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American Journal of Critical Care. 2008;17: 124-132
Copyright © 2008 by the American Association of Critical-Care Nurses.
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Predictors and Effect of Physical Symptom Status on Health-Related Quality of Life in Patients With Heart Failure

By Seongkum Heo, RN, PhD, Lynn V. Doering, RN, DNSc, Jeanne Widener, RN, MSN and Debra K. Moser, RN, DNSc. Seongkum Heois an assistant professor at the Indiana University School of Nursing in Indianapolis. Debra K. Moseris a professor and holds the Gill Endowed Chair of Nursing at the University of Kentucky College of Nursing in Lexington. Lynn V. Doeringis an associate professor and section chair in acute care at the University of California, Los Angeles, School of Nursing. Jeanne Wideneris a doctoral student at Ohio State University in Columbus.

Corresponding author: Seongkum Heo, Indiana University School of Nursing, 1111 Middle Dr, NU426, Indianapolis, IN 46202-5107 (e-mail: heo2{at}iupui.edu).


   Abstract
Top
 Abstract
Theoretical Framework
 Methods
 Results
 Discussion
 Conclusions
 References
 
Background Physical symptoms are common and distressing problems for patients with heart failure and may be the strongest predictor of health-related quality of life. Identification of variables predictive of physical symptom status is needed to develop effective interventions to improve health-related quality of life.

Methods A total of 84 patients discharged after being hospitalized for exacerbation of heart failure were followed up for 3 months. The Minnesota Living With Heart Failure Questionnaire and the Dyspnea-Fatigue Index were used to assess health-related quality of life and physical symptom status, respectively. Relationships of health-related quality of life and physical symptom status to baseline demographic, behavioral, biophysiological, and psychological variables were examined with bivariate correlations and stepwise multiple regression analyses.

Results Patients with better physical symptom status and those who worked, were older, and were less anxious at baseline reported better health-related quality of life (F=12.4, P<.001); physical symptom status was the strongest predictor. Patients who had less depression, worked, had higher perceived control, and were younger at baseline reported better physical symptom status (F=14.4, P<.001); depression was the strongest predictor.

Conclusions Physical symptom status is the most important predictor of health-related quality of life, and baseline depression and perceived control are the best predictors of physical symptom status. Interventions targeted to improve psychological status may improve physical symptom status and thereby improve health-related quality of life.

Dyspnea and fatigue are the most common and distressing physical symptoms in patients with heart failure.1,2 About 80% of patients with heart failure experience these 2 symptoms during daily activities, and about 20% have dyspnea and fatigue even at rest.3 The symptoms adversely affect several aspects of daily living; they limit daily physical, work, and social activities and are associated with negative moods.3–6

Physical symptoms themselves are key determinants of hospitalizations or emergency department visits in patients with heart failure.5,7 In one study,7 more than 90% of patients experienced dyspnea for a mean of 3 days before their hospitalizations for heart failure. In another study,5 dyspnea was the primary reason for visits to the emergency department in 70% of patients with heart failure. The importance of physical symptoms is underscored by reports that patients with heart failure rate improvement in symptoms more important than longer survival.8 Limitations in patients’ daily lives because of physical symptom status are likely to be associated with adverse changes in the patients’ health-related quality of life (HRQOL).9,10

To improve physical symptom status and, in turn, HRQOL, clinicians and researchers need to understand the variables that are predictive of physical symptom status. Few investigators, however, have used longitudinal designs and psychobiobehavioral approaches to examine such predictors. Therefore, the purpose of this study was to determine predictors of physical symptom status in patients with heart failure at 3 months after hospital discharge. Before testing a model of predictors of physical symptom status, we determined the effect of physical symptom status on HRQOL. Our specific aims were to determine whether baseline physical symptom status is an important predictor of HRQOL at 3-month follow-up and to determine the best model of predictors of physical symptom status at 3-month follow-up.


   Theoretical Framework
Top
 Abstract
 Theoretical Framework
Methods
 Results
 Discussion
 Conclusions
 References
 
Physical symptom status is not simply a reflection of a patient’s abnormal physical sensations (specifically, dyspnea and fatigue); rather, it is a patient’s subjective perception of the sensations resulting from an abnormal physical condition and the effect of these sensations on daily life.11 Thus, patients’ perceptions of their physical symptom status may be influenced by demographic, behavioral,12 biophysiological, and psychological variables. Demographic variables include age, sex, and marital status.13,14 Potential biophysiological predictors include left ventricular ejection fraction, the cause of the heart failure, and comorbid conditions.15 Psychological variables such as perceived control, anxiety, and depression may worsen or improve physical symptom status in patients with chronic diseases, such as heart failure or cancer.4,13,16


Eighty percent of patients with heart failure experience dyspnea and fatigue during daily activities.

 

We examined the direct effect of demographic, behavioral, bio-physiological, and psychological variables on physical symptom status (see FigureGo). Because the variables in the model also may affect HRQOL,17–19 we also determined the direct effect of the variables on HRQOL to show how physical symptom status affects HRQOL.


Figure 1
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  		Figure Theoretical framework of predictors of physical symptom status.

 

   Methods
Top
 Abstract
 Theoretical Framework
 Methods
Results
 Discussion
 Conclusions
 References
 
Design, Sample, and Study Setting
A longitudinal, observational study using a convenience sample of patients with heart failure was conducted to determine the effect of physical symptom status in the first week after hospital discharge on HRQOL measured 3 months later and to determine predictors (measured within the first week after hospital discharge) of physical symptom status measured 3 months after hospital discharge. Among patients who were hospitalized because of exacerbation of heart failure, 84 were recruited from 4 hospitals in Columbus, Ohio, and Lexington, Kentucky. Patients were included in the study if they had a primary diagnosis of heart failure confirmed by clinical signs and symptoms and radiographic evidence, were in New York Heart Association (NYHA) functional class II to IV, were discharged to home, and were living within the greater metropolitan area. Patients were excluded if they were discharged to an extended care facility or hospice, referred to cardiac rehabilitation programs, or had cognitive or psychiatric problems.


Patients who had better physical symptom status, who were older, and who worked reported better quality of life.

 

Measures
  Physical Symptom Status.   Physical symptom status, defined as a patient’s subjective perception of his or her abnormal physical sensations and the effects of the sensations on daily life, was measured by using the Dyspnea and Fatigue Index.20 This index is commonly used to assess physical symptom status and the effect of symptoms on function during daily activities or rest in patients with heart failure.21–23 It has 3 components: magnitude of the task at which dyspnea or fatigue occurs, magnitude of the pace at which the symptoms occur, and functional impairment due to these symptoms. Each component has 5 response options ranging from 0 to 4; the total score is calculated by summing the ratings. The possible total score is from 0 to 12; higher scores indicate better physical symptom status. In our study, the Cronbach {alpha} of this instrument (total score) was .87 at baseline and .88 at 3 months.

  Health-Related Quality of Life.   HRQOL, defined as a patient’s subjective perception of the effects of heart failure and its treatment on his or her daily life,24 was assessed using the Minnesota Living With Heart Failure Questionnaire.25,26 This disease-specific instrument was developed to assess HRQOL of patients with heart failure.25 The questionnaire consists of 21 items with 6 response options ranging from 0 (no impact on HRQOL) to 5 (most negative impact on HRQOL). The total score is calculated by summing the ratings of all items; higher scores indicate poorer HRQOL. The possible total score is from 0 to 105. The measure has acceptable reliability and validity.26–28 In our study, the Cronbach {alpha} was .91 at baseline and .93 at 3 months.

  Potential Predictors of Physical Symptom Status.   A number of possible relevant demographic and clinical variables commonly associated with physical symptom status or HRQOL were measured. Demographic variables included age, sex, marital status, ethnicity, and educational status. Behavioral variables included employment status and smoking. Biophysiological status included left ventricular ejection fraction, the cause of heart failure, comorbid conditions, and NYHA functional class. These variables should be controlled in any predictive model in order to isolate the contribution of the specific variables under investigation. The NYHA functional class was used solely for examination of predictors of HRQOL, because functional status is suggested as a predictor of HRQOL but not as a predictor of physical symptom status.29 Demographic and biophysiological variables were obtained by interviewing each patient and reviewing the patient’s medical record.

Perceived control, defined as a patient’s subjective perception of the degree of personal control related to his or her clinical condition, was assessed using the Cardiac Attitudes Index. This measure consists of 15 items rated on a Likert scale with 5 possible responses (1–5). The possible range of the score is 15 (no perceived control) to 75 (best perceived control). In our study, the Cronbach {alpha} for this measure at baseline was .71.

The Depression and Anxiety subscales of the Brief Symptom Inventory were used to measure depression and anxiety, respectively.30 Each subscale consists of 6 items with 5 response options (0–4). Each subscale score is calculated by adding the ratings of the responses and dividing the total by the number of items responded to in each subscale. The possible range of each subscale is from 0 (no depression or anxiety) to 4 (always depressed or anxious). Mean scores for adult nonpsychiatric patients are 0.28 for depression and 0.35 for anxiety. These means are commonly used as cutoff points for the presence of depression and anxiety. The reliability and validity of the Brief Symptom Inventory are considered acceptable.30,31 In our study, the Cronbach {alpha} at baseline was .78 for depression and .83 for anxiety.

Procedure
The study was reviewed and approved by the appropriate institutional review boards and was carried out in accordance with the ethical standards set forth in the Helsinki Declaration of 1975. All patients who participated gave written, informed consent. Eligible patients were identified during their hospitalization by trained nurse research assistants. All baseline data, including demographic, behavioral, biophysiological, psychological, physical symptom status, and HRQOL, were collected by the nurse research assistants via face-to-face contact with patients or from the medical records from 2002 to 2004. At 3 months after discharge, data on physical symptom status and HRQOL were collected by the nurse research assistants via face-to-face contact with patients at the patients’ homes.

Data Analysis
Data were analyzed by using SPSS for Windows (version 12.0, SPSS Inc, Chicago, Illinois). The assumptions of normality and homoscedasticity were not violated. No multicollinearity problems occurred. Measures of central tendency and frequency were used to describe demographic characteristics, behavioral status, biophysiological status, physical symptom status, and functional status. Correlational or associational analyses and stepwise multiple regression analysis were used to address the hypothesis that baseline physical symptom status is the most powerful predictor of HRQOL. First, the bivariate relationships between HRQOL at 3 months and the following variables were examined using the Pearson r for interval measures, the Spearman {rho} for ordinal measures, and the {chi}2 test for categorical measures. Baseline variables included demographic variables (age, sex, marital status, ethnicity, and education), behavioral variables (employment status and smoking), biophysiological variables (left ventricular ejection fraction, cause of heart failure, number of comorbid conditions, and NYHA functional class), psychological variables (perceived control, anxiety, and depression), and physical symptom status.

Second, the baseline variables with P <.10 in the bivariate analyses were included in a stepwise multiple regression analysis to determine whether physical symptom status at baseline is an important predictor of HRQOL at 3 months. It is common practice to use a less rigid entry criterion to ensure that all possible variables are considered because, at times, even apparently unrelated variables can affect the model when included in a multiple regression.


Interventions to improve psychological status, especially depression, may improve quality of life in heart failure patients.

 

The same procedures were used to determine which baseline variables are predictive of physical symptom status at 3 months. Variables with P <.10 in the bivariate analyses were included in a stepwise multiple regression analysis. For multivariate analyses, significance was set at P<.05.


   Results
Top
 Abstract
 Theoretical Framework
 Methods
 Results
Discussion
 Conclusions
 References
 
Characteristics of the Sample
A total of 84 patients with heart failure were included in the study. Their characteristics are described in Table 1Go.


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  		Table 1 Characteristics of the study sample (N = 84)

 
A total of 95% of the patients had physical symptoms such as dyspnea and/or fatigue while performing daily activities, and 94% experienced functional impairment because of these symptoms. At baseline, 70% of the patients had depression and anxiety scores greater than the nonpatient norm mean score for the Depression and Anxiety subscales of the Brief Symptom Inventory. The mean score of the Living With Heart Failure Questionnaire25,26 was 44 (SD, 24). This score is considerably greater than that of healthy older adults (mean, 14; SD, 16),17 indicating that patients with heart failure had considerably poorer HRQOL than did other older adults of similar age.

Effects of Physical Symptom Status on HRQOL
In the analyses of bivariate relationships between 3-month HRQOL and baseline variables, the following variables had P < .10: age, employment status, NYHA functional class, perceived control, anxiety, depression, and physical symptom status (Table 2Go). In the stepwise multiple regression analysis, physical symptom status, age, employment status, and anxiety as a group at baseline were predictors of HRQOL at 3 months (Table 3Go). Patients who had better physical symptom status, were older, worked full-time or part-time inside or outside the home, and had less anxiety reported better HRQOL (R2=0.45). Physical symptom status was the strongest predictor of HRQOL. Sex, marital status, ethnicity, education, smoking, left ventricular ejection fraction, cause of the heart failure, and number of comorbid conditions were not related to and were not predictive of HRQOL.


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  		Table 2 Relationships between health-related quality of life and demographic, behavioral, biophysiological, and psychological variables

 

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  		Table 3 Stepwise regression analysis: predictors of health-related quality of life

 
Predictors of Physical Symptom Status
In the bivariate analyses of relationships between 3-month physical symptom status and baseline variables, age, ethnicity, employment status, perceived control, anxiety, and depression had P <.10 (Table 4Go). In the stepwise multiple regression analysis, depression, perceived control, employment status, and age were important predictors of physical symptom status at 3 months (Table 5Go). Patients who had less depression, worked, had better perceived control related to heart failure and its management, and were younger reported better physical symptom status (R2=0.42). Sex, marital status, education, smoking, left ventricular ejection fraction, cause of heart failure, and number of comorbid conditions were not related to and were not predictive of physical symptom status.


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  		Table 4 Relationships between physical symptom status and demographic, behavioral, biophysiological, and psychological variables

 

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  		Table 5 Stepwise regression analysis: predictors of physical symptom status

 

   Discussion
Top
 Abstract
 Theoretical Framework
 Methods
 Results
 Discussion
Conclusions
 References
 
Most of the patients in the sample experienced dyspnea and/or fatigue every day, and their daily activities were limited by these symptoms. In our study, baseline physical symptom status was the strongest predictor of HRQOL at 3-month follow-up, and depression and perceived control were the most important predictors of physical symptom status.

Other investigators9,10 have documented the association of physical symptom status with HRQOL. Our findings add a unique dimension to current knowledge by showing that depression and perceived control measured early after hospital discharge are associated with subsequent physical symptom status. Our results suggest that interventions to improve depression and perceived control might improve physical symptom status and, in turn, enhance HRQOL. Also, the results provide strong impetus for the development of interventions to improve psychological status, especially depression, in patients with heart failure.

Physical symptoms are important problems in patients with heart failure for 2 major reasons: their high prevalence and their effect on patients’ lives. In our study, more than 90% of patients experienced dyspnea and/or fatigue. In the study by Carlson et al,1 more than 90% of patients with heart failure had had multiple symptoms during the previous year, and more than 80% of the patients had had both dyspnea and fatigue. In other studies,1,2,12,32,33 other physical symptoms in patients with heart failure included cough, chest pain, leg or ankle swelling, sudden weight gain, palpitation, and dizziness.

Physical symptoms may commonly affect various aspects of patients’ lives. A few investigators have examined the impact of physical symptom status, but our results and those of other studies9,17,34,35 have consistently indicated the strong adverse impact of physical symptom status on HRQOL. In addition, physical symptoms are important reasons why patients are hospitalized or visit the emergency department.5,7 Therefore, research is needed on the direct and indirect effects of physical symptoms on patients’ daily activities, HRQOL, other clinical outcomes, and medical costs so that physical symptom status can be managed effectively.


Cognitive therapy, stress management, and dietary intervention may improve quality of life in patients with heart failure.

 

Effective management of physical symptoms requires knowledge of the variables that influence physical symptom status. Although many variables may affect patients’ perception of physical symptom status, the predictors of physical symptom status have not been widely investigated. Our results and those of earlier studies4,13 have shown that depression and perceived control and physical symptom status are strongly correlated with each other. The cause-and-effect relationship between depression and physical symptoms is not definitive, but in our study, baseline depression was a strong predictor of physical symptom status at 3 months, even when other potential mediators were taken into account. In earlier studies,36–39 depression was directly related to HRQOL in patients with heart failure.

Perceived control was an important predictor of physical symptom status in our study. We defined perceived control as a patient’s perception of how much he or she believes heart failure and its effects, including symptoms, can be controlled or managed. Patients who report higher levels of perceived control may engage more actively in self-care and thus their symptom status is better than that of patients with lower levels of perceived control, who may not be engaged to the same degree in self-care activities.40 In one study,39 perceived control was directly related to HRQOL in patients with heart failure.

Employment status and age were related to physical symptom status or HRQOL in our study and in other studies.10,13 In our study, patients who did not work reported poorer physical symptom status and HRQOL than did patients who worked. In contrast, Grady et al10 found that being unemployed was a predictor of better HRQOL in patients with advanced heart failure who were awaiting transplantation. These conflicting results may be related to the severity of heart failure in the 2 groups of patients. In our study, 77% of patients were in NYHA class II to III, whereas 92% of the patients awaiting transplantation were in NYHA class III to IV. The relationship between employment status and physical symptom status or age and physical symptom status has not been fully examined in patients with heart failure. Knowledge of how these variables are related both to depression and perceived control and to physical symptom status in patients with heart failure will be important for future development of nursing interventions.


Left ventricular ejection fraction did not predict health-related quality of life or physical symptom status.

 

Our results provide important data on psychosocial and behavioral predictors of physical symptom status and HRQOL in patients with heart failure. Our findings also are theoretically and clinically important because they indicate the independent effect of psychological factors on physical symptom status and, in turn, on HRQOL. Healthcare providers, including nurses, can modify patients’ psychological status by assessing that status and providing appropriate interventions on the basis of the results. Interventions to improve psychological status may improve physical symptom status and, in turn, HRQOL in patients with heart failure.

The most common intervention tested in patients with heart failure is drug therapy. Although appropriate drug therapy extends life modestly and prevents some hospitalizations, quality of life often remains unchanged.41 The role of nonpharmacological, nondevice therapy has received considerably less attention than that of drug therapy, yet evidence42 indicates that various nonpharmacological approaches can improve HRQOL. Some approaches that may improve symptom status include cognitive therapy, stress management, dietary intervention, and comprehensive education programs for self-management.43,44 Our findings, along with those of other studies,43,44 suggest that more attention should be given to developing and testing nonpharmacological interventions that can be used in combination with optimal drug therapy to maximize patients’ HRQOL.

Limitations and Implications for Further Studies
We used prospective data to examine the predictors of physical symptom status and the effect of physical symptom status on HRQOL. However, our study was limited by the small size of the sample. A larger sample would have allowed inclusion of additional putative indicator variables, such as adherence to treatment regimens and inflammation. In addition, psychological status was measured by using a single self-report instrument. Using established diagnostic criteria for depression and anxiety to measure clinical mood disorders might have been more powerful for identifying clinically important levels of psychological distress.

Finally, further studies are necessary to more thoroughly examine the causes and effects of physical symptom status. Even though we included a variety of variables that potentially influence physical symptom status, other variables such as medication, diet and nutrition, and inflammation also may affect physical symptom status. Therefore, further studies that include these variables are necessary. Also, comprehensive studies of physical symptom status, of its predictors, and of variables affected by physical symptom status should be undertaken using statistical modeling techniques, such as structural equation modeling, that can reveal the intricacies of the relationships.


   Conclusions
Top
 Abstract
 Theoretical Framework
 Methods
 Results
 Discussion
 Conclusions
References
 
Physical symptom status was the most powerful predictor of HRQOL in patients with heart failure. Depression, perceived control, employment status, and age were important predictors of physical symptom status. Biophysiological variables such as left ventricular ejection fraction and cause of heart failure were not predictive of HRQOL or of physical symptom status. These results suggest that development and provision of interventions to improve psychological status may improve physical symptom status and HRQOL in patients with heart failure.

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FINANCIAL DISCLOSURES
The research was funded in part by a National American Heart Association Established Investigator Award (D. K. Moser) and by the American Association of Critical-Care Nurses (D. K. Moser).


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 Methods
 Results
 Discussion
 Conclusions
 References
 

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S. J. Goodlin
Palliative care in congestive heart failure.
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S. Lauck, M. Mackay, C. Galte, and M. Wilson
A New Option for the Treatment of Aortic Stenosis: Percutaneous Aortic Valve Replacement
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