Content uploaded by Gilles Dupuis
Author content
All content in this area was uploaded by Gilles Dupuis on Oct 27, 2015
Content may be subject to copyright.
Research
Recherche
From *the Department of
Surgery and the Division of
Clinical Epidemiology,
McGill University and
Montreal General Hospital,
and †the Montreal Heart
Institute, and the Department
of Psychology, Université du
Québec à Montréal,
Montreal, Que.
This article has been peer reviewed.
CMAJ 2001;165(4):429-33
Abstract
Background: A lack of resources has created waiting lists for many elective surgical
procedures within Canada’s universal health care system. Coronary artery by-
pass grafting (CABG) for the treatment of atherosclerotic ischemic heart disease
is one of these affected surgical procedures. We studied the impact of waiting
times on the quality of life of patients awaiting CABG.
Methods: A prospective cohort of 266 patients from 3 hospitals in Montreal was
used. Patients who gave informed consent were followed from the time they
were registered for CABG until 6 months after surgery; recruitment began in No-
vember 1993, and the last follow-up was completed in July 1995. Patient
groups were classified according to the duration of the wait for CABG
(≤97 days or > 97 days). We measured the following outcomes: quality of life
(using the Medical Outcomes Study 36-item Short Form [SF-36]), incidence of
chest pain (using the New York Heart Association angina classification), fre-
quency of symptoms (using the Cardiac Symptom Inventory) and rates of com-
plications and death before and after surgery.
Results: There were no differences in quality of life at baseline between the 2
groups. Immediately before surgery, compared with patients who waited
97 days or less, those who waited longer had significantly reduced physical
functioning (change from baseline SF-36 score 0 v. –4 respectively, p=
0.001), vitality (change from baseline score –0.1 v. –1.3, p= 0.01), social
functioning (change from baseline score 0.4 v. –0.4, p= 0.03) and general
health (change from baseline score 1.1 v. –1.7, p= 0.001). At 6 months after
surgery, compared with patients who waited 97 days or less for CABG, those
who waited longer had reduced physical functioning (change from baseline
SF-36 score 4.0 v. –0.1 respectively, p= 0.001), physical role (change from
baseline score 0.8 v. 0.0, p= 0.001), vitality (change from baseline score 2.2
v. 0.9, p= 0.001), mental health (change from baseline score 1.2 v. 0.0, p=
0.001) and general health (change from baseline score 1.8 v. –0.3, p=
0.001). The incidence of postoperative adverse events was significantly
greater among the patients with longer waits for CABG than among those
with shorter waits (32 v. 14 events respectively, p= 0.005). Longer waits be-
fore CABG were associated with an increased likelihood of not returning to
work after surgery (p= 0.08): 10 (53%) of the 19 patients with longer waiting
times remained employed after CABG, as compared with 17 (85%) of the 20
with shorter waiting times.
Interpretation: The significant decrease in physical and social functioning, both
before and after surgery, for patients waiting more than 3 months for CABG is an
important observation. Longer waiting times were also associated with in-
creased postoperative adverse events. By decreasing waiting times for CABG,
we may improve patients’ quality of life and decrease the psychological morbid-
ity associated with CABG.
Impact of waiting time on the quality
of life of patients awaiting coronary
artery bypass grafting
John Sampalis,*Stella Boukas,*Moishe Liberman,*Tracey Reid,*
Gilles Dupuis†
CMAJ • AUG. 21, 2001; 165 (4) 429
© 2001 Canadian Medical Association or its licensors
Cardiovascular disease is a major cause of morbidity
and death in the Western world and remains the
primary cause of death in North America, with
about 50 000 Canadians dying of cardiovascular disease
every year. In 1990, cardiovascular disease caused 39% of
all deaths in Canada, and over half of these deaths re-
sulted from ischemic coronary artery disease (CAD).1Be-
cause of improvements in health care and changes in pa-
tients’ attitudes and behaviours, the rate of death from
cardiovascular disease has decreased in recent years.2–7 As
a result, the number of individuals alive with cardiovascu-
lar disease has grown, leading to an increased demand for
health care services.
Coronary artery bypass grafting (CABG) is an effective
treatment of CAD. It has been shown both to relieve
angina in the majority of patients undergoing the proce-
dure and to prolong life in a large proportion of patients.8–10
The more severe the CAD, the stronger the indication for
CABG as opposed to treatment with lifestyle modification,
medical treatment or angioplasty.11–17 Coronary artery
revascularization as a treatment of CAD is common, and its
popularity and use in Canada and throughout the Western
world continues to rise.18 In Quebec, the number of CABG
procedures increased from 2016 in 1981 to 3273 in 1987
and has risen further since then.3,6
In the United States, because of alternatives in the
health care system, there is virtually no wait for coronary
artery revascularization procedures. Between 1981 and
1987, there was a 108% increase in the number of CABG
procedures performed there, compared with only a 39%
increase in Canada. The annual population rate of CABG
in the United States is about twice the Canadian rate.2,3,19 In
Canada, economic constraints of an overloaded medical
system have meant a lack of resources and facilities to ac-
commodate all of the patients requiring bypass surgery.
Waiting lists vary in length from 3 to 9 months. In 1980,
the average waiting time for CABG at the Montreal Heart
Institute was 3–4 months, and by 1990 the wait had in-
creased to 9 months.20
In 1991, there were 13 618 CABG procedures per-
formed in Canada, with a mean waiting time to elective
surgery of 21.3 weeks. The longest waiting times occurred
in Quebec, with a mean of 34 weeks.21 Long waiting times
before coronary artery revascularization procedures have
been associated with an increased number of cardiac events,
increased mortality, increased costs and decreased quality
of life.18,22,23 During long waits, patients may experience psy-
chological distress, anxiety and depression.24,25 Such psycho-
logical effects have been found to persist after surgery.26–28
Priority scoring systems have been implemented in some
settings to triage patients to shorter or longer waiting peri-
ods for CABG on the basis of disease severity. However,
these systems have been shown to be poor predictors of
clinical events and outcome.21,29–31 Quality of life is used as an
outcome measure when studying chronic disease states, such
as CAD, and when evaluating treatments that may prolong
life while concurrently increasing morbidity.32–34 CABG may
increase the life span of selected patients with CAD; how-
ever, patients remain ill with progressive chronic atheroscle-
rosis. Symptoms may thus recur even within the first 10
years after surgery.35 The evaluation of quality of life of pa-
tients undergoing CABG is therefore essential.36–39
The rationale behind the present study is based on the
strong evidence that CABG significantly improves the
quality of many patients’ lives by reducing angina and de-
creasing psychological distress. However, this improve-
ment depends on the physical, social and psychological sta-
tus of the patient before surgery, which may deteriorate as
waiting times for CABG increase. We prospectively evalu-
ated the effects of a prolonged waiting time on the quality
of life of patients before and after CABG.
Methods
All patients who were registered to undergo elective CABG at
3 hospitals in Montreal (the Royal Victoria Hospital, the Mon-
treal General Hospital and the Montreal Heart Institute) were eli-
gible for inclusion in the study. Patients were prospectively en-
rolled at the time of their initial evaluation when it was decided
that CABG was indicated by the treating cardiac surgeon (on the
basis of angiogram, symptoms or stress test results). The treating
surgeon described the study to the patient, and study personnel
enrolled the patient after receiving informed consent. Patients
were excluded if the CABG was performed on an emergency basis
(because of unstable angina or myocardial infarction) and the pa-
tient was not on the waiting list; there was a language barrier, or
physical or neuropsychological health problem that prevented ad-
equate comprehension or prevented the interview from being
properly conducted; or the patient had undergone previous angio-
plasty or CABG.
The recruitment period was from November 1993 to Decem-
ber 1994. A total of 280 patients were enrolled; 6 were excluded
before follow-up (4 did not undergo surgery and 2 died during
surgery). Of the 274 remaining patients, 8 were lost to follow-up
before the 6-month postoperative evaluation. This left 266 pa-
tients who completed the study.
Participants were followed from the time they were enrolled
until 6 months after CABG. They were interviewed at the time of
their enrolment, immediately before surgery, 6 weeks after
surgery and 6 months after surgery. One of 3 research assistants
conducted interviews in hospital, at the patients’ homes and over
the telephone.
Sociodemographic data, baseline clinical characteristics and
baseline clinical status of all patients were recorded at the initial
interview. The baseline clinical status was based on medical his-
tory (previous cerebrovascular event or myocardial infarction) and
the presence of comorbid conditions (congestive heart failure, dia-
betes mellitus, chronic obstructive pulmonary disease (COPD),
rheumatologic disease, cancer). The New York Heart Association
angina classification40 was used to evaluate the severity of angina
symptoms by evaluating the patient’s pain, discomfort and limita-
tion of activities. The Cardiac Symptom Inventory39 was used to
measure the frequency of 8 cardiac-related symptoms: fatigue,
pain in the arm or neck, chest heaviness, breathlessness, palpita-
tions, chest pain, edema of the extremities and chest tightness. Pa-
tients were asked to rate the frequency of these symptoms on a 4-
Sampalis et al
430 JAMC • 21 AOÛT 2001; 165 (4)430 JAMC • 21 AOÛT 2001; 165 (4)
point scale. Total scores, out of a possible 24, were standardized
to scores out of 100; higher scores signified a higher frequency of
symptoms. Quality of life was measured with the use of the Med-
ical Outcomes Study 36-item Short Form (SF-36).41–43 This in-
strument measures physical functioning, physical role, vitality,
pain, emotional role, social functioning, mental health and gen-
eral health. It was administered at baseline, immediately before
surgery, 6 weeks after surgery and 6 months after surgery.
We recorded the incidence of the following adverse events be-
fore, and up to 6 months after, CABG: myocardial infarction (deter-
mined by clinical ischemic pain, new appearance of Q waves or left
bundle branch block, elevated creatine kinase [CK] level [to more
than twice the upper limit of normal] or elevated CK-MB fraction);
new unstable angina (determined by decreased threshold and in-
creased intensity, frequency or duration of pain, and by rest pain
with ST-segment elevation, ST-segment depression or T-wave in-
version); hospital admission (admission for any reason; admissions
were subclassified according to relation to CAD); and death (death
from any cause). In addition, we reviewed the patients’ charts to de-
termine the occurrence of postoperative complications (myocardial
infarction, cerebrovascular accident or stroke, or death).
Mean SF-36 scores were calculated for each study period and
for each patient group. The cohort was divided into 2 groups ac-
cording to the number of days’ waiting from enrolment to
surgery. The number of days for each group, corresponding
roughly to 3 months, was determined to allow similar numbers of
patients in each group for comparison of outcomes. Patients with
a short waiting time were those who underwent CABG within
97 days after enrolment; those with a long waiting time under-
went CABG after 97 days. Differences in the mean SF-36 scores
were tested by means of one-way analysis of variance. Differences
in proportions were tested by means of the χ2test.
Results
The sociodemographic characteristics of the 266 pa-
tients included in the study are presented in Table 1. The
majority of the patients in both groups were men (80%),
and the mean age of the participants was 62 years. The
baseline clinical characteristics and severity of cardiac
symptoms were similar for the 2 groups (Table 1). The co-
morbidity at baseline was also similar for the 2 groups.
However, there was a slightly lower prevalence of COPD
and diabetes in the group with a longer waiting time; this
difference was not statistically significant. The frequency of
cerebrovascular events and myocardial infarctions at base-
line was similar for both groups.
The SF-36 scores are given in Table 2. At baseline,
there were no differences in the quality of life between the
2 groups. Immediately before surgery, patients who waited
longer than 97 days for CABG had significantly lower
scores for physical functioning (p= 0.001), vitality (p=
0.010), social functioning (p= 0.030) and general health
(p= 0.001) than the patients with a shorter waiting time. At
6 months after surgery, patients who waited more than
97 days had significantly lower scores for physical function-
ing (p= 0.001), physical role (p= 0.001), vitality (p= 0.001),
mental health (p= 0.001) and general health (p= 0.001)
than patients with a shorter waiting time.
The incidence of adverse events before CABG did not
differ between the 2 groups. There were 13 adverse events
during this period: 6 patients were admitted to hospital be-
cause of cardiac-related illness, and 4 had myocardial in-
farction; 1 patient, in the long-wait group, died while
awaiting surgery.
The incidence of postoperative adverse events did differ
significantly between the groups: 32 occurred in the group
with a long waiting time, as compared with 14 in the group
with a shorter waiting time (p= 0.005). The number of
cerebrovascular accidents in each group was 14 and 6 re-
Impact of waiting for CABG
CMAJ • AUG. 21, 2001; 165 (4) 431
Table 1: Baseline sociodemographic and clinical
characteristics of patients awaiting coronary artery bypass
grafting (CABG) in Montreal, by duration of waiting period
Waiting period;*
no. (and %) of patients†
Characteristic
Short
n = 133 Long
n = 132
Sociodemographic
Mean age (and SD), yr 60 (14) 64 (15)
Sex
Male 109 (82) 103 (78)
Female 24 (18) 29 (22)
Marital status
Married 103 (77) 100 (76)
Single 12 (9) 6 (5)
Divorced 8 (6) 9 (7)
Widowed 10 (8) 17 (13)
Education level
Primary school 30 (23) 30 (23)
High school 20 (15) 18 (14)
College 53 (40) 54 (41)
University 30 (23) 30 (23)
Clinical
Mean CSI score (and SD) 42 (15) 43 (14)
NYHA angina class
I 82 (62) 63 (48)
II 15 (11) 29 (22)
III 28 (21) 31 (23)
IV 5 (4) 6 (5)
Not available 3 (2) 3 (2)
Comorbid condition
Congestive heart failure 15 (11) 18 (14)
Diabetes mellitus 31 (23) 26 (20)
COPD 12 (9) 5 (4)
Rheumatologic disease 8 (6) 6 (5)
Cancer 5 (4) 7 (5)
Medical history
Cerebrovascular event 4 (3) 6 (5)
Myocardial infarction 59 (44) 55 (42)
Note: CSI = Cardiac Symptom Inventory, NYHA = New York Heart Association, COPD =
chronic obstructive pulmonary disease.
*Short = 97 days or less, long = more than 97 days.
†Unless otherwise stated. No statistically significant difference was seen for any variable
between the 2 groups (p > 0.05).
spectively (p= 0.10, p= 0.07 in test for trend), and the num-
ber of myocardial infarctions was 7 and 2 respectively (p=
0.17, p= 0.09 in test for trend).
Among the patients whose employment status was
known, those with a long waiting time before CABG were
less likely than those with a shorter waiting time to be em-
ployed at 6 months after surgery (p= 0.08). At baseline, the
proportion of people working was similar in the long- and
short-wait groups: 35% (19/54) and 36% (20/55) respec-
tively. At 6 months after surgery, 10 (53%) of the 19 patients
with longer waiting times remained employed, as compared
with 17 (85%) of the 20 with shorter waiting times.
Interpretation
The patients’ quality of life, both before and after
surgery, decreased significantly with increasing waiting
times before CABG. The significant decrease in physical
and social functioning and in general health that occurred in
the preoperative period among patients waiting more than
97 days is alarming. This effect is compounded by the fact
that these patients fared significantly worse after surgery
than did the patients with a shorter waiting time. With de-
creased waiting times for CABG, patients’ preoperative
conditions could be maintained at a more optimum level
and hence postoperative morbidity could be decreased.
The increase in the number of postoperative adverse
events, specifcally cerebrovascular accident and myocardial
infarction, with increasing waiting times is also of concern.
These complications can significantly decrease quality of
life and increase mortality. In addition, these postoperative
complications are costly to the health care system.18
One strength of our study was the homogeneity of the
patients: the 2 groups were similar in terms of age, sex,
marital status, clinical characteristics, history of cerebrovas-
cular accident and myocardial infarction, comorbid condi-
tions and baseline quality of life. Another strength was the
low dropout rate; only 14 (4.9%) of the patients did not
complete the study.
Study limitations included an insufficient sample size to
detect a statistically significant increase in the number of
individual adverse events occurring postoperatively in pa-
tients with longer waiting times before CABG. The short
follow-up period did not allow long-term evaluation of ad-
verse events and mortality. Another major limitation was
the age of the data. However, the waiting time for CABG
in Quebec has not shortened since these data were col-
lected, and in some situations it has grown longer.
An important observation in our study is the homogene-
ity of the patient groups with respect to disease severity and
comorbidity. This indicates that these factors were not
considered when the patients were placed on the waiting
list for surgery. In fact, a subsequent analysis of the data in
our study showed that the most significant determinant of
the duration of waiting was the surgeon, followed by the
institution, whereas disease severity and comorbidity were
not significant determinants. This result indicates a lack of
triaging and calls for the implementation of policies that
would standardize the availability of surgical services and
ensure proper queuing of patients with more severe disease.
References
1. Christenson JM, Solimano AJ, Williams J, Connolly B, Monik L, Erb-
Campbell H, et al. The new American Heart Association guidelines for car-
diopulmonary resuscitation and emergency cardiac care: presented by the
Emergency Cardiac Care Subcommittee of the Heart and Stroke Foundation
of Canada. CMAJ 1993;149(5):585-90.
Sampalis et al
432 JAMC • 21 AOÛT 2001; 165 (4)
Competing interests:None declared.
Contributors:John Sampalis and Moishe Liberman were the principal authors, and
their coauthors contributed to the revising of the manuscript. In addition, John
Sampalis was the study coordinator and contributed to the study design and data
analysis; Stella Boukas contributed to the study design, study implementation and
data analysis; Moishe Liberman and Tracey Reid contributed to the data analysis;
and Gilles Dupuis contributed to the study design and study implementation.
Table 2: Qualit
y
of life of
p
atients before and after CABG, b
y
waiting period*
Change from baseline
SF-36 score†
Quality of life
measure; waiting time
Mean SF-36
score at
baseline
Immediately
before CABG
6 mo after
CABG
Physical functioning
Short 21.4 0.0 4.0
Long 21.8 –4.0 –0.1
p value 0.70 0.001 0.001
Physical role
Short 5.2 –0.6 0.8
Long 5.1 –0.5 0.0
p value 0.95 0.85 0.001
Vitality
Short 15.2 –0.1 2.2
Long 14.2 –1.3 0.9
p value 0.89 0.010 0.001
Pain
Short 7.9 1.1 1.8
Long 7.7 0.9 2.0
p value 0.85 0.75 0.50
Emotional role
Short 5.4 –1.4 –0.4
Long 5.4 –1.5 –0.4
p value 0.99 0.85 0.99
Social functioning
Short 8.3 0.4 0.9
Long 7.8 –0.4 1.4
p value 0.35 0.030 0.56
Mental health
Short 24.1 0.6 1.2
Long 23.2 0.0 0.0
p value 0.60 0.15 0.001
General health
Short 17.4 1.1 1.8
Long 17.5 –1.7 –0.3
p value 0.88 0.001 0.001
Note: SF-36 = Medical Outcomes Study 36-item Short Form.41–43
*Quality of life was measured using the SF-36.
†p values represent differences, based on actual SF-36 scores, between patients with short
waits (97 days or less) and those with long waits (more than 97 days).
2. Health, United States, 1988. Hyatsville (MD): National Center for Health Sta-
tistics; 1989. Pub no (PHS) 89-1232.
3. Nair C, Colburn H, Maclean DR, Petrasovits A. Cardiovascular disease in
Canada. Health Rep 1989;1(1).
4. Mortality, summary list of causes. Vital Statistics series. Ottawa: Statistics
Canada; 1988. Cat no 84-209-XPB.
5. 1990 World Health Statistics Annual. Geneva: World Health Organization; 1991.
6. Peters S, Chagani K, Paddon P, Nair C. Coronary artery bypass surgery in
Canada. Health Rep 1990;2(1):9-26.
7. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Ef-
fect of coronary artery bypass graft surgery on survival: overview of 10-year
results from randomized controlled trials by the Coronary Artery Bypass
Graft Trialists Collaboration. Lancet 1994;344:563-70.
8. Moliterno DJ, Elliott JM, Topol EJ. Clinical trials of myocardial revascular-
ization. Curr Probl Cardiol 1995;20:121-92.
9. Guidelines and indications for coronary artery bypass graft surgery. A report
of the American College of Cardiology/American Heart Association Task
Force on Assessment of Diagnostic and Therapeutic Cardiovascular Proce-
dures (Subcommittee on Coronary Artery Bypass Graft Surgery). J Am Coll
Cardiol 1991;17:543-89.
10. Coronary artery surgery study (CASS): a randomized trial of coronary artery
bypass surgery. Quality of life in patients randomly assigned to treatment
groups. Circulation 1983;68:951-60.
11. Anderson RP. Will the real CASS stand up? A review and perspective on the
coronary artery surgery study. J Thorac Cardiovasc Surg 1986;91:698-709.
12. Frye RL, Fisher L, Schaff HV, Gersh BJ, Vlietstra RE, Mock MB. Random-
ized trials in coronary artery bypass surgery. Prog Cardiovasc Dis 1987;30:1-22.
13. Califf RM, Pryor DB, Greenfield JC. Beyond randomized clinical trials: ap-
plying clinical experience in the treatment of patients with coronary artery
disease. Circulation 1986;74:1192-4.
14. Julian DG. The practical implications of the coronary artery surgery trials. Br
Heart J 1985;54:343-50.
15. Katz NM. Expectations of coronary artery surgery. Am Fam Physician 1987;
35:181-94.
16. Landolt CC, Guyton RA. Lessons learned from randomized trials of coronary
bypass surgery: viewpoint of the surgeon. Cardiology 1986;73:212-22.
17. Black N, Langham S, Coshall C, Parker J. Impact of the 1991 NHS reforms
on the availability and use of coronary revascularisation in the UK (1987–
1995). Heart 1996;76(Suppl 4):1-30.
18. Dupuis G, Kennedy E, Perrault J. The hidden cost of delayed bypass surgery.
Clin Invest Med 1990;13:C35.
19. Higginson LAJ, Cairns JA, Smith ER. Rates of cardiac catheterization, coro-
nary angioplasty and coronary artery bypass surgery in Canada (1991). Can J
Cardiol 1994;10:728-32.
20. Causes of death. Vital Statistics series. Ottawa: Statistics Canada; 1988. Cat no
84-208-XPB.
21. Jackson NW, Doogue MP, Elliott JM. Priority points and cardiac events
while waiting for coronary bypass surgery. Heart 1999;81:367-73.
22. Naylor CD, Sykora K, Jaglal SB, Jefferson S. Waiting for coronary artery by-
pass surgery: population-based study of 8517 consecutive patients in Ontario,
Canada. Lancet 1995;346:1605-9.
23. Bryant B, Mayou R. Prediction of outcome after coronary artery surgery. J
Psychosom Res 1989;33:419-27.
24. Horgan D, Davies B, Hunt D, Westlake GW, Mullerworth M. Psychiatric
aspects of coronary artery surgery. Med J Aust 1984;141:587-90.
25. Peduzzi P, Hultgren H, Thomsen J, Detre K. Ten-year effect of medical and
surgical therapy on quality of life: Veterans Administration Cooperative
Study of Coronary Artery Surgery. Am J Cardiol 1987;59:1017-23.
26. Bass C. Psychosocial outcome after coronary artery bypass surgery. Br J Psy-
chiatry 1984;145:526-32.
27. Magni G, Unger HP, Valfre C, Polesel E, Cesari F, Rizzardo R, et al. Psy-
chosocial outcome one year after heart surgery. A prospective study. Arch In-
tern Med 1987;147:473-7.
28. Agnew TM, Whitlock RM, Neutze JM, Kerr AR. Waiting lists for coronary
artery surgery: Can they be better organised? N Z Med J 1994;107:211-5.
29. Seddon ME, French JK, Amos DJ, Ramanathan K, McLaughlin SC, White
HD. Waiting times and prioritization for coronary artery bypass surgery in
New Zealand. Heart 1999;81:586-92.
30. Doogue M, Brett C, Elliott JM. Life and death on the waiting list for coro-
nary bypass surgery. N Z Med J 1997;110:26-30.
31. Troidl H, Spitzer WO, McPeck B, Mulder DS, McKneally MS. Principles and
practice of research strategies for surgical investigators. Berlin: Springer-Verlag;
1986. p. 63-4.
32. Wood-Dauphinee S, Troidl H. Assessing quality of life in surgical studies.
Theor Surg 1989;4:35-44.
33. Margolese RG. The place of psychosocial studies in medicine and surgery. J
Chronic Dis 1987;40:627-8.
34. Varnauskas E. Survival, myocardial infarction, and employment status in a
prospective randomized study of coronary bypass surgery. Circulation 1985;72
(6 Pt 2):V90-101.
35. Scheidt S. Ischemic heart disease: a patient-specific therapeutic approach with
emphasis on quality of life considerations. Am Heart J 1987;114(1 Pt 2):251-7.
36. Kaplan RM. Health-related quality of life in cardiovascular disease. J Consult
Clin Psychol 1988;56:382-92.
37. Wenger NK, Mattson ME, Furberg CD, Elinson J, editors. Assessment of
quality of life in clinical trials of cardiovascular therapies. New York: Le Jacq;
1984. p. 908-14.
38. Fletcher AE, Hunt BM, Bulpitt CJ. Evaluation of quality of life in clinical tri-
als of cardiovascular disease. Br J Clin Pharmacol 1986;21:173S-81S.
39. Frasure-Smith N. The psychological outcomes of coronary bypass surgery. A study of
patient and spouse adjustment during the first post-surgical year. Final report to the
National Health Research and Development Program. Ottawa: National Health
Research and Development Program, Health Canada; 1988. Report no 6605-
2021-44.
40. Criteria Committee of the New York Heart Association. Nomenclature and cri-
teria for the diagnosis of diseases of the heart and great vessels. 9th ed. Boston: Lit-
tle Brown; 1994. p. 253-6.
41. Tarlov AR, Ware JE Jr, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The
Medical Outcomes Study. An application of methods for monitoring the re-
sults of medical care. JAMA 1989;262:925-30.
42. Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health sur-
vey. Reliability and validity in a patient population. Med Care 1988;26:724-35.
43. Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, et al.
Functional status and well-being of patients with chronic conditions. JAMA
1989;262:907-13.
Impact of waiting for CABG
CMAJ • AUG. 21, 2001; 165 (4) 433
Correspondence to: Dr. John Sampalis, Department of Clinical
Epidemiology, Montreal General Hospital, 1650 Cedar Ave.,
Montreal QC H3G 1A4; fax 514 934-8293;
mcsa@musica.mcgill.ca
Nous recherchons
Rédacteur scientifique adjoint
Le JAMC a créé un nouveau poste principal à la rédaction.
En collaborant de près avec le rédacteur, le rédacteur
scientifique adjoint sera chargé avant tout d’améliorer la
qualité des manuscrits scientifiques publiés dans le Journal.
Le candidat idéal aura probablement de solides antécédents
en épidémiologie, de l’expérience de la recherche en
médecine, connaîtra très bien les principes de l’examen
critique par les pairs et aura une vaste connaissance des
tendances cliniques et des enjeux stratégiques qui ont une
incidence sur la pratique de la médecine d’aujourd’hui.
Nous cherchons des candidats qui ont de bonnes techniques
de communication, l’esprit critique, et sont capables
d’écrire avec clarté et humour. L’expérience de la rédaction
serait un atout. Ce poste à plein temps est offert à Ottawa.
Il faut faire parvenir son curriculum vitæ et des échantillons
de textes rédigés et révisés, au plus tard le 30 septembre
2001, à John Hoey, rédacteur, JAMC, 1867, promenade
Alta Vista, Ottawa (ON) K1G 3Y6.
