Cardiovascular Health: The Importance of Measuring Patient-Reported Health Status

Abstract

HomeCirculationVol. 127, No. 22Cardiovascular Health: The Importance of Measuring Patient-Reported Health Status Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBCardiovascular Health: The Importance of Measuring Patient-Reported Health StatusA Scientific Statement From the American Heart Association John S. Rumsfeld, MD, PhD, FAHA, Karen P. Alexander, MD, FAHA, David C. GoffJr, MD, PhD, FAHA, Michelle M. Graham, MD, P. Michael Ho, MD, PhD, FAHA, Frederick A. Masoudi, MD, MSPH, FAHA, Debra K. Moser, DNSc, RN, FAHA, Véronique L. Roger, MD, MPH, FAHA, Mark S. Slaughter, MD, FAHA, Kim G. Smolderen, PhD, John A. Spertus, MD, MPH, FAHA, Mark D. Sullivan, MD, PhD, Diane Treat-Jacobson, PhD, RN, FAHA and Julie J. Zerwic, PhD, RN, FAHAon behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Stroke Council John S. RumsfeldJohn S. Rumsfeld Search for more papers by this author , Karen P. AlexanderKaren P. Alexander Search for more papers by this author , David C. GoffJrDavid C. GoffJr Search for more papers by this author , Michelle M. GrahamMichelle M. Graham Search for more papers by this author , P. Michael HoP. Michael Ho Search for more papers by this author , Frederick A. MasoudiFrederick A. Masoudi Search for more papers by this author , Debra K. MoserDebra K. Moser Search for more papers by this author , Véronique L. RogerVéronique L. Roger Search for more papers by this author , Mark S. SlaughterMark S. Slaughter Search for more papers by this author , Kim G. SmolderenKim G. Smolderen Search for more papers by this author , John A. SpertusJohn A. Spertus Search for more papers by this author , Mark D. SullivanMark D. Sullivan Search for more papers by this author , Diane Treat-JacobsonDiane Treat-Jacobson Search for more papers by this author and Julie J. ZerwicJulie J. Zerwic Search for more papers by this author and on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Stroke Council Originally published6 May 2013https://doi.org/10.1161/CIR.0b013e3182949a2eCirculation. 2013;127:2233–2249Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 1. IntroductionThe principal goals of health care are to help people “live longer and live better,” that is, to optimize both survival and health. In the American Heart Association’s (AHA) special report, “Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond,” the AHA set the following goal:“By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.”1The emphasis on improving cardiovascular health is laudable, yet it raises the question of how cardiovascular health is best measured. Indeed, the metrics of cardiovascular health have not been well delineated compared with other cardiovascular mortality and morbidity outcomes.The AHA’s strategic goals primarily focus on ideal health behaviors (eg, not smoking) and ideal health factors (eg, blood pressure control) as metrics of cardiovascular health.1 Although these are of clear import, they do not directly address the World Health Organization’s definition of health as “… a state of complete physical, mental and social well-being.”2 Moreover, the Institute of Medicine identified patient-centered care as 1 of the 6 domains of high-quality health care, wherein patient-centered care supports clinicians in “attending to their patients’ physical and emotional needs, and maintaining or improving their quality of life.”3 The Patient-Centered Outcomes Research Institute emphasizes the goal of “focusing on outcomes that people notice and care about such as survival, function, symptoms, and health related quality of life.”4 Recent concepts of value in health care and the “triple aim” center on improving patients’ health and experience with health care while reducing costs; each reinforces the importance of assessing the impact of disease and medical treatment on patients’ functional status and quality of life.5,6 The definition of health and concepts of patient-centered care directly support the measurement of patient health status as a key metric of cardiovascular health.Accordingly, the goal of this scientific statement is to review and advocate for patient-reported health status as a measure of cardiovascular health. The present statement defines patient health status in the context of cardiovascular health and then describes key aspects of patient health status surveys, with an emphasis on currently available cardiovascular disease (CVD)–specific instruments. Subsequent sections synthesize the current literature, providing examples of studies that have used cardiovascular patient–reported health status measures both as outcomes and as independent (predictor) variables. Areas of need for additional research are highlighted throughout. The statement then describes potential uses of cardiovascular patient–reported health status in clinical decision making and population health surveillance, noting barriers that need to be overcome to realize this potential. Ultimately, the present statement is intended to support the AHA’s efforts to promote inclusion of patient health status as a measure of cardiovascular health when setting organizational goals and advocating for cardiovascular health (Table 1).Table 1. Top Things to Know•Improving cardiovascular health is a central goal of cardiovascular care and a specific aim of the American Heart Association’s strategic goals; however, measures of cardiovascular health beyond mortality and morbidity outcomes have not been well specified.•Patient-reported health status, which includes symptom burden, functional status, and HRQL, is an important measure of health.•Validated patient health status surveys, including disease-specific instruments for patients with cardiovascular disease, allow for the quantification of this critical, patient-centered outcome.•Cardiovascular patient health status surveys have been used successfully in clinical trials and other research studies to quantify treatment benefits with regard to symptoms, functional status, and HRQL; however, they remain underutilized.•In addition to cardiovascular disease–specific factors contributing to worse patient health status (eg, amount of angina in coronary artery disease), other key cofactors must be recognized (eg, comorbid depression). There are also special considerations in the measurement of health status in cohorts such as the elderly.•Patient-reported health status is an independent predictor of subsequent mortality, cardiovascular events, hospitalization, and costs of care. This has potential implications for risk adjustment and targeting of healthcare resources.•Patient health status data have the potential to inform clinical decision making. In particular, such information can be important for shared decision making.•Cardiovascular patient health status assessments can facilitate disease surveillance and quantify populations’ health for entities such as accountable care organizations but have not yet been incorporated into population health/disease surveillance efforts. The integration of health status into these activities may enhance the patient-centeredness of care and better characterize the impact of healthcare delivery on patient health.•Additional research is needed to better understand the determinants of patient health status, the effects of interventions on cardiovascular health, and the most effective strategies to incorporate cardiovascular patient health status measurement in clinical practice and disease surveillance.HRQL indicates health-related quality of life.2. Executive SummaryPatient health status includes 3 components: symptom burden, functional status, and health-related quality of life (HRQL; Figure).7 Symptom burden includes the types and frequency of symptoms a patient may have as a manifestation of disease or from medical treatments (eg, symptoms from side effects of medications). Functional status includes physical, mental/emotional, and social function. Finally, HRQL is the perception of discrepancy between actual and desired functional status and overall impact of disease on well-being for a givenpatient.Download figureDownload PowerPointFigure. Patient-reported health status. *From disease or from medical treatments (eg, side effects or complications). Modified from Rumsfeld et al.7 Copyright © 2002, American Heart Association, Inc. Modified from Spertus et al8; reprinted with permission from Elsevier. Copyright © 2002, American Heart Journal. Modified from Wilson and Cleary9; reprinted with permission of the American Medical Association. Copyright © 1995, American Medical Association. All rights reserved.Although there are performance tests that can help quantify physical functional status (eg, exercise treadmill testing), most aspects of patient health status are best captured by patient self-report. HRQL reflects how an individual views and adapts to his or her symptom burden, functional limitations, and prognosis, as well as how patients perceive their overall health. Because each person differentially experiences the degree to which symptoms and functional limitations of disease and medical therapies impact their well-being, HRQL can only be accurately quantified by patient self-report.An important