International research in cardiovascular nursing: Getting insight in the role of system factors

In the current issue of the European Journal of Cardio-vascular Nursing, Van Bulck and co-workers have published an article on patient-reported outcomes (PROs) of adults with congenital heart disease from eight European countries.1 The main aim of that study was to investigate the relationship between components of healthcare system performance and PROs. In other words, does the performance of a healthcare system by and large reflect in outcomes as perceived by individuals from a particular patient population? The study indicated that, indeed, several features of healthcare system performance are associated with perceived physical health and health risk behaviours in adults with congenital heart disease.1 This article stems from the ‘Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease – International Study’ (APPROACH-IS).2 The aims of APPROACH-IS were: (i) to investigate differences in PROs in adults with congenital heart disease who are living in different areas of the world; and (ii) to gain insight into how international differences can be understood.2 Overall, 4028 patients from 24 centres in 15 countries of five continents have been included.3 Numerous articles have described findings obtained in this global sample3–11 or on patients from specific countries or regions.1,12–19 Substantial inter-country variation in PROs was observed, with Switzerland generally having the highest PRO scores and India the lowest.6 Functional class, age and unemployment status were patient-related factors that independently and consistently predicted PRO.6 Illness perceptions were related to patients’ quality of life, such that patients with a poorer quality of life perceived their illness as having more consequences, had weaker perceptions of personal control, believed to a lesser extent that their treatment can control their illness, perceived more symptoms, had a less coherent illness understanding and experienced more negative emotions.4 Religion and spirituality also played a role in explaining PRO.9 Self-identification as religious/spiritual and attributing a higher importance of religion/spirituality in one’s life was positively associated with quality of life, satisfaction with life and with health behaviours. However, in patients who are living in more secular countries, religion and spirituality are negatively associated with physical and mental health, which indicates that religion/spirituality has a differential impact on health outcomes in various countries.9 When patient-related factors are evaluated as predictors of PROs, still 30% to 90% of the variance cannot be explained.4,6 Therefore, it is worthwhile to explore country-specific features and healthcare system factors that may explain the variance in PROs above and beyond patient characteristics. In APPROACH-IS, the level of national happiness,3 cultural dimensions,3 standard of living6 and healthcare system factors1,6 were investigated in predicting PROs. These analyses demonstrated that a higher standard of living, as expressed by the Gross Domestic Product per capita and the Human Development Index, predicted certain PROs above and beyond patient factors.6 The same was observed for healthcare system factors, operationalized in terms of total health expenditure per capita and the overall health system performance.6 The current paper of Van Bulck and colleagues in this journal1 adds to this body of knowledge. The example of APPROACH-IS illustrates the value and increasing importance of international research in cardiovascular nursing. International, multicentre studies yield findings that are more generalizable and better applicable in different settings. Furthermore, it allows to investigate (healthcare) system factors. Over the past two years, seven studies have been published in the European Journal of Cardiovascular Nursing, including international samples.18,20–25 Four of these studies were performed in nurses and other healthcare professionals.20,22–24 The three other studies included patients.18,21,25 The studies that targeted healthcare professionals were surveys on nurses’ attitudes towards family involvement in care,20 on nurses’ and allied professionals’ awareness and barriers regarding the implementation of clinical guidelines,24 on clinicians’ practice patterns regarding adherence assessment and intervention strategies for heart transplant recipients22 and one study assessed the practical skills in cardiopulmonary resuscitation of cardiovascular nurses and allied professionals.23 The studies that included patients pertained to adults with congenital heart disease,18 patients with heart failure21 and persons with coronary artery disease who were scheduled for coronary artery bypass graft surgery.25 The study in congenital heart disease recruited patients in Switzerland and Canada, and investigated self-efficacy as predictor of PROs.18 The study in heart failure patients was performed in Sweden, The Netherlands and Japan. It was a psychometric study on the Thirst Distress Scale for patients with Heart Failure.21 The third study compared health-related quality of life and associated factors in patients with coronary artery disease from The Netherlands and Slovakia.25 Although these studies were performed in respondents from different countries, none of the articles reported on system factors or country-specific characteristics that may have explained the patient outcomes. In that respect, the Van Bulck article1 may indicate that there is a growing need for research in which patient outcomes are linked to general healthcare features. Nursing research in an international context is increasingly important. It gives answers to research questions that can never be answered using single-country studies. Therefore, researchers should be stimulated to look further than the typical patient factors and ought to scrutinize healthcare system factors and country-specific characteristics that may impact on outcomes above and beyond patient qualities.