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2008 Widener Dissertation DISEASE SEVERITY AND DISABILITY IN PERSONS WITH PERIPHERAL ARTERIAL DISEASE DISSERTATION Presented in Partial Fulfillment of the Requirements for The Degree of Doctor of Philosophy in the Graduate School of The Ohio State University By Jeanne Malcom Widener * * * * * The Ohio State University 2008 Dissertation Committee: Professor Pamela J. Salsberry, advisor Approved by: Professor Kathleen A. Stone Professor Barbara Polivka _________________________ Professor Linda K. Daley Advisor College of Nursing Copyright by Jeanne M. Widener 2008 ABSTRACT Peripheral arterial disease (PAD) is a serious condition that can lead to long-term disability. Recently the National Heart, Lung and Blood Institute began a campaign to educate the public and increase awareness of PAD. The diagnosis of PAD frequently occurs late in the process. The purpose of this study was to understand the relationship between mild or severe PAD and disability (health-related quality of life) and determine which factors affect that relationship. This study explored pain, mobility and activity alterations in response to PAD. Sociodemographic, chronic diseases and biological risk factors were also examined. A cross-sectional design was used to examine 4559 adults age 40 and over from the NHANES 2001-2004 data. An ankle- brachial index (ABI) measured PAD severity and the Center for Disease Control and Prevention Health-Related Quality of Life 4 question set measured physical, mental and activity disability. Comparisons of PAD levels: severe (ABI less than 0.7), mild (ABI 0.7- 0.9) and no disease showed that differences in pain, activity, mobility and risk factors become apparent when PAD is considered asymptomatic. Logistic regression showed physical disability was 1.7 times (95% CI 1.3, 2.2) more likely with mild PAD than no disease. No effect was found between PAD and ii mental or activity disability. Education, poverty income ratio and hypertension were confounding factors. Mobility difficulty and calf pain with walking were mediators between PAD and physical disability. Age, ability to do vigorous activity, total cholesterol and obesity were effect moderators. Compared with no disease, odds ratio of physical disability were 4.4 times higher (95% CI 1.5, 13.2) at age 48 with severe PAD, 2.9 times higher (95% CI 1.39, 5.97) with elevated total cholesterol and mild PAD and 4.14 times higher (95% CI 1.23, 13.98) for obesity with severe PAD. Mobility, vigorous activity and calf pain made the most difference in the relationship between PAD and physical disability. Low prevalence of PAD in the general population (6.1%, 95% CI 4.9, 7.1) makes monitoring for disability impractical. Mean number of physically unhealthy days was higher for mild PAD, so surveillance with the CDC HRQOL- 4 may be helpful in monitoring PAD impact. iii DEDICATION To God be the Glory iv ACKNOWLEDGMENTS Greg, Becca, Keven; Thank you for your steadfast love, prayer and encouragement. Also the large extended family both physically related and through the church, you have all been a continuous source of encouragement and support. Cathy and Chantal Thank you! Dr. Pamela Salsberry has been a God send to completing this dissertation and learning large data set research, which I will be able to continue using. I thank Dr. Susan Frazier who was my advisor for the major portion of my doctoral study. Thank you also to the current and previous committee members for support and wonderful suggestions. Thank you to the Society for Vascular Nursing for funding to do this research and the encouragement to keep revising the proposal as needed to complete the research process. Dr. Lee Cohen and the dissertation support group where would I be without all of you over the years encouraging me in the writing, grieving with me when obstacles were blocking my progress, and celebrating the accomplishment with me. Last, to my statistical consultants, Amy Lehman and Chris Holloman who helped me understand how to reach my research goals. v VITA June 6, 1955 . Born, Pittsfield, IL 1976 . Diploma, Mennonite Hospital School of Nursing, Bloomington, IL 1980 . B. S. N. Nursing East Tennessee State University 1983 . M. S. N. Nursing Vanderbilt University 1976 1977 . Staff Nurse University of Missouri Medical Center Columbia, MO. 1977 1981 . Staff Nurse Johnson City Medical Center Hospital Johnson City, TN 1981 1983 . Staff Nurse II Vanderbilt University Hospital, Nashville, TN 1986 1999 . Staff Nurse Pattie A. Clay Hospital Richmond, KY. 1989 1998 . Visiting Instructor, Instructor, and Assistant Professor (Tenure: 1995) Eastern Kentucky University Richmond, KY vi 1999 Present . Staff Nurse Mt. Carmel East Hospital Columbus, OH 1999 2000 . Graduate Teaching Associate The Ohio State University 2000-2004 . Graduate Research Associate The Ohio State University Dr. Debra Moser (2000-2003) Dr. Terry Lennie (2002-2003) Dr. Kathy Stone (2003-2004) 2003 Present . Instructor, Basic Life Support and Advanced Cardiac Life Support Mount Carmel Training Center Columbus, OH 2004 2007 . Clinical Evaluator (CPNE) Excelsior College Midwest Performance Assessment Center (MPAC) Ohio Columbus and Mansfield, Ohio PUBLICATIONS Heo, Seongkum, Doering, Lynn V., Widener, Jeanne, and Moser, Debra K. (2008). Predictors and effect of physical symptom status on health- related quality of life in patients with heart failure. American Journal of Critical Care, 17(2), 124-132. Widener, J.M. (2007). C-reactive protein measurement in the patient with vascular disease. Journal of Vascular Nursing, 15(3), 51-54. Heo, Seongkum, Moser, Debra K, Widener, Jeanne. (2007). Gender differences in the effects of physical and emotional symptoms on health- related quality of life in patients with heart failure. European Journal of Cardiovascular Nursing, 6 (2), 146-152. vii Frazier, S. K., Stone, K. S., Moser, D., Schlanger, R., Carle, C., Pender, L. and Widener, J. (2006). Hemodynamic changes during discontinuation of mechanical ventilation in medical intensive care unit patients. American Journal of Critical Care, 15(6), 580-593. Frazier, S. K., Brom, H., Widener, J., Pender, L., Stone, K. S. and Moser, D. K. (2006). Prevalence of myocardial ischemia during mechanical ventilation and weaning and its effects on weaning success. Heart & Lung, 35, 363- 373. Widener, J., Yang, C., Costello, P. and Allen, K. (1999). Modifications to standard guidelines and changes in blood pressure readings using an automatic blood pressure devise. AAOHN Journal, 47(3), 107 113. Widener, J. and Reid, C. (1993). Use of inquiry in allied health education. AHN Forum, 9(1), 3-6. FIELDS OF STUDY Major Field: Nursing Cognate: Psycho-Physiology viii TABLE OF CONTENTS Page ABSTRACT. ii DEDICATION. iv ACKNOWLEDGMENTS. v VITA. vi LIST OF FIGURES. xiii CHAPTERS: 1. INTRODUCTION. 1 Significance of the Problem. 1 Purpose. 5 Specific Aims and Hypotheses. 6 Specific Aim 1. 6 Specific Aim 2. 6 Specific Aim 3. 7 Specific Aim 4. 7 2. REVIEW OF THE LITERATURE. 8 Epidemiology of Peripheral Arterial Disease. 8 Conceptual Model. 11 Biological Function. 13 Interaction of local and systemic inflammatory factors. 17 Peripheral Arterial Disease (PAD) severity. 20 Health practices, chronic diseases and peripheral 21 arterial disease. Socioeconomic status and biological function. 27 ix Symptoms. 28 Relation of biological status to symptoms. 29 Functional Status. 30 General Health Perception. 32 Health-Related Quality of Life. 33 Disability. 37 Summary. 38 Specific Aims and Hypotheses. 39 Specific Aim 1. 39 Specific Aim 2. 39 Specific Aim 3. 39 Specific Aim 4. 40 3. METHODS. 41 Study Design. 41 Description of the Data Source. 41 Sample. 42 MEASURES . 44 Dependent variable . 45 Independent variables . 47 Demographics and Socioeconomic status. 47 Peripheral arterial disease severity . 51 Chronic disease. 52 Biological risks. 53 Symptoms . 55 Functional Status. 55 General Health Perception . 56 Data Analysis . 57 Model 1. 58 Specific Aim 1 . 58 x Order of Model 1 Analysis . 58 Model 2. 60 Specific Aim 2 . 60 Order of Model 2 Analysis . 61 Model 3. 62 Specific Aim 3 . 62 Order of Model 3 Analysis . 63 Model 4. 65 Specific Aim 4 . 65 Order of Model 4 Analysis . 66 4. RESULTS . 68 Descriptive Statistics . 68 Demographic and socioeconomic . 69 Symptom, Functional Status, and General Health 71 Perception . Biological risk and select chronic diseases. 73 Health-related quality of life and disability. 77 Correlations. 78 Logistic Regression. 80 Crude estimates odds ratios. ..
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