title: Patient-Provider Communication and Health Outcomes Among Individuals With Atherosclerotic Cardiovascular Disease in the United States: Medical Expenditure Panel Survey 2010 to 2013.
abstract: Consumer-reported patient-provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative US adult population with established atherosclerotic cardiovascular disease.
  
  
  
  The study population consisted of a nationally representative sample of 6810 individuals (aged ≥18 years), representing 18.3 million adults with established atherosclerotic cardiovascular disease (self-reported or International Classification of Diseases, Ninth Edition diagnosis) reporting a usual source of care in the 2010 to 2013 pooled Medical Expenditure Panel Survey cohort. Participants responded to questions from Consumer Assessment of Health Plans Survey that assessed PPC, and we developed a weighted PPC composite score using their responses, categorized as 1 (poor), 2 (average), and 3 (optimal). Outcomes of interest were (1) patient-reported outcomes: 12-item Short Form physical/mental health status, (2) quality of care measures: statin and ASA use, (3) healthcare resource utilization: emergency room visits and hospital stays, and (4) total annual and out-of-pocket healthcare expenditures. Atherosclerotic cardiovascular disease patients reporting poor versus optimal were over 2-fold more likely to report poor outcomes; 52% and 26% more likely to report that they are not on statin and aspirin, respectively, had a significantly greater utilization of health resources (odds ratio≥2 emergency room visit, 1.41 [95% confidence interval, 1.09-1.81]; odds ratio≥2 hospitalization, 1.36 [95% confidence interval, 1.04-1.79]), as well as an estimated $1243 ($127-$2359) higher annual healthcare expenditure.
  
  
  
  This study reveals a strong relationship between PPC and patient-reported outcomes, utilization of evidence-based therapies, healthcare resource utilization, and expenditures among those with established atherosclerotic cardiovascular disease.
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Victor
authors.initials: V
authors.lastname: Okunrintemi
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Erica S
authors.initials: ES
authors.lastname: Spatz
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Paul
authors.initials: P
authors.lastname: Di Capua
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Salami
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Javier
authors.initials: J
authors.lastname: Valero-Elizondo
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Haider
authors.initials: H
authors.lastname: Warraich
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Salim S
authors.initials: SS
authors.lastname: Virani
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Adeel A
authors.initials: AA
authors.lastname: Butt
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: William B
authors.initials: WB
authors.lastname: Borden
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Kumar
authors.initials: K
authors.lastname: Dharmarajan
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Henry
authors.initials: H
authors.lastname: Ting
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.).
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
authors.affiliation: From the Center for Healthcare Advancement and Outcomes (V.O., J.A.S., J.V.-E., K.N.) and Miami Cardiac and Vascular Institute (K.N.), Baptist Health South Florida, Miami; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (E.S.S., K.D., H.M.K.); Section of Cardiovascular Medicine, Yale University, New Haven, CT (E.S.S.); Department of Internal Medicine, Baptist Health Medical Group, Miami, FL (P.D.C.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work (K.N.) and Department of Medicine, Herbert Wertheim College of Medicine (K.N.), Florida International University, Miami; Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (H.W.); Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.); Baylor College of Medicine, Houston, TX (S.S.V.); Brigham and Women's Hospital, Boston, MA (R.B.); Department of Medicine, Hamad General Hospital, Doha, Qatar (A.A.B.); Healthcare Delivery Transformation, George Washington University, DC (W.B.B.); New York-Presbyterian/Columbia University Medical Center (H.T.); and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD (M.J.B., K.N.). KhurramN@baptisthealth.net.
authors.forename: Khurram
authors.initials: K
authors.lastname: Nasir
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D050197:Atherosclerosis / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology / Q000628:therapy*; D003142:Communication; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs; D019538:Health Care Surveys; D005102:Health Expenditures; D006304:Health Status; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D007902:Length of Stay; D008297:Male; D008603:Mental Health; D008875:Middle Aged; D016017:Odds Ratio; D000071066:Patient Reported Outcome Measures; D018802:Patient-Centered Care; D010817:Physician-Patient Relations; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin
keywords: American Heart Association; adult; cardiovascular diseases; health status; patient-centered care