was in the warning-zone range (0–88). Comparative data were available from a study15 in which researchers evaluated 2 groups of community-dwelling subjects, geriatric and nongeriatric. The basic ADL scores of the geriatric and nongeriatric groups did not differ significantly from the basic ADL scores of the women with heart failure. However, the women with heart failure had significantly lower intermediate ADL scores than did the 2 normative groups.

The basic ADL scores of the women with heart failure were significantly better than the basic scores of frail hospitalized older adults,16 outpatients who had Parkinson disease,17 and outpatients who had chronic obstructive pulmonary disease (COPD).18 However, the intermediate scores of the women with heart failure were significantly worse than the intermediate scores of the other 3 groups.

These data suggest that women with heart failure can perform basic ADL, such as taking care of themselves (bathing, eating, dressing) and moving in and out of bed, within normal ranges and have better basic ADL functioning than do patients with COPD or Parkinson disease or elderly hospitalized patients. However, women with heart failure are quite limited in their ability to perform intermediate ADL tasks; their scores were significantly lower than those of normative subjects, hospitalized older adults, patients with Parkinson disease, and patients with COPD.

More than half of the women with heart failure felt that their health limited their ability to perform their daily activities. We had no comparative data for analyses.

  Emotional Distress.   Anxiety and depression were measured by using subscales of the POMS instrument, with higher scores signifying more mood disturbance. Women with heart failure had significantly worse anxiety (P<.001) and depression (P<.001) scores than did the normative sample from the vitamin D study12 and patients in the antihypertensive study.12 Additionally, women with heart failure had a worse mean anxiety score than did the geriatric subjects in a study19 of the use of over-the-counter medications; the mean depression score of the women with heart failure, however, was similar to that of the geriatric subjects.

Compared with elderly patients with cancer,14 the women with heart failure had significantly better mean depression scores (P<.001) but significantly worse mean anxiety scores (P<.001). Women with heart failure also had significantly lower depression scores than did cancer patients enrolled in a brief weekend psychoeducational program.20 However, the anxiety scores of the cancer patients were significantly better than the anxiety scores for the women with heart failure (8.50 ± 7.66 vs 9.14 ± 6.65, P = .02).

In a study21 of 32 women, mood disturbance was evaluated 1 and 4 months after acute myocardial infarction. The mean anxiety (P = .20) and depression (P = .50) scores of these women 4 months after myocardial infarction did not differ significantly from the scores of the women with heart failure. However, mean anxiety (P<.001) and depression (P<.001) scores 1 month after myocardial infarction as well as the mean scores of subjects with COPD who were not receiving oxygen therapy at home22 were significantly worse than the mean scores for the women with heart failure.

Overall, women with heart failure had worse feelings of anxiety than did the normative group of women in the vitamin D study, both cancer patient cohorts, the geriatric subjects, and the patients in the antihypertensive study. Women with heart failure did have better anxiety scores than did patients with COPD and patients 1 month after acute myocardial infarction. Feelings of depression were higher in the women with myocardial infarction at 1 month, the cancer patients (both groups), and the COPD cohort. The depression scores of the women with heart failure were worse than those of the geriatric patients, the normative women in the vitamin D trial, and the patients in the antihypertensive study.

  Social Health   The FSQ expert panel defined a normal range for the social activity scale as a score between 79 and 100. The mean social activity score for the women with heart failure was below this normal range. The women had statistically lower mean social activity scores than did frail hospitalized older adults16 (P<.05); however, women with heart failure had significantly better social activity scores than did patients with Parkinson disease17 (P<.001) and COPD18 (P<.001).

Among the women with heart failure, 66% were very or fairly satisfied with their social life, 19% had mixed feelings, and 15% felt some degree of dissatisfaction.

  General Health.   Fewer than half of the women with heart failure felt that their general health was excellent, very good, or good. Forty-five percent felt that their general health was fair, and 9% thought that their general health was poor. After this item was converted to a 100-point scaled score,23 the mean score for the women with heart failure was significantly lower than the mean score of a normative population of women (P<.001) and the mean scores of groups of men and women with heart failure (P<.001), diabetes (P<.001), Parkinson disease (P<.001), COPD (P<.001), recent myocardial infarction (P<.001), and hypertension (P<.001). The women with heart failure had significantly worse general health than did patients with other chronic and acute diseases.17,23


   Discussion
Top
 Abstract
 Study Aims
 Methods
 Results
 Discussion
Limitations
 Summary
 References
 
The hypothesis that women with heart failure have poor quality of life was mostly supported. With regards to global quality of life, the women with heart failure had significantly lower current life situation scores than did the normative group of women. Normative data were not available for the life satisfaction item, but 65% of the women with heart failure had some degree of satisfaction with their lives.

For the quality-of-life dimensions, when comparative data were available, women with heart failure had worse vigor, intermediate ADL, anxiety, depression, social activity, and general health ratings. Women with heart failure had scores consistent with normative populations for basic ADL dimensions. Fewer than half of the women with heart failure felt that they were healthy enough to perform normal activities.

Heart failure is a devastating condition that produces fatigue, dyspnea, and limitations in exercise capacity, all of which severely affect the quality of life.25 Patients with heart failure report high anxiety and score low for general health and functioning.26 The morbidity that accompanies heart failure results in increases in the number of hospital readmissions, early retirement, loss of income, and the inability to perform physical activities—all of which can lead to depression.2,27

Our results indicate that heart failure places a tremendous burden on quality of life in women with heart failure; this burden is greater than in most other chronic conditions. These findings are consistent with those of Bennett et al,28 who found that women with heart failure (n = 30) had high physical symptom impact and poor perceived physical health status. In another study, Chin and Goldman,27 using the Medical Outcomes Short Form 36, found that quality of life was low in patients with heart failure. Additionally, despite controls for socioeconomic and clinical variables, women with heart failure (n = 90) had significantly lower scores for physical function and vitality than did men. These findings persisted even after 1 year.

In a study29 of the same SOLVD cohort (691 women) as the one in our study, women had significantly worse general life satisfaction, physical function, social health, and general health scores than did men. The differences between men and women for current life situation and emotional distress were not significant. After the researchers controlled for NYHA classification, women still had significantly worse ratings for intermediate ADL and social activity. In a study30 of gender and quality of life in patients with heart failure (n = 191), quality of life was significantly more impaired in women than in men. In another investigation,31 patients with advanced heart failure (111 men and 23 women) felt that their quality of life was significantly compromised. Although they had a wide range of physical abilities, the patients rated themselves as moderately anxious and hostile and moderately to severely depressed.

Compared with normative populations, the women with heart failure who participated in the SOLVD trials had worse overall quality-of-life scores and worse scores for vigor, intermediate ADL, general health, anxiety, and depression; they had similar scores for basic ADL. Women with heart failure also had a quality of life that was worse than that of patients with other chronic diseases, including cancer and Parkinson disease. This finding is significant because of the increasing prevalence of heart failure. Although the basic ADL scores of the women with heart failure were normal, their scores for intermediate ADL functioning such as grocery shopping climbing stairs, and walking several blocks were poor.

The majority of the women with heart failure reported that their health interfered with the performance of normal activities; overall, general health ratings were also lower for the women with heart failure than for the other groups. Despite these findings, the majority of the women with heart failure were satisfied with their lives in general. This satisfaction may be a result of effective coping behavior and needs further exploration.

Heart failure disease management programs have been developed to reduce variation in care.2,32–38 Goals include decreasing heart failure symptoms, decreasing hospital length of stay and hospital readmissions, and increasing physical functioning. Many clinicians equate quality of life with physical functioning, which is an important dimension of quality of life; however, other dimensions are equally important and need attention, including, but not limited to, emotional and social function.

In elderly patients, higher levels of quality of life are related to fewer readmissions and thus decreases in cost.39 It may be cost-effective to include interventions that improve quality of life in patients with heart failure. The programs for managing patients with heart failure may not be reducing cost as much as possible because of the lack of interventions that focus on quality of life. Programs may be able to include interventions that improve on other dimensions of quality of life, thereby improving the overall health-related quality of life of women with heart failure and reducing costs by decreasing readmission rates.


   Limitations
Top
 Abstract
 Study Aims
 Methods
 Results
 Discussion
 Limitations
Summary
 References
 
This study has several limitations. First, generalizability is a potential limitation, because the subjects were participants in a randomized clinical trial. Results may not be generalizable to the general female population with heart failure. Second, the research was limited to the data collected in the SOLVD trials and the variables contained therein. All data were taken at face value and were considered accurate; this assumption may not have been the case in all instances.


   Summary
Top
 Abstract
 Study Aims
 Methods
 Results
 Discussion
 Limitations
 Summary
References
 
Heart failure imposes a great burden on quality of life. Women, as indicated by our findings, tend to have a poor quality of life in most dimensions. Further research is needed to determine why women with heart failure have such poor quality of life compared with that of other populations and to test interventions to improve quality of life. Quality of life may be less valued by clinicians who focus more heavily on improving survival in patients with heart failure. However, Rector et al40 found that a substantial number of patients with heart failure were willing to accept a risk of drug-induced death for improved quality of life. Clinicians and those who design disease management programs need to focus not only on reducing the number of hospital readmissions and increasing physical functioning and survival but also on improving the psychosocial aspects of quality of life in women with heart failure.

Reprint requests: Dr Mary S. Riedinger, Cedars-Sinai Medical Center, 8631 W Third St, Suite 800E, Los Angeles, CA 90048.

* A complete list of the SOLVD investigators has been published ( N Engl J Med. 1992;327:685–691[Abstract]). Back


   REFERENCES
Top
 Abstract
 Study Aims
 Methods
 Results
 Discussion
 Limitations
 Summary
 References
 

  1. American Heart Association. Statistics. 1999. Available at: http://americanheart.org/statistics/07other.html.
  2. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–1195.[Abstract/Free Full Text]
  3. West JA, Miller JA, Parker KM, et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol. 1997;79:58–63.[Medline]
  4. Felce D, Perry J. Quality of life: its definition and measurement. Res Dev Disabil. 1995;16:51–74.[Medline]
  5. Lindenfeld J, Krause-Steinrauf J, Salerno J. Where are all the women with heart failure? J Am Coll Cardiol. 1997;30:1417–1419.[Abstract]
  6. Studies of Left Ventricular Dysfunction (SOLVD)—rationale, design and methods: two trials that evaluate the effect of enalapril in patients with reduced ejection. Am J Cardiol. 1990;66:315–322.[Medline]
  7. Gorkin L, Norvell NK, Rosen RC, et al. Assessment of quality of life as observed from the baseline data of the Studies of Left Ventricular Dysfunction (SOLVD) trial quality-of-life substudy. Am J Cardiol. 1993;71:1069–1073.[Medline]
  8. Rogers WJ, Johnstone DE, Yusuf S, et al. Quality of life among 5025 patients with left ventricular dysfunction randomized between placebo and enalapril: the Studies of Left Ventricular Dysfunction. The SOLVD investigators. J Am Coll Cardiol. 1994;23:393–400.[Abstract]
  9. Wiklund I, Gorkin L, Pawitan Y, et al. Methods for assessing quality of life in the Cardiac Arrhythmia Suppression Trial (CAST). Qual Life Res. 1992;1:187–201.[Medline]
  10. Gorkin L, Follick MJ, Geltman E, et al. Quality of life among patients post-myocardial infarction at baseline in the Survival and Ventricular Enlargement (SAVE) trial. Qual Life Res. 1994;3:111–119.[Medline]
  11. Bortner RW, Hultsch F. A multivariate analysis of correlates of satisfaction in adulthood. J Gerontol. 1970;25:41–47.[Medline]
  12. Harris S. Seasonal mood changes in 250 normal women. Psychiatry Res. 1993;49:77–87.[Medline]
  13. Fletcher AE, Bulpitt CJ, Chase DM, et al. Quality of life with three antihypertensive treatments. Hypertension. 1992;19:499–507.[Abstract/Free Full Text]
  14. Fehring RJ, Miller JF, Shaw C. Spiritual well-being, religiosity, hope, depression, and other mood states. Oncol Nurs Forum. 1997;24: 663–671.[Medline]
  15. Yarnold PR, Stille FC, Martin GJ. Cross-sectional psychometric assessment of the Functional Status Questionnaire: use with geriatric versus non-geriatric ambulatory medical patients. Int J Psychiatry Med. 1995;25:305–317.[Medline]
  16. Kim SH, Wolde-Tsadik G, Reuben DB. Predictors of perceived health in hospitalized older persons: a cross-sectional and longitudinal study. J Am Geriatr Soc. 1997;45:420–426.[Medline]
  17. Rubenstein LM, Voelker MD, Chrischilles EA, Glenn DC, Wallace RB, Rodnitzky RL. The usefulness of the Functional Status Questionnaire and the Medical Outcomes Study Short Form in Parkinson’s disease research. Qual Life Res. 1998;7:279–290.[Medline]
  18. Jette DU, Manago D, Medved E, Nickerson A, Warzycha T, Bourgeois M. The disablement process in patients with pulmonary disease. Phys Ther. 1997;77:385–394.[Abstract/Free Full Text]
  19. Conn VS. Older adults: factors that predict the use of over-the-counter medication. J Adv Nurs. 1991;16:1190–1196.[Medline]
  20. Cunningham AJ, Jenkins G, Edmonds CVI, Lockwood GA. A randomised comparison of two forms of a brief, group, psychoeducational program for cancer patients: weekly sessions versus a "weekend intensive." Int J Psychiatry Med. 1995;25:173–189.[Medline]
  21. Conn VS, Taylor SG, Abele PB. Myocardial infarction survivors: age and gender differences in physical health, psychosocial state and regimen adherence. J Adv Nurs. 1991;16:1026–1034.[Medline]
  22. Graydon JE, Ross E. Influence of symptoms, lung function, mood and social support on level of functioning of patients with COPD. Res Nurs Health. 1995;18:525–533.[Medline]
  23. Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide. Boston, Mass: The Health Institute, New England Medical Center; 1993.
  24. Jette AM, Davies AR, Cleary PD, et al. The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med. 1986;1:143–149.[Medline]
  25. Poole-Wilson PA. Relation of pathophysiologic mechanisms to outcome in heart failure. J Am Coll Cardiol. 1993;22(4 suppl A):22A–29A.[Medline]
  26. Hawthorne MH, Hixon ME. Functional status, mood disturbance and quality of life in patients with heart failure. Prog Cardiovasc Nurs. 1994;9:22–32.[Medline]
  27. Chin MH, Goldman L. Gender differences in 1-year survival and quality of life among patients admitted with congestive heart failure. Med Care. 1998;36:1033–1046.[Medline]
  28. Bennett SJ, Baker SL, Huster GA. Quality of life in women with heart failure. Health Care Women Int. 1998;19:217–229.[Medline]
  29. Riedinger MS, Dracup KA, Brecht ML. Quality of life in women with heart failure: do gender differences exist? Heart Lung. 2001;30:105–116.[Medline]
  30. Cline CM, Willenheimer RB, Erhardt LR, Wiklund I, Israelsson BY. Health-related quality of life in elderly patients with heart failure. Scand Cardiovasc J. 1999;33:278–285.[Medline]
  31. Dracup K, Walden JA, Stevenson LW, Brecht ML. Quality of life in patients with advanced heart failure. J Heart Lung Transplant. 1992;11:273–279.[Medline]
  32. Knox D, Mischke L. Implementing a congestive heart failure disease management program to decrease length of stay and cost. J Cardiovasc Nurs. 1999;14:55–74.[Medline]
  33. Rich MW. Heart failure disease management: a critical review. J Card Fail. 1999;5:64–75.[Medline]
  34. Schulman KA, Mark DB, Califf RM. Outcomes and costs within a disease management program for advanced congestive heart failure. Am Heart J. 1998;135(6 pt 2 suppl):S285–S292.[Medline]
  35. Simons WR, Haim M, Rizzo J, Zannad F. Effect of improved disease management strategies on hospital length of stay in the treatment of congestive heart failure. Clin Ther. 1996;18:726–746.[Medline]
  36. Rich MW, Gray DB, Beckham V, Wittenberg C, Luther P. Effect of a multi-disciplinary intervention on medication compliance in elderly patients with congestive heart failure. Am J Med. 1996;101:270–276.[Medline]
  37. Rich MW, Vinson JM, Sperry JC, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study. J Gen Intern Med. 1993;8:585–590.[Medline]
  38. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc. 1990;38:1290–1295.[Medline]
  39. Candlish P, Watts P, Redman S, Whyte P, Lowe J. Elderly patients with heart failure: a study of satisfaction with care and quality of life. Int J Qual Health Care. 1998;10:141–146.[Abstract]
  40. Rector TS, Tschumperlin LK, Kubo SH, et al. Use of Living with Heart Failure questionnaire to ascertain patients’ perspectives on improvement in quality of life versus risk of drug-induced death. J Card Fail. 1995;1:201–206.[Medline]



This article has been cited by other articles:


Home page
 Palliat MedHome page
D. Janssen, M. Spruit, E. Wouters, and J. Schols
Daily symptom burden in end-stage chronic organ failure: a systematic review
Palliative Medicine, December 1, 2008; 22(8): 938 - 948.
[Abstract] [PDF]

Home page
 Am J Crit CareHome page
A. G. Rosenfeld
State of the Heart: Building Science to Improve Women's Cardiovascular Health
Am. J. Crit. Care., November 1, 2006; 15(6): 556 - 566.
[Abstract] [Full Text] [PDF]

Home page
 FocusHome page
J. K. Schulman, P. R. Muskin, and P. A. Shapiro
Psychiatry and Cardiovascular Disease
Focus, April 1, 2005; 3(2): 208 - 224.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Respond to This Article
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Right arrow Take the CE Test
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Riedinger, M. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Riedinger, M. S.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS