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Health-Related Quality of Life in Coronary Heart Disease in Korea: The Korea National Health and Nutrition Examination Survey 2007 to 2011 Hyung Tak Lee, Jinho Shin, Young-Hyo Lim, Kyung Soo Kim, Soon Gil Kim, Jeong Hyun Kim and Heon Kil Lim ANGIOLOGY published online 2 May 2014 DOI: 10.1177/0003319714533182 The online version of this article can be found at: http://ang.sagepub.com/content/early/2014/05/01/0003319714533182

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Health-Related Quality of Life in Coronary Heart Disease in Korea: The Korea National Health and Nutrition Examination Survey 2007 to 2011

Angiology 1-7 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003319714533182 ang.sagepub.com

Hyung Tak Lee, MD, MSc1, Jinho Shin, MD, PhD1, Young-Hyo Lim, MD, PhD1, Kyung Soo Kim, MD, PhD1, Soon Gil Kim, MD, PhD2, Jeong Hyun Kim, MD, PhD1, and Heon Kil Lim, MD, PhD1

Abstract Using data from 2007 to 2011 of the Korea National Health and Nutrition Examination Survey, we evaluated the influence of coronary heart disease (CHD) on health-related quality of life (HRQoL) as measured by the EQ-5D in comparison with the general population and the predictors of HRQoL in CHD. Compared with the general population, HRQoL was impaired in the EQ-5D dimensions of mobility, usual activities, pain/discomfort, and anxiety/depression. The impairment of HRQoL was much greater in the older age group and in females. In subjects with CHD, the predictors for a low EQ-5D index were old age, female sex, low education, stroke, and noncardiovascular comorbidities, and the predictors for a low EQ Visual Analogue Scale were low income and noncardiovascular comorbidities. For the improvement in HRQoL, preventing stroke and noncardiovascular comorbidities is important, especially among female and older Asian patients with CHD. Keywords health-related quality of life, EQ-5D, coronary heart disease, KNHANES

Introduction Coronary heart disease (CHD) is a major cause of death worldwide. In the past decades, the mortality rate associated with CHD has declined continuously as a result of advancements in disease prevention and treatment.1-3 Therefore, the importance of health-related quality of life (HRQoL) in survivors of CHD is growing. These days, the purpose of treatment has expanded from reducing morbidity and mortality to improving quality of life. Furthermore, one study suggested that HRQoL is a predictor of long-term mortality in patients with CHD.4 Accordingly, an understanding of HRQoL in CHD is needed to decide on proper treatment and to determine disease prognosis. Some studies investigated the influence of CHD on HRQoL in comparison with the unaffected population.5-7 However, national-level studies regarding this issue are lacking in Asia. Considering ethnic and sociodemographic differences, a study regarding the impact of CHD on HRQoL and the predictors of HRQoL in the Korean population could contribute to knowledge on HRQoL in CHD. The HRQoL can be measured by several instruments, such as the short-form generic measure of health status and the

EQ-5D, one of the most frequently used measures developed by the EuroQol group.8 A previous study demonstrated that the EQ-5D is suitable for patients with cardiac disease.9 The aim of this study was to determine the influence of CHD on HRQoL as measured by the EQ-5D in comparison with the unaffected population and the predictors of HRQoL in CHD.

Methods Population We used data from the fourth to the fifth Korea National Health and Nutrition Examination Surveys (KNHANES IV-V) 1

Division of Cardiology, Department of Internal Medicine, Hanyang University Medical Center, Seoul, Korea 2 Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea Corresponding Author: Jinho Shin, Division of Cardiology, Department of Internal Medicine, Hanyang University Medical Center, 222 Wangsimniro, Seongdong-gu, Seoul 133-792, Korea. Email: [email protected]

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conducted by the Korean Centers for Disease Control and Prevention (KCDC). The data were collected from July 2007 to December 2011. The KNHANES is a cross-sectional and nationally representative survey on the health and nutritional status of the civilian, noninstitutionalized Korean population. The KNHANES is composed of a health examination, nutrition survey, and health questionnaire survey including HRQoL. The participants were chosen from the candidates using proportional allocation-systematic sampling with multistage stratification (age, sex, and region). The 7 metropolitan cities and 9 provinces were considered as urban and rural areas, respectively. The subjects in this study were all 19 years of age who were interviewed between July 2007 and December 2011. The health interview survey sample consisted of 42 347 people. Of those samples, 31 712 people were 19 years of age. The KNHANES was approved by the KCDC institutional review board, and all participants signed a written consent form. The present study and the use of the data were approved by the KCDC.

Measures The HRQoL was evaluated by the EQ-5D questionnaire, which generates assessment scores across 5 dimensions of health: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.10 The responses for each dimension were divided into 3 categories—no problem, moderate problem, or severe problem—and were then converted into an EQ-5D index score, which is a preference-based health status index. The preference weights of Korea are quite different from those of Western countries.11 Therefore, in this analysis, we used the Korean preference weight to generate the EQ-5D index score.12 Additionally, the EQ-5D questionnaire contains a Visual Analogue Scale (VAS) ranging from 0 (worst imaginable health state) to 100 (best imaginable health state), which enables respondents to assess their health subjectively. A history of CHD was defined as a self-reported physician’s diagnosis of myocardial infarction or angina pectoris. Covariates included sociodemographic factors such as age, sex, spouse status, education level, and income level; CHD risk factors such as hypertension, diabetes mellitus, hyperlipidemia, obesity, and current smoking; presence of comorbidities such as stroke and noncardiovascular disease; and time from CHD diagnosis. Unmarried subjects, separated subjects, widowed subjects, and divorced subjects were given ‘‘no spouse’’ status. The education level was categorized as elementary school or lower, middle school, high school, and university or higher. The income level was divided into national quartile groups. Hypertension was defined as blood pressure 140/90 mm Hg or the use of antihypertensive medication. Diabetes mellitus was defined as a self-reported physician’s diagnosis, the use of hypoglycemic agents including insulin, or a fasting blood glucose 126 mg/dL. Obesity was defined as a body mass index 25 kg/m2. Hyperlipidemia was defined as total cholesterol 240 mg/dL or the current use of lipid-lowering medications. The presence of comorbidities was defined as a selfreported physician’s diagnosis.

Table 1. Sociodemographic and Clinical Characteristics of the Study Sample by History of CHD.a Non-CHD (n ¼ 28 901)

CHD (n ¼ 708)

Sociodemographic factors Age, years 44.5 (+0.19) 63.5 (+0.60) Age (%) 19-44 years 53.6 (+0.6) 5.4 (+1.4) 45-64 years 33.4 (+0.5) 45.8 (+2.4) 65 years 13.0 (+0.3) 48.7 (+2.3) Sex (%) Male 49.3 (+0.3) 52.5 (+2.3) Female 50.7 (+0.3) 47.5 (+2.3) Presence of spouse (%) No 31.4 (+0.5) 24.8 (+2.0) Yes 68.6 (+0.5) 75.2 (+2.0) Education level (%) Elementary school 19.3 (+0.4) 49.0 (+2.4) Middle school 10.2 (+0.3) 17.6 (+1.9) High school 39.5 (+0.5) 20.7 (+2.1) University 30.9 (+0.6) 12.7 (+1.6) Income level (%) Low income 25.3 (+0.6) 25.4 (+2.1) Middle–low income 25.0 (+0.5) 26.9 (+2.2) Middle–high income 25.3 (+0.4) 24.4 (+2.0) High income 24.5 (+0.6) 23.4 (+1.9) CHD risk factors (%) Hypertension 25.9 (+0.4) 59.0 (+2.3) Diabetes mellitus 8.3 (+0.2) 26.6 (+2.2) Hyperlipidemia 10.6 (+0.2) 27.7 (+2.2) Obesity 31.5 (+0.4) 43.3 (+2.4) Current smoking 26.5 (+0.4) 21.2 (+2.2) Comorbidities Stroke (%) 1.4 (+0.1) 7.0 (+1.2) Noncardiovascular 0.312 (+0.004) 0.628 (+0.036) disease (number) Time from CHD diagnosis, – 6.8 (+0.3) years

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Health-related quality of life in coronary heart disease in Korea: the Korea National Health and Nutrition Examination Survey 2007 to 2011.

Using data from 2007 to 2011 of the Korea National Health and Nutrition Examination Survey, we evaluated the influence of coronary heart disease (CHD)...
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