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  • Quality of Life in Veterans with Ischemic Heart Disease: METHODS


We performed a cross-sectional analysis of baseline data collected as part of the Ambulatory Care Quality Improvement Project (ACQUIP). ACQUIP was a multicenter, group-randomized trial designed to determine whether health outcomes and satisfaction with care could be improved by giving primary care providers access to regular, systematic assessments of their patients’ health and functional status, combined with routine clinical data and information regarding practice guidelines.


ACQUIP was conducted in the General Internal Medicine (GIM) clinics at seven Department of Veterans Affairs (VA) medical centers throughout the United States. Participating facilities were: White River Junction, VT; Birmingham, AL; Little Rock, AR; Richmond, VA; San Francisco and West Los Angeles, CA; and Seattle, WA. We excluded White River Junction from these analyses because the number of African Americans with ischemic heart disease (IHD) who sought care there was small.


Patients who were enrolled in the GIM clinic at each facility between February 1997 and July 1999 were identified using the VA’s computerized medical information system, the Veterans Health Information Systems and Technology Architecture (VistA) database. Eligible participants included all patients who were assigned to a primary care provider between February 1997 and July 1999 and who made at least one visit during the prior year. VA employees and patients without a valid mailing address were ineligible.
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Each subject was mailed an initial health-screening questionnaire with a postage-paid return envelope, followed by a reminder postcard and repeat mailing to nonrespondents.

The self-administered screening questionnaire asked the patient to indicate whether a doctor or nurse had ever reported that he/she had any major chronic medical conditions.

Also included on the health-screening questionnaire were questions about sociodemographic characteristics, including marital status, ethnicity, sex, education, working status, income, and whether medical care was received outside the VA.

The Medical Outcomes Study 36-Item Health Survey (SF-36), an outpatient satisfaction questionnaire and relevant condition-specific health status questionnaires were mailed to each subject after receipt of their screening questionnaire. Questionnaires received through June 30,2000 were included in the analyses. Analyses presented in this paper focus on 7,985 African-American and Caucasian veterans who reported ischemic heart disease and returned the Seattle Angina Questionnaire (SAQ). cheap cialis canadian pharmacy


The SF-36 was used as the general measure of health-related quality of life. The SF-36 consists of eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. For each domain, a raw score is computed and transformed to a scale of 0 (worst) to 100 (best). We also computed the physical and mental component summary scores (PCS and MCS, respectively) as overall measures of physical and mental function, respectively. The PCS and MCS are normalized to a population mean of 50 with a range of 0-100 and a standard deviation of 10.

Subjects who reported having ischemic heart disease were mailed the SAQ, a condition-specific measure for which reliability, validity, and responsiveness have been demonstrated. Ischemic heart disease was defined as self-reported angina, history of myocardial infarction, coronary artery disease, or a coronary artery revascularization procedure (i.e., bypass grafting or angioplasty) on the screening questionnaire. In the veteran population, this definition has been shown to be 97% sensitive and 93% specific for IHD. The SAQ consists of 19 items that quantify five clinically relevant domains of ischemic heart disease: physical function, anginal frequency, anginal stability, disease perception, and satisfaction with care. Each domain produces a raw score that is transformed to a scale of 0 (worst) to 100 (best).

In addition, the Seattle Outpatient Satisfaction Questionnaire (SOSQ) was sent to respondents of the screening questionnaire. The SOSQ consists of 21 items measuring two domains of satisfaction. Twelve items comprise the humanistic scale, which measures the interpersonal skills of the provider and is derived from the American Board of Internal Medicine’s Patient Satisfaction Questionnaire. The other nine items comprise the organizational scale and pertain to the system of care, for example, waiting time, ease of making appointments or refilling prescriptions, and overall quality of care and services. The organizational scale was adapted from the RAND Patient Satisfaction Questionnaire. For our study, both domains are scored from 0 (least satisfied) to 100 (most satisfied).

Statistical Methods

To identify potential response bias, we compared respondents to the screening questionnaire to non-respondents with regard to age and ethnicity, using t-tests on the mean age, and Chi-square tests on the ethnicity categories. Because of the small number of other ethnic group respondents, we subsequently restricted analyses to African Americans and Caucasians, and compared respondents to the SAQ to nonrespondents with regard to age, ethnicity, socio-demographic characteristics, and self-reported chronic conditions on the screening questionnaire. Chi-square tests were used for the categorical variables and independent t-tests (two tailed) for continuous variables.
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We further restricted the study sample to those with angina that had returned the SAQ. We computed unadjusted mean scores for each domain of the SF-36, the SAQ, and the SOSQ, and tested for significance of the difference in mean scores between African Americans and Caucasians using independent t-tests (Table 2).

Because differences in health status and satisfaction measures might have been confounded by patient characteristics, we created linear regression models using statistical software packages SPSS and STATA. Site, sociodemographic factors, and comorbid illnesses were each entered as blocks into the models based on a priori specification. Significance of the effects was assessed using t-tests for individual variables and partial F tests for blocks of like variables. Sociodemographic factors included age, age-squared, education (specified as high school degree or higher), marital status (specified as single or not), employment (currently working or not), income (under $10,000/year or not), and whether or not the patient received medical care outside of the VA. tadalis sx

Comorbid conditions were entered as the total number of additional conditions reported on the screening questionnaire with a possible range of 0-21. To assess whether the effect of ethnicity depended on the value of another covariate, we added interaction terms between ethnicity and the covariate into specific regression models. We tested for two interactions: 1) ethnicity and site and 2) ethnicity and depression. We then used the final regression model to examine differences between African-American and Caucasian respondents in adjusted mean scores for the domains of each survey.

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