Objective: To assess the determinants of poor mid-term health related quality of life (HRQoL) at one year after primary isolated coronary artery bypass grafting (CABG). Methods: 463 patients who underwent primary isolated CABG for multivessel disease and came for their annual follow up at the outpatient clinic during one year at Harefield Hospital, Middlesex, were approached to participate in the present study. Prospective clinical data were collected as part of the clinical care of the patients and were retrospectively analysed when the patients consented to participate in the study at their outpatient visit. After their consent they were given three HRQoL assessment questionnaires. Scores, together with clinical data, were analysed by both univariate and multivariate analyses with regard to poor HRQoL outcome. Results: 437 (94.4%) patients consented to participate in the study and filled in the HRQoL questionnaires. Ten variables were identified in the univariate analysis as potential predictors of poor scores of the physical element of HRQoL; however, only three variables-gastrointestinal problems, congestive heart failure, and type D personality trait-predicted poor physical scores independently. Eleven variables were identified in the univariate analysis as potential predictors of poor scores of the mental element of HRQoL; however, only three variables-peripheral vascular disease, infective complications, and type D personality trait-predicted poor physical scores independently. Conclusion: Preoperative gastrointestinal problems, preoperative congestive heart failure, and type D personality trait were independent predictors of the poor physical component of HRQoL. Peripheral vascular disease, infective complications, and type D personality trait were independent predictors of the poor mental component of HRQoL. Interestingly, patients with type D personality were more than twice as likely to have poor physical HRQoL and more than five times as likely to have poor mental HRQoL.

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Recent advances in interventional cardiology and cardiac surgery have changed the traditional therapeutic algorithms by altering indications, timing and patterns of referral for subsequent surgical treatment. The traditional longitudinal sternomy incision has been the surgical approach of choice for multi-vessel coronary revascularisation. Drawbacks of this incision include potential postoperative morbidity, which translates to a prolonged postoperative length of stay. The combination of minimally invasive direct coronary artery bypass (MIDCAB) with percutaneous transluminal coronary angioplasty (PTCA) or stenting (a hybrid approach) is an alternative therapeutic method for patients with multivessel coronary artery disease. Recent advances in percutaneous interventions have attempted to address the problem of re-stenosis, initially through the deployment of bare metal intra-coronary stents and, more recently, with drug-eluting stents. Developments in coronary revascularisation have focused on reducing both surgical invasiveness and trauma. Patients with significant co-morbid pathologies, the ones undergoing re-interventions, and especially the elderly may benefit from such hybrid procedures by avoiding cardiopulmonary bypass and midline sternotomy. Minimally invasive techniques have revolutionized cardiothoracic surgery by increasing patient satisfaction and by reducing surgical trauma, hospital stay and consequently overall costs. There are however limitations. Robot assisted surgery endeavours to minimise these technical hindrances and so allow better and more accurate surgical practice whilst minimising surgical trauma.

Recent advances in interventional cardiology and cardiac surgery have changed the traditional therapeutic algorithms by altering indications, timing and patterns of referral for subsequent surgical treatment. The traditional longitudinal sternomy incision has been the surgical approach of choice for multi-vessel coronary revascularisation. Drawbacks of this incision include potential postoperative morbidity, which translates to a prolonged postoperative length of stay. The combination of minimally invasive direct coronary artery bypass (MIDCAB) with percutaneous transluminal coronary angioplasty (PTCA) or stenting (a hybrid approach) is an alternative therapeutic method for patients with multivessel coronary artery disease. Recent advances in percutaneous interventions have attempted to address the problem of re-stenosis, initially through the deployment of bare metal intra-coronary stents and, more recently, with drug-eluting stents. Developments in coronary revascularisation have focused on reducing both surgical invasiveness and trauma. Patients with significant co-morbid pathologies, the ones undergoing re-interventions, and especially the elderly may benefit from such hybrid procedures by avoiding cardiopulmonary bypass and midline sternotomy. Minimally invasive techniques have revolutionized cardiothoracic surgery by increasing patient satisfaction and by reducing surgical trauma, hospital stay and consequently overall costs. There are however limitations. Robot assisted surgery endeavours to minimise these technical hindrances and so allow better and more accurate surgical practice whilst minimising surgical trauma.

There is increasing interest in evaluating the quality of care delivered by health care providers and its impact on the overall satisfaction of the end-user, namely the patient. Despite the political incentives that such research evokes, important questions surrounding this topic must be answered to improve the way in which care is delivered. This signals important changes in the way that patients, clinicians, scientists and administrators, evaluate outcomes of treatment.Such an example is illustrated in a recent study by Malin et al., 1 which analyses adherence to quality measures for cancer care, including patients with a new diagnosis of either stage I to III breast cancer or stage II or III colorectal cancer as index cases. The incorporation of clinical domains representative of the entire patient episode is unique: diagnostic evaluation, surgery, adjuvant therapy, management of treatment toxicity and post-treatment surveillance. Further examination was made of eight components of care integral to these clinical domains: testing, pathology, documentation, referral, timing, receipt of treatment, technical quality and respect for patient preferences. In all, adherences to respectively 36 and 25 explicit quality measures with clinically detailed eligibility criteria, specific to the process of cancer care, were identified for breast and colorectal cancer. Overall adherence to these quality measures was 86% (95% CI 86-87%) for breast cancer patients and 78% (95% CI 77-79%) for colorectal cancer patients. Subgroup analysis across the clinical domains and components of care did however identify significant adherence variability: 13-97% for breast cancer and 50-93% for colorectal cancer. This is the first study to evaluate adherence to identifiable and reproducible indicators of quality in a specific area of health care. So novel is this piece of work, that there is at present no objective, validated tool for scoring studies looking at quality of care or quality of life outcomes. We are therefore unable to measure the 'quality' of this article as we can for randomized controlled trials (Jadad score), 2 nonrandomized studies in surgery (MINORS) 3 and diagnostic accuracy studies (QUADAS and STARD). 4 The term 'quality' encompasses so much more than merely the speed and cost at which a patient episode can be completed. It is important to evaluate measures beyond traditional surrogate endpoints, such as length of stay, morbidity and mortality, and include factors such as referral networks, diagnostics, perioperative and operative factors, adjuvant therapies, follow-up including surveillance, and patient values using qualitative indicators such as EQ-5D, SF 36, or newer SF 12 and SF 8 health surveys. 5,6 Consideration will also need to be given to cost-utility ratios using either quality adjusted life years or incremental cost-effectiveness ratios. Indeed, in the operational system that is the NHS, the current key performance indicators for trusts, treatment centres, and independent sector treatment centres, are mainly ...