Aquarius A E, Denollet J, Hamming J F, Breek J C, De Vries J
Department of Psychology and Health, Medical Psychology, Tilburg University, Warandelaan 2, PO Box 90153, 5000 LE Tilburg, The Netherlands.
J Vasc Surg. 2005 Mar;41(3):436-42. doi: 10.1016/j.jvs.2004.12.041.
It has been argued that health status and quality of life (QOL) should be taken into account in the treatment policy of patients with peripheral arterial disease (PAD). In cardiac patients, it has been shown that poor perceived health status is an independent predictor of mortality and hospitalization. We therefore examined (1) the role of health status, QOL, and clinical indices of disease severity as determinants of invasive treatment in patients with PAD and (2) the effect of invasive treatment on health status and QOL.
At their first visit, patients completed the RAND 36-item Health Survey and World Health Organization Quality of Life assessment instrument questionnaires to assess health status and QOL, respectively. During the 1-year follow-up period, data concerning hospitalization were derived from the patients' medical files. Furthermore, patients completed the RAND 36 and the World Health Organization Quality of Life assessment instrument again at 1-year follow-up. The setting was a vascular outpatient clinic of a teaching hospital in Tilburg, The Netherlands; participants were 200 consecutive patients newly diagnosed with intermittent claudication, a common expression of PAD. Diagnosis was based on history, physical examination, treadmill walking distance, and ankle-brachial pressure indices. Main outcome measures were (1) invasive treatment of PAD that took place during the 1-year follow-up, derived from the patients' medical files, and (2) health status and QOL after 1 year of follow-up.
After 1 year of follow-up, 107 patients (53.5%) were event free, whereas 77 patients (38.5%) had been hospitalized for invasive treatment of PAD. Sixteen patients (8%) were hospitalized for other cardiovascular reasons. In a multivariate logistic regression model, age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.91-0.99; P = .024), pain-free walking distance (OR, 2.74; 95% CI, 1.05-7.17; P = .04), and physical functioning (OR, 4.46; 95% CI, 1.79-11.12; P = .001) were independent predictors of invasive treatment of intermittent claudication. After 1 year of follow-up, patients who were treated invasively experienced a significant improvement in their physical functioning ( P = .004), role limitations due to emotional problems ( P = .018), and bodily pain ( P = .026).
Patients with poor self-reported physical functioning, limited walking distance, and a younger age were likely to be treated invasively. The physician's clinical judgment about when to intervene adequately reflects the patient's own opinion about his or her health status. Invasive treatment led to a significant improvement in patients' health status. These findings indicate the effectiveness of the strategy to include patients' perceived physical functioning into the process of clinical decision-making.
有人认为，外周动脉疾病（PAD）患者的治疗策略应考虑健康状况和生活质量（QOL）。在心脏病患者中，已表明健康状况不佳是死亡率和住院率的独立预测因素。因此，我们研究了（1）健康状况、生活质量和疾病严重程度的临床指标作为PAD患者侵入性治疗决定因素的作用，以及（2）侵入性治疗对健康状况和生活质量的影响。
患者首次就诊时分别完成兰德36项健康调查和世界卫生组织生活质量评估工具问卷，以评估健康状况和生活质量。在1年的随访期内，有关住院的数据来自患者的医疗档案。此外，患者在1年随访时再次完成兰德36项问卷和世界卫生组织生活质量评估工具。研究地点为荷兰蒂尔堡一家教学医院的血管门诊；参与者为200例新诊断为间歇性跛行（PAD的常见表现）的连续患者。诊断基于病史、体格检查、跑步机行走距离和踝臂压力指数。主要结局指标为：（1）从患者医疗档案中得出的1年随访期间进行的PAD侵入性治疗，以及（2）随访1年后的健康状况和生活质量。
随访1年后，107例患者（53.5%）无事件发生，而77例患者（38.5%）因PAD侵入性治疗而住院。16例患者（8%）因其他心血管原因住院。在多因素逻辑回归模型中，年龄（比值比[OR]，0.95；95%置信区间[CI]，0.91 - 0.99；P = 0.024）、无痛行走距离（OR，2.74；95% CI，1.05 - 7.17；P = 0.04）和身体功能（OR，4.46；95% CI，1.79 - 11.12；P = 0.001）是间歇性跛行侵入性治疗的独立预测因素。随访1年后，接受侵入性治疗的患者在身体功能（P = 0.004）、因情绪问题导致的角色限制（P = 0.018）和身体疼痛（P = 0.026）方面有显著改善。
自我报告身体功能差、行走距离受限且年龄较小的患者可能接受侵入性治疗。医生关于何时进行充分干预的临床判断充分反映了患者对自身健康状况的看法。侵入性治疗使患者的健康状况有显著改善。这些发现表明将患者自我感知的身体功能纳入临床决策过程这一策略的有效性。
