Beckie, Theresa M. PhD, RN, FAHA; Biddle, Martha PhD, ARNP, CCNS; McCabe, Pamela J. PhD, RN, ACNS-BC
Theresa M. Beckie, PhD, RN, FAHA Professor, College of Nursing, University of South Florida, Tampa.
Martha Biddle, PhD, ARNP, CCNS Assistant Professor, College of Nursing, University of Kentucky, Lexington.
Pamela J. McCabe, PhD, RN, ACNS-BC Clinical Nurse Specialist/Clinical Nurse, Researcher, Assistant Professor of Nursing, College of Medicine, Mayo Clinic, Rochester, Minnesota.
The authors have no funding or conflicts of interest to disclose.
Correspondence Theresa M. Beckie, PhD, RN, FAHA, College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612 (firstname.lastname@example.org).
In the spirit of highlighting the accomplishments and contributions of the American Heart Association (AHA) in general and the members of the Council on Cardiovascular and Stroke Nursing (CVSN) in particular, we review both a scientific statement and a policy statement from AHA that reflect the valuable involvement of our members in achieving the goal of improving the health of all Americans. Despite impressive reductions in cardiovascular (CV) mortality over the past several decades, the CV health of Americans remains suboptimal. Cardiovascular health, defined by 4 health behaviors (smoking, physical activity, diet, and body mass index) and 3 health factors (cholesterol, blood pressure, and plasma glucose), is the core concept of the AHA 2020 goals of improving CV health of all Americans.1 Physical activity, compared with other widely accepted CV preventive measures, is underutilized despite the significant benefits for general health and quality of life (QOL). Inadequate physical activity is a major modifiable risk factor with negative consequences, including obesity, hypertension, and reduced cardiorespiratory (aerobic) fitness levels.
The Importance of Cardiorespiratory Fitness
Whereas various health behaviors and risk factors are tracked through federally funded programs, data regarding cardiorespiratory fitness (CRF) are limited. That CRF is currently the only risk factor that is not routinely evaluated in either general or specialized clinical settings prompted multidisciplinary AHA committees and councils to craft a policy statement outlining the rationale for broadening CRF assessment across multiple environmental settings, from the workplace to clinical settings.2 Many CVSN members, both nurse scientists and clinicians, have enhanced our current understanding of the assessment of CRF and have tested evidence-based behavioral interventions for promoting physical activity in many settings, including cardiac rehabilitation. Because of the significant association between CRF and frailty, functional limitations, depression, QOL, and mortality, there is a compelling need for a CRF registry to assist with determining normative CRF levels in diverse subgroups of the US population for improving their QOL, their independence, and their performance of normal daily tasks. The AHA policy statement provides convincing evidence for the prognostic advantages of CRF over physical activity and outlines how CRF assessment could be broadened and stratified by important demographics such as age, race, and ethnicity.
The proposed national registry would help define norms for CRF levels across physical activity levels. The registry could also serve as a tracking device for future public health campaigns for fostering physical activity. The value of such a registry includes clearly defined and standardized quantitative metrics and outcome variables that could potentially be incorporated into the annual AHA CV disease (CVD) and stroke statistical updates. Such a common registry would facilitate clinical research on a larger scale that can be accomplished by isolated research teams. Arena et al3 argue that CRF may ultimately become a critical vital sign in clinical practice. The Department of Health and Human Services, specifically the Centers for Disease Control and Prevention, would serve as a key partner for the expansion of the national surveillance of CRF. Dr Theresa Beckie, a CVSN member and contributor to the policy writing group, suggests that “the CRF registry has potential to examine novel bio-behavioral and environmental factors associated with gender, ethnic and racial disparities in physical activity and CRF that disproportionately contribute to adverse CV outcomes.” Widely available evidence-based guidelines exist for traditional CV risk factors such as hypertension, dyslipidemia, and fasting glucose; such guidelines for CRF are unavailable for this important health metric.
Measuring Patient-Reported Health Status
Contemporary medical advances have significantly reduced CV mortality and improved longevity. Historically, the effectiveness of treatment options has largely been evaluated by such hard endpoints as composite outcomes of major CV events (eg, death, myocardial infarction, coronary revascularization). Patient-reported outcome (PRO) is an umbrella term describing data collected directly from the patient using standardized questionnaires, diaries, or event logs to measure explicit concepts such as physical or emotional functioning and health-related QOL (HRQOL). The Patient-Centered Outcomes Research Institute (PCORI; www.pcori.org), an independent, nonprofit organization, was created to conduct research that provides information about the best evidence for assisting patients and their healthcare providers to make more informed healthcare decisions. In the wake of PCORI, there has been an increasingly widespread application of PRO measures in both research and clinical practice. Cardiovascular and stroke nurse scientists and clinicians have always been patient centered and have long been at the forefront of evaluating PROs such as health status, QOL, depression, and other psychosocial and symptom burden outcomes. Aligned with the AHA goal of improving CV health, a recent scientific statement provided clarification of useful and standardized metrics for delineating CV health beyond mortality and morbidity outcomes.4 Reduced mortality from CVD is a laudable achievement only if the quality of the patients’ life, from their perspective, is also improved. Patients’ views of their QOL represent their own “gold standard” and are best measured by patient-reported measures.
Rumsfeld and colleagues4 not only advocate for operationalizing CV health as patient-oriented health status but also describe key domains of health status and currently available instruments for measuring CVD-related health status. The key domains of health status that are highlighted by the various measures include symptom burden, functional status, and HRQOL. Although many of these health status surveys have been used in numerous clinical trials, there is potential that their use in clinical practice may contribute to improved shared decision making of patients with their healthcare providers. Rumsfeld et al4 present comprehensive information about the most widely used and psychometrically evaluated health status surveys for such subpopulations as those with atrial fibrillation, heart failure, peripheral artery disease, and myocardial infarction. The National Institutes of Health’s Patient-Reported Outcomes Measurement Information System (www.nihpromis.org), an initiative begun in 2004, is presented as an additional resource for collecting data that provide important PRO information about the effects of interventions (eg, sleep quality, pain) that supplement objective clinical measures.
Although not meant to be exhaustive, Rumsfeld et al4 provide valuable information about the psychometric properties of health surveys that capture all 3 health status domains (eg, symptom burden, functional status, and HRQOL). Recommendations for administration, scoring, and interpretation of health surveys are offered, and examples of their use in various clinical trial populations are provided. The literature regarding the influence of sex, race, ethnicity, socioeconomic status, and age on patient-reported health status is also summarized. Although patient-reported health status surveys have been used as both primary and secondary outcomes of intervention studies for decades by nurse scientists, their use in biomedical research has only recently gained momentum. Despite the challenges of clinical interpretation, patient health status measures have potential utility for clinical monitoring and prognosis and as tools for shared medical decision making in treatment decisions and improved healthcare quality. Most importantly, healthcare reform initiatives emphasize the value of patient-centered outcomes, the promotion of wellness, and shared decision making and examining the impact of therapies not only on the length but also the quality of life.
The promotion of wellness and QOL of Americans has been the central focus of CVSN members. Better PRO metrics to compare health condition effects, interventions, and treatments are important endpoints of our research and clinical care and are important supplements to mere mortality outcomes. Cardiovascular and stroke nurses have a long and successful history of adopting an ecological perspective for considering person and environment factors in explaining health status. We have always taken a more holistic approach to research and patient care that spans biobehavioral and health ecological dimensions. We excel at thinking through endpoints beyond mortality that are relevant to patients (eg, self-efficacy) and especially exploring beyond disease endpoints to include wellness, HRQOL, and disease-related morbidity (eg, symptom clusters). Cardiovascular and stroke nurses are well aware that complex diseases such as CVD require not only an understanding of biology but also the behavioral, social, and cultural environments in which patients manage nutrition, physical activity, disease self-management, and the stresses involved in daily life.
Over and above their utility in research, the value of a national surveillance of CRF and assessing patient-reported health status is evident. These constructs are important both as risk factors and as health outcomes. The policy statement arguing for a national CRF registry and the scientific statement recommending evaluation of patient-reported health provide direction for future research and clinical practice. Dr Debra Moser, a CVSN member, made valuable contributions as a member of the writing group that developed the scientific statement on the importance of measuring PROs. Dr Moser said, “I found the process delightful because of the collaborative, interdisciplinary approach.” As a successful recipient of a recent PCORI research award, Dr Moser suggests that “this document will help people writing PCORI grants, but more than that, will truly put patients at the center of care with the hope that the healthcare system will finally make changes that have been needed for years.”
1. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010; 121 (4): 586–613.
2. Kaminsky LA, Arena R, Beckie TM, et al. The importance of cardiorespiratory fitness in the United States: the need for a national registry: a policy statement from the American Heart Association. Circulation. 2013; 127 (5): 652–662.
3. Arena R, Myers J, Guazzi M. The future of aerobic exercise testing in clinical practice: is it the ultimate vital sign? Future Cardiol. 2010; 6 (3): 325–342.
4. Rumsfeld JS, Alexander KP, Goff DC Jr, et al. Cardiovascular health: the importance of measuring patient-reported health status: a scientific statement from the American Heart Association. Circulation. 2013; 127 (22): 2233–2249.