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Cardiopulm Phys Ther J. 2010 December; 21(4): 5–13.
PMCID: PMC3004758

The Use of Health Related Quality of Life Measurement in Cardiovascular and Pulmonary Physical Therapy Practice: An Exploratory Study

Kristin Lefebvre, PT, PhD, CCS,corresponding author Terri Anderson, DPT, Kim Herbertson, DPT, Aliah Keirsey, DPT, Heather Wnorowski, DPT, and Kerstin M Palombaro, PT, PhD, CAPS

Abstract

Background: The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommends health related quality of life (HRQL) measurement with all cardiovascular and pulmonary patients. The current pattern of use of HRQL measurement among cardiovascular and pulmonary physical therapists is unknown. Objective: The purpose of this study was to evaluate the pattern of use of HRQL measurement among cardiovascular and pulmonary physical therapists. Design: The study used a semi-structured interview format within the context of 3 focus groups. Methods: Eleven physical therapists participated in this study and all were members of the Cardiovascular and Pulmonary Section of the American Physical Therapy Association (APTA). Participants participated in a conference call and were provided a question tree to guide discussion. Results: Several primary themes emerged, including decreased knowledge, barriers, and poor indicators of patient status. In addition, several subthemes developed including lack of familiarity, lack of use, administrative and cost limitations, inappropriateness of tool for patient population, correlation between function and quality of life, and suggestions for future outcome measures. Conclusions: A lack of familiarity and use of HRQL measurement and barriers to their use were established. In addition, ideas for future research on HRQL measurements with specific patient populations in physical therapy practice were defined.

Key Words: health related quality of life, outcomes measurement

INTRODUCTION

Objective measurement of outcomes in the practice of cardiovascular and pulmonary physical therapy is essential for determining response to intervention, treatment effectiveness, and validating reimbursement for therapy services. Although primarily focused towards secondary prevention, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommends outcomes assessment with all patients across cardiac and pulmonary rehabilitation settings. According to the AACVPR, objective outcomes assessment includes evaluation of physiological measures such as cholesterol, lipids, blood pressure and blood glucose levels, lifestyle outcomes such as smoking cessation and nutritional behavior, and measures of health related quality of life (HRQL).1,2

Health related quality of life outcomes measurement involves comprehensive evaluation of variables affecting a patient's perceived disease burden, general health perception, symptoms, functional status, and coping.2 In summary, measurement of HRQL is an evaluation of the impact of disease and treatment on the quality of life of patients.3 Although there are ample valid and reliable HRQL outcomes measures specific to the cardiovascular and pulmonary patient and his or her defined pathologies, lack of guidance, lack of exposure, or partiality to a specific scale often results in health care practitioners struggling with which HRQL outcome measures to use with specific patient populations.46

Even though daunting, measurement of HRQL is imperative for comprehensive evaluation, treatment, and measurement of outcomes of patients with cardiovascular and pulmonary comorbidities. Variables affecting HRQL such as anger, depression, anxiety, social and physical functioning can be significantly elevated in the presence of cardiovascular and pulmonary disease.7,8 In addition, specific cardiovascular procedures, such as percutaneous coronary intervention and ventricular reconstruction, and cardiac pathologies, such as coronary artery disease, cardiac arrest and heart failure, have been significantly linked with decreases in HRQL.915 Appropriate exercise prescription and cardiac and pulmonary rehabilitation have been found to positively influence outcomes in depression, anxiety, and HRQL among individuals with symptomatic cardiovascular or pulmonary disease.1622

Many valid, reliable, and accessible disease-specific measurements of HRQL are found throughout the literature for assessment of outcomes among individuals with cardiovascular and pulmonary disease. Examples of these HRQL measures include the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, Minnesota Living with Heart Failure Questionnaire, Edinburgh Claudication Questionnaire, St. George's Respiratory Questionnaire, and Chronic Respiratory Disease Questionnaire, just to name a few.2228 These measures have been found to be sensitive to change in specific disease populations with regard to HRQL, but their current pattern of use is unknown.

Discussion and evaluation of how therapists approach and use the HRQL measures among cardiovascular and pulmonary patients can be useful to determine both if comprehensive evaluation and treatment is being provided and what barriers might exist to performing HRQL measurement. In addition, it is valuable to assess therapist knowledge of the more disease specific HRQL measurements to determine a need for increased education and awareness. Currently, there is a lack of literature in this area.

The purpose of this study was to describe usage patterns of HRQL measurements specific to the cardiovascular and pulmonary patient and to describe the types of objective measurement of HRQL used by physical therapists working with patients with cardiovascular and pulmonary problems.

METHODS

Research Design

Due to the lack of literature in the area of physical therapist usage patterns and decision-making with respect to HRQL, a qualitative, exploratory study was designed. The study design of semi-structured interviews within the context of a focus group was chosen. Focus groups were selected instead of individual semi-structured interviews in order to create a dialog among the therapists regarding HRQL. A smaller qualitative study was selected in order to gain richer data to help shape a larger objective survey of physical therapists nationwide on our research questions. Using a qualitative study for the initial exploratory study has provided the first step in designing a survey for a national study of cardiopulmonary physical therapists. The methodology for this study was reviewed and approved by the Widener University Institutional Review Board.

Participants

Participants in this study were physical therapist members of the Cardiovascular and Pulmonary Section of the American Physical Therapy Association (APTA). Permission was received from the executive board of this organization to use the Section listserv for recruitment of participants. Once permission was granted, 2 separate study announcements were sent out. Individuals interested in the study were asked to reply via E-mail to the research principal investigator. Once individuals indicated interest in study participation, they were E-mailed with an informed consent form and a list of questions to guide discussion during the focus-group discussions (Figure (Figure11).

Figure 1
Question tree provided to participants prior to interview.

Eleven individuals agreed to participate in the study. Participant confidentiality was secured during the study by assignment of a code name by the principal investigator. The assignment of a code name allowed participants to maintain their anonymity to the rest of the research group and to other participants during the phone call focus-group discussions. Group phone conference calls were then set up in groups of 3 to 4 participants based on individual availability. Group discussion allowed for interaction by the participants and development of themes and ideas. On the day of the conference call, individuals identified themselves by their code name, provided permission to be recorded, and were subsequently assigned numbers to identify themselves throughout the conversation.

All participants in the study identified themselves as members of the Cardiovascular and Pulmonary Section of the APTA. The participants in this study represent diverse treatment areas. Although many of the participants identified more than one practice area, of the 11 participants in this study, 2 identified a primary practice area of academics, 3 acute care, one home health, one outpatient cardiac rehabilitation, one outpatient pulmonary rehabilitation, one inpatient cardiac rehabilitation, one subacute care, and one long term acute care (LTACH). Ten of the 11 participants reported that they currently work with cardiovascular and pulmonary patients on a regular basis, with the other participant having extensive practice with this population throughout the course of her career. The level of experience measured in number of years among the participants varied from 5 to 33 years with a mean length of practice of 15.8 years. In addition, 9 of 11 participants identified themselves as board certified cardiovascular and pulmonary clinical specialists (CCS), 3 participants were male and 9 were female.

Data Collection

Focus group discussion was conducted via semi-structured interviews to allow the participants to express what they did in practice and how they interpreted their decisions and actions.31 Three semi-structured focus group discussions were completed via conference call. These conference calls consisted of focus groups with individuals who identified themselves as cardiopulmonary physical therapists. The first 2 calls included 4 participants and the final call consisted of 3 participants. The researcher leading the call was always located within the academic office of the research advisor using a speaker phone and hand-held recording device to record data. All members of the research team were present to listen during the interview process. The role of lead interviewer was alternated among the team members with each call.

Calls lasted approximately 45 minutes to 1 hour in length. All calls were completed at 7:00 AM during the work week. Interviews were guided by the question tree (see Figure Figure1).1). Once initial demographic data were gathered, questions were administered to the group. Although initial questions were yes/no in nature, participants were asked to explain or expand upon their answers on subsequent open ended questions. All participants were asked to state their number before talking in order to help facilitate transcription. Open discussion occurred between all participants and researchers throughout the call. Saturation was reached after the third conference call and no further focus groups were conducted.

Data Analysis

Each interview was initially transcribed by one member of the research group into a Microsoft Word document. Transcribed interviews were sent to the participants via email by the principal investigator to ensure the accuracy of the information. No discrepancies were identified by any of the participants in the 3 focus groups. Five copies of each interview were created for data analysis and coding by the research group.

Thematic analysis of the surveys was performed. Each interview was coded by each of the 5 individual researchers. Researchers were asked to highlight major statements made by the participants and to designate different categories, hypotheses, or ideas with different colors. Any specific statement noted at least 3 times either within one interview or within all 3 interviews was recorded as a possible theme or subtheme. After each individual researcher coded the interviews, all researchers gathered to discuss the major themes. Themes were then analyzed for consistency and were noted by the researchers.

RESULTS

The results of this study answer our research questions on usage and knowledge of HRQL measures in cardiovascular and pulmonary physical therapy practice. According to data collected during this study, there is distinct decreased knowledge and therefore decreased usage of HRQL measures specific to the cardiovascular and pulmonary patient. When HRQL is being used by therapists, therapists are most often deferring to more general HRQL, such as the short form – 36 (SF-36). Reasons for this decision will be considered in the discussion.

Three primary themes emerged from the data based on participant discussion. The primary themes include— “decreased knowledge,” “barriers,” and “poor indicators of patient status.” These themes address the current use, usefulness, and barriers to use of HRQL outcome measures among physical therapists treating the cardiovascular and pulmonary patient population. Each primary theme also contained several subthemes. The first theme, “decreased knowledge,” was composed of 2 subthemes: “lack of familiarity” and “lack of use.” The second theme “barriers” consisted of two subthemes: “administrative and cost limitations,” and “inappropriateness of tool for patient population.” The final theme “poor indicators of patient status” was divided into the subthemes of “correlation between function and quality of life,” and “suggestions for future outcome measures.”

Primary Theme #1 Decreased Knowledge

A recurring theme throughout the interviews was a general decreased level of familiarity and overall lack of use of the valid and reliable HRQL outcome measures specific to patients with cardiovascular and pulmonary disease, as compared with more general outcome measures. Regardless of years of experience and current area of practice, participants in the study more often used the generic outcome measures such as the SF-36, compared to cardiovascular and pulmonary disease-specific measures. Several participants also commented on using HRQL measures in research, but did not carry over their use to clinical practice. In addition, participants often indicated several outcome measures with which they were familiar with in title but had never administered for various reasons.

Subtheme: Lack of Familiarity

In response to the question, “Are you familiar with cardiopulmonary specific QOL measures?”, the pattern in discussion among participants in this study was a familiarity with the names of one to 3 HRQL outcome measures for specific use with the cardiovascular and pulmonary patient.

“I'm familiar vaguely with Minnesota, and the Kansas City.”

“I'm familiar with the Minnesota Living with Heart Failure Questionnaire, the CRQ Chronic Respiratory Questionnaire, and the St. Georges Respiratory or Living with COPD. I guess I'm familiar with what it asks but I don't remember the name of it.”

In general however, there was a noted pattern of increased familiarity of broad outcome measurement tools. Participants provided the Duke Activity Index, Short Form – 36 (SF-36), Six Minute Walk Test, the Functional Independence Measure (FIM) or Sickness Impact Profile as examples of HRQL outcome measurements that they were either familiar with or used in current practice. However, these tools were either not measures of HRQL or not specific to the cardiovascular and pulmonary patient.

“I'm familiar with the Sickness Impact Profile, the SF-36, the FIM, and the Six Minute Walk Test if you use that as an outcome.”

“The SF-36 is probably the one I can think of right now.”

“As far as the ones I'm aware of are the Kansas City Heart Failure Questionnaire, …Minnesota Heart Failure Questionnaire. In terms of pulmonary ones and outpatient I know there is the McGill there.”

Finally, although 2 separate participants reported using the Kansas City Cardiomyopathy Questionnaire with their patients, each reported the incorrect name of the outcome measure, which may indicate a decreased familiarity with the measure overall.

“We looked at a couple to use with our heart failure group and there was Minnesota Heart Failure Questionnaire and Kansas City Shortness of Breath Questionnaire which again are disease specific and we use the Kansas City with those specific patient types.”

“The SF-36, the CRQ which has been mentioned…I've played around with…Kansas City Shortness of Breath Questionnaire as well as the University of California San Diego Dyspnea Survey which I've played around with but I'm not really familiar with but I know they exist.”

Subtheme: Lack of Use in Clinical Practice

Several participants voiced using HRQL in research settings to quantify changes or progress with the patient populations being examined.

“I recently used the CFQ in…a clinical research project.”

“I've only really used the SF-36 in research settings and the CFQ in research settings.”

Yet, there was a clear lack of use in clinical practice with an additional inability to pinpoint an exact reason for why these measures are not currently being used.

“On the inpatient side, we are not using any health related quality of life measures…I have no good reasons to give you.”

“We do not do any quality of life assessments right now in our heart failure crowd…but we probably should.”

“It may be different depending whether you're in pulmonary rehab or cardiac rehab, but our inpatients get nothing.”

For those participants using outcome measurement in their practice, many participants deferred to the use of the SF-36, even in the presence of knowledge of the outcome measures more specific to the cardiovascular and pulmonary patient. In response to the question, “Are you currently using any quality of life measures in your practice?”, 9 of the 11 participants indicated that the SF-36 was an outcome measure currently being used.

“I use the SF-36 continuously.”

“We're using the SF-36.”

Participants described their decreased use of HRQL tools as a reflection of the available outcome measures. There was decreased confidence expressed in the current available measures and an inability to connect the currently available tools to their patient populations.

“I think that we just, as a profession, we haven't found really good [measures], especially for the cardiovascular and respiratory population.”

“I haven't found a measure that has really a direct relevance to what I am doing. To check for general the CFQ helps but it's so broad it doesn't cover the things I am doing with a patient.”

In addition, participants referred to a decreased exposure to objective measurement of quality of life during their education process.

“One of the problems is multiple people that teach cardio may not be familiar with some specialized tools and so they don't teach a lot of this stuff… an idea would be to develop a PowerPoint for educators for quality of life measures in cardio and pulmonary so the student will come out with the information and if you have a tool that was easier to use…that would also be good.”

A participant and current professor of physical therapy admitted to encouraging the use of outcome measures to her students, but failed to express teaching HRQOL measurement as an objective measurement for use with the cardiovascular and pulmonary patient.

“To advance the care we are giving, I'm strongly advocating the use of outcome measures…we started to use the 6 minute walk test more on some patients for objective measures, so anything that would be more [specific] to evaluate our patients, we would use that more.”

Others agree with the idea of educating physical therapy students on outcome measures so that they graduate with the knowledge and spread awareness in this way. A current educator made the following comment in response to how to educate currently practicing physical therapists about cardiopulmonary objective measures since they have already graduated from a PT program,

“There is a large amount of people in the acute care setting. If you look at the distribution of cardiac specialists, they tend to be in education or the acute care setting…Maybe focusing efforts into the acute care setting rather than the cardiopulmonary specialist that may already be familiar with it. To help spread the word.”

The participants in the study reported a low awareness of currently available outcome measures. In addition, they reflected concern that there were more effective ways to make this information accessible to physical therapists in order to optimize treatment of patients and provide better ways to measure progress.

Primary Theme #2 Barriers

Participants in the study collectively reported 3 categories of barriers to disease-specific HRQL outcome measurement that could possibly contribute to the lack of use and/or knowledge: administrative and cost limitations, inappropriateness of the tool to the patient population, and failure of outcome measures to consider a patient's environment. Participants expressed that even if they wanted to measure HRQL with their patients, these specific variables might be interfering with their ability to do so.

Subtheme: Administrative and Cost Limitations

Several participants spoke of administrative and cost limitations related to the use of HRQL measurement with their patients. Participants spoke to the fact that certain facilities require approval of outcome measures through their administration. In addition, many facilities are part of a health care network in which consistency of outcome measurement and approval of their use across settings becomes a concern. Time constraints were also repeatedly suggested as a primary limitation. In summary, because organizations may control what resources their employees are allowed to access at work or the time they have to work individually with each patient, the HRQL measures specific to the cardiovascular and pulmonary patient may not be used.

“We have some of the same barrier of being part of a larger group of hospitals and needing consistency across.”

“I would say that presently because we have an outside contractor who does our outcomes and that is part of the reason it comes down to cost.”

In addition to the administrative and cost barriers, several participants alluded to time being a limiting factor. The participants spoke to the idea that sometimes the HRQL outcome measures are too time consuming, especially in a setting such as acute care where many cardiovascular and pulmonary patients are seen in phase I cardiac rehabilitation or during an exacerbation of their illness.

“The time to complete them is definitely a barrier in the kind of setting that I usually have about 10 minutes maybe 15 minutes to see the patients when they come to their multiple discipline visits.”

“There is also a time issue with some of these if I am going to be evaluating on a full functional evaluation. I find it difficult to do in the time I have allotted.”

Some participants reflected on the idea that a tool of greater ease and less cost to measure HRQL may be valuable to the clinician with time constraints. In addition such a tool could provide therapists with a method to measure disease specific HRQL outcomes and quantify quality of care in an efficient manner. A tool of greater ease to use and less cost to implement and use may also address some of the administrative barriers spoken to by participants. As one participant reflected,

“If there was an efficient quality of life measure that was easily applicable, absolutely I would make an effort to assess appropriateness in the use in the environment…we are trying to use any objective measure to assess the status that we can.”

Subtheme: Inappropriateness of Tool to the Patient Population

Another subtheme under barriers was that measuring disease-specific HRQL outcomes may not be possible due to length of stay and acuity of the patients. In the acute care environment, for example, length of stay is often shorter than one week. In addition, participants noted that the extensive question lists associated with disease specific HRQL measurement often have questions that are too difficult for acutely ill or disoriented patients to comprehend in a timely manner. A patient's ability to provide accurate information through self report may be influenced by cognitive status, or by the medications that are administered as a result of his or her medical condition.

Initially, many participants reflected on the shortened time frame with which they had to work with patients in their work settings. Many of the therapists working in the acute care setting commented on the fact that length of stay inhibited use of the HRQL measurement. The HRQL outcome measures did not allow for evaluation of progress or measurement of change due to the narrow timeframe associated with the acute care stay or across some other environments where a firm start and stop point of therapy does not exist. As participants stated,

“We need to look at a narrower time frame.”

“We don't really have a good firm start and finish with patients.”

“There is also a time issue with some of these…I find it difficult to do in the time I have allotted for and I know that a lot of these necessarily haven't been evaluated in an acute setting in the short time in which we see them.”

Subsequently, participants in the study voiced concern about the ability of the tool to measure appropriate HRQL outcomes based on the subjective response of the patient. Many participants reflected that outcome measures did not provide accurate information regarding a patient's quality of life if it is not administered correctly or if a patient is unable to contribute accurate information.

“Some of them are just very ill and to read a question and come up with a relevant coherent, you know, valid response…I think that's a significant barrier.”

“I just trust the 6 minute walk test more than I trust the subjective responses on this multiple choice questionnaire.”

“What I find with questionnaires is that patients are not filling them out correctly regardless of how much we instruct them and also when they do fill it out correctly, I don't find it incredibly accurate all of the time.”

As indicated by participants, the limitations of length of stay and patient acuity across various environments, particularly the acute care environment, are of concern when considering whether or not to use disease specific HRQL outcomes measurement.

Primary Theme #3 Poor Indicators of Patient Status

Although all of the measures mentioned by participants in this study have been found to have high reliability and validity in the literature, participants often spoke to their lack of confidence in the HRQL outcome measure's ability to quantify meaningful change. Several participants mentioned that the transcripts provided in the HRQL outcomes measures are not necessarily good indicators of patient status and voiced the concern that function within the patient's environment and HRQL may not be directly correlated and therefore difficult to predict.

Subtheme: Correlation Between Function and Quality of Life

Several participants expressed concern that HRQL was not the best measure of patient progress.

“Your goals are individualized [for the patient] and so your outcomes and things that would affect that particular patient's quality of life tend to be pretty individualized…so it's hard to capture on a tool.”

The groups felt that quantifiable progress was difficult to portray through the use of HRQL outcome measures. Another participant elaborated,

“There are very nonlinear relationships between function and quality of life and we sometimes expect linear relationships…you can have at some level of physiological function a 25 to 30% change but no difference in the person's ability to work in their environment.”

Despite evidence to the contrary, this therapist's perception was that function and quality of life may be related in a nonlinear way or there may be no apparent relationship. Another participant also voiced concern that improvement in function would not always translate into an improvement in quality of life.

“When I see somebody doubling, tripling their 6 minute walk test distance and not seeing nearly the same increase in their quality of life…I would like to think there would be something that looks not necessarily onetoone but as one goes up, the other should go up somewhat.”

In response, a different participant clarified,

“When you double [a patient's distance on] the 6 minute walk test, I guess where it's doubled has an influence…if it's doubled from 200 feet to 400 feet, that is different than doubling it from 400 to 800 feet or from 800 to 1600 feet…From 200 to 400 feet you may not actually see any change at all or you may see a big change in function in certain functional domains …but you might see big changes in others…if you went from 800 to 1600 feet, you might not see any difference at all if you were asking questions about ADLs because the ADLs were being met easily at the 800 feet.”

Based on the variability in function among patients, participants overall were concerned that HRQL measures did not correctly detect and indicate a patient's actual quality of life within his or her own environment. Participants in this study found this perception to be a deterrent to the use of outcome measures in the cardiovascular and pulmonary physical therapy setting.

Subtheme: Suggestions for Future Outcome Measures

Several participants suggested that current HRQL outcome measures failed to capture a patient's self-perceived quality of life by being too lengthy, inappropriate given patient acuity, and by not taking environment into consideration. These concerns provide an opportunity for innovation in the area of HRQL outcome measurement in cardiopulmonary and pulmonary physical therapy practice. Participants indicated the need for tools that would be useful in their own settings, which current HRQL outcome measures do not satisfy.

“I would prefer or love something that is efficient or valid in the acute care setting to teach the students.”

Another participant reflected on the fact that we lack a tool that addresses both depression and decreased function, two consistent problems related to cardiovascular and pulmonary disease and surgical intervention. One participant was interested in the development of another HRQL outcome measure to address the depression and decreased function that could be related to HRQL,

“I think one of the biggest problems is depression and the only tool we have is the BDI [Beck Depression Inventory] and I would like a tool to pick more up on depression. The ones we've used don't really specifically address that. So instead of using two, the SF-36 and the BDI, we would like to have one that did that…there is some redundancy with the SF-36 and BDI so patients get frustrated with those.”

As depression is frequently an issue present with cardiovascular and pulmonary patients, a tool to measure depression in the physical therapy setting could be very useful, as well as any tool that measures a patient's report of his or her own quality of life during a shorter time frame of treatment. A participant expressed,

“In an ideal world, I would like an outcome measure that somehow captures a patient's understanding of how their quality of life may have changed in this setting…and how in this short time that the patient actually feels that their quality of life has been impacted.”

In summary, several themes emerged from discussion with the focus groups that can guide future research. First, there was a clear and evident lack of use and understanding of the available HRQL measures for cardiovascular and pulmonary physical therapy practice. In addition, several barriers to the use of these tools emerged in the discussions, including time, administrative and cost barriers emerged. Within these barriers, acuity of certain patient populations and their ability to adequately complete the HRQL was of concern. A concern about the ability of HRQL to both measure depression and correlate function and quality of life was considered. Finally, ideas for future research in this area were discussed by participants.

DISCUSSION

According to the literature, disease-specific assessment of HRQL is generally used in the research setting, with less overall use seen in general practice.29,30 Due to a lack of literature regarding the use of HRQL in the clinical setting, an exploratory study was conducted. Semi-structured interviews within the context of focus groups were performed to create a dialog regarding usage patterns and decision making with respect to HRQL. This study of cardiovascular and pulmonary physical therapists supports the decreased use of disease-specific, yet reliable and valid measurement in practice. In general, cardiovascular and pulmonary physical therapists assess general HRQL with use of generic outcomes measures, such as the SF-36, but lack knowledge and familiarity with specific cardiopulmonary measures. The majority were using nonspecific measures with their cardiopulmonary patients. It is important to note that a few of the practitioners were using specific measures within their patient populations and within their research. These individuals, however, found many barriers to use of the measures in a clinical environment. The results of this exploratory study point to the need for a larger objective survey of cardiopulmonary physical therapists. Responses to the semi-structured interviews will be used to shape the survey questions.

The purpose of this study was to evaluate usage patterns and types of HRQL being used by cardiovascular and pulmonary physical therapists. The main findings of these focus groups were a decreased knowledge and use of these tools. Barriers noted include administrative and cost limitations, acuity of the patient, time with the patient, and failure of the measure to consider a patient's environment. Currently available disease-specific cardiovascular and pulmonary HRQL measures have known limitations including cost, access, length, and ability for use with acutely ill patients in the acute care environment. The cost of a tool depends on the tool's creator. Some tools are open to public use while others require a fee for copyright privileges. If the fee is high, it may impact a practitioner's choice to use the tool in practice. Patients may also be limited in their ability to complete HRQL measures due to literacy or cognitive disabilities. As with any setting and any patient population, it is important to mention the possibility for inaccuracy and decreased credibility of the patient's responses when completing the questionnaires. There could be a potential bias in patient outcomes regarding quality of life when patients are provided assistance to complete the tools. Barriers could be addressed through clinician education regarding available tools, or design of a tool that would consider the barriers of time and cost. The tool would need to be able to measure change, but be able to be completed in a short amount of time. Finally, according to our participants, in order to make such a tool valuable to multiple patient populations it would be necessary to take into account differences within the home environment. Reflection led to a consensus of lack of confidence in the HRQL tool's ability to measure effective change in quality of life because the patient's home environment was not taken into account.

In addition, with regard to lack of use, several participants discussed the idea of context within the assessment of HRQL. In this case, it would be necessary to have tools that measured patients within their own environments in order to get an accurate measurement of HRQL. Therapists might be more inclined to use a measurement tool that would allow for measureable change in the home environment for example, to date, this type of measurement of HRQL does not exist and would need to be created and validated.

Several therapists suggested that cardiopulmonary measures were not suitable for the acute care population. The participants also noted cognition of an acute care patient as a limitation in completing the quality of life measure. A tool that fit the average stay for the acute care patient would allow for a pre and post measure to be conducted in order to track any progress made by the patient while in the hospital. This would also allow for the clinician to recognize the patients' biggest limitations and address these specifically while in the acute care environment.

A domain that may need to be expanded upon or in some instances added to the available tools is depression and the effect of depression on a patient's function and quality of life. As one participant stated, “the research has shown that cardiovascular and pulmonary disease is closely correlated with depression.” Assessing the mental health of this patient population may be necessary in determining appropriate treatment approaches. By incorporating mental health with functional mobility and HRQL many of the group participants felt that they may be able to more accurately assess patients' limiting factors and in turn determine what is primarily affecting the outcomes.

Although attempts were made to recruit a larger number of participants in this study, only 11 committed to participation. Valuable information was gathered from this group, but the small sample size does not allow for generalizing this data to all cardiovascular and pulmonary physical therapists' practice. In addition, many different areas of cardiovascular and pulmonary practice were represented. Although this provided us with a snapshot of HRQL measurement across various practice areas, it would be valuable to examine larger numbers of participants in specific practice areas in order to make generalizations about cardiovascular and pulmonary physical therapist practice. To this end, the thematic analysis has provided us direction to perform a larger survey of physical therapists that will explore the generalizability of these themes nationwide as well as in different practice settings.

There may be many areas in which to expand this research in order to more accurately provide a disease specific outcome measure applicable to some areas of physical therapy practice. One main area that provided the underlying theme for future research is the need for development and validation of an HRQL outcome measure that includes depression, function, environment, and quality of life. Further investigation is needed in order to determine more specific administrative barriers, how common these barriers actually are, and how they are limiting the use of outcome measures throughout multiple physical therapy practice settings. It may be of value to determine if educational sessions on HRQL measures specific to the cardiovascular and pulmonary patient would increase use and carryover in practice. This could be evaluated either qualitatively or quantitatively with a period of follow up to see if carryover continued over a designated period of time. Finally, there is a clear need to perform a larger survey of physical therapists nationwide who work in a variety of practice settings to determine if the themes remain consistent in a larger sample.

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