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Quality of life among patients with atrial fibrillation: A theoretically-guided cross-sectional study

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Title: Quality of life among patients with atrial fibrillation: A theoretically-guided cross-sectional study
Authors: Kathy L. Rush, Cherisse L. Seaton, Lindsay Burton, Peter Loewen, Brian P. O’Connor, Lana Moroz, Kendra Corman, Mindy A. Smith, Jason G. Andrade
Source: PLoS ONE, Vol 18, Iss 10 (2023)
Publisher Information: Public Library of Science (PLoS), 2023.
Publication Year: 2023
Collection: LCC:Medicine
LCC:Science
Subject Terms: Medicine, Science
Document Type: article
File Description: electronic resource
Language: English
ISSN: 1932-6203
Relation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10553272/?tool=EBI; https://doaj.org/toc/1932-6203
Access URL: https://doaj.org/article/d24403782c3c4765bf730247d507c192
Accession Number: edsdoj.24403782c3c4765bf730247d507c192
Database: Directory of Open Access Journals
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  Value: <anid>AN0172825726;[78be]05oct.23;2023Oct09.06:47;v2.2.500</anid> <title id="AN0172825726-1">Quality of life among patients with atrial fibrillation: A theoretically-guided cross-sectional study </title> <sbt id="AN0172825726-2">Introduction</sbt> <p>Background: Patients with atrial fibrillation (AF) have significantly lower health-related quality of life (HRQoL) compared to the general population and patients with other heart diseases. The research emphasis on the influence of AF symptoms on HRQoL overshadows the role of individual characteristics. To address this gap, this study's purpose was to test an incremental predictive model for AF-related HRQoL following an adapted HRQoL conceptual model that incorporates both symptoms and individual characteristics. Methods: Patients attending an AF specialty clinic were invited to complete an online survey. Hierarchical regression analyses were conducted to examine whether individual characteristics (overall mental health, perceived stress, sex, age, AF knowledge, household and recreational physical activity) incremented prediction of HRQoL and AF treatment satisfaction beyond AF symptom recency and overall health. Results: Of 196 participants (mean age 65.3 years), 63% were male and 90% were Caucasian. Most reported 'excellent' or 'good' overall and mental health, had high overall AF knowledge scores, had low perceived stress scores, and had high household and recreation physical activity. The mean overall AF Effect On Quality-Of-Life Questionnaire (AFEQT) and AF treatment satisfaction scores were 70.62 and 73.84, respectively. Recency of AF symptoms and overall health accounted for 29.6% of the variance in overall HRQoL and 20.2% of the variance in AF treatment satisfaction. Individual characteristics explained an additional 13.6% of the variance in overall HRQoL and 7.6% of the variance in AF treatment satisfaction. Perceived stress and household physical activity were the largest contributors to overall HRQoL, whereas age and AF knowledge made significant contributions to AF treatment satisfaction. Conclusions: Along with AF symptoms and overall health, individual characteristics are important predictors of HRQoL and AF treatment satisfaction in AF patients. In particular, perceived stress and household physical activity could further be targeted as potential areas to improve HRQoL.</p> <p>Atrial fibrillation (AF) is a cardiac arrhythmia affecting 3% of the population worldwide [[<reflink idref="bib1" id="ref1">1</reflink>]], and frequently impairs patients' quality of life [[<reflink idref="bib2" id="ref2">2</reflink>]]. Compared to the general population and patients with other heart diseases (e.g., coronary heart disease), patients with AF have significantly lower health-related quality of life (HRQoL) [[<reflink idref="bib3" id="ref3">3</reflink>]–[<reflink idref="bib5" id="ref4">5</reflink>]]. Efforts to assist patients in managing AF, requires understanding of the aspects of their illness that present the greatest challenges and opportunities to improve their HRQoL, including their general health and well-being, treatment concerns, and satisfaction with their AF treatment.</p> <p>A wealth of research has established that AF symptoms are related to HRQoL among patients with AF [[<reflink idref="bib6" id="ref5">6</reflink>]]. Emphasis on the influence of AF symptoms on HRQoL has not often included the role of individual characteristics such as demographic, psychological, and behavioral attributes of patients. Yet these characteristics have factored prominently in established conceptual models of HRQoL [[<reflink idref="bib7" id="ref6">7</reflink>]]. Recent empirical evidence has begun to show the contribution of these individual characteristics to HRQoL in patients with AF. For example, anxiety has been found to be one of the factors most consistently associated with HRQoL [[<reflink idref="bib6" id="ref7">6</reflink>]].</p> <p>Despite this beginning work, there remain a number of under-explored individual characteristics that have been linked to HRQoL in patients with AF, including perceived stress, physical activity/exercise, and AF knowledge. For example, research has reported that perceived stress contributes to mental health and anxiety among patients with AF [[<reflink idref="bib9" id="ref8">9</reflink>]] and perceived stress in conjunction with AF symptoms can be a primary trigger or cause of AF symptom episodes and influence HRQoL [[<reflink idref="bib10" id="ref9">10</reflink>]–[<reflink idref="bib13" id="ref10">13</reflink>]]. Additionally, physical activity/exercise has been suggested to play a role in reducing AF burden and improving AF-related symptoms and QoL [[<reflink idref="bib14" id="ref11">14</reflink>]]. Indeed, following cardioversion, exercise was positively related to QoL among patients with AF that returned to and maintained sinus rhythm [[<reflink idref="bib16" id="ref12">16</reflink>]]. Increasing patients' AF knowledge may be an effective means of promoting symptom management and potentially improving HRQoL [[<reflink idref="bib17" id="ref13">17</reflink>]]. Not only have these relevant characteristics been under-studied but also the extent of their contributions relative to symptoms remains unknown. Therefore, the purpose of this study was to examine the extent to which individual characteristics (age, sex, mental health, stress, AF knowledge, and physical activity) contribute to AF HRQoL and treatment satisfaction while controlling for AF symptoms and overall health.</p> <hd id="AN0172825726-3">Material and methods</hd> <p></p> <hd id="AN0172825726-4">Study design and setting</hd> <p>We used a cross-sectional design that was guided by an expansion of Ferrans et al.'s [[<reflink idref="bib8" id="ref14">8</reflink>]] revised version of Wilson and Cleary's HRQoL model [[<reflink idref="bib7" id="ref15">7</reflink>]]. This involved including individual characteristics of AF patients based on current evidence [[<reflink idref="bib6" id="ref16">6</reflink>]]. The model is displayed in Fig 1. The study was carried out in collaboration with a specialized AF clinic in an urban Western Canada area. Upon referral, the clinic provided integrated AF specialty care including acute interventions, education, disease management, and advanced treatments (e.g., ablation). The multi-disciplinary AF care team included cardiologists, electrophysiologists, nurse practitioners, pharmacists, and registered nurses. Since the onset of the COVID-19 pandemic clinic appointments have primarily been conducted remotely by telephone. University Behavioural Research Ethics Board approval was obtained [REB # anonymous for review]. The conduct and reporting of the study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for reporting cross-sectional studies [[<reflink idref="bib18" id="ref17">18</reflink>]].</p> <p>Graph: Fig 1 Theoretical model for prediction of Quality-of-Life measures based on patient characteristics.Note: model adapted from Ferrans et al. [[<reflink idref="bib8" id="ref18">8</reflink>]] model based on Wilson and Clearly [[<reflink idref="bib7" id="ref19">7</reflink>]].</p> <hd id="AN0172825726-5">Sample and recruitment</hd> <p>All patients of the clinic with an AF diagnosis who were over 18 years and could complete an online survey or had a family member who could assist, were eligible to participate. The clinic's booking clerk sent a letter detailing the research study (by mail or email) to all patients with upcoming appointments during the recruitment period. The letter informed patients of the ongoing study and to expect a telephone initiation from a research team member regarding their eligibility and interest in the study. Patient contact information was then shared with the research team using secure file transfer. Subsequently a research assistant (a physician or a licensed practical nurse) who had no prior relationship with participants contacted patients by telephone. Recruitment began in November 2020 and continued for one year until a sample size of approximately 200 was achieved. A post hoc power analysis assuming a medium effect size estimated required sample size for modelling to be 114, indicating appropriate sample size had been achieved for analyses [[<reflink idref="bib19" id="ref20">19</reflink>]].</p> <hd id="AN0172825726-6">Data collection</hd> <p>Study data were collected using an online survey hosted on Qualtrics (Qualtrics, Provo, UT). Prior to taking the survey, all participants gave electronic consent. Participants who finished the survey were eligible for a chance to win one of three $150 gift certificates through a random draw. Clinical participant data were obtained via clinician referral letters as part of another project [[<reflink idref="bib20" id="ref21">20</reflink>]]. Clinical patient history data included treatment history, chronic disease history, number of chronic conditions, medication, and cardiac risk factors. Type of AF (paroxysmal, persistent, permanent), and reason for referral (e.g., ablation consultation), were also included if reported by the referring clinician. Participants were given a unique survey ID and all identifying information was removed prior to data analysis.</p> <hd id="AN0172825726-7">Measures</hd> <p></p> <hd id="AN0172825726-8">Recency of AF symptoms</hd> <p>Participants were asked "When was the last time you were aware of having an episode of atrial fibrillation?" Ordinal response choices were coded as (<reflink idref="bib1" id="ref22">1</reflink>) currently in AF or earlier today, (<reflink idref="bib2" id="ref23">2</reflink>) within the past week, (<reflink idref="bib3" id="ref24">3</reflink>) within the past month, (<reflink idref="bib4" id="ref25">4</reflink>) 1 month to 1 year ago, (<reflink idref="bib5" id="ref26">5</reflink>) more than 1 year ago, and (<reflink idref="bib6" id="ref27">6</reflink>) I was never aware of having atrial fibrillation; an interval based on the AFEQT that acts somewhat as an internal control [[<reflink idref="bib21" id="ref28">21</reflink>]]. Additionally, these choices were collapsed into another binary variable "AF symptoms < or > 1 month" representing if the patient had experienced symptoms over one month ago or within the past month. Patients who identified as asymptomatic were included in the "over one month ago" group.</p> <hd id="AN0172825726-9">Overall health</hd> <p>Participants were asked to rate their overall health on a scale ranging from 1 (poor) to 4 (excellent) [[<reflink idref="bib22" id="ref29">22</reflink>]].</p> <hd id="AN0172825726-10">Overall mental health</hd> <p>Participants were asked to rate their overall mental health on a scale ranging from 1 (poor) to 4 (excellent) [[<reflink idref="bib23" id="ref30">23</reflink>]].</p> <hd id="AN0172825726-11">Perceived stress [24]</hd> <p>The Perceived Stress Scale (PSS-10), a 10-item, 5-point scale, measures the degree to which situations in one's life are appraised as stressful, ability to control aspects of life, confidence in handling problems, or being unable to cope with demands. The PSS-10 previously had a reliability alpha of.78 and correlated in a predictable way with other measures of stress [[<reflink idref="bib24" id="ref31">24</reflink>]].</p> <hd id="AN0172825726-12">Socio-demographic characteristics</hd> <p>These included sex, age, marital status, race/ethnicity, education, and income.</p> <hd id="AN0172825726-13">AF knowledge [25]</hd> <p>The Knowledge about AF tool is a 28-item multiple choice-style questionnaire including questions about AF symptoms, treatment, medications, risk factors, and lifestyle. Participants are asked to choose one of 3 options for each question, only one of which is the correct response. The tool was developed using research on gaps in patient knowledge and patient values and management preferences. Knowledge scores are calculated as a percentage of correct answers, with higher numbers indicating higher knowledge. Four items were removed from the overall knowledge percent scores, as per McCabe et al. [[<reflink idref="bib25" id="ref32">25</reflink>]] finding that these items had factor loadings below.45 and were not reliable predictors of overall test performance and knowledge. The Knowledge about AF tool demonstrated an internal consistency reliability coefficient of.86, convergent validity (i.e., was positively related to another knowledge about AF test), and distinguished between patients recently diagnosed with AF from those seeking advanced treatment for AF [[<reflink idref="bib25" id="ref33">25</reflink>]].</p> <hd id="AN0172825726-14">Household and recreational physical activity [26]</hd> <p>Physical activity scores are calculated based on the Phone-FITT questionnaire. The questionnaire was originally designed to be administered via telephone, so it was adapted for the use in an online survey by displaying the questions as checkboxes. First, participants were asked to indicate their participation in various household and recreational activities in a typical week within the past month, or specific months for season dependent activities. If they participated in an activity, participants were also asked to provide a frequency (times per week, and months per year for seasonal activities only), as well as choose a duration from 1 (1–15 minutes) to 4 (1 hour or more) and an intensity from 1 (breathing normally and able to carry on a conversation) to 3 (too out of breath to carry on a conversation). Scores are calculated as the sum of the frequency, duration, and intensity for all household and all recreational activities, with higher scores indicating higher physical activity. The Phone-FITT has previously demonstrated test-retest reliability as well as convergent validity (i.e., positive correlations with accelerometer counts) [[<reflink idref="bib26" id="ref34">26</reflink>]].</p> <hd id="AN0172825726-15">Atrial Fibrillation Effect on QualiTy-of-Life Questionnaire (AFEQT) [21]</hd> <p>The AFEQT is a 20-item, 7-point scale comprising overall HRQoL and three sub-domains: symptoms, daily activities, treatment concerns, along with AF treatment satisfaction. The AFEQT was developed for use as an outcome measure in trials and interventions and for disease management. In the present study, Cronbach α reliability coefficient was >0.88 for the AFEQT overall score and the symptoms (0.95), daily activities (0.94), treatment concern (0.90), and.88 for treatment satisfaction. Overall HRQoL scores are calculated as the sum of items 1–18, accounting for unanswered items, and normed on a scale from 0–100, with higher numbers indicating higher HRQoL. Treatment satisfaction scores follows the same calculation for items 19–20, with higher scores indicating higher treatment satisfaction; while it is included in the AFEQT, AF treatment satisfaction is not calculated in the overall HRQoL with the other subscales. A difference of + or minus 5 points on the AFEQT are clinically meaningful [[<reflink idref="bib2" id="ref35">2</reflink>]].</p> <hd id="AN0172825726-16">Data cleaning</hd> <p>Two-hundred and three participants responded to the survey. Seven participants were missing one third or more of the scale scores and were removed. Of the remaining 196 participants, less than 1% of data were missing for variables included in the primary analyses. Missing data were replaced using multiple imputation [[<reflink idref="bib27" id="ref36">27</reflink>]] A large portion of clinical data obtained from referrals was missing, and ranged from 24.0% (use of anticoagulants) to 50.5% (type of AF). Missing referral data were not replaced.</p> <hd id="AN0172825726-17">Analysis</hd> <p>Descriptive statistics were used to summarize patient characteristics and socio-demographic data. We conducted bivariate analyses using Wilcoxon rank sum test, Pearson's Chi-squared test, and Fisher's exact test to evaluate relationships between the dichotomized AF symptoms < or > 1 month with all variables because experiencing AF symptoms within the past 4 weeks is a clinically meaningful cutoff, and the AFEQT scores specifically assess symptoms "over the past 4 weeks" [[<reflink idref="bib21" id="ref37">21</reflink>]].</p> <p>Spearman's rank order (Rho) correlations were conducted to examine preliminary associations between all study variables. In addition, multidimensional scaling analyses were conducted to examine the associations between all variables visually and guided our decisions when to enter each of the predictors in the regression models. Five separate linear regressions were conducted with overall HRQoL, along with the component AFEQT sub-scales and AF treatment satisfaction as the dependent variables. Recency of AF symptoms and overall health were entered as predictors on step 1, overall mental health and perceived stress as predictors of step 2, and sex, age, AF knowledge, and household and recreational physical activity as predictor variables on step 3. Cohen's [[<reflink idref="bib28" id="ref38">28</reflink>]] benchmarks (i.e., 2% = small, 15% = medium, and 35% = large) were used to interpret strength of the variance accounted for by variables in each step of the regressions. P-values less than 0.05 were considered statistically significant.</p> <p>Standardized statistical diagnostics for determining normality, detecting outliers, and ensuring that the data met the assumptions of regression were performed. Where necessary, variables were Windsorized to improve normality of distributions. All regression analyses met assumptions of linearity, heteroscedasticity, and multicollinearity. Analyses were performed using R [[<reflink idref="bib29" id="ref39">29</reflink>]] and IBM<sups>TM</sups> SPSS software (version 28) [[<reflink idref="bib30" id="ref40">30</reflink>]].</p> <hd id="AN0172825726-18">Results</hd> <p></p> <hd id="AN0172825726-19">Characteristics of the study population</hd> <p>Of the 579 patients eligible for inclusion, 352 (61%) agreed to be sent the online survey invitation. Of those, 203 started the survey and 196 completed the survey (response rate = 56%). Participants were an average age of 65.28 years (range 33 to 91 years, SD = 10.26), primarily male (n = 123, 63%), and Caucasian (n = 176, 90%). Characteristics of the study populations are shown in Table 1.</p> <p>Graph</p> <p>Table 1 Participant characteristics.</p> <p> <ephtml> <table><thead><tr><th align="left" /><th align="center" /><th align="center" colspan="2">AF Symptoms < or > 1 month</th><th align="center" /></tr><tr><th align="left">Characteristics</th><th align="center">All Participants (<italic>n</italic> = 196)</th><th align="center">Within the past month (<italic>n</italic> = 115)</th><th align="center">Over a month ago (<italic>n</italic> = 81)</th><th align="center"><italic>p</italic>-value</th></tr></thead><tbody><tr><td align="left">Age<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">65 (10)</td><td align="center">65 (10)</td><td align="center">66 (11)</td><td align="center">0.56<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Sex<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.34<xref ref-type="table-fn" rid="tfn4">4</xref></td></tr><tr><td align="left">Female</td><td align="center">73 (37)</td><td align="center">46 (40)</td><td align="center">27 (33)</td><td align="center" /></tr><tr><td align="left">Male</td><td align="center">123 (63)</td><td align="center">69 (60)</td><td align="center">54 (67)</td><td align="center" /></tr><tr><td align="left">Ethnicity<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.21<xref ref-type="table-fn" rid="tfn5">5</xref></td></tr><tr><td align="left">Caucasian/White</td><td align="center">176 (91)</td><td align="center">103 (91)</td><td align="center">73 (91)</td><td align="center" rowspan="4" /></tr><tr><td align="left">Asian</td><td align="center">15 (7.8)</td><td align="center">10 (8.8)</td><td align="center">5 (6.2)</td></tr><tr><td align="left">Indigenous</td><td align="center">2 (1.0)</td><td align="center">0 (0)</td><td align="center">2 (2.5)</td></tr><tr><td align="left">Missing</td><td align="center">3</td><td align="center">2</td><td align="center">1</td></tr><tr><td align="left">Marital Status<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.71<xref ref-type="table-fn" rid="tfn5">5</xref></td></tr><tr><td align="left">Single, divorced, separated, or widowed</td><td align="center">47 (24)</td><td align="center">27 (23)</td><td align="center">20 (25)</td><td align="center" /></tr><tr><td align="left">Married, remarried or common law</td><td align="center">147 (75)</td><td align="center">86 (75)</td><td align="center">61 (75)</td><td align="center" /></tr><tr><td align="left">Missing</td><td align="center">2</td><td align="center">2</td><td align="center">0</td><td align="center" /></tr><tr><td align="left">Education<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.29<xref ref-type="table-fn" rid="tfn4">4</xref></td></tr><tr><td align="left">College, University, Graduate or Professional Degree</td><td align="center">129 (66)</td><td align="center">71 (62)</td><td align="center">58 (72)</td><td align="center" /></tr><tr><td align="left">Some post-secondary</td><td align="center">37 (19)</td><td align="center">21 (18)</td><td align="center">14 (17)</td><td align="center" /></tr><tr><td align="left">High School or less</td><td align="center">30 (15)</td><td align="center">21 (18)</td><td align="center">9 (11)</td><td align="center" /></tr><tr><td align="left">Income<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.29<xref ref-type="table-fn" rid="tfn5">5</xref></td></tr><tr><td align="left">Less than $25,000</td><td align="center">13 (6.6)</td><td align="center">10 (8.7)</td><td align="center">3 (3.7)</td><td align="center" /></tr><tr><td align="left">$25,000-$50,000</td><td align="center">38 (19)</td><td align="center">25 (22)</td><td align="center">13 (16)</td><td align="center" /></tr><tr><td align="left">$51,000-$75,000</td><td align="center">41 (21)</td><td align="center">26 (23)</td><td align="center">15 (19)</td><td align="center" /></tr><tr><td align="left">Over $75,000</td><td align="center">99 (51)</td><td align="center">51 (44)</td><td align="center">48 (59)</td><td align="center" /></tr><tr><td align="left">Missing</td><td align="center">5</td><td align="center">3</td><td align="center">2</td><td align="center" /></tr><tr><td align="left">Overall Health<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.002<xref ref-type="table-fn" rid="tfn5">5</xref></td></tr><tr><td align="left">Excellent</td><td align="center">26 (13)</td><td align="center">10 (8.7)</td><td align="center">16 (20)</td><td align="center" /></tr><tr><td align="left">Good</td><td align="center">117 (60)</td><td align="center">63 (55)</td><td align="center">54 (67)</td><td align="center" /></tr><tr><td align="left">Fair</td><td align="center">44 (22)</td><td align="center">35 (30)</td><td align="center">9 (11)</td><td align="center" /></tr><tr><td align="left">Poor</td><td align="center">6 (3.1)</td><td align="center">4 (3.5)</td><td align="center">2 (2.5)</td><td align="center" /></tr><tr><td align="left">Overall Mental Health<xref ref-type="table-fn" rid="tfn2">2</xref></td><td align="center" /><td align="center" /><td align="center" /><td align="center">0.29<xref ref-type="table-fn" rid="tfn5">5</xref></td></tr><tr><td align="left">Excellent</td><td align="center">74 (38)</td><td align="center">41 (36)</td><td align="center">33 (41)</td><td align="center" /></tr><tr><td align="left">Good</td><td align="center">99 (51)</td><td align="center">58 (50)</td><td align="center">41 (51)</td><td align="center" /></tr><tr><td align="left">Fair</td><td align="center">22 (11)</td><td align="center">16 (14)</td><td align="center">6 (7.4)</td><td align="center" /></tr><tr><td align="left">Poor</td><td align="center">1 (0.5)</td><td align="center">0 (0)</td><td align="center">1 (1.2)</td><td align="center" /></tr><tr><td align="left">Perceived Stress<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">12 (6)</td><td align="center">13 (7)</td><td align="center">11 (6)</td><td align="center">0.009<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Missing</td><td align="center">5</td><td align="center">1</td><td align="center">4</td><td align="center" /></tr><tr><td align="left">AF Knowledge (Overall)<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">83 (12)</td><td align="center">84 (12)</td><td align="center">82 (13)</td><td align="center">0.32<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Basic AF Knowledge</td><td align="center">97 (12)</td><td align="center">98 (10)</td><td align="center">96 (15)</td><td align="center" /></tr><tr><td align="left">Common symptom knowledge</td><td align="center">94 (16)</td><td align="center">95 (14)</td><td align="center">92 (19)</td><td align="center" /></tr><tr><td align="left">Consequences knowledge</td><td align="center">65 (21)</td><td align="center">66 (23)</td><td align="center">63 (18)</td><td align="center" /></tr><tr><td align="left">Recurrent knowledge</td><td align="center">82 (23)</td><td align="center">83 (22)</td><td align="center">81 (25)</td><td align="center" /></tr><tr><td align="left">Treatment Knowledge</td><td align="center">78 (21)</td><td align="center">79 (21)</td><td align="center">76 (21)</td><td align="center" /></tr><tr><td align="left">Monitoring knowledge</td><td align="center">86 (15)</td><td align="center">88 (14)</td><td align="center">84 (16)</td><td align="center" /></tr><tr><td align="left">Risk factors knowledge</td><td align="center">93 (16)</td><td align="center">93 (16)</td><td align="center">92 (18)</td><td align="center" /></tr><tr><td align="left">Psyc knowledge</td><td align="center">100 (0)</td><td align="center">100(0)</td><td align="center">100(0)</td><td align="center" /></tr><tr><td align="left">Missing (overall)</td><td align="center">4</td><td align="center">2</td><td align="center">2</td><td align="center" /></tr><tr><td align="left">Household Activity<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">32 (13)</td><td align="center">31 (14)</td><td align="center">33 (11)</td><td align="center">0.19<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Recreational Activity<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">37 (21)</td><td align="center">37 (22)</td><td align="center">36 (20)</td><td align="center">0.74<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Overall HRQoL (AFEQT)<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">71 (21)</td><td align="center">61 (20)</td><td align="center">84 (15)</td><td align="center"><.001<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Symptoms Subscale</td><td align="center">75 (21)</td><td align="center">65 (21)</td><td align="center">89 (12)</td><td align="center"><.001<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Daily Activities Subscale</td><td align="center">70 (27)</td><td align="center">60 (26)</td><td align="center">84 (22)</td><td align="center"><.001<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Treatment Concern</td><td align="center">68 (22)</td><td align="center">61 (23)</td><td align="center">80 (16)</td><td align="center"><.001<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Treatment Satisfaction (AFEQT)<xref ref-type="table-fn" rid="tfn1">1</xref></td><td align="center">74 (26)</td><td align="center">66 (26)</td><td align="center">86 (22)</td><td align="center"><.001<xref ref-type="table-fn" rid="tfn3">3</xref></td></tr><tr><td align="left">Missing</td><td align="center">2</td><td align="center">0</td><td align="center">2</td><td align="center" /></tr></tbody></table> </ephtml> </p> <p>1 <sups><emph>1</emph></sups> Mean (SD)</p> <ulist> <item>2 <sups><emph>2</emph></sups> n (%)</item> <item>3 <sups>3</sups>Wilcoxon rank sum test</item> <item>4 <sups>4</sups>Pearson's Chi-squared test</item> <item>5 <sups>5</sups>Fisher's exact test</item> </ulist> <p>Despite over half of patients (59%) experiencing AF symptoms within the past month, the majority of participants had 'excellent' or 'good' overall health (73%) and mental health (89%) ratings. Overall knowledge scores were high (83%), ranging from 29% to 100% and with highest scores for basic AF knowledge (97%), and lowest scores for knowledge of the consequences of untreated AF (65%). On average perceived stress scores were low according to scale guidelines [[<reflink idref="bib24" id="ref41">24</reflink>]]. Household and recreation physical activity were on average high, compared to a sample of adults aged 70 years or older enrolled in an adult exercise program [[<reflink idref="bib26" id="ref42">26</reflink>]]. The mean overall AFEQT score in our sample was 70.6, with a range of 7.4 to 100. The mean overall AF treatment satisfaction score was 73.8, with a range of 0 to 100. As shown in Table 1, those experiencing AF symptoms within the past month had significantly lower ratings for overall health, HRQoL, treatment satisfaction, and higher perceived stress.</p> <p>In terms of clinical descriptors, referring clinicians stated that 23 (11.7%) of patients were newly diagnosed and 85 (43%) referrals mentioned ablation consultation. Patients had on average 2.45 co-morbidities and 5% listed congestive heart failure. Of those recorded, patient participants' AF type was paroxysmal (69%), persistent (27%), or permanent (2%). Approximately 46% had undergone previous cardioversion, 26% had undergone previous ablation, and 3% had pacemaker implantations. The majority (62%) were prescribed anticoagulants and patients were taking an average of 2.87 medications.</p> <hd id="AN0172825726-20">Model building</hd> <p>Correlations between all continuous (and ordinal) variables are presented in Table 2. Initial inspection of these bivariate correlations suggested the importance of recency of AF symptoms, overall health, overall mental health and perceived stress for HRQoL and AF treatment satisfaction. A multidimensional scaling analysis with all variables entered simultaneously (i.e., weighted equally) further confirmed our hypothesis that recency of AF symptoms and overall health were the most closely related to HRQoL (i.e., should be entered first in the regression models), followed by mental health variables (overall mental health and perceived stress), with all other variables more distally related to HRQoL and AF treatment satisfaction.</p> <p>Graph</p> <p>Table 2 Correlations between all study variables.</p> <p> <ephtml> <table><thead><tr><th align="left" rowspan="2" /><th align="center">1</th><th align="center">2</th><th align="center">3</th><th align="center">4</th><th align="center">5</th><th align="center">6</th><th align="center">7</th><th align="center">8</th><th align="center">9</th><th align="center">10</th></tr><tr><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th><th align="center"><italic>r</italic> (<italic>p</italic>)</th></tr></thead><tbody><tr><td align="left">1. Overall HRQoL</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">2. AF Treatment Satisfaction</td><td align="center">.511 (<.001)</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">3. Recency of AF Symptoms</td><td align="center">.475 (<.001)</td><td align="center">.459 (<.001)</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">4. Overall Health</td><td align="center">.431 (<.001)</td><td align="center">.329 (<.001)</td><td align="center">.278 (<.001)</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">5. Overall mental health</td><td align="center">.189 (.008)</td><td align="center">.247 (<.001)</td><td align="center">.046 (.526)</td><td align="center">.397 (<.001)</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">6. Perceived stress</td><td align="center">-.385 (<.001)</td><td align="center">-.221 (.002)</td><td align="center">-.122 (.088)</td><td align="center">-.248 (<.001)</td><td align="center">-.515 (<.001)</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">7. Age</td><td align="center">-.082 (.253)</td><td align="center">.123 (.086)</td><td align="center">.096 (.180)</td><td align="center">-.015 (.830)</td><td align="center">.174.014)</td><td align="center">-.115 (.108)</td><td align="center">1.0</td><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left">8. AF knowledge</td><td align="center">-.005 (.944)</td><td align="center">-.153 (.032)</td><td align="center">-.117 (.103)</td><td align="center">.041 (.564)</td><td align="center">.030 (.672)</td><td align="center">-.020 (.783)</td><td align="center">.057 (.430)</td><td align="center">1.0</td><td align="center" /><td align="center" /></tr><tr><td align="left">9. Household activity</td><td align="center">.155 (.030)</td><td align="center">.091 (.207)</td><td align="center">.082 (252)</td><td align="center">.058 (.423)</td><td align="center">-.020 (.785)</td><td align="center">.022 (.764)</td><td align="center">-.104 (.148)</td><td align="center">.033 (.651)</td><td align="center">1.0</td><td align="center" /></tr><tr><td align="left">10. Recreational activity</td><td align="center">.051 (.482)</td><td align="center">.065 (.366)</td><td align="center">.015 (.830)</td><td align="center">.204 (.004)</td><td align="center">.005 (.942)</td><td align="center">-.103 (.149)</td><td align="center">.082 (.253)</td><td align="center">.266 (<.001)</td><td align="center">.301 (<.001)</td><td align="center">1.0</td></tr></tbody></table> </ephtml> </p> <p>6 Note: Correlations based on Spearman's Rho; HRQoL = Health-Related Quality of Life</p> <hd id="AN0172825726-21">Regressions</hd> <p>See Table 3 for the results of regression analyses examining the association between predictors (recency of AF symptoms, overall health, overall mental health, perceived stress, sex, age, AF knowledge, household PA, and recreational PA) and overall HRQoL, three HRQoL subscales, and treatment satisfaction (outcomes).</p> <p>Graph</p> <p>Table 3 Regression analyses examining the association between recency of AF symptoms and overall health along with individual characteristics and HRQoL outcomes and treatment satisfaction.</p> <p> <ephtml> <table><thead><tr><th align="left" /><th align="center">B (95% CI)</th><th align="center">β</th><th align="center">Coefficient <italic>P</italic> value</th><th align="center">Partial <italic>r</italic></th><th align="center">Semi-partial r</th><th align="center">R Square</th><th align="center">Model <italic>F</italic> (<italic>df</italic>)</th><th align="center">F change <italic>P</italic> value</th></tr></thead><tbody><tr><td align="left">Overall HRQoL</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">     Step 1</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.296</td><td align="left">40.49 (2, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Recency of AF symptoms</td><td align="left">5.32 (3.58, 7.17)</td><td align="left">.38</td><td align="left"><.001</td><td align="left">.40</td><td align="left">.36</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Overall health</td><td align="left">9.73 (5.50, 13.64)</td><td align="left">.31</td><td align="left"><.001</td><td align="left">.34</td><td align="left">.30</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 2</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.386</td><td align="left">30.07 (4, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Overall mental health</td><td align="left">-3.97 (-8.51,.603)</td><td align="left">-.12</td><td align="left">.089</td><td align="left">-.12</td><td align="left">-.10</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Perceived Stress</td><td align="left">-1.19 (-1.62, -.70)</td><td align="left">-.35</td><td align="left"><.001</td><td align="left">-.35</td><td align="left">-.30</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 3</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.432</td><td align="left">15.73 (9, 195)</td><td align="left">.012</td></tr><tr><td align="left">    Sex<xref ref-type="table-fn" rid="tfn7">a</xref></td><td align="left">-2.11 (-7.08, 3.20)</td><td align="left">-.05</td><td align="left">.411</td><td align="left">-.06</td><td align="left">-.05</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Age</td><td align="left">-.18 (-.43,.06)</td><td align="left">-.09</td><td align="left">.148</td><td align="left">-.11</td><td align="left">-.08</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    AF Knowledge</td><td align="left">.09 (-.11,.28)</td><td align="left">.05</td><td align="left">.396</td><td align="left">.06</td><td align="left">.05</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Household PA</td><td align="left">.30 (.08,.49)</td><td align="left">.18</td><td align="left">.004</td><td align="left">.21</td><td align="left">.16</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Recreational PA</td><td align="left">-.12 (-.25,.02)</td><td align="left">-.12</td><td align="left">.063</td><td align="left">-.14</td><td align="left">-.10</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">HRQoL Symptoms subscale</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 1</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.218</td><td align="left">26.92 (2, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Recency of AF symptoms</td><td align="left">6.17 (4.54, 8.05)</td><td align="left">.44</td><td align="left"><.001</td><td align="left">.43</td><td align="left">.42</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Overall health</td><td align="left">2.77 (-1.59, 6.72)</td><td align="left">.09</td><td align="left">.178</td><td align="left">.10</td><td align="left">.09</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 2</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.297</td><td align="left">20.22 (4, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Overall mental health</td><td align="left">-2.33 (-7.60, 2.41)</td><td align="left">-.07</td><td align="left">.349</td><td align="left">-.07</td><td align="left">-.06</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Perceived Stress</td><td align="left">-1.07 (-1.53, -.58)</td><td align="left">-.32</td><td align="left"><.001</td><td align="left">-.30</td><td align="left">-.27</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 3</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.357</td><td align="left">11.48 (9, 195)</td><td align="left">.005</td></tr><tr><td align="left">    Sex<xref ref-type="table-fn" rid="tfn7">a</xref></td><td align="left">-3.53 (-8.86, 1.76)</td><td align="left">-.08</td><td align="left">.195</td><td align="left">-.10</td><td align="left">-.08</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Age</td><td align="left">.12 (-.13,.37)</td><td align="left">.06</td><td align="left">.351</td><td align="left">.07</td><td align="left">.06</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    AF Knowledge</td><td align="left">.06 (-.17,.30)</td><td align="left">.03</td><td align="left">.617</td><td align="left">.04</td><td align="left">.03</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Household PA</td><td align="left">.35 (.13,.58)</td><td align="left">.20</td><td align="left">.002</td><td align="left">.23</td><td align="left">.19</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Recreational PA</td><td align="left">-.22 (-.36, -.08)</td><td align="left">-.22</td><td align="left">.001</td><td align="left">-.23</td><td align="left">-.19</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">HRQoL Daily Activities subscale</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 1</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.320</td><td align="left">45.51 (2, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Recency of AF symptoms</td><td align="left">4.89 (2.65, 7.33)</td><td align="left">.27</td><td align="left"><.001</td><td align="left">.31</td><td align="left">.26</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Overall health</td><td align="left">17.21 (11.58, 22.36)</td><td align="left">.43</td><td align="left"><.001</td><td align="left">.45</td><td align="left">.42</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 2</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.371</td><td align="left">28.16 (4, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Overall mental health</td><td align="left">-6.58 (-12.10, -1.04)</td><td align="left">-.16</td><td align="left">.028</td><td align="left">-.16</td><td align="left">-.13</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Perceived Stress</td><td align="left">-1.15 (-1.75, -.55)</td><td align="left">-.27</td><td align="left"><.001</td><td align="left">-.27</td><td align="left">-.22</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 3</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.436</td><td align="left">15.97 (9, 195)</td><td align="left">.001</td></tr><tr><td align="left">    Sex<xref ref-type="table-fn" rid="tfn7">a</xref></td><td align="left">-1.43 (-7.47, 4.87)</td><td align="left">-.03</td><td align="left">.659</td><td align="left">-.03</td><td align="left">-.02</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Age</td><td align="left">-.53 (-.84, -.23)</td><td align="left">-.20</td><td align="left"><.001</td><td align="left">-.24</td><td align="left">-.19</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    AF Knowledge</td><td align="left">.11 (-.12,.35)</td><td align="left">.05</td><td align="left">.389</td><td align="left">.06</td><td align="left">.05</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Household PA</td><td align="left">.30 (.03,.57)</td><td align="left">.14</td><td align="left">.022</td><td align="left">.17</td><td align="left">.13</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Recreational PA</td><td align="left">-.07 (-.25,.09)</td><td align="left">-.05</td><td align="left">.400</td><td align="left">-.06</td><td align="left">-.05</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">HRQoL Treatment subscale</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 1</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.169</td><td align="left">19.57 (2, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Recency of AF symptoms</td><td align="left">5.22 (3.38, 7.04)</td><td align="left">.36</td><td align="left"><.001</td><td align="left">.35</td><td align="left">.34</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Overall health</td><td align="left">4.39 (-.18, 8.95)</td><td align="left">.14</td><td align="left">.048</td><td align="left">.14</td><td align="left">.13</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 2</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.295</td><td align="left">19.97 (4, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Overall mental health</td><td align="left">-1.38 (-6.80, 4.26)</td><td align="left">-.04</td><td align="left">.594</td><td align="left">-.04</td><td align="left">-.03</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Perceived Stress</td><td align="left">-1.34 (-1.82, -.87)</td><td align="left">-.39</td><td align="left"><.001</td><td align="left">-.36</td><td align="left">-.32</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 3</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.316</td><td align="left">9.56 (9, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Sex<xref ref-type="table-fn" rid="tfn7">a</xref></td><td align="left">-2.15 (-8.09, 4.23)</td><td align="left">-.05</td><td align="left">.461</td><td align="left">-.06</td><td align="left">-.05</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Age</td><td align="left">.08 (-.23,.35)</td><td align="left">.04</td><td align="left">.583</td><td align="left">.04</td><td align="left">.03</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    AF Knowledge</td><td align="left">.05 (-.16,.27)</td><td align="left">.03</td><td align="left">.699</td><td align="left">.03</td><td align="left">.02</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Household PA</td><td align="left">.25 (.01,.48)</td><td align="left">.14</td><td align="left">.034</td><td align="left">.16</td><td align="left">.12</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Recreational PA</td><td align="left">-.11 (-.26,.05)</td><td align="left">-.11</td><td align="left">.125</td><td align="left">-.11</td><td align="left">-.09</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">AF Treatment Satisfaction</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 1</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.202</td><td align="left">24.50 (2, 195)</td><td align="left"><.001</td></tr><tr><td align="left">    Recency of AF symptoms</td><td align="left">5.99 (3.89, 8.25)</td><td align="left">.35</td><td align="left"><.001</td><td align="left">.35</td><td align="left">.34</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Overall health</td><td align="left">8.11 (2.71, 13.03)</td><td align="left">.21</td><td align="left">.002</td><td align="left">.23</td><td align="left">.21</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 2</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.225</td><td align="left">13.86 (4, 195)</td><td align="left">.065</td></tr><tr><td align="left">    Overall mental health</td><td align="left">2.31 (-3.42, 8.48)</td><td align="left">.06</td><td align="left">.468</td><td align="left">.05</td><td align="left">.05</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Perceived Stress</td><td align="left">-.49 (-1.06,.08)</td><td align="left">-.12</td><td align="left">.120</td><td align="left">-.11</td><td align="left">-.10</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Step 3</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left">.278</td><td align="left">7.96 (9, 195)</td><td align="left">.021</td></tr><tr><td align="left">    Sex<xref ref-type="table-fn" rid="tfn7">a</xref></td><td align="left">-6.61 (-13.71,.77)</td><td align="left">-.12</td><td align="left">.062</td><td align="left">-.14</td><td align="left">-.12</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Age</td><td align="left">.39 (.06,.71)</td><td align="left">.15</td><td align="left">.025</td><td align="left">.16</td><td align="left">.14</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    AF Knowledge</td><td align="left">-.34 (-.61, -.09)</td><td align="left">-.15</td><td align="left">.019</td><td align="left">-.17</td><td align="left">-.15</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Household PA</td><td align="left">.26 (-.06,.51)</td><td align="left">.12</td><td align="left">.069</td><td align="left">.13</td><td align="left">.11</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">    Recreational PA</td><td align="left">-.01 (-.20,.16)</td><td align="left">-.01</td><td align="left">.916</td><td align="left">-.01</td><td align="left">-.01</td><td align="left" /><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p>7 Note: <sups>a</sups>Dummy variable, 0 = male, 1 = female; B = Unstandardized Coefficient; 95%CI = Bootstrapped 95% confidence interval; β = Standardized Beta Coefficients. AF = Atrial fibrillation; PA = physical activity</p> <hd id="AN0172825726-22">HRQoL and subscales</hd> <p>On Step 1 of the regressions, length of time since participants last had AF symptoms was positively related to all three HRQoL subscales and individuals' overall HRQoL. In addition, higher overall health was positively related to the daily activities HRQoL subscale, and overall HRQoL. These two variables together contributed 29.6% of the variance in overall HRQoL, explaining the most variance on the HRQoL daily activities subscale (32%) and the least variance in the HRQoL treatment subscale (16.9%). On Step 2 of the regressions, overall mental health was positively related to HRQoL treatment subscale and higher perceived stress was related to lower HRQoL on all three subscales, as well as lower overall HRQoL. In Step 3, age was negatively related to HRQoL for daily activities and higher household physical activity was related to higher HRQoL on all three subscales, as well as higher overall HRQoL whereas higher recreational physical activity was related to lower HRQoL for symptoms. Together the individual characteristics increased the total variance accounted for in overall HRQoL to 43.2%, accounting for an additional 13.6% of the variance over and above recency of AF symptoms. The amount of variance accounted for within each subscale was similar; notably, the highest proportion of variance these individual characteristics accounted for was in the HRQoL treatment sub-scale (14.7%), which neared (but did not pass) the contribution of AF symptoms and overall health to this outcome.</p> <hd id="AN0172825726-23">Treatment satisfaction</hd> <p>On Step 1 of the regression, length of time since participants last had AF symptoms was positively related to AF treatment satisfaction. In addition, higher overall health was positively related to AF treatment satisfaction. Together, these variables accounted for 20.2% of the variance in AF treatment satisfaction. On Step 2 of the regressions, overall mental health and perceived stress did not add to the incremental prediction in AF treatment satisfaction. On step 3, age was positively related to AF treatment satisfaction, whereas greater AF knowledge was related to lower AF treatment satisfaction. Together the individual characteristics increased the total variance accounted for in overall HRQoL to 27.8%, accounting for an additional 7.6% of the variance in AF treatment satisfaction over and above recency of AF symptoms and overall health.</p> <hd id="AN0172825726-24">Discussion</hd> <p>In this study of patients attending a specialized AF clinic, we found that along with AF symptoms and overall health, individual characteristics including perceived stress and physical activity were important predictors of HRQoL and AF treatment satisfaction. These findings are consistent with those predicted by Ferrans et al.'s model of HRQoL [[<reflink idref="bib8" id="ref43">8</reflink>]].</p> <p>Consistent with other well-established findings was a relationship between HRQoL and recency of AF symptoms. Indeed, in the original AFEQT scale validation study, patients who had AF symptoms within the past 4 weeks had lower mean overall AFEQT scores compared to those with more remote symptoms (57.1 vs. 66.6, P = 0.01) [[<reflink idref="bib21" id="ref44">21</reflink>]]. In the present study, overall health ratings were also associated with overall HRQoL (and the daily activities and treatment subscales), as well as AF treatment satisfaction. In a systematic review, general health perceptions fully mediated the relationship between symptoms and HRQoL among patients living with chronic illness in some studies, whereas in other studies the direct link between symptoms and HRQoL was not fully mediated by general health perceptions, consistent with our findings that both variables independently contributed to HRQoL [[<reflink idref="bib31" id="ref45">31</reflink>]]. This highlights the importance of managing and monitoring symptoms and supporting overall health for patients with AF [[<reflink idref="bib32" id="ref46">32</reflink>]].</p> <p>The addition of individual characteristics to the overall HRQoL model, in particular perceived stress and physical activity (household/recreational) added significantly to the explained variance in HRQoL. These two variables were significant predictors in all three HRQoL subscales as well as in overall HRQoL scores. The additional contribution of perceived stress and physical activity in explaining HRQoL over and above recency of symptoms is an important finding. Although the individual characteristics accounted for about half the proportion of variance that recency of AF symptoms and overall health did in overall HRQoL, an additional 13.6% is still substantial variance [[<reflink idref="bib28" id="ref47">28</reflink>]]. According to Cohen's [[<reflink idref="bib28" id="ref48">28</reflink>]] benchmarks, AF symptoms and overall health were approaching having a large effect on HRQoL, whereas the individual variables had a medium effect. In addition, for the HRQoL treatment subscale, the proportion of variance accounted for by the individual characteristics (14.7%) was nearing that accounted for by AF symptoms and overall health (16.9%)—each contributing medium effects. It is not just the case that those who have more recently experienced symptoms are more stressed, but instead, stress <emph>in itself</emph> adds additional variance explained over and above recency of symptoms. Although prior studies have reported that patients perceive that stress triggers/causes their AF symptom episodes [[<reflink idref="bib10" id="ref49">10</reflink>]–[<reflink idref="bib13" id="ref50">13</reflink>]] or increases symptom severity [[<reflink idref="bib33" id="ref51">33</reflink>]] this is the first study to link perceived stress as a unique contributor to HRQoL in the AF population. Further, it expands on other evidence showing the impact of psychological distress, namely depression and/or anxiety on greater AF symptom severity, diminished HRQoL, and recurrence of AF [[<reflink idref="bib34" id="ref52">34</reflink>]] and draws attention to the need to address patients perceived stress in addition to symptom control in enhancing patients HRQoL and AF management [[<reflink idref="bib35" id="ref53">35</reflink>]].</p> <p>The role of activity in HRQoL for patients with AF is unclear. In our study, recreational activity negatively predicted AF HRQoL symptoms; those doing higher recreational activity had lower HRQoL around symptoms, meaning their symptoms have been bothering them more. This is consistent with AF studies of endurance athletes in which moderate activity appears to reduce AF risk but intense exercise increases both incident AF [[<reflink idref="bib36" id="ref54">36</reflink>]] and AF burden; the latter, possibly due to the psychological impact of AF and medication impacts on recreational activities [[<reflink idref="bib37" id="ref55">37</reflink>]]. Interestingly, higher household physical activity was related to higher HRQoL on all three subscales, as well as overall HRQoL. This may indicate that the ability to engage in one's daily activities for older individuals represented in our study is more important for their HRQoL than the potential benefits of recreational exercise. In fact, although regular exercise and high cardiorespiratory fitness contribute to a reduction in incident AF [[<reflink idref="bib36" id="ref56">36</reflink>]] and exercise interventions improve exercise capacity in patients with AF [[<reflink idref="bib38" id="ref57">38</reflink>]], exercise interventions do not appear to improve HRQoL in the long term [[<reflink idref="bib39" id="ref58">39</reflink>]].</p> <p>Treatment satisfaction, an AFEQT component not included in the overall score, also showed significant relationships with recency of AF symptoms and overall health, similar to the subscale and overall HRQoL scores. However, age and knowledge significantly contributed over and above to explaining the variance in AF treatment satisfaction. The finding that older patients had higher satisfaction with their AF treatment is consistent with literature that suggests older adults are more satisfied with healthcare generally [[<reflink idref="bib40" id="ref59">40</reflink>]], as well as with findings that older adults (65+ years) had slightly higher AF treatment satisfaction scores both pre and post ablation compared to younger adults (<65 years) [[<reflink idref="bib41" id="ref60">41</reflink>]]. Although AF knowledge is considered to be important for promoting symptom management [[<reflink idref="bib17" id="ref61">17</reflink>]], the role of AF knowledge in HRQoL is not well defined. Possessing high knowledge may serve to raise treatment outcome expectations that when unmet, contribute to dissatisfaction.</p> <p>Despite being related to AF treatment satisfaction in the present study, AF knowledge was unrelated to overall HRQoL or the three HRQoL subscales. Consistent with our findings, in a previous study targeting education to address knowledge gaps in patients with AF, in-person education improved knowledge scores but had no influence on quality of life, symptom burden or medication adherence [[<reflink idref="bib42" id="ref62">42</reflink>]]. Yet, interestingly, in another RCT, patients with AF assigned to an education intervention reported improved knowledge and higher AFEQT scores at 1- and 3- month follow-up for both overall HRQoL and treatment satisfaction [[<reflink idref="bib43" id="ref63">43</reflink>]]. More research is needed into the relationship between AF knowledge and HRQoL and AF treatment satisfaction.</p> <p>Although a recent systematic review highlighted the importance of both symptoms and individual characteristics in HRQoL across diverse studies [[<reflink idref="bib6" id="ref64">6</reflink>]], our study is among the first to comprehensively co-examine both clinical and individual characteristics and the role each independently plays in HRQoL among an AF patient population. The finding that individual characteristics such as perceived stress, physical activity and AF knowledge accounted for variability in HRQoL/treatment satisfaction over and above the variability accounted for by recency of AF symptoms and overall health suggests that these variables could potentially be targets for intervention, given they are modifiable. It has long been suggested that HRQoL among patients with AF can be improved with better symptom control, and we suggest that reducing perceived stress and improving household activity could further be targeted as potential areas to improve HRQoL, although the relationship between recreational activity and AF knowledge with HRQoL may be more complicated. These results suggest the importance of considering multidimensional interventions to support HRQoL among patients with AF, and potentially considering targeting different interventions for specific groups (e.g., those high/low in AF knowledge). Indeed, researchers have recently been observing the diversity/variability in AF populations [[<reflink idref="bib44" id="ref65">44</reflink>]], suggesting that in future we may need to move beyond assuming linearity in theorizing the relationships between personal characteristics and HRQoL.</p> <hd id="AN0172825726-25">Strengths/limitations</hd> <p>This study provides an expanded understanding of the role of personal characteristics over and above AF symptoms and overall health in explaining HRQoL and contributes to further theorizing of HRQoL in the AF population. It should be noted that variables were based on self-report, and participant responses might be subject to recall bias; however, standardized and validated measures were used, reducing potential for misinterpretation. Future research may seek to explore less subjective measures (e.g., objective assessments of physical activity, such as accelerometer readings, or objective measures of stress, such as cortisol levels). Our population was patients referred to a specialty AF clinic, and only included 7–8% who were asymptomatic; indeed patients referred to tertiary clinics often have a greater disease burden than average AF patients [[<reflink idref="bib6" id="ref66">6</reflink>]] potentially reducing the relevance of our findings to general AF populations, where closer to 25 or 30% of patients are typically asymptomatic populations [[<reflink idref="bib1" id="ref67">1</reflink>]]. In an effort to reduce sampling bias, all patients with upcoming appointments were invited to participate. Because 34% of eligible participants completed the survey, responses may be influenced by self-selection bias; further, patient participants may not be representative of the diversity of the AF population as they are predominantly well-educated, high income, male, and Caucasian; however, they reflect the larger AF clinic population (i.e., the clinic participants were sampled from had a similar demographic breakdown). Nevertheless, overall, our selection of patients referred to a specialty clinic likely resulted in a sample with more high risk/advanced AF patients (e.g., many referred for ablation), limiting our ability to generalize the findings to broader populations of AF patients (e.g., those under primary care). Future research is needed to determine whether psychological, demographic, and behavioral characteristics play a larger or smaller role in HRQoL relative to AF symptoms and overall health for broader populations of patients with AF.</p> <hd id="AN0172825726-26">Conclusion</hd> <p>Patients with AF receiving care at an AF specialty clinic had moderate HRQoL and treatment satisfaction, with higher HRQoL among patients who had not experienced AF symptoms in over a month. Findings showed that individual characteristics, namely perceived stress and physical activity made unique contributions in explaining HRQoL over and above AF symptoms and overall health. Similarly, the individual characteristics age and AF knowledge contributed additionally to AF symptoms and overall health in explaining the variance in AF treatment satisfaction. There has been considerable emphasis on symptoms in predicting HRQoL in the AF population. These findings point to the need to give increasing attention to other characteristics of the individual as they play an important role in AF patients' HRQoL.</p> <hd id="AN0172825726-27">Decision Letter 0</hd> <p>Samala Venkata Vikramaditya Academic Editor</p> <p>19 Jun 2023</p> <p>PONE-D-23-08648Quality of life among patients with atrial fibrillation:  A Theoretically-guided Cross-Sectional StudyPLOS ONE</p> <p>Dear Dr. Rush,</p> <p>Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE's publication criteria as it currently stands. 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Has the statistical analysis been performed appropriately and rigorously?</p> <p>Reviewer #1: Yes</p> <p>Reviewer #2: I Don't Know</p> <p>Reviewer #3: Yes</p> <p>Reviewer #4: Yes</p> <p>Reviewer #5: Yes</p> <p>Reviewer #6: Yes</p> <p>***</p> <p>3. Have the authors made all data underlying the findings in their manuscript fully available?</p> <p>The <ulink href="http://www.plosone.org/static/policies.action#sharing">http://www.plosone.org/static/policies.action#sharing</ulink> requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.</p> <p>Reviewer #1: Yes</p> <p>Reviewer #2: Yes</p> <p>Reviewer #3: Yes</p> <p>Reviewer #4: Yes</p> <p>Reviewer #5: Yes</p> <p>Reviewer #6: Yes</p> <p>***</p> <p>4. Is the manuscript presented in an intelligible fashion and written in standard English?</p> <p>PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.</p> <p>Reviewer #1: Yes</p> <p>Reviewer #2: Yes</p> <p>Reviewer #3: Yes</p> <p>Reviewer #4: Yes</p> <p>Reviewer #5: Yes</p> <p>Reviewer #6: Yes</p> <p>***</p> <p>5. Review Comments to the Author</p> <p>Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)</p> <p>Reviewer #1: Overall a well designed study with a good analysis of results with a reasonable conclusion. Not sure why Hypothesis 1 was included in the study as the Authors mention in the introduction that studies have already been conducted on it and the Hypothesis has already been proven. Other than that, well executed study.</p> <p>Reviewer #2: Well presented original cross sectional research article. Atrial fibrillation patients with individual characteristics including perceived stress, household physical activity, AF treatment satisfaction, AF knowledge, recent AF symptoms <1 month being important overall predictors of Health related quality of life are well described. Data acquirement is well explained.</p> <p>Reviewer #3: Appreciate the effort for this well presented abstract. The physician community is highly focused on symptoms rather the individual factors considered here. This paper should help bring more attention to the less appreciated characteristics.</p> <p>Reviewer #4: Quality of life with atrial fibrillation is well picked topic. However I see a lot of confounders as the classification of atrial fibrillation is not taken into account. Paroxysmal atrial fibrillation has a different set of symptoms or a different frequency of symptoms and Persistent and permanent atrial fibrillation have various set of symptoms as well. A lot of these patients have multiple comorbidities and various patients have a different regimen for treatment. It would have been great if there is more granularity in choice of patients and cohorts. Also a lot of patients may have had procedures like ablation and pacemaker implantations. Some have heart failure as a comorbidity which can worsen the quality of life. Statistically may be sound but the as mentioned above choice of patients should have been tighter and not just every patient that comes to an A.fib clinic. Moreover it is a very subjective study.</p> <p>Reviewer #5: This is a study conducted on a population of Atrial fibrillation(AF) patients attending a specialty clinic. Authors have used hierarchal regression analyses to assess whether individual characteristics of patients are predictors of Health-related Quality of Life(HRQoL) and AF treatment satisfaction. Prior studies have explored these contributions with more focus on AF symptoms rather than individual characteristics. The findings are similar to other studies that authors have cited.</p> <p>The authors have given enough background to justify the need for this study. The stated objectives of the study are clear. Results have been reported in a satisfactory manner. They have outlined the strength and limitations of their study in detail. They have reported reliability and validity for all the instruments used in the study.</p> <p>This study tested unexplored individual characteristics including perceived stress and AF knowledge. It has been investigated before whether Perceived stress contributes to mental health and anxiety in AF patients (DA Lane et al, 2009) but it has not been investigated for contribution to HRQoL.</p> <p>Authors have claimed that physical activity has not been studied as an individual characteristic which is not true. Exercise performance has been found to have a significant contribution to AF-related HRQoL by SN Singh et al in 2006. In this study, authors have further dichotomized physical activity into household activity and recreational activity which has given contrasting and interesting results.</p> <p>Authors have reported taking help from family members if the patient could not understand English. They should elaborate on why a certified translator was not used if language was a barrier.</p> <p>Authors should explain the concept of variance change in more simple terms to readers who need to become more familiar with the statistical significance of this measure.</p> <p>Reference 9 is incomplete. It should be completed.</p> <p>Lane D.A., Langman C.M., Lip G.Y., Nouwen A. Illness perceptions, affective response, and health-related quality of life in patients with atrial fibrillation. J. Psychosom. Res. 2009;66:203–210.</p> <p>Singh S.N., Tang X.C., Singh B.N., Dorian P., Reda D.J., Harris C.L., Fletcher R.D., Sharma S.C., Atwood J.E., Jacobson A.K. Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: A Veterans Affairs Cooperative Studies Program Substudy. J. Am. Coll. Cardiol. 2006;48:721–730. doi: 10.1016/j.jacc.2006.03.051.</p> <p>Reviewer #6: the present is an interesting single center study.</p> <p>Some issues should be addressed.</p> <p>introduction: maybe it may be worth to make it more narrative, without dividing hyphothesis by number</p> <p>methods: the referral to a specialized AF clinics may hide a selection bias towards high risk patients or for those referred to af ablation. please comment</p> <p>methods: the statistical analysis is well performed and fit from a clinical point of view. Maybe (from a formal point of view) also performing a multivariate analysis with all the predictors may be worth of.</p> <p>***</p> <p>6. PLOS authors have the option to publish the peer review history of their article (https://journals.plos.org/plosone/s/editorial-and-peer-review-process#loc-peer-review-history). If published, this will include your full peer review and any attached files.</p> <p>If you choose "no", your identity will remain anonymous but your review may still be made public.</p> <p> <bold>Do you want your identity to be public for this peer review?</bold> For information about this choice, including consent withdrawal, please see our https://<ulink href="http://www.plos.org/privacy-policy">www.plos.org/privacy-policy</ulink>.</p> <p>Reviewer #1: No</p> <p>Reviewer #2: <bold>Yes: </bold>Jyotsna Gummadi MD</p> <p>Reviewer #3: No</p> <p>Reviewer #4: <bold>Yes: </bold>PARITHARSH GHANTASALA</p> <p>Reviewer #5: No</p> <p>Reviewer #6: <bold>Yes: </bold>Fabrizio D'Ascenzo</p> <p>***</p> <p>[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]</p> <p>While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.</p> <hd id="AN0172825726-29">Author response to Decision Letter 0</hd> <p>4 Aug 2023</p> <p>Editor Comments</p> <p>1. Article language especially in the introduction of the manuscript is very complicated and difficult to understand on the first read. Please note comments by reviewers. I highlighted the top 2 as noted below Thank you, we have simplified the language, as suggested.</p> <ulist> <item>2. Variance change should be explained in more simple terms for readers to understand the significance of the study We have added a simplified explanation of % change, and a reference to Cohen's benchmarks in the data analysis section to aid interpretation of these.</item> <item>3. Please refer to the reviewer comments suggesting making the study more narrative without dividing hypothesis by number and to assess for selection bias. We have made the study more narrative without dividing the hypotheses by number, and we have added greater clarification to the limitations section re: selection bias.</item> <item>4 Please refer to other reviewer comments and have a response. Completed as requested (see below).</item> </ulist> <p>Reviewer 1 Comments</p> <p>Overall a well designed study with a good analysis of results with a reasonable conclusion. Not sure why Hypothesis 1 was included in the study as the Authors mention in the introduction that studies have already been conducted on it and the Hypothesis has already been proven. Other than that, well executed study. Thank you for this feedback. It is correct that studies have already been conducted on hypothesis 1 (i.e., the link between patient symptoms and QoL); however this was included primarily so that we could explore whether the other variables were significantly related to QoL outside of symptoms. If we hadn't entered symptoms and overall health in the regression models first, we would not be able to determine if variables such as exercises were independently related to QoL, or whether both exercise and QoL were simply varying together because of symptoms. We have simplified language about variance change in order to try and make this clearer, and we have removed reference to individual hypotheses, as per other reviewer suggestions, which re-directs focus to the key hypotheses.</p> <p>Reviewer 2 Comments</p> <p>Well presented original cross sectional research article. Atrial fibrillation patients with individual characteristics including perceived stress, household physical activity, AF treatment satisfaction, AF knowledge, recent AF symptoms <1 month being important overall predictors of Health related quality of life are well described. Data acquirement is well explained. Thank you for this feedback.</p> <p>Reviewer 3 Comments</p> <p>Appreciate the effort for this well presented abstract. The physician community is highly focused on symptoms rather the individual factors considered here. This paper should help bring more attention to the less appreciated characteristics. Thank you for this feedback.</p> <p>Reviewer 4 Comments</p> <p>Quality of life with atrial fibrillation is well picked topic. However I see a lot of confounders as the classification of atrial fibrillation is not taken into account. Paroxysmal atrial fibrillation has a different set of symptoms or a different frequency of symptoms and Persistent and permanent atrial fibrillation have various set of symptoms as well. A lot of these patients have multiple comorbidities and various patients have a different regimen for treatment. It would have been great if there is more granularity in choice of patients and cohorts. Also a lot of patients may have had procedures like ablation and pacemaker implantations. Some have heart failure as a comorbidity which can worsen the quality of life. Statistically may be sound but the as mentioned above choice of patients should have been tighter and not just every patient that comes to an A.fib clinic. Moreover it is a very subjective study. Thank you for this clear description with respect to how patient populations with AF may vary.</p> <p>Clinic referral data abstraction was completed for these patients as part of another study. As such, we do know clinical details for this sample as a whole and have added a summary to the results section.</p> <p>Indeed, our patient population included diversity with respect to AF classification, and this reviewer is correct that many were referred, at least in part, for ablation consultation (as 43% of clinicians mentioned 'ablation consultation' as part of the referral), and many had already undergone previous ablations, had co-morbidities, etc.</p> <p>We have added a brief summary description of these patient clinic characteristics as well as expanded on the implications of this selection bias in the limitations.</p> <p>Tighter selection of patients (e.g., focused just on those with advanced/persistent AF and heart failure) would have allowed for a very granular look at a sub-population, but may not have allowed for generalizability across more diverse sub-populations. The diversity within our sample was a strength because we were able to demonstrate that even when AF symptoms and overall health were considered (i.e., "controlled" in the regressions), AF patients' psychological, demographic, and behavioral characteristics were associated with HRQoL. Whether this finding holds true for all of the different patients represented in our sample is a good direction for future research.</p> <p>We appreciate the view that this is a very subjective study, as that is the nature of many self-report inventories, and we have added this to the limitations as a suggestion for future research.</p> <p>Reviewer 5 Comments</p> <p>This is a study conducted on a population of Atrial fibrillation(AF) patients attending a specialty clinic. Authors have used hierarchal regression analyses to assess whether individual characteristics of patients are predictors of Health-related Quality of Life(HRQoL) and AF treatment satisfaction. Prior studies have explored these contributions with more focus on AF symptoms rather than individual characteristics. The findings are similar to other studies that authors have cited. Thank you for this feedback.</p> <p>The authors have given enough background to justify the need for this study. The stated objectives of the study are clear. Results have been reported in a satisfactory manner. They have outlined the strength and limitations of their study in detail. They have reported reliability and validity for all the instruments used in the study.</p> <p>Thank you for this feedback.</p> <p>This study tested unexplored individual characteristics including perceived stress and AF knowledge. It has been investigated before whether Perceived stress contributes to mental health and anxiety in AF patients (DA Lane et al, 2009) but it has not been investigated for contribution to HRQoL. Thank you for this feedback. We have added information about the link between perceived stress and mental health/anxiety.</p> <p>Authors have claimed that physical activity has not been studied as an individual characteristic which is not true. Exercise performance has been found to have a significant contribution to AF-related HRQoL by SN Singh et al in 2006. In this study, authors have further dichotomized physical activity into household activity and recreational activity which has given contrasting and interesting results.</p> <p>Thank you for drawing our attention to this work. We have modified wording to say that exercise has been 'under-explored' (as opposed to 'unexplored'), and have added a description of and reference to Singh et al. (2006).</p> <p>Authors have reported taking help from family members if the patient could not understand English. They should elaborate on why a certified translator was not used if language was a barrier.</p> <p>Language was not a barrier as patients attending the clinic and comprising our sample were primarily white, highly educated, and spoke English. Instead, the suggestion to have a family member assist was due to concern that elderly patients may not be able to navigate the online survey alone. We have modified the wording for clarity.</p> <p>Authors should explain the concept of variance change in more simple terms to readers who need to become more familiar with the statistical significance of this measure.</p> <p>We have added additional explanation of % variance, including a reference to Cohen for interpretation of small, medium and large effects based on % change.</p> <p>Reference 9 is incomplete. It should be completed.</p> <p>Thank you for noting this. We have corrected the Ferrans et al reference (now reference 8).</p> <p>Reviewer 6 Comments</p> <p>the present is an interesting single center study.</p> <p>Some issues should be addressed. Thank you for this feedback.</p> <p>introduction: maybe it may be worth to make it more narrative, without dividing hyphothesis by number Thank you for this suggestion, we have edited as suggested.</p> <p>methods: the referral to a specialized AF clinics may hide a selection bias towards high risk patients or for those referred to af ablation. please comment This is plausible that our focus on patients referred to a specialty clinic likely resulted in selection of a higher risk/more advanced AF population, as our AF symptom data indicates. We have enhanced the description of this and the implications of it in the limitations section.</p> <p>methods: the statistical analysis is well performed and fit from a clinical point of view. Maybe (from a formal point of view) also performing a multivariate analysis with all the predictors may be worth of. We are unsure what type of multivariate analysis the reviewer is referring to here. Multivariate analysis (MVA) includes any analyses evaluating multiple variables (more than two) to identify any possible associations. We chose linear regression as it allowed for the examination of associations between continuous variables; we also provide a table of correlations between all variables (Table 2), and we conducted a multidimensional scaling analysis with all predictors entered simultaneously to confirm which variables were most closely related to HRQoL. We have now highlighted this multidimensional scaling analysis further in the text for clarity.</p> <p>Attachment.</p> <p>Submitted filename: Response to PLOS ONE Reviewers - 06 JULY 2023.docx</p> <hd id="AN0172825726-30">Decision Letter 1</hd> <p>Samala Venkata Vikramaditya Academic Editor</p> <p>1 Sep 2023</p> <p>Quality of life among patients with atrial fibrillation:  A theoretically-guided cross-sectional study</p> <p>PONE-D-23-08648R1</p> <p>Dear Dr. Rush,</p> <p>We're pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.</p> <p>Within one week, you'll receive an e-mail detailing the required amendments. When these have been addressed, you'll receive a formal acceptance letter and your manuscript will be scheduled for publication.</p> <p>An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at <ulink href="http://www.editorialmanager.com/pone/,">http://www.editorialmanager.com/pone/,</ulink> click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.</p> <p>If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.</p> <p>Kind regards,</p> <p>Vikramaditya Samala Venkata</p> <p>Academic Editor</p> <p>PLOS ONE</p> <p>Additional Editor Comments (optional):</p> <p>Reviewers' comments:</p> <p>Reviewer's Responses to Questions</p> <hd1 id="AN0172825726-31">Comments to the Author</hd1> <p>1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the "Comments to the Author" section, enter your conflict of interest statement in the "Confidential to Editor" section, and submit your "Accept" recommendation.</p> <p>Reviewer #5: All comments have been addressed</p> <p>***</p> <p>2. Is the manuscript technically sound, and do the data support the conclusions?</p> <p>The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.</p> <p>Reviewer #5: Yes</p> <p>***</p> <p>3. Has the statistical analysis been performed appropriately and rigorously?</p> <p>Reviewer #5: Yes</p> <p>***</p> <p>4. Have the authors made all data underlying the findings in their manuscript fully available?</p> <p>The <ulink href="http://www.plosone.org/static/policies.action#sharing">http://www.plosone.org/static/policies.action#sharing</ulink> requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.</p> <p>Reviewer #5: Yes</p> <p>***</p> <p>5. Is the manuscript presented in an intelligible fashion and written in standard English?</p> <p>PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.</p> <p>Reviewer #5: Yes</p> <p>***</p> <p>6. Review Comments to the Author</p> <p>Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)</p> <p>Reviewer #5: Authors have addressed all the raised questions and concerns. They have made appropriate changes to the manuscript to make it more narrative, explained variance better, answered queries raised by all the reviewers and changed the references.</p> <p>***</p> <p>7. PLOS authors have the option to publish the peer review history of their article (https://journals.plos.org/plosone/s/editorial-and-peer-review-process#loc-peer-review-history). If published, this will include your full peer review and any attached files.</p> <p>If you choose "no", your identity will remain anonymous but your review may still be made public.</p> <p> <bold>Do you want your identity to be public for this peer review?</bold> For information about this choice, including consent withdrawal, please see our https://<ulink href="http://www.plos.org/privacy-policy">www.plos.org/privacy-policy</ulink>.</p> <p>Reviewer #5: No</p> <p>***</p> <hd id="AN0172825726-32">Acceptance letter</hd> <p>Samala Venkata Vikramaditya Academic Editor</p> <p>28 Sep 2023</p> <p>PONE-D-23-08648R1</p> <p>Quality of life among patients with atrial fibrillation:  A theoretically-guided cross-sectional study</p> <p>Dear Dr. Rush:</p> <p>I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.</p> <p>If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.</p> <p>If we can help with anything else, please email us at plosone@plos.org.</p> <p>Thank you for submitting your work to PLOS ONE and supporting open access.</p> <p>Kind regards,</p> <p>PLOS ONE Editorial Office Staff</p> <p>on behalf of</p> <p>Dr. Vikramaditya Samala Venkata</p> <p>Academic Editor</p> <p>PLOS ONE</p> <p>The authors wish to extend their thanks to all the patient participants who shared their insights during the study and to Kaylee Neill and Sarah Singh, who assisted with recruitment.</p> <ref id="AN0172825726-33"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> I have read the journal's policy and the authors of this manuscript have the following competing interests: JGA reports grants from Medtronic and the Heart and Stroke Foundation of Canada during the conduct of this study; personal fees from Medtronic and Biosense Webster Inc, outside the submitted study. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The other authors have no conflicts to declare.</bibtext> </blist> </ref> <ref id="AN0172825726-34"> <title> References </title> <blist> <bibtext> Rienstra M, Lubitz SA, Mahida S, et al. Symptoms and functional status of patients with atrial fibrillation: State of the art and future research opportunities. Circulation2012; 125: 2933–2943. doi: 10.1161/CIRCULATIONAHA.111.069450, 22689930</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Holmes DN, Piccini JP, Allen LA, et al. Defining clinically important difference in the atrial fibrillation effect on quality-of-life score: Results from the outcomes registry for better informed treatment of atrial fibrillation. Circ Cardiovasc Qual Outcomes2019; 12: 1–8.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Dorian P, Jung W, Newman D, et al. 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