• Cardiothoracic transplant;
  • caregivers;
  • psychosocial resources;
  • quality of life


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

Cardiothoracic transplant programs generally require that transplant recipients have family caregivers to assist them posttransplant. The burden of caregiving on the family members remains poorly understood. If caregivers’ well-being is compromised by caregiving, it may bode poorly for transplant recipients’ own health in the long-term posttransplant. We examined caregiver health-related quality of life (HRQOL) during the first year after their family member's transplant, its predictors and its relationship to subsequent patient survival. Adult (aged 18+) caregivers of 242 cardiothoracic transplant recipients (lung = 134; heart = 108) completed assessments of demographics, psychosocial characteristics and caregiver burden at 2 months posttransplant, and HRQOL at 2, 7 and 12 months posttransplant. Recipients’ survival time was obtained from medical records. Caregiver HRQOL was generally high across the first-year posttransplant in emotional and social functioning; caregiver physical functioning significantly worsened. There were no differences by type of recipient transplant. Greater caregiver burden predicted poorer caregiver HRQOL in several physical domains at 12 months posttransplant. Transplant recipients whose caregivers had lower perceived general health at 12 months posttransplant showed poorer survival rates during the subsequent 7 years of follow up. Transplant teams should identify those caregivers at risk for poorer general health posttransplant to maximize positive outcomes for the entire family.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

Current trends in medical treatment and healthcare economics have resulted in shortened hospital stays, and extended life expectancies for chronically ill adults, thus placing increased responsibility for their care on the family (1). Caregivers provide over $257 billion worth of unpaid services each year, which is more than double the cost of home health and nursing home care combined (2,3). As hospitals rely more heavily on family caregivers to assist with patient recovery, it is imperative to determine the effects that such burden may have on caregivers. Previous research on caregivers has focused primarily on the impact of caregiving to adults whose health deteriorates over time (2–14). This research has demonstrated that providing care to a chronically ill family member increases the risk of compromised health and well-being in caregivers (10,15–18).

Caregiving in the context of organ transplantation presents a different scenario from that studied in most caregiving research: transplant recipients’ medical course is usually dramatically improved with receipt of the new organ and caregivers to transplant recipients are more likely to be spouses than adult children. Furthermore, as the field of transplantation has advanced, the benefits of transplantation to the organ recipient have increased, both in the short term (e.g. fewer postsurgical complications, shorter hospital stays related to the initial surgery) and long term (greater posttransplant life expectancy, longer periods of good physical functional status and quality of life [22–38]) These benefits for the recipient might be expected to positively affect the caregiver's health-related quality of life (HRQOL) as well. Thus, one might hypothesize that caregivers would show high levels of HRQOL following their family member's transplant, with those levels becoming even better as the transplant recipient regains health across the first months and years posttransplant. Alternatively, the advantages of rapid hospital discharge postsurgery and a longer posttransplant lifespan may pose additional challenges to caregivers, including increased levels and durations of caregiving responsibility (19–21). Indeed, the first year posttransplant is critical, but fraught with change and readjustment for recipients and their caregivers, with issues including medical instability and complications for the recipient and high task loads for the caregiver. This might lead to declines rather than improvements in caregiver HRQOL during this period. Thus, it is not clear whether caregiver HRQOL improves or deteriorates as a result of transplantation.

To date, most studies of caregivers’ HRQOL after transplantation are either cross-sectional or focus on caregivers of kidney or liver patients (17,22–26). Less is known about cardiothoracic recipients, and whether their HRQOL improves or deteriorates over time. In particular, despite the growth in rates of lung transplantation, few data exist on lung recipients’ caregivers; the focus has been solely on caregivers to lung transplant candidates (18,21,27–30). Further, because lung transplant recipients have higher rates of medical complications after transplant and tend to show a slower pattern of HRQOL improvement posttransplant than other types of solid organ transplant recipients (4,22,25,31–41), we speculate that lung transplant caregivers’ well-being might be poorer than that of other types of transplant caregivers.

The issue of caregiver well-being is important to address because the well-being of transplant recipients depends, in large part, on the help they receive from their family caregiver, and transplant programs generally require that cardiothoracic transplant recipients have family caregivers. Caregiver burden and impaired HRQOL may lead to negative downstream consequences for the transplant recipient including problems with adherence and increased risks of morbidities and mortality (25,29,30,42–44), as well as recipient mental health and HRQOL (39,40,45). These issues have received little attention in cardiothoracic recipients and their family caregivers. Therefore, examining caregivers’ HRQOL and identifying predictors of caregiver HRQOL posttransplant are important in determining how caregiver HRQOL may influence recipient outcomes. Based on both conceptual models and empirical evidence regarding factors associated with caregiver HRQOL, we included potential predictors representing the following domains: caregiver demographics, patient characteristics, caregiver psychosocial resources and caregivers’ perceptions of caregiving burden (10,15–18,20,21,23,24, 26,27,29,46). We hypothesized that, controlling for caregiver demographics and patient characteristics, caregivers with fewer psychosocial resources (e.g. lower optimism, poorer social supports) and greater caregiving burden would have poorer HRQOL at 1-year posttransplant.

Thus, the objectives of our study were to: (1) determine how the HRQOL of caregivers to cardiothoracic transplant recipients changes over the first year posttransplant; (2) compare the trajectory of change in HRQOL in caregivers of lung versus heart transplant recipients; (3) determine whether we can predict caregiver HRQOL at 1-year posttransplant with caregiver demographic and psychosocial factors assessed early after transplant; and (4) determine whether caregiver HRQOL at 1-year posttransplant would predict subsequent cardiothoracic recipient survival.

Materials and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

Study sample

In collaboration with the Cardiothoracic Transplantation Program at the University of Pittsburgh Medical Center, all family caregivers of all lung or heart transplant recipients (aged 18+), who underwent transplantation between November 1999 and August 2004 and survived beyond the first two months posttransplant, were recruited to participate in a prospective investigation of their well-being. Eligible caregivers were identified by asking recipients to name their primary caregiver, i.e. the person who provided them the greatest amount of daily care and assistance. We attempted to recruit the caregiver of every recipient who enrolled in our parallel study of cardiothoracic transplant recipients (41). Of the 304 recipients in our study, 289 had a primary caregiver, and 269 of those caregivers enrolled in our study (response rate, 93.1%). Because our focus was on caregivers who maintained the caregiving role, this study focuses on those caregivers whose recipient remained alive during the study period (up to 12 months posttransplant) and who did not exit the caregiver role during this time. Thus, our study sample included 242 caregivers (134 lung recipient caregivers, 108 heart recipient caregivers).


Following protocol approval by the University of Pittsburgh Institutional Review Board, all respondents gave informed consent and received individual interviews. Face-to-face interviews were conducted if caregivers accompanied patients to posttransplant evaluations at 2, 7 and 12 months posttransplant. Otherwise, home or telephone interviews were conducted to accommodate the schedules and/or preferences of caregivers to maintain their participation. Participants were paid $40 for each completed interview, which took an average of 60 min. There were no significant differences for mode of interview on the variables examined in our study. All interviewers had master's degrees in mental health or behavioral disciplines. Following interview training, inter-rater reliability was evaluated and exceeded an intraclass correlation of 0.90 on each instrument. Transplant-related information about the patients was obtained from medical record reviews.


Caregiver HRQOL:  Caregivers’ HRQOL was measured with the Medical Outcomes Study Short Form (SF-36; 47). It assesses 8 components of HRQOL (general health, physical functioning, vitality, bodily pain, role limitations due to physical health, role limitations due to emotional health, social functioning, mental health). The psychometric properties of the SF-36 are well documented (47,48). Each scale is scored from 0 to 100 with a higher score being more positive (i.e. less pain, less limitation). Cronbach's alphas for the present sample ranged from 0.74 to 0.90 for the 8 HRQOL areas.

Transplant recipient survival:  Patients’ medical records maintained by the transplant team were reviewed through a maximum of 7.5 years posttransplant (because the last patient in our cohort was enrolled in 2004). Years of survival were calculated.

Predictors of caregiver HRQOL and transplant recipient survival: 

Four predictor domains were assessed at the initial interview and through medical record review. These included caregiver demographics, care recipient's health-related background information, psychosocial resources and coping strategies and caregiver burden.

Caregiver demographics:  Caregivers reported standard demographic characteristics (e.g. gender, age, race, income, education, occupation) during their initial interview.

Transplant recipient health characteristics:  Care recipients’ health-related history data were obtained from medical records, and their physical functional status was obtained via the SF-36 physical functioning subscale, as rated by transplant recipients at 12 months posttransplant in our parallel study of transplant recipients (41; Cronbach's α= 0.89).

Psychosocial resources:  Caregiver optimism was measured with the Life Orientation Test (LOT; 49), a measure for assessing expectations about the future. Items were averaged to yield an overall score (1 = low optimism, 5 = high optimism; Cronbach's α= 0.81 for the present sample). Mastery, or the degree to which respondents felt they had personal control over the things that happen to them, was measured with the Sense of Mastery Scale (50). The items were averaged to yield an overall score (1 = low mastery, 4 = high mastery; α= 0.80).

Social support was examined with two measures. First, the quality of the caregiver's relationship with the patient was assessed with a 20-item measure modeled on the work of Spanier (51) and Pearlin and Schooler (50) and used in transplant-related caregiver samples (19–21). This instrument yields an overall support score (1 = poor relationship, 5 = excellent relationship; α= 0.94). Second, friend support was assessed with 12 items concerning the degree to which caregivers felt they could rely on friends for emotional or practical support (52). The measure yields a summary index (0 = low support; 3 = high support; alpha = 0.91). These two measures had skewed distributions; scores were dichotomized to identify respondents with the poorest support (lower third of the distribution) relative to remaining respondents.

We assessed coping strategies with the 28-item Brief COPE scale (53). Caregivers were asked to focus on their strategies for coping with what they considered to be their care recipient's most serious recent health problem and rated the frequency of their use of each strategy on a four-point scale (1 = not at all, 4 = a lot). We created four composite scores from this measure, based on results of a principal components analysis. (We conducted this analysis because the Brief COPE is a short form of a longer measure. Although the Brief COPE is widely used, whether or not the items in the Brief COPE conform to the validated subscales in the full COPE has not been established.) They were consistent with the higher-order coping factors identified by Carver et al. (54). Active coping reflected plans or behavior to actively deal with the stressor (α= 0.81). The support-seeking/expression of emotions factor reflected attempts to turn to others for support and express one's feelings about the problem (α= 0.71). Acceptance coping indicated that the person accepted the reality of the health problem (α= 0.62). Avoidant coping reflected attempts to shun or deny the problem. Because caregivers rarely endorsed avoidant items (i.e. little variability across respondents), the internal consistency reliability of this measure was low (α= 0.31) and we could not use it further. Thus, we used three coping measures in our analyses. (Although the Brief COPE also includes two items that tap self-blame coping, these items were not originally identified in Carver et al.'s [54] previous work, nor did they load on a separate factor in our analysis).

Caregiver burden:  We assessed burden with four measures to capture different aspects of caregiver burden. To assess caregivers’ daily responsibilities, caregivers indicated which of 10 household management tasks they performed for the care recipient (e.g. housework, running errands). The sum of endorsed items was calculated. Caregivers also indicated which of 10 personal care and nursing tasks they performed for the care recipient (e.g. assisting with medications, helping with bathing). The sum of endorsed items was calculated. Next, caregivers rated nine items concerning how much the caregiver role limited the time they had for other noncaregiving domains of their lives (e.g. personal affairs, recreational or vacation activities; adapted from Montgomery et al. (55)). The items were averaged (1 = little time restriction; 5 = high time restriction for other activities; α= 0.88). Finally, to assess perceived psychological burden, we used the 18-item version of the Zarit Burden Interview (56), which focuses on caregiver feelings of role strain and personal strain. The items were averaged (1 = low personal burden; 5 = high personal burden; α= 0.81).


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

The study groups’ background and clinical characteristics were compared with χ2 tests for categorical variables and t tests for continuous variables. Descriptive data on caregivers’ HRQOL at each time point, as well as temporal patterns of HRQOL change were compared between caregivers to lung and heart recipients using mixed-model, hierarchical analysis of variance (ANOVA) for continuous variables (57,58). Each model included an effect for group (lung vs. heart), time (2, 7 and 12-month interviews) and the group x time interaction, which determined whether the rate of change over time differed across the two study groups. The mixed-model approach allowed us to use data from all time points for all caregivers included in our sample, under the assumption that missing data are missing at random. We included all caregivers who had missing HRQOL data at any of the three interviews (n = 23 at Time 1, n = 28 at Time 2, n = 27 at Time 3) in the analyses because we found no large or significant relationship between data missingness at any follow-up assessment and the other variables examined in this report.

We examined potential predictors’ associations with caregiver HRQOL at 12 months posttransplant via Pearson correlation coefficients. We then entered variables showing at least a modest association with any of the HRQOL outcomes (r > 0.20) into a multivariable analysis to identify each variable's independent effect, controlling for all others. These effects were estimated via multiple regression analysis for each HRQOL variable, with predictors entered in two blocks. Block 1 included demographic and recipient health-related variables. In Block 2, we added psychosocial resources and caregiver burden (as well as early posttransplant caregiver HRQOL), to identify their predictive value over and above the Block 1 variables. The predictors were examined and found to meet all analytic assumptions adequately (59). These regression analyses focused on the 216 caregivers who provided data at 12 months posttransplant. Cases with missing data on any of the variables were excluded from the regression analysis.

Finally, to evaluate the impact of caregiver HRQOL at 1-year posttransplant on subsequent patient survival time, we fit a Cox proportional hazards model, controlling for patient characteristics likely to be linked to mortality (type of transplant received, patient age, length of initial hospitalization after transplant and patients’ physical functional status at 1-year posttransplant, the latter two characteristics serving as proxies to reflect patient morbidity during the first year). In addition, we controlled for type of caregiver relationship to the patient (spouse vs. other family member) because this might affect mortality risk as well. The proportionality assumption was evaluated before fitting the models (59).


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

Caregiver demographics, psychosocial resources and perceived burden

Table 1 presents descriptive information on assessed variables for the entire sample, as well as separately for lung and heart transplant caregivers. Like other caregiver populations, there were more women than men in our sample. The majority of caregivers were over 50 (M[SD]= 52.1[11.2]), and European American. About half had at least some education beyond high school and had annual incomes of less than $40 000. There were very few differences between lung and heart subgroups. A larger proportion of the heart caregivers were female, most likely because heart recipients are more likely to be men (and hence have their spouses as caregivers), whereas the gender distribution among lung recipients is equal. Caregivers of lung recipients indicated more transplant-related health worries than did caregivers of heart recipients. Although there appeared to be a trend for lung recipients to have longer posttransplant hospital stays, this difference was not significant (p = .095).

Table 1.  Background characteristics, psychosocial resources, coping strategies and caregiver burden in 242 lung and heart transplant caregivers
CharacteristicTotal Sample (N = 242)Lung Caregivers (n = 134)Heart Caregivers (n = 108)Group Comparison test statistic1p-Value
  1. 1 t-tests for continuous variables and Chi-square tests for categorical variables.

  2. 2Lung caregivers had missing data on: income (n = 2), recipient physical functioning (n = 1).

  3. 3Heart caregivers had missing data on: recipient physical functioning (n = 2).

  4. 4Lung caregivers had missing data on: optimism (n = 5), mastery (n = 5), family support (n = 6), coping measures (n = 5), caregiver household tasks (n = 3), nursing tasks (n = 3), activities impairment (n = 4), personal burden (n = 4).

  5. 5Heart caregivers had missing data on: optimism (n = 1), mastery (n = 3), family support (n = 5), coping measures (n = 4), caregiver household tasks (n = 1), nursing tasks (n = 2), activities impairment (n = 1), personal burden (n = 1).

Background characteristics
 Caregiver demographic characteristics2,3–%     
  Gender (female)71.565.778.74.98*0.026
  Age (≤50)37.239.634.30.720.397
  Race (European–American)90.994.087.03.540.856
  Educational level (≤high school)43.843.344.40.030.090
  Occupation (≤clerical/sales workers)50.445.556.52.870.128
  Family income (≤$39 999)52.948.558.32.310.128
  Relationship to recipient (spouse/partner)78.579.176.90.320.572
 Recipient transplant-related characteristics
  Indication for transplant-–% lung recipients   
   (COPD/emphysema) 37.3  
   (Idiopathic pulmonary fibrosis) 24.6   
   (Cystic fibrosis) 14.9   
   (Other) 23.2   
  Indication for transplant-–% heart   
   (Idiopathic myopathy) 37.0  
   (Ischemic myopathy)  38.0  
   (Other)  25.0  
  Days in hospital posttransplant—-%   6.370.095
   ≤14 days41.437.346.3  
   15–21 days22.319.425.9  
   22–28 days13.615.711.1  
   >29 days22.727.616.7  
  Physical functional status at 2 months post55.6 (25.2)54.0 (25.2)57.7 (25.1)1.110.267
   Transplant, mean (SD)     
  Acute rejection early posttransplant (% yes)39.340.338.00.140.711
Caregiver psychosocial resources4,5     
 Psychosocial resources     
  Optimism–Mean (SD; 1 = low, 5 = high)3.9 (0.7)3.9 (0.6)3.8 (0.7)1.120.263
  Mastery–Mean (SD; 1 = low, 4 = high)3.0 (0.5)3.1 (0.5)3.0 (0.5)1.060.288
  Relationship with recipient, % poor35.533.638.00.500.479
  Family support, % poor35.535.
  Friend support, % poor30.631.329.60.080.774
 Coping strategies—Mean (SD), (1 = low use, 5 = high use)
  Active2.8 (0.9)2.9 (0.9)2.8 (0.9)0.310.755
  Seeking support2.1 (0.6)2.1 (0.6)2.1 (0.6)0.360.719
  Acceptance2.2 (0.5)2.2 (0.5)2.2 (0.5)1.010.272
 Caregiving burden—Mean (SD)
   No. of daily household tasks6.0 (2.3)5.9 (2.2)6.1 (2.5)0.560.577
   No. of nursing tasks (0 = none, 1 = one, 2 = two or more)0.8 (.8)0.8 (0.8)0.8 (0.8)0.440.659
   Activities impairment (1 = low, 5 = high)2.3 (0.7)2.4 (0.7)2.3 (0.7)0.370.709
   Personal burden (1 = low, 5 = high)1.9 (0.5)1.9 (0.5)1.9 (0.6)0.020.981

Enrolled caregivers showed no large or statistically significant differences from caregivers who refused to enroll on demographic characteristics or their family member's health status or history. Typical reasons for refusal to enroll included lack of time and lack of interest in participating. Within our sample, no caregivers were unable to be relocated for follow up. Twenty-four caregivers withdrew consent after either the first interview (n = 14) or the second interview (n = 10). Typical reasons for withdrawal included not enough time, or not interested in further participation. However, we observed no differences on variables collected at the initial interview among caregivers who continued in the study versus those lost to attrition.

HRQOL in caregivers of lung and heart transplant recipients

Figure 1 plots caregivers’ mean scores for each HRQOL scale at 2, 7 and 12 months posttransplant. The first three columns in Table 2 present the means (and their standard errors) separately by lung and heart transplant caregiver subgroups on each of the HRQOL outcomes. The mixed effects analysis indicated no differences between these subgroups, as shown in the table. However, there were several significant changes across time. Thus, as indicated in Table 2 and shown in Figure 1, although caregivers’ energy level (vitality) improved during the course of the year, their average level of physical functional impairment significantly worsened, as did their level of pain. No other domain of HRQOL showed reliable change over time, and there was no differential change by caregiver subgroups over time.


Figure 1. Quality of life in 242 caregivers of cardiothoracic transplant patients at 2, 7 and 12 months posttransplant. The line across the time points on each QOL component represents the normative value on that component for adults aged 18–64. GH = general health, PF = physical functioning, VT = Vitality, BP = bodily pain, RP = role physical, RE = role emotional, SF = social functioning, and MH = mental health.

Download figure to PowerPoint

Table 2.  Quality of life outcomes, Mean (SE), among 242 caregivers of cardiothoracic transplant recipients across three posttransplant interviews (using mixed-model analysis)a
SF-36 HRQOL measureMonths posttransplantGroup effect1p-ValueChange over time effect1p-ValueGroup by time interaction effect1p-Value
2 months7 months12 months
  1. 1F tests, mixed-model analysis.

  2. 2Log transformed before analyses to reduce skewness in its distribution. Raw means are presented to facilitate

  3. interpretation.

General health2   0.750.3880.240.7900.290.745
 Lung recipients78.2 (1.8)77.6 (1.7)76.6 (1.8)      
 Heart recipients76.0 (2.0)76.8 (1.9)75.7 (2.0)      
Physical functioning2   0.020.8885.740.0030.320.724
 Lung recipients90.1 (1.7)88.4 (1.8)85.7 (1.7)      
 Heart recipients90.4 (1.9)88.6 (1.9)86.7 (1.9)      
Vitality   0.710.4013.320.0370.120.889
 Lung recipients61.7 (1.9)65.0 (1.9)63.9 (1.9)      
 Heart recipients59.5 (2.0)62.6 (2.1)62.7 (2.1)      
Bodily pain   1.150.2843.370.0351.340.262
 Lung recipients78.9 (2.2)73.7 (2.2)75.4 (2.2)      
 Heart recipients74.8 (2.4)73.7 (2.4)70.7 (2.5)      
Role physical2   0.190.8901.980.1400.140.871
 Lung recipients87.1 (2.8)85.7 (2.8)84.8 (2.8)      
 Heart recipients88.6 (3.1)83.8 (3.1)82.8 (3.1)      
Role emotional2   0.210.6461.960.1430.580.562
 Lung recipients87.1 (2.4)90.9 (2.4)92.8 (2.4)      
 Heart recipients88.7 (2.6)88.8 (2.6)88.7 (2.7)      
Social functioning2   0.090.7600.200.8141.70.189
 Lung recipients90.4 (1.7)91.8 (1.7)91.4 (1.7)      
 Heart recipients92.4 (1.9)90.4 (1.9)89.7 (1.9)      
Mental health2   0.540.4650.950.3870.380.682
 Lung recipients77.4 (1.5)80.3 (1.5)78.5 (1.5)      
 Heart recipients78.8 (1.6)79.6 (1.7)79.8 (1.7)      

Figure 1 also shows normative scores on the HRQOL subscales. At 12 months posttransplant, caregivers significantly exceeded normative levels on role-emotional (t = 5.08, p < .001), social functioning (t = 4.54, p < .001) and mental health subscales (t = 4.67, p < .001). However, because caregiver physical functioning and pain levels worsened, they were similar to or below normative levels on these measures as well as general health, vitality and role-physical at 12 months posttransplant. Pain level was significantly worse than the normative level (t = 2.05, p = .041; all other p's > .05).

Predictors of Caregiver HRQOL at 12 months posttransplantation

Table 3 shows the results of regression analyses examining whether caregivers’ background, psychosocial characteristics and their HRQOL early posttransplant predicted their HRQOL at 12 months posttransplant. As would be expected, HRQOL at 2 months posttransplant was a strong predictor of 12-month caregiver HRQOL. However, even beyond this variable, there were other significant predictors. These predictors were generally more related to physical than mental or social components of HRQOL. Among the demographic variables, younger caregivers reporting better general health, physical functioning and fewer role performance limitations due to physical problems. Among the psychosocial resources, greater optimism predicted greater vitality and a stronger sense of mastery shortly after transplant predicted greater general health and mental health. Among caregiver burden variables, less activities impairment predicted better physical functioning, and less perceived personal burden was associated with greater vitality and less bodily pain.

Table 3.  Standardized regression coefficients indicating effects of demographic, psychosocial resources and perceived caregiver burden factors on HRQOL at 12 months posttransplant (controlling for HRQOL at 2 months posttransplant)
Potential predictors1,2Quality of life measures
General healthPhysical functioningVitalityBodily painRole physicalRole emotionalSocial functioningMental health
  1. *p < 0.05; **p < 0.01; ***p < 0.001 (Note: specific p values for each coefficient are available from the first author upon request.)

  2. 1All models examining potential risk factors controlled for transplant group (lung vs heart recipients; no significant effects). Additional demographic characteristics (race/ethnicity, occupation, type of relationship with recipient), patient health characteristics (physical functional status, length of hospital stay posttransplant, occurrence of acute graft rejection) and posttransplant caregiver psychosocial characteristics (active coping, support/emotional expression coping, acceptance coping, friend support, caregiving tasks related to household management) showed small bivariate associations with all HRQOL outcomes variables (r or phi <0.20).

  3. Thus, they were not included in the multivariate models.

  4. 2Caregivers had missing data on: family support (n = 8), nursing tasks (n = 4).

Caregiver demographics
 Age, younger0.21**0.22**−*0.030.00−0.02
 Gender, female0.080.06−0.02−**0.00−0.02
 Education, >high school0.16**−0.01
 Income, >$39 9990.030.17**0.00
R 2
F (df = 5, 201)4.04**6.23***0.432.93*1.842.201.500.12
Caregiver psychosocial resources
 Optimism, higher0.090.110.18*
 Mastery, higher0.15*0.02−0.110.01−**
 Relationship with recipient, better−0.01−0.080.07−0.08−0.050.02−0.060.03
 Family support, better0.08−0.03−
Caregiver burden variables
 Nursing tasks, more0.02−0.04−−0.09−0.08−0.05
 Activities impairment, greater−0.01−0.17*−0.02−0.03−−0.08
 Personal burden, greater−0.07−0.03−0.18*−0.16*−0.08−0.13−0.11−0.02
 Caregiver HRQOL at 2 months post0.45***0.44***0.29***0.43***0.19*0.18*0.19**0.26**
Increment to R20.270.240.330.
F (df = 8, 193)10.06***9.30***11.92***8.00***2.29*3.63**3.31**7.27***

Caregiver HRQOL as a predictor of transplant recipients’ survival time

These analyses examined whether poorer caregiver HRQOL at 12 months posttransplant predicted reduced patient survival time through 7.5 years posttransplantation, controlling for other patient-related characteristics (see Methods). The parameters of caregivers’ HRQOL that we included were the SF-36 physical health scales, encompassing general health, physical functioning, vitality, bodily pain and role-physical. We excluded other caregiver HRQOL scales for two reasons. First, on average, caregivers did not show poor HRQOL in these areas (they significantly exceeded normative levels, as noted earlier). Second, we had to limit the number of predictors included because we did not have a sufficient ratio of events to predictor variables to examine all possible predictors (60,61).

Results indicated that the set of predictors contributed significantly to explaining time to mortality (improvement in fit over null model, χ2 (10) = 32.13, p <.001; see Table 4). Type of transplant and patients’ own physical functional status at 12 months posttransplant were both significant predictors of mortality: lung recipients were over twice as likely to die during the follow-up period as heart recipients, and for every 1 point decline in patients’ SF-36 physical functioning scores, patients’ risk of death was increased by 2% during the follow-up period. Beyond these effects, caregiver general health was also a significant, independent predictor of patients’ mortality risk. Thus, for every 1 point decline on the caregiver general health subscale, patients’ mortality risk increased by 2%. Analogously, for each 5-point decline on the caregiver general health subscale (the size of the change on the SF-36 scales that has been suggested to indicate a clinically important change; 62), patient mortality rates worsened by 10%.

Table 4.  Hazard ratios of patient and caregiver factors as a predictor of transplant recipient's survival time up to 8 years posttransplant
Potential predictorsSurvival time
HRConfidence intervalp Value
  1. 1Ordinal variable defined as in Table 1.

  2. 2Higher score = better functioning/HRQOL.

Patient age, older0.990.97, 1.020.549
Type of transplant, lung2.281.32, 2.270.003
Length of hospital stay posttransplant11.110.89, 1.370.361
Patient physical functioning, 1-year posttransplant20.980.97, 0.990.001
Relationship to caregiver, spouse0.780.40, 1.480.439
Caregiver's general health (SF-36)20.980.96, 0.990.025
Caregiver's physical functioning (SF-36)21.010.99, 1.030.322
Caregiver's vitality (SF-36)21.000.99, 1.020.754
Caregiver's bodily pain (SF-36)21.011.00, 1.030.131
Caregiver's role physical (SF-36)21.000.99, 1.010.876

The impact of caregiver general health on patient mortality is shown graphically in Figure 2 in which we arbitrarily divided caregivers’ scores into 5 levels (scores of 0–20, 21–40, 41–60, 61–80 and 81–100) for illustrative purposes (because we considered the measure as a continuous variable in the analyses). The poorer the caregivers’ general health score, the poorer the patients’ survival time. Because 24 caregivers had withdrawn consent by 1-year posttransplant, these survival analyses are based only on caregivers remaining in the cohort. However, we examined whether patient survival time among these 24 caregivers differed from those who remained in the study and we found no differences in patient survival time between these groups.


Figure 2. Proportion of patients surviving as a function of caregivers’ general health scores.

Download figure to PowerPoint


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

To our knowledge, ours is the first study to examine HRQOL in lung transplant recipients’ family caregivers over the first year posttransplant and to identify predictors of their HRQOL. In our sample, which included heart transplant caregivers as well, we found no differences by transplant type but instead observed that our total caregiver sample had HRQOL levels that remained high during the first year posttransplant across most domains, with two important exceptions. Caregivers’ physical functioning and bodily pain worsened over time and was no longer higher than normative levels by the end of the first year. Further, even after controlling for earlier HRQOL, we found that several demographic factors, psychosocial resources and caregiver burden variables significantly predicted caregivers’ HRQOL by the end of the first year posttransplant, which attests to their robust effect on the outcome. Namely, we found that younger age, greater optimism, a stronger sense of mastery, lower activities impairment and less perceived personal burden were each independently associated with different aspects of caregivers’ HRQOL.

Our results indicate that transplant teams should identify caregivers who may be at risk for poorer HRQOL (namely, those with high perceived burden or low levels of psychosocial resources) to maximize positive outcomes for the entire family after transplant. Caregivers who are identified with these risk factors may be targeted for increased psychosocial support from the transplant team to strengthen their psychosocial resources. For example, support from a therapist or social worker may help caregivers better cope with the burdens they perceive, or they may be provided with resources to get instrumental support with caregiving tasks to help lighten the load. Similarly, psychological or group support may be provided to help boost caregivers’ optimism and mastery levels, such as in-person or online support groups. The costs associated with such care may be justified to avoid future problems for family caregivers, especially given the important role they appear to play in the well-being of transplant recipients based on our own and other's findings (25,29,30,39,40,42,43,45).

Of particular importance, greater impairments in caregiver health perceptions by the end of the first year predicted poorer patient survival, independent of patients’ own health status. We speculate that this may occur because caregivers with poorer health perceptions may be unable to provide needed assistance to their family member so that this individual's health can be maximized. This finding complements and augments previous work with caregivers of lung transplant candidates and other organ recipients that showed the critical role that caregivers play in the health and well-being of transplant recipients and the potential toll that caregiving responsibilities may have on the caregiver (18,21,25,27,29,30,39,40,42,43,45). Future research should examine caregiver health and HRQOL changes beyond the first year posttransplant so that we can further explore potential mechanisms accounting for caregiver HRQOL and patient mortality linkages.

Our findings also indicate that it is important to address the potential impacts of transplant on family caregivers in initial education and counseling efforts by the transplant team (if they don't already do so), and that the team should encourage development of family strategies to protect caregivers’ well-being to maximize patients’ health and longevity. Although transplant teams may already provide this education pretransplant, it may be difficult for families to retain the information or process it completely at the same time that they face the stresses of maintaining the patient's health while they are awaiting a transplant. Even if teams provide this information at discharge, there may not be enough time for families to understand all the information they are receiving, given brief posttransplant hospital stays. We suggest that a new approach may be to develop ongoing educational sessions posttransplant for recipients and their family caregivers to ensure that information is processed and families’ questions and concerns are addressed.

Some study limitations deserve mention. First, because this study was conducted in one transplant center, our findings may lack generalizability. However, our sample of cardiothoracic recipients was similar to national and international data on basic demographics and indications for transplant (63,64), and our caregivers are demographically similar to other transplant caregiver samples (18,19,21,23,24,26,29,30). Another study limitation was that our sample was predominantly European–American, and generalizing to other ethnic groups may not be possible. However, at least for the lung recipient cohort, our sample's ethnicity is similar to that of the US recipient population (63). Yet another limitation may be that we did not include a noncaregiver control group with whom to compare changes in HRQOL over time. However, published results of noncaregiving community-dwelling older adults (65,66) indicate that HRQOL remains stable over time, and shows little variability, particularly over a 1-year period. Thus, we believe that our findings regarding the decline in physical health and pain over the first year posttransplant are more likely due to caregiving demands rather than a function of normative changes over time. Finally, though our study examined the predictive effects of caregiver HRQOL on patient mortality, we could not examine the factors explaining this relationship. It would be important to examine these outcomes in future work. Future work might also consider impact on HRQOL of exiting the caregiver role. Because we chose to focus specifically on individuals who remained as caregivers during the course of the study, we have no information on whether the HRQOL of caregivers who exited the role due to recipient death or by their own choice experienced better or worse HRQOL levels compared to their levels while caregiving.

In sum, among a sample of individuals who served as caregivers during the first year after their family member's transplant, we found that their HRQOL is high and generally remains so during this time. Decrements in caregivers’ physical well-being indicate an important aspect of HRQOL that should be addressed while they are busy caring for their transplant recipient. Finally, our results showed that caregiver HRQOL should be an important concern for transplant teams because of its potential as a risk factor for transplant recipients’ mortality. Directions for future work include replicating our study in other samples to ensure generalizability of findings, tracking the influence of the identified significant factors on caregivers’ HRQOL outcomes, and exploring the mechanisms by which the HRQOL of caregivers may come to predict patient health outcomes in the long-term after transplant.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

Work on this manuscript was supported in part by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Service (IIR-06-220; Myaskovsky, PI), the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK081325; Myaskovsky, PI) and the National Institute of Mental Health (R01 MH59229; Dew, PI).


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Analysis
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Disclosure
  10. References
  • 1
    Canning RD, Dew MA, Davidson S. Psychological distress among caregivers to heart transplant recipients. Soc Sci Med 1996; 42: 599608.
  • 2
    Gibson M, Houser A. Valuing the invaluable: A new look at the economic value of family caregiving. Issue Brief (Public Policy Institute – American Association of Retired Persons) 2007; IB82: 112.
  • 3
    National Alliance for Caregiving and AARP. Caregiving in the US. Bethesda, MD & Washington, DC : AARP Public Policy Institute, 2008.
  • 4
    Beach S, Schulz R, Yee J, Jackson S. Negative and positive health effects of caring for a disabled spouse: Longitudinal findings from the caregiver health effects study. Psychol Aging 2000; 15: 259271.
  • 5
    Gaugler JE, Hanna N, Linder J, et al. Cancer caregiving and subjective stress: A multi-site, multi-dimensional analysis. Psychooncology 2005; 14: 771785.
  • 6
    Halm MA, Treat-Jacobson D, Lindquist R, Savik K. Caregiver burden and outcomes of caregiving of spouses of patients who undergo coronary artery bypass graft surgery. Heart Lung 2007; 36: 170187.
  • 7
    Hauser JM, Chang C-H, Alpert H, Baldwin D, Emanuel EJ, Emanuel L. Who's caring for whom? Differing perspectives between seriously ill patients and their family caregivers. Am J Hosp Palliat Care 2006; 23: 105112.
  • 8
    Link G, Dize V, Folkemer D, Curran C. Family caregiver support: State facts at a glance. Washington, DC : National Association of State Units on Aging and National Conference of State Legislatures, 2006.
  • 9
    Lyons K, Zarit S, Sayer A, Whitlatch C. Caregiving as a dyadic process: Perspectives from caregiver and receiver. J. Gerentol Psychol Sci 2002; 57B: 195204.
  • 10
    Schulz R, Beach S. Caregiving as a risk factor for mortality: The caregiver health effects study. JAMA 1999; 282: 22152219.
  • 11
    von Kanel R, Mausbach BT, Patterson TL, et al. Increased framingham coronary heart disease risk score in dementia caregivers relative to non-caregiving controls. Gerontology 2008; 54: 131137.
  • 12
    Williamson G, Shaffer D. Relationship quality and potentially harmful behaviors by spousal caregivers: how we were then, how we are now: The family relationships in late life project. Psychol Aging 2001; 16: 217226.
  • 13
    Biegel DE, Sales E, Schulz R. Family caregiving in chronic illness: Alzheimer's disease, cancer, heart disease, mental illness, and stroke. Newbury Park, CA : Sage, 1991.
  • 14
    Porter LS, Keefe FJ, Garst J, McBride CM, Baucom D. Self-efficacy for managing pain, symptoms, and function in patients with lung cancer and their informal caregivers: Associations with symptoms and distress. Pain 2008; 137: 306315.
  • 15
    Schulz R, Newsom J, Mittelmark M, Burton L, Hirsch C, Jackson S. Health effects of caregiving: The caregiver health effects study: An ancillary study of the cardiovascular health study. Ann Behav Med 1997; 19: 110116.
  • 16
    Schulz R, O’Brien A, Bookwala J, Fleissner K. Psychiatric and physical morbidity effects of dementia caregiving: Prevalence, correlates, and causes. Gerontologist 1995; 35: 771791.
  • 17
    Bolkhir A, Loiselle MM, Evon DM, Hayashi PH. Depression in primary caregivers of patients listed for liver or kidney transplantation. Prog Transplant 2007; 17: 193198.
  • 18
    Meltzer LJ, Rodrigue JR. Psychological distress in caregivers of liver and lung transplant candidates. Clin Psychol Med Settings 2001; 8: 173180.
  • 19
    Dew MA, Goycoolea JM, Stukas AA, et al. Temporal profiles of physical health in family members of heart transplant recipients: Predictors of health change during caregiving. Health Psychol 1998; 17: 138151.
  • 20
    Dew MA, Myaskovsky L, DiMartini AF, Switzer GE, Schulberg HC, Kormos RL. Onset, timing, and risk for depression and anxiety in family caregivers of heart transplant recipients. Psychol Med 2004; 34: 10651082.
  • 21
    Myaskovsky L, Dew MA, Switzer GE, McNulty ML, DiMartini AF, McCurry KR. Quality of life and coping strategies among lung transplant candidates and their family caregivers. Soc Sci Med 2005; 60: 23212332.
  • 22
    Cetingok M, Hathaway D, Winsett R. Contribution of post-transplant social support to the quality of life of transplant recipients. Soc Work Health Care 2007; 45: 3956.
  • 23
    Cohen M, Katz D, Baruch Y. Stress among the family caregivers of liver transplant recipients. Prog Transpl 2007 17: 4853.
  • 24
    Rodrigue J, Dimitri N, Reed A, et al. Spouse caregivers of kidney transplant patients: Quality of life and psychosocial outcomes. Prog Transpl 2010; 20: 335342.
  • 25
    Stilley C, DiMartini A, de Vera M, et al. Individual and environmental correlates and predictors of early adherence and outcomes after liver transplantation. Prog Transpl 2010; 20: 5866.
  • 26
    Wicks M, Milstead E, Hathaway D. Cetingok M. Family caregivers’ burden, quality of life, and health following patients’ renal transplantation. J Transpl Coord 1998; 8: 170176.
  • 27
    Casida J. The lived experience of spouses of patients with a left ventricular assist device before heart transplantation. Am J Crit Care 2005; 14: 145151.
  • 28
    Green MR. Coping and mental health among patients with end-stage pulmonary disease and primary caregivers. Columbus, OH : Ohio State University, 2010.
  • 29
    Lewis Claar R, Parekh PI, Palmer SM, et al. Emotional distress in quality of life in caregivers of patients awaiting lung transplant. J Psychosom Res 2005; 59: 16.
  • 30
    Rodrigue JR, Baz MA. Waiting for lung transplantation: Quality of life, mood, caregiving strain and benefit, and social intimacy of spouses. Clin Transpl 2007; 21: 722727.
  • 31
    Chaparro C, Scavuzzo M, Winton T, Keshavjee S, Kesten S. Status of lung transplant recipients surviving beyond five years. J Heart Lung Transpl 1997; 16: 511516.
  • 32
    Gross C, Savik K, Bolman R, Hertz M. Long-term health status and quality of life outcomes of lung transplant recipients. Chest 1995; 108: 15871593.
  • 33
    Gross CR, Raghu G. The cost of lung transplantation and the quality of life post-transplant. Clin Chest Med 1997; 18: 391403.
  • 34
    Limbos MM, Joyce DP, Chan CKN, Kesten S. Psychological functioning and quality of life in lung transplant candidates and recipients. Chest 1997; 112: 11651174.
  • 35
    MacNaughton K, Rodrigue J, Cicale M, Staples EM. Health-related quality of life and symptom frequency before and after lung transplantation. Clin Transpl 1998; 12: 320323.
  • 36
    Rodrigue JR, Baz MA, Kanasky WF, MacNaughton KL. Does lung transplantation improve health-related quality of life? The University of Florida experience. J Heart Lung Transpl 2005; 24: 755763.
  • 37
    TenVergert EM, Essink-Bot M-L, Geertsma A, van Enckevort PJ, de Boer WJ, van der Bij W. The effect of lung transplantation on health-related quality of life: A longitudinal study. Chest 1998; 113: 358364.
  • 38
    Dew MA, Manzetti JD, Goycoolea JM, et al. Psychosocial aspects of transplantation. In: Smith S, Ohler L, eds. Organ transplantation: Concepts, issues, practice and outcomes. New York : Medscape Transplant, WebMD, Inc., 2002.
  • 39
    Dew MA, Switzer GE, Dimartini AF, Matukaitis J, Fitzgerald MG, Kormos RL. Psychosocial assessments and outcomes in organ transplantation. Prog Transpl 2000; 10: 239259.
  • 40
    Goetzmann L, Klaghofer R, Wagner-Huber R, et al. Psychosocial vulnerability predicts psychosocial outcome after an organ transplant: Results of a prospective study with lung, liver, and bone-marrow patients. J Psychosom Res 2007; 62: 93100.
  • 41
    Myaskovsky L, Dew M, McNulty M, et al. Trajectories of change in quality of life in 12-month survivors of lung or heart transplant. Am J Transpl 2006; 6: 19391947.
  • 42
    Chisholm-Burns M, Spivey C, Wilks S. Social support and immunosuppressant therapy adherence among adult renal transplant recipients. Clin Transpl 2010 24: 312320.
  • 43
    Tong A, Howell M, Wong G, Webster A, Howard K, Craig J. The perspectives of kidney transplant recipients on medicine taking: A systematic review of qualitative studies. Nephrol Dial Transpl 2011; 26: 344354.
  • 44
    Xu J, Adeboyejo O, Wagley E, et al. Daily burdens of recipients and family caregivers after lung transplantation. Prog Transpl 2012; 22: 4148.
  • 45
    Telles-Correia D, Barbosa A, Mega I, Barroso E, Monteiro E. Psychiatric and psychosocial predictors of medical outcome after liver transplantation: A prospective, single-center study. Transpl Proc 2011; 43: 155157.
  • 46
    Einollahi B, Taheri S, Nemati E, Abbaszadeh S, Pourfarziani V, Nourbala M. Burden among caregivers of kidney transplant recipients and its associated factors. Saudi J Kid Disease Transpl 2009; 20: 3034.
  • 47
    Ware J, Snow K, Kosinski M, Gandek B. SF-36 Health Survey: Manual and interpretation guide. Boston : The Health Institute, New England Medical Center, 1993.
  • 48
    McHorney C, Ware J, Lu J. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 1994; 32: 40–66.
  • 49
    Scheier MF, Carver CS. Optimism, coping, and health: Assessment and implications of generalized outcome expectancies. Health Psychol 1985; 4: 219247.
  • 50
    Pearlin L, Schooler C. The structure of coping. J Health So Behav 1978; 19: 221.
  • 51
    Spanier G. Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. J Marriage Family 1976; 38: 15–30.
  • 52
    Dew MA, Ragni M, Nimorwicz P. Infection with human immunodeficiency virus and vulnerability to psychiatric distress: A study of men with hemophilia. Arch Gen Psychiat 1990; 47: 737744.
  • 53
    Carver C. You want to measure coping but your protocol's too long: Consider the brief COPE. Int J Behav Med 1997; 4: 92100.
  • 54
    Carver C, Scheier M, Weintraub J. Assessing coping strategies: A theoretically based approach. J Pers Soc Psychol 1989; 56: 267283.
  • 55
    Montgomery R, Gonyea J, Hooyman N. Caregiving and the experience of subjective and objective burden. Family Rel 1985; 34: 1936.
  • 56
    Whitlatch C, Zarit S, von Eye A. Efficacy of interventions with caregivers: A reanalysis. The Gerontologist 1991; 31: 914.
  • 57
    Laird N, Ware J. Random-effects models for longitudinal data. Biometrics 1982; 38: 963974.
  • 58
    SPSS. SPSS Advanced Models 11.5. Chicago, IL : SPSS Inc., 2002.
  • 59
    Tabachnick BG, Fidell LS. Using multivariate statistics (5th Edition). Boston, MA : Allyn and Bacon, 2007.
  • 60
    Peduzzi P, Concato J, Feinstein A, Holford T. Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. J Clin Epidemiol 1995; 48: 15031510.
  • 61
    Vittinghoff E, McCulloch C. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007; 165: 710718.
  • 62
    Samsa G, Edelman D, Rothman ML, Williams GR, Lipscomb J, Matchar D. Determining clinically important differences in health status measures: A general approach with illustration to the Health Utilities Index Mark II. Pharmacoeconomics 1999; 15: 141155.
  • 63
    OPTN/SRTR. 2010 Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR) Annual Report: Transplant Data 2000–2009. Rockville, MD : Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, 2011.
  • 64
    Christie JD, Edwards LB, Kucheryavaya AY, et al. The registry of the International Society for Heart and Lung Transplantation: Twenty-eight adult lung and heart-lung transplant report – 2011. J Heart Lung Transpl 2011; 30: 11041122.
  • 65
    Der-Martirosian C, Kritz-Silverstein D, Barrett-Connor E. Fiver-year stability in associations of health-related quality of life measures in community-dwelling older adults: The Rancho Bernardo Study. Qual Life Res 2010; 19: 13331341.
  • 66
    Richardson J, Chan D, Risdon K, Giles C, Mulveney S, Cripss D. Does monitoring change in function in community-dwelling older adults alter outcome? A randomized controlled trial. Clin Rehab 2008; 22: 10611070.