• 27
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  • Quality of Life in Veterans with Ischemic Heart Disease: Results

At enrollment into ACQUIP, the health-screening questionnaire was sent to 55,222 patients, of whom 32,149 were Caucasian and 12,816 were African-American. A total of 31,360 were returned, including 10,385 Caucasian and African-American patients, who reported ischemic heart disease and were sent the SAQ. Responses were received from 7,985 of these patients, of whom 6,704 (84.0%) were Caucasian and 1,281 (16.0%) were African-American. The percentage of African-American respondents at sites А, В, C, D, E, and F was 18% (of 1,377), 10% (of 2,429), 27% (of 1,289), 17% (of 548), 7% (of 1,715) and 37% (of 627), respectively.

Characteristics of Respondents and Nonrespondents

Compared with patients who did not respond to the SAQ questionnaire (Table 1), respondents were more likely to be older, married, to have an income greater than $10,000, and were more likely to have answered the questionnaire themselves. Respondents were also more likely to report having undergone coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and to have hypertension. Respondents reported lower current smoking and had lower CAGE scores, which is indicative of increased risk for alcohol abuse and dependence. Respondents were similar to nonrespondents with regard to educational level, receipt of healthcare outside of the VA, prevalence of self-reported diabetes, and depression.

Table 1. Characteristics of Respondents and Nonrespondents

Total

Participant Characteristics

Respondents N=7,985

Nonrespondents N=2,400

p-value

Respondents N=6,704

Age, years (mean, SD) 65.9 ±10.1

63.2 ± 11.8

O.001

66.3 ± 9.8
Males (%) 98.4

97.9

0.11 98.3
CABG or PCI (%) 49.0

41.9

<0.001

52.0
Reported conditions (n) 5.4 ± 2.5

5.6 ± 2.7

0.01 5.4 ± 2.4
Number ot target comorbidities* (n) 2.0 ± 1.1

2.0 ± 1.1

0.03

2.0 ± 1.1
(%) 29.7

28.3

0.18

28.4
Hypertension (%) 70.2

64.9

O.001

68.1
(%) 41.6

43.1

0.19

41.7
CAGE (mean, SD) 1.06 ± 1.4

1.18± 1.5

O.001

1.00 ± 1.4
Current smoker (%) 23.8

32.1

O.001

23.0
Non-VA healthcare (%) 38.6

37.5

0.32

40.0
Income below $10,000 27.5

34.7

<0.001

24.9
High-school graduate or greater (%) 67.6

67.3

0.76

68.7
Single (%) 35.4

45.4

O.001

32.7
Unemployed (%) 14.2

16.0

0.03

14.4
Survey completed by proxy other than veteran 6.7

13.3

O.001

5.6
* Target comorbid conditions include: diabetes, hypertension, chronic obstructive lung disease, alcohol abuse, and n = number, sd = standard deviation, CABG = coronary artery bypass graft, PCI = percutaneous coronary intervention.

to the Seattle Angina Questionnaire (SAQ) by Ethnicity

Caucasian

African-American

Nonrespondents

p-value

Respondents

Nonrespondents

p-value

N=1,801

N=1,281

N=599
63.9 ± 11.4

<0.001

64.0 ± 11.4

61.2 ± 12.8

<0.001
97.9

0.23

98.6

97.8

0.23
46.0

O.001

32.5

28.9

0.14
5.5 ± 2.5

0.13

5.8 ±

5.9 ±3.1

O.001
1.9 ± 1.1

<0.001

2.3 ±

2.2 ± 1.1

0.25
26.8

0.19

37.0

32.9

0.08
60.6

O.001

81.0

77.8

0.11
42.1

0.73

40.7

45.7

0.04
1.09 ± 1.4

0.02

1.38 ± 1.5

1.45 ± 1.5

0.41
31.3

<0.001

27.4

34.3

O.001
40.3

0.83

31.2

28.7

0.29
30.7

O.001

41.0

46.4

0.03
67.8

0.45

61.7

65.7

0.09
42.3

<0.001

49.3

54.6

0.03
16.0

0.10

12.9

16.0

0.07
11.4

O.001

12.4

19.2

O.001

Among respondents, African Americans were significantly more likely to be younger, single, current smokers, and to have lower educational attainment than Caucasians. African-American patients also reported fewer past cardiac procedures (32.5% vs. 52.0%, p<0.001) and less medical care outside of the VA than Caucasians (31.2% vs. 40%, p O.001), but more comorbid conditions, such as diabetes mellitus (37.0% vs. 28.4%, pO.001) and hypertension (81.0% vs. 68.1%, pO.001).

Ethnic Differences in Health Status

Between African Americans and Caucasians, unadjusted scores of several domains of the SF-36 differed significantly for veterans with IHD (Table 2). Mean scores for physical function, role physical, and vitality domains were higher for African Americans. Scores for the role emotional and mental function domains were lower. Consistent with these findings, African Americans also had higher mean PCS and lower MCS scores. However, after adjustment for age, education, marital status, employment, income, comorbid conditions, smoking, site, and baseline IHD, African Americans maintained higher scores for physical function, role physical, bodily pain, general health, and vitality but had lower scores for role emotional. buy antibiotics canada

Table 2. Mean Unadjusted Scores for the SAQ, SF-36, and SOSQ

Questionnaire Domain

Caucasian (mean ± SD) African-American (mean ± SD)

SAQ Stability 56.2 ± 27.6 57.6 ± 30.6
Disease Perception’ 63.0 ± 25.7 58.5 ± 27.6
Angina Frequency 76.5 ± 24.4 76.0 ± 24.9
Satisfaction 83.0 ±21.1 77.6 ± 25.3
Physical Functioning 50.8 ± 26.4 51.9 ±26.1
SF-36 SF-PCS (Physical Component) 30.6 ± 10.7 32.3 ±10.1
SF-MCS (Mental Component) 44.6 ± 13.2 43.1 ±12.9
Physical Function 40.0 ± 27.6 42.2 ± 27.6
Role Physical 22.8 ± 35.4 26.8 ± 38.4
Bodily Pain 46.5 ± 26.7 47.8 ±28.1
General Health 38.0 ± 22.3 37.5 ±21.0
Vitality 34.2 ±23.1 41.0 ±22.6
Social Function 55.5 ± 30.5 54.5 ± 30.0
Role Emotional 51.0 ±44.4 41.6 ±43.5
Mental Function 63.2 ± 24.4 61.4 ±23.9
SOSQ Humanistic 71.8 ±24.5 66.0 ±25.1
Organizational 61.5 ±23.9 58.6 ± 23.7
* = significant, p<0.05. Definitions: SD = standard deviation, SAQ = Seattle Angina Questionnaire, SOSQ = Seattle Outpatient Satisfaction Questionnaire, PCS = Physical Component Score, MCS = Mental Component Score

A significant interaction occurred between ethnicity and site, such that the degree of ethnic difference in health status varied greatly according to geographic location (site), which necessitated that those results be reported separately by site (Table 3). Table 3 presents the difference in mean scores between African Americans and Caucasians overall and stratified by site. For each site, the first column (model

1) is the difference of the means based on a regression model, including site, ethnicity, and a site/ethnicity interaction term. The second column (model

2) represents the first model with the addition of the following sociodemographic and disease specific variables: age, education, marital status, employment, income, access to non-VA care, comorbidities, CABG or PCI, and smoking status. A positive difference indicated that African Americans had a higher mean adjusted score, while a negative difference indicated that African Americans had a lower mean adjusted score than Caucasians.

For example, after adjusting the model for multiple sociodemographic variables, the overall difference in SF-36 Physical Function scores between African Americans and Caucasians was significant, However, differences by site ranged from -5.42 points at site D to +6.43 points at site A, but were significant for three of the six sites (A [6.43], В [5.45], С [5.78]). Similarly, these three sites showed significantly higher scores for African Americans on the PCS (A [2.76], В [2.55], С [3.64]). These three sites are located in the east/southeast area of the country. In contrast, for one west coast site, PCS scores were significantly lower (D [-2.76]). For all six sites, mean differences in adjusted SF-36 Vitality scores ranged from 3.1 to 12.9, also favoring African Americans. This difference was significant for five of the six sites (А, В, С, E, F). For all sites combined, the adjusted difference between African-American and Caucasian Vitality scores was significantly different (Table 3).

Table 3. Difference in Mean Scores between African Americans and

Site

Site A

Site, SES Comorb

Site

Site В

Site, SES Comorb

Site

Site С

Site, SES Comorb

Seattle Angina Questionnaire (n)
Stability (7,205)

3.4

5.7

-3.1

0.8

7.2

9.6

Disease Perception (7,320)

-2.7

-0.1

-6.7

-0.2

-0.2

3.2
Angina Frequency (7,628) 0.72

2.7

-2.3

1.2

2.7

4.3

Satisfaction (7,235)

-5.8

-3.7

-8.9

-4.4

-2.1

0.4
Physical Functioning (6,968)

4.4

6.3

-0.9

2.4

3.8

6.6

SF-36 Summary Scores (n)
Physical (SF-PCS) (7,347)

2.6

2.8

1.9

2.6

2.4

3.6

Mental (SF-MCS) (7,346)

-1.3

0.3

-4.3

-1.9

1.4

1.9

SF-36 Domains (n)
Physical Function (7,810)

5.5

6.4

3.0

5.5

3.0

5.8

Role Physical (7f655)

5.8

5.5

2.7

3.8

8.5

10.8

Bodily Pain (7,808)

0.9

2.7

-1.1

2.9

6.2

9.1

General Health (7,790)

0.5

3.7

-2.3

1.3

5.1

7.1

Vitality (7,828)

7.6

10.3

4.7

8.3

10.9

12.9

Social Function (7,899)

1.1

4.3

-5.0

-0.7

1.9

4.5

Role Emotional (7,550)

-8.3

-6.2

-14.5

-9.8

-2.0

-0.8
Mental Function (7,791)

-2.4

1.4

-6.4

-1.1

3.8

4.7

Seattle Outpatient
Satisfaction Questionnaire
Humanistic (7,759)

-1.1

0.7

-4.2

-1.9

-1.9

-0.1
Organizational (7,681)

-0.3

0.4

-0.7

-0.4

1.2

1.9
Based on ordinary linear regression on the respective domain with regression; a) site and ethnicity and site*ethnicity; b) completed the form, presence of depression, number of comorbid conditions, CABG or PTCA, and whether the patient score, MCS = Mental Component Score; Bold indicates P<0.05; t Since there was a significant interaction with ethnicity

The SF-36 MCS was significantly higher for African Americans at only one of the six sites (C [1.86]) and significantly lower at one site (В [-1.93]). These differences, however, were less than two points and may not be of clinical relevance. African Americans did score consistently lower on the SF-36 Role Emotional scale at all six sites, significantly so at four sites (А, В, E, F); mean adjusted differences ranged from -11.4 to -6.2. The mean adjusted difference between African Americans and Caucasians for all sites combined remained significant at -6.6.
Table 3 also reveals other significant differences in adjusted SF-36 domain scores across sites. Except for the Role Emotional scale, African Americans tended to have higher differences in scores on most of the other domains at the eastern/southeastern sites (А, В, C), most of which were significant for sites A and C. Within the western sites (D, E, F), most differences were not significant, except for the Vitality and Role Emotional domains. For all sites combined, mean adjusted differences between African Americans and Caucasians remained significant for physical function, role physical, bodily pain, and general health but not for social function or mental function.
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In addition to general measures of health, disease-specific measures of quality of life were evaluated. With regard to SAQ scores, the disease-specific measure of quality of life, summary scores indicated that African Americans had greater angina stability, reported less problems with angina frequency, and reported sig nificantly better physical functioning, although scores may not have been clinically significant. However, taking into account the significant site-ethnicity interaction, African Americans had significantly lower adjusted Disease Perception scores at sites D (-6.42) and E (-5.26) but not for the combined sites. Adjusted differences in SAQ Physical Function scores were significantly higher for African Americans at sites A (6.34) and С (6.58).

Ethnic Differences in Satisfaction

For the unadjusted SOSQ scores, African Americans reported lower satisfaction with their providers (66.0 vs. 71.8, p<0.05) and lower satisfaction with organizational aspects of their care (58.6 vs. 61.5, p<0.05) compared with Caucasians. Summary scores were not significantly different between African Americans and Caucasians after adjustment for sociodemographic variables. However, after adjustment for sociodemographic variables and ethnicity-site interactions, scores were significantly lower for only two of the six sites (D [-7.09] and F [6.31]), both of which were located on the west coast. African Americans had lower mean adjusted scores for the organizational scale at only one of the six sites (D [-6.73]), but adjusted results from all sites combined were not statistically significant. Satisfaction specifically with angina treatment (SAQ satisfaction scale) was lower for African Americans at five of six sites with differences ranging from -4.37 points to -2.08 points, but results were only significant for three (sites A, B, and F) (Table 3). viagra soft

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