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Sluman, M. A., Apers, S., Sluiter, J. K., Nieuwenhuijsen, K., Moons, P., Luyckx, K., . . . Mulder, B. J. .. (2019). Education as important predictor for successful employment in adults with congenital heart disease worldwide. Congenital Heart Disease
Open this publication in new window or tab >>Education as important predictor for successful employment in adults with congenital heart disease worldwide
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2019 (English)In: Congenital Heart Disease, ISSN 1747-079X, E-ISSN 1747-0803Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background

Conflicting results have been reported regarding employment status and work ability in adults with congenital heart disease (CHD). Since this is an important determinant for quality of life, we assessed this in a large international adult CHD cohort.

Methods

Data from 4028 adults with CHD (53% women) from 15 different countries were collected by a uniform survey in the cross-sectional APPROACH International Study. Predictors for employment and work limitations were studied using general linear mixed models.

Results

Median age was 32 years (IQR 25-42) and 94% of patients had at least a high school degree. Overall employment rate was 69%, but varied substantially among countries. Higher education (OR 1.99-3.69) and having a partner (OR 1.72) were associated with more employment; female sex (OR 0.66, worse NYHA functional class (OR 0.67-0.13), and a history of congestive heart failure (OR 0.74) were associated with less employment. Limitations at work were reported in 34% and were associated with female sex (OR 1.36), increasing age (OR 1.03 per year), more severe CHD (OR 1.31-2.10), and a history of congestive heart failure (OR 1.57) or mental disorders (OR 2.26). Only a university degree was associated with fewer limitations at work (OR 0.62).

Conclusions

There are genuine differences in the impact of CHD on employment status in different countries. Although the majority of adult CHD patients are employed, limitations at work are common. Education appears to be the main predictor for successful employment and should therefore be encouraged in patients with CHD.

Keywords
adult, congenital heart defects, disability, education, employment, work ability
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-13526 (URN)10.1111/chd.12747 (DOI)30714326 (PubMedID)
Note

First published: 04 February 2019

Available from: 2019-03-21 Created: 2019-03-21 Last updated: 2019-07-25Bibliographically approved
Larsson, L., Johansson, B., Sandberg, C., Apers, S., Kovacs, A. H., Luyckx, K., . . . Moons, P. (2019). Geographical variation and predictors of physical activity level in adults with congenital heart disease. International Journal of Cardiology : Heart & Vasculature, 22, 20-25
Open this publication in new window or tab >>Geographical variation and predictors of physical activity level in adults with congenital heart disease
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2019 (English)In: International Journal of Cardiology : Heart & Vasculature, ISSN 2352-9067, Vol. 22, p. 20-25Article in journal (Refereed) Published
Abstract [en]

Background

Physical activity is important to maintain and promote health. This is of particular interest in patients with congenital heart disease(CHD) where acquired heart disease should be prevented. The World Health Organization (WHO) recommends a minimum of 2.5 h/week of physical activity exceeding 3 metabolic equivalents (METS) to achieve positive health effects. It is unknown whether physical activity levels (PAL) in adult CHD patients differ by country of origin.

Methods

3896 adults with CHD recruited from 15 countries over 5 continents completed self-reported instruments, including the Health Behaviour Scale (HBS-CHD), within the APPROACH-IS project. For each patient, we calculated whether WHO recommendations were achieved or not. Associated factors were investigated using Generalized Linear Mixed Models.

Results

On average, 31% reached the WHO recommendations but with a great variation between geographical areas (India: 10%–Norway: 53%). Predictors for physical activity level in line with the WHO recommendations, with country of residence as random effect, were male sex (OR 1.78, 95%CI 1.52–2.08), NYHA-class I (OR 3.10, 95%CI 1.71–5.62) and less complex disease (OR 1.46, 95%CI 1.16–1.83). In contrast, older age (OR 0.97, 95%CI 0.96–0.98), lower educational level (OR 0.41, 95%CI 0.26–0.64) and being unemployed (OR 0.57, 95%CI 0.42–0.77) were negatively associated with reaching WHO recommendations.

Conclusions

A significant proportion of patients with CHD did not reach the WHO physical activity recommendations. There was a large variation in physical activity level by country of origin. Based on identified predictors, vulnerable patients may be identified and offered specific behavioral interventions.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Adult congenital heart disease, Physical activity level, Patient-reported outcome, Health-behaviour scale, Physical activity recommendation, Metabolic equivalent
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-13176 (URN)10.1016/j.ijcha.2018.11.004 (DOI)30511012 (PubMedID)2-s2.0-85056806669 (Scopus ID)
Funder
Swedish Heart Lung Foundation, 20130607
Available from: 2018-12-03 Created: 2018-12-03 Last updated: 2019-02-18Bibliographically approved
Van Bulck, L., Luyckx, K., Goossens, E., Apers, S., Kovacs, A. H. H., Thomet, C., . . . Moons, P. (2019). Patient-reported outcomes of adults with congenital heart disease from eight European countries: scrutinising the association with healthcare system performance. European Journal of Cardiovascular Nursing
Open this publication in new window or tab >>Patient-reported outcomes of adults with congenital heart disease from eight European countries: scrutinising the association with healthcare system performance
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2019 (English)In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background: Inter-country variation in patient-reported outcomes of adults with congenital heart disease has been observed. Country-specific characteristics may play a role. A previous study found an association between healthcare system performance and patient-reported outcomes. However, it remains unknown which specific components of the countries' healthcare system performance are of importance for patient-reported outcomes.

Aims: The aim of this study was to investigate the relationship between components of healthcare system performance and patient-reported outcomes in a large sample of adults with congenital heart disease.

Methods: A total of 1591 adults with congenital heart disease (median age 34 years; 51% men; 32% simple, 48% moderate and 20% complex defects) from eight European countries were included in this cross-sectional study. The following patient-reported outcomes were measured: perceived physical and mental health, psychological distress, health behaviours and quality of life. The Euro Health Consumer Index 2015 and the Euro Heart Index 2016 were used as measures of healthcare system performance. General linear mixed models were conducted, adjusting for patient-specific variables and unmeasured country differences.

Results: Health risk behaviours were associated with the Euro Health Consumer Index subdomains about patient rights and information, health outcomes and financing and access to pharmaceuticals. Perceived physical health was associated with the Euro Health Consumer Index subdomain about prevention of chronic diseases. Subscales of the Euro Heart Index were not associated with patient-reported outcomes.

Conclusion: Several features of healthcare system performance are associated with perceived physical health and health risk behaviour in adults with congenital heart disease. Before recommendations for policy-makers and clinicians can be conducted, future research ought to investigate the impact of the healthcare system performance on outcomes further.

Keywords
Healthcare system performance, heart defect, congenital, health services accessibility, patient reported outcome measures
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-13738 (URN)10.1177/1474515119834484 (DOI)2-s2.0-85062451438 (Scopus ID)
Funder
Swedish Heart Lung Foundation, 20130607
Note

Funders: KU Leuven (Leuven, Belgium) , OT/11/033;University of Gothenburg

Available from: 2019-03-21 Created: 2019-03-21 Last updated: 2019-06-04Bibliographically approved
Holbein, C. E., Veldtman, G. R., Moons, P., Kovacs, A. H., Luyckx, K., Apers, S., . . . Cedars, A. (2019). Perceived Health Mediates Effects of Physical Activity on Quality of Life in Patients With a Fontan Circulation.. American Journal of Cardiology, Article ID S0002-9149(19)30398-4.
Open this publication in new window or tab >>Perceived Health Mediates Effects of Physical Activity on Quality of Life in Patients With a Fontan Circulation.
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2019 (English)In: American Journal of Cardiology, ISSN 0002-9149, E-ISSN 1879-1913, article id S0002-9149(19)30398-4Article in journal (Refereed) Epub ahead of print
Abstract [en]

Patients with a Fontan circulation are at risk of a sedentary lifestyle. Given the direct relationship between physical activity and health, promotion of physical activity has the potential to improve outcomes, including quality of life (QOL). This study aimed to describe self-reported physical activity levels in adult Fontan patients and examine associations between physical activity, perceived health status and QOL. The sample consisted of 177 Fontan patients (Mage = 27.5 ± 7.6 years, 52% male) who reported their physical activity, perceived health status, and QOL as part of the cross-sectional Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study. Descriptive statistics and univariate analyses of variance with planned contrasts were computed to describe physical activity characteristics. Mediation analyses tested whether perceived health status variables mediated the association between physical activity and QOL. Forty-six percent of patients were sedentary while only 40% met international physical activity guidelines. Higher physical activity was associated with younger age, lower NYHA class, higher perceived general health, and greater QOL. Patients who commuted by walking and engaged in sports reported better perceived health and QOL. Mediation analyses revealed that perceived general health but not NYHA functional class mediated the association between physical activity and QOL (αβ = 0.22, 95% confidence interval = 0.04 to 0.49). In conclusion, Fontan patients likely benefit from regular physical activity, having both higher perceived general health and functional capacity; greater perceived health status may contribute to enhanced QOL. In conclusion, these data support the pivotal role of regular physical activity for Fontan patients.

Keywords
quality of life, fontan circulation, physical activity
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-13842 (URN)10.1016/j.amjcard.2019.03.039 (DOI)31030969 (PubMedID)2-s2.0-8506489968 (Scopus ID)
Available from: 2019-05-24 Created: 2019-05-24 Last updated: 2019-07-25Bibliographically approved
Holbein, C. E., Fogleman, N. D., Hommel, K., Apers, S., Rassart, J., Moons, P., . . . Veldtman, G. (2018). A multinational observational investigation of illness perceptions and quality of life among patients with a Fontan circulation. Congenital Heart Disease, 13(3), 392-400
Open this publication in new window or tab >>A multinational observational investigation of illness perceptions and quality of life among patients with a Fontan circulation
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2018 (English)In: Congenital Heart Disease, ISSN 1747-079X, E-ISSN 1747-0803, Vol. 13, no 3, p. 392-400Article in journal (Refereed) Published
Abstract [en]

Objective First, to compare QOL and illness perceptions between patients with a Fontan circulation and patients with anatomically simple defects (ie, atrial septal defects [ASD] or ventricular septal defects [VSD]). Second, to explore illness perceptions as a mediator of the association between congenital heart disease (CHD) diagnosis and QOL. Design Cross-sectional observational study. Setting Twenty-four cardiology centers from 15 countries across five continents. Patients Four hundred thirty-five adult patients with congenital heart disease (177 Fontan and 258 ASD/VSD) ages 18-83 years. Outcome Measures QOL and illness perceptions were assessed by the Satisfaction With Life Scale and the Brief Illness Perceptions Questionnaire, respectively. Results Patients with a Fontan circulation reported lower QOL (Wald Z = −3.59, p = <.001) and more negative perceptions of their CHD (Wald Z = −7.66, p < .001) compared with patients with ASD/VSD. After controlling for demographics, anxiety, depressive symptoms, and New York Heart Association functional class, path analyses revealed a significant mediation model, αβ = 0.15, p = .002, 95% CI = 0.06-0.25, such that CHD diagnosis was indirectly related to QOL through illness perceptions. Conclusions The Fontan sample’s more negative perceptions of CHD were likely a reflection of life with a more complex defect. Illness perceptions appear to account for unique differences in QOL between groups of varying CHD complexity. Psychosocial screening and interventions may be important treatment components for patients with CHD, particularly those with Fontan circulations.

Keywords
congenital heart disease, Fontan circulation, illness perceptions, quality of life
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-12145 (URN)10.1111/chd.12583 (DOI)000434637400008 ()29457362 (PubMedID)2-s2.0-85048272375 (Scopus ID)
Funder
Swedish Heart Lung Foundation, 20130607
Note

Version of record online: 18 February 2018

Funders: KU Leuven,  OT/11/033; University of Gothenburg Centre for Person-centered Care; Cardiac Children’s Foundation Taiwan, CCF2013_02;  the National Institutes of Health, T32HD068223

Available from: 2018-02-26 Created: 2018-02-26 Last updated: 2019-02-19Bibliographically approved
Bratt, E.-L., Burström, Å., Hanseus, K., Rydberg, A. & Berghammer, M. (2018). Do not forget the parents: Parents' concerns during transition to adult care for adolescents with congenital heart disease. Child Care Health and Development, 44(2), 278-284
Open this publication in new window or tab >>Do not forget the parents: Parents' concerns during transition to adult care for adolescents with congenital heart disease
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2018 (English)In: Child Care Health and Development, ISSN 0305-1862, E-ISSN 1365-2214, Vol. 44, no 2, p. 278-284Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Growing up with congenital heart disease (CHD) often means transfer to adult care and lifelong medical follow-up. An optimal transition process usually involves a multipart collaboration between the patient, their parents and other family members, and the healthcare providers. Taking an active role while knowing when it is time to step aside can be difficult for all the concerned parties, even the healthcare professionals. The aim of the present study therefore, was to explore parents' expectations and needs during their adolescent's transition to adult care.

METHOD: Semi-structured interviews were conducted with 18 parents of 16 adolescents (aged 13-18 years) with CHD in 4 pediatric cardiology settings in Sweden. The interviews were analysed with qualitative content analysis.

RESULTS: The analysis resulted in 2 main themes: (a) Feeling secure-the importance of being prepared and informed. This theme focused on the need to be prepared and informed about transition and future transfer to adult care. (b) Recognizing when to hand over at the right time. This theme addressed the process of handing over the responsibility from the parent to the adolescents and contained handing over from pediatric care to adult care.

CONCLUSION: Being prepared and informed about the upcoming transition process was essential. The parents underlined the importance of being involved in the transition planning for gradually handing over responsibility to the adolescent. They also considered establishing contact with the adult healthcare team before transfer as important and needed to be assured that CHD-related information of importance for the young person's daily life would be given.

Keywords
adolescence, chronic (health) condition, congenital heart disease, parenting, parents, transition
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-11805 (URN)10.1111/cch.12529 (DOI)000424230000014 ()28980341 (PubMedID)2-s2.0-85041634080 (Scopus ID)
Note

First published: 5 October 2017

Funders: The Swedish Children's Heart Association;  Göteborg barnklinikers forskningsfond 

Available from: 2017-11-23 Created: 2017-11-23 Last updated: 2019-02-18Bibliographically approved
Berghammer, M., Johansson, B., Mattson, E., Moons, P. & Dellborg, M. (2018). Exploration of disagreement between the patient’s self reported limitations and limitations assessed by caregivers in adults with congenital heart disease. European Heart Journal, 39(Suppl 1), Article ID 2406.
Open this publication in new window or tab >>Exploration of disagreement between the patient’s self reported limitations and limitations assessed by caregivers in adults with congenital heart disease
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2018 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 39, no Suppl 1, article id 2406Article in journal, Meeting abstract (Refereed) Published
Abstract [en]

Background: The New York Heart Association (NYHA) classification is applied in a wide spectrum of heart diseases including adult patients with congenital heart disease (ACHD). The NYHA-class assessment is often based on the evaluation by the caregiver, but to what extent it correlates with the patient's view of their function is not fully known.Purpose: To investigate the relation between the patient's self-reported physical limitations, symptoms, other heart defect related factors and NYHA-class assessed by the caregiver.Methods: Eligible patients (n=333, age 39.2±13.6 years) were identified and randomly selected from the national registry for CHD. All of the patients completed a standardized questionnaire measuring different PRO-domains. By combing self-reported data with registry data including NYHA-class, analyses of agreement of physical limitations were performed.Results: Almost 30% of the patients rated their limitations higher compared to the NYHA-class estimated by the caregiver. Patients with self-reported limitations and their NYHA-class underestimated by caregivers, more often reported symptoms, anxiety, lower health and worked fewer hours/week compared to other patients with CHD. There were no differences regarding sex, type of symptoms, prescribed medications, or complexity of cardiac lesion. In patients without self-reported limitations agreement with NYHA-class estimated by caregivers was 97%.Conclusion: Adult patients with CHD and self-reported limitations may not be correctly identified by the care-giver. Instruments for patient reported outcomes might improve the assessment of physical limitations and could further improve the correctness in evaluating the patient's status.

Keywords
congenital heart disease adult caregivers self-report
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-13732 (URN)10.1093/eurheartj/ehy565.2406 (DOI)000459824001478 ()
Funder
Swedish Heart Lung Foundation
Available from: 2019-03-21 Created: 2019-03-21 Last updated: 2019-07-25Bibliographically approved
Bay, A., Berghammer, M., Lamas, K., Sandberg, C. & Johansson, B. (2018). Facilitators and barriers for physical activity in adults with congenital heart disease. Paper presented at ESC Congress 2018 25 - 29 August Munich, Germany. European Heart Journal, 39(suppl_1), 1120-1121, Article ID ehy566.P5433.
Open this publication in new window or tab >>Facilitators and barriers for physical activity in adults with congenital heart disease
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2018 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 39, no suppl_1, p. 1120-1121, article id ehy566.P5433Article in journal, Meeting abstract (Refereed) Published
Abstract [en]

Background: A majority of adults with congenital heart disease (CHD) have reduced exercise capacity and do not reach the recommended level of physical activity. A physically active lifestyle is essential to maintain health and counteract acquired cardiovascular disease. This study illuminates aspects that may be relevant for performing physical activity.Purpose: To describe facilitators and barriers for physical activity in adults with CHD.Methods: Semi-structured interviews were performed individually with fourteen adults (age 19–68 years, women=7) with complex CHD. The interviews were analyzed using qualitative content analysis.Results: Aspects that may enable or inhibit physical activity were found in two domains; Facilitators and Barriers, which both consisted of four categories physical, psychological, psychosocial and environmental aspects (Table 1).

Keywords
Physical activity, congenital heart disease, adult
National Category
Nursing Cardiac and Cardiovascular Systems
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-12867 (URN)10.1093/eurheartj/ehy566.P5433 (DOI)000459824003524 ()
Conference
ESC Congress 2018 25 - 29 August Munich, Germany
Funder
Swedish Heart Lung Foundation, 20150579
Available from: 2018-10-26 Created: 2018-10-26 Last updated: 2019-05-28Bibliographically approved
Bay, A., Lämås, K., Berghammer, M., Sandberg, C. & Johansson, B. (2018). It's like balancing on a slackline: A description of how adults with congenital heart disease describe themselves in relation to physical activity. Journal of Clinical Nursing, 27(15-16), 3131-3138
Open this publication in new window or tab >>It's like balancing on a slackline: A description of how adults with congenital heart disease describe themselves in relation to physical activity
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2018 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 27, no 15-16, p. 3131-3138Article in journal (Refereed) Published
Abstract [en]

AIMS AND OBJECTIVES: To illuminate how adults with CHD describe themselves in relation to physical activity.

BACKGROUND: Several studies have shown that adults with congenital heart disease (CHD) have reduced exercise capacity and do not reach the recommended daily level of physical activity. With this in view, it is of immense importance to investigate how this population experiences physical activity.

DESIGN: Qualitative study with semi-structured interviews analysed with qualitative content analysis.

METHODS: Semi-structured interviews were individually performed with fourteen adults (women=7, age 19-68 years) with complex CHD. Patients were purposively recruited from the clinic waiting list, based on a scheduled follow-up and diagnosis.

RESULTS: The overall theme, It's like balancing on a slackline, illustrates how adults with CHD described themselves in relation to physical activity. This overall theme consisted of four subthemes: (1) Being an adventurer- enjoying the challenges of physical activity; (2) Being a realist- adapting to physical ability; (3) Being a non-doer- lacking prerequisites for physical activity; and (4) Being an outsider- feeling excluded depending on physical ability.

CONCLUSIONS: Adults with CHD seem to have a diverse relationship to physical activity and it involves various aspects throughout the lifespan. The findings point out factors that might constitute as obstacles for being physically active, specific for people with chronic conditions like CHD. This highlights the importance of further exploring the hindering and facilitating factors for being physically active in order to get a deeper understanding of how to support adults with CHD to be physically active.

RELEVANCE TO CLINICAL PRACTICE: Given the diverse relationship to physical activity, nurses have to further investigate the patients' relationship to physical activity, in order to support a healthy lifestyle. Nurses and allied health professionals should offer individualized exercise prescriptions and education about suitable physical activities in relation to physical ability. This article is protected by copyright. All rights reserved.

Keywords
Congenital heart disease, content analysis, interviews, nursing, physical activity, prevention
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-12293 (URN)10.1111/jocn.14507 (DOI)000439796600022 ()29752846 (PubMedID)2-s2.0-85050400287 (Scopus ID)
Funder
Swedish Heart Lung Foundation, 20150579
Note

Funders: Heart Foundation of Northern Sweden; Swedish Heart and Lung Association, E143-15); Umeå University; County Council of Västerbotten; Swedish Society of Nursing.

Available from: 2018-06-04 Created: 2018-06-04 Last updated: 2019-02-18Bibliographically approved
Moons, P., Kovacs, A. H., Luyckx, K., Thomet, C., Budts, W., Enomoto, J., . . . Apers, S. (2018). Patient-reported outcomes in adults with congenital heart disease: Inter-country variation, standard of living and healthcare system factors. International Journal of Cardiology, 251, 34-41
Open this publication in new window or tab >>Patient-reported outcomes in adults with congenital heart disease: Inter-country variation, standard of living and healthcare system factors
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2018 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 251, p. 34-41Article in journal (Refereed) Published
Abstract [en]

AimsGeographical differences in patient-reported outcomes (PROs) of adults with congenital heart disease (ConHD) have been observed, but are poorly understood. We aimed to: (1) investigate inter-country variation in PROs in adults with ConHD; (2) identify patient-related predictors of PROs; and (3) explore standard of living and healthcare system characteristics as predictors of PROs.Methods and resultsAssessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease – International Study (APPROACH-IS) was a cross-sectional, observational study, in which 4028 patients from 15 countries in 5 continents were enrolled. Self-report questionnaires were administered: patient-reported health (12-item Short Form Health Survey; EuroQOL-5D Visual Analog Scale); psychological functioning (Hospital Anxiety and Depression Scale); health behaviors (Health Behavior Scale–Congenital Heart Disease) and quality of life (Linear Analog Scale for quality of life; Satisfaction With Life Scale). A composite PRO score was calculated. Standard of living was expressed as Gross Domestic Product per capita and Human Development Index. Healthcare systems were operationalized as the total health expenditure per capita and the overall health system performance. Substantial inter-country variation in PROs was observed, with Switzerland having the highest composite PRO score (81.0) and India the lowest (71.3). Functional class, age, and unemployment status were patient-related factors that independently and consistently predicted PROs. Standard of living and healthcare system characteristics predicted PROs above and beyond patient characteristics.ConclusionsThis international collaboration allowed us to determine that PROs in ConHD vary as a function of patient-related factors as well as the countries in which patients live.

Keywords
Cross-cultural comparison, Heart defects, congenital, Multilevel analysis, Quality of life, Patient-reported outcomes, Healthcare system
National Category
Nursing
Research subject
NURSING AND PUBLIC HEALTH SCIENCE, Nursing science
Identifiers
urn:nbn:se:hv:diva-11799 (URN)10.1016/j.ijcard.2017.10.064 (DOI)000416951600008 ()29107358 (PubMedID)2-s2.0-85032353892 (Scopus ID)
Note

Available online 21 October 2017

Funders: the Research Fund – KU Leuven (Leuven, Belgium) ,OT/11/033; Swedish Heart-Lung Foundation, 20130607;   University of Gothenburg Centre for Person-centred Care; Cardiac Children's Foundation (Taiwan), CCF2013_02

Available from: 2017-11-23 Created: 2017-11-23 Last updated: 2019-02-19Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-4181-695x

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