European Journal of Cardiovascular Prevention

& Rehabilitation
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Is the MacNew quality of life questionnaire a useful diagnostic and evaluation instrument for cardiac
rehabilitation?
Stan Maes, Véronique De Gucht, Rick Goud, Irene Hellemans and Niels Peek
European Journal of Cardiovascular Prevention & Rehabilitation 2008 15: 516
DOI: 10.1097/HJR.0b013e328303402b

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 Original Scientific Paper

Is the MacNew quality of life questionnaire a useful

diagnostic and evaluation instrument for cardiac
rehabilitation?
Stan Maesa, Véronique De Guchta, Rick Goudb, Irene Hellemansb
and Niels Peekb

a
Health Psychology, Leiden University and bDepartment of Medical Informatics, Academic Medical Center,
Universiteit van Amsterdam, Amsterdam, The Netherlands
Received 26 October 2007 Accepted 3 April 2008

Purpose The MacNew health-related quality of life questionnaire is internationally used as a standard for psychosocial
assessment in many cardiac rehabilitation centres. This study investigates its discriminating capacity between diagnostic
disease categories, sex and age at entry (T1) and at the end (T2) of cardiac rehabilitation as well as the responsiveness of
the MacNew during this period.
Method Data were used from 6749 cardiac rehabilitation patients at T1 and 1654 at T2.
Results Results show that the global MacNew as well as the three (physical, emotional, social) subscales have high
internal consistencies, and differentiate well and in the expected direction at T1 between diagnostic groups (heart surgery,
myocardial infarction with and without percutaneous coronary intervention, stable angina with and without percutaneous
coronary intervention, implantable cardioverter defibrillator, and heart failure patients), sex and age. The MacNew also
proves to be an adequate evaluation instrument for cardiac rehabilitation, as all scales are responsive enough to capture
changes from T1 to T2. At T2, however, the MacNew seems to lose some of its discriminating power, partly because of
ceiling effects.
Conclusion It is suggested to complement the use of the MacNew both at T1 and T2 with a brief anxiety and depression
measure, which is valid and responsive for different groups of cardiac rehabilitation patients. Eur J Cardiovasc Prev Rehabil
15:516–520 c 2008 The European Society of Cardiology

European Journal of Cardiovascular Prevention and Rehabilitation 2008, 15:516–520

Keywords: cardiac rehabilitation, psychosocial outcomes, quality of life, screening, sex

Introduction HRQL for one disease in particular. The main advantage

Health-related quality of life (HRQL) refers to physical,
emotional, and social well-being, and can as such be an
important indicator of the impact of a disease and/or
treatment effects [1]. The assessment of a patient’s
HRQL gives an indication of his or her (restoration of)
well-being and the likelihood of returning to former daily
activities and social life [2]. It is important to distinguish
between generic and disease-specific HRQL measures.
Generic instruments assess HRQL across a variety of
diseases. Specific instruments are developed to assess
Correspondence to Stan Maes, MSc, PhD, Professor of Health Psychology,
Leiden University, Wassenaarse weg 52, PO Box 9555, 2300 RB Leiden,
The Netherlands
Tel: + 31 71 527 3737; fax: + 31 71 527 4678; e-mail: maes@fsw.leidenuniv.nl
1741-8267
c 2008 The European Society of Cardiology
Downloaded from cpr.sagepub.com at Universiteit Leiden \ LUMC on June 10, 2013
of generic measures is that they allow for comparisons
between diseases, whereas disease-specific measures
usually differentiate better between patients within a
specific-disease category and are more responsive (detect
more easily change over time and/or as a result of
treatment) than generic ones [1]. For this reason, it has
been suggested to use both types of instruments in
combination [3]. Although this compromise seems
reasonable, there is a growing need for instruments that
are not only valid and reliable, but also short and easy to
complete and to interpret [1]. The combined use of
various instruments does not meet this need. For cardiac
rehabilitation patients, this would imply the use of a
generic instrument such as the Sickness Impact Profile
DOI: 10.1097/HJR.0b013e328303402b

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

consisting of 136 items or at least the Short Form Health
Survey next to a different specific instrument for each
disease category [4].
The impracticality of using a combination of instruments
for psychosocial assessment, together with the absence of
clear guidelines, possibly contributed to a lack of
psychosocial assessment, or, when systematic assessment
did take place, to idiosyncratic procedures. To simplify
and standardize the assessment of patients for cardiac
rehabilitation, national guidelines were developed in The
Netherlands [5]. These guidelines recommend a needs
assessment and therapy indication procedure on the basis
of the patient’s medical condition, physical condition,
emotional condition, social condition, and risk behavior. A
computerized patient information management system,
called Cardiac Rehabilitation Decision Support System,
was developed to assist professionals in implementing the
guidelines in practice. The system stores all relevant
criteria for each patient and provides assistance in
decision making.
With regard to the assessment of psychosocial functioning
at entry of cardiac rehabilitation (about 2 weeks after
discharge), the guidelines recommend administering the
MacNew HRQL questionnaire [6]. This instrument was
chosen, because, according to experts, it could be
administered to various diagnostic groups, such as heart
surgery (HS), including patients with prosthetic valve or
valve repair surgery and coronary artery bypass grafting,
implantable cardioverter defibrillator (ICD) patients,
myocardial infarction (MI) patients with and without
percutaneous coronary intervention (MI + ), patients
with stable angina pectoris (AP) with and without
percutaneous coronary intervention (AP + ), and patients
with heart failure (HF), New York Heart Association class
II and III (HF). The MacNew has already been
demonstrated to be valid, reliable, and responsive in
patients with MI, AP [6–10], and coronary artery bypass
grafting [11].
The present study investigates whether the decision to
use the MacNew as a diagnostic instrument for all cardiac
rehabilitation patients is justified. To this end, the
discriminating power of the MacNew, that is, the capacity
of the MacNew to differentiate between different
diagnostic disease categories, sex, and age groups was
investigated. In addition, the usefulness of the MacNew
as an evaluation instrument for the cardiac rehabilitation
period was explored.
Methods
Data was collected prospectively with a computerized
patient information management system (Commands
Architecture Repository and Decision Support Source)
in 19 cardiac rehabilitation outpatient clinics in The
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
MacNew quality of life questionnaire Maes et al. 517
Netherlands. Each participating clinic used the system on
a routine basis for at least 6 months between 1 January
2005 and 31 March 2007. For each patient referred to
cardiac rehabilitation, the system recorded demographic
data, diagnosis, and some lifestyle parameters (smoking,
exercise, and diet). In addition, the system could be used
to assess HRQL with the MacNew. To prevent a
selection bias, only data were included from clinics where
the questionnaire was filled in for at least 70% of the
patients before their rehabilitation trajectory (T1). To
assess the discriminating power and the responsiveness of
the MacNew during and at the end of cardiac rehabilita-
tion, data were used from all patients where, in addition,
the MacNew was assessed a second time at average 3
months after the onset of rehabilitation (T2).
To check the internal consistency of the three subscales
and the global scale for all patient groups, Cronbachs’ a
was calculated. One-way analyses of variance (ANOVA)
and t tests were used to explore differences. To
determine whether changes over time were clinically
important, the standardized response mean (SRM) was
calculated. The SRM is the mean change in scores over
time divided by the SD of the change. An SRM or effect
size of 0.2–0.5 is called a small change, 0.5–0.8 a moderate
change, and a change of 0.8 or higher a strong change [9].
The Dutch validated version of the MacNew is compar-
able to the English version and consists of 26 items
related to three domains of HRQL, namely physical (11
items), emotional (10 items), and social HRQL (seven
items). Each of the items is rated on a 7-point Likert
scale, where ‘1’ indicates poor and ‘7’ indicates good
HRQL. Scores are calculated by averaging the responses
to the items of each domain, whereas averaging all items
provides a global score [9].
Research questions
(1) Do the subscales (physical/emotional/social HRQL)
and the global score of the MacNew have an
acceptable internal consistency within each of the
main disease groups (ICD, HS, MI + , AP + , and
HF) that qualify for cardiac rehabilitation? These
disease groups were defined by one of the authors,
a cardiologist (I.H.), on the basis of available
diagnoses.
(2) (i) Do these subscales (and the global score)
differentiate between these disease groups both at
the start and at the end of the cardiac rehabilitation
phase? (ii) Do they differentiate between male and
female patients, and (iii) between younger (less than
65 years) and older (65–75 and 75 + years) patients?
On the basis of existing empirical findings [9–12],
it is expected that HS and MI + patients report
a higher HRQL than patients with AP + , ICD, and
HF and that AP + patients report, in turn, a higher
 518 European Journal of Cardiovascular Prevention and Rehabilitation 2008, Vol 15 No 5

HRQL than patients with ICD and HF. For the same
reason [9,13–15], it is expected that female patients
report a lower HRQL than male patients, and that
patients in between 65 and 75 years of age report a
higher HRQL than younger and older patients.
(3) Are the subscales and the global HRQL score
responsive (sensitive for change over time and/or as
the result of treatment) for all disease groups during
the cardiac rehabilitation phase? It is expected that
all disease groups will improve during the cardiac
rehabilitation period.
Results
Table 1 presents the number of patients divided in sex
and age groups both at T1 and T2 for the total population
and the five disease categories. Table 2 provides the mean
scores and SDs for physical, emotional, social, and total
HRQL scores for the total patient population and all
diagnostic subgroups at T1 and T2.
Research question 1: internal consistencies
Cronbachs’ a for the total patient group and the different
subgroups (ICD, HS, MI + , AP + , and HF) of cardiac
rehabilitation patients, range from 0.85 to 0.88 at T1 and
from 0.86 to 0.88 at T2 for physical, from 0.90 to 0.92 at T1
and from 0.88 to 0.92 at T2 for emotional, from 0.78 to 0.81
at T1 and from 0.78 to 0.87 at T2 for social, and from 0.92
to 0.93 at T1 and from 0.92 to 0.95 at T2 for global HRQL.
Research question 2: discriminating power between
diagnostic groups, sex, and age
Differences in HRQL between diagnostic groups
(research question 2a) both at T1 and at T2 were
explored by means of ANOVA. At T1, there were
significant differences between the five diagnostic groups
for the physical [F(4,6057) = 14.55; P < 0.001],
emotional [F(4,6057) = 15.07; P < 0.001], social [F(4,
6057) = 8.34; P < 0.001], and the global HRQL scores
[F(4,6057) = 10.62; P < 0.001]. Post-hoc tests (Bonferr-
oni and Games–Howell) revealed that for physical
HRQL, HF patients scored significantly lower than all
other diagnostic groups, whereas HS patients and AP +
patients scored significantly lower than patients with
MI+. For emotional HRQL, HS patients and MI +
patients scored significantly higher than ICD, AP +, and
HF patients. For social HRQL, MI + patients scored
significantly higher than patients with ICD, HS, and HF,
and patients with AP + scored significantly higher than
ICD and HF patients. Finally, for global HRQL, MI +
patients scored significantly higher than ICD, AP + , and
HF patients, HS patients scored significantly higher than
AP + and HF patients, and AP + patients scored
significantly higher than HF patients.
At T2, there were significant differences between the five
diagnostic groups for physical [F(4,1600) = 4.90;
P < 0.01], emotional [F(4,1600) = 3.53; P < 0.01], social
[F(4,1600) = 4.27; P < 0.01], and global HRQL scores
[F(4,1600) = 4.31; P < 0.01]. Post-hoc tests (Bonferroni
and Games–Howell) revealed that for physical HRQL HF
patients scored significantly lower than HS and MI +
patients. For emotional HRQL, AP + patients scored
significantly lower than HS patients, and HF patients
scored significantly lower than HS patients on global
HRQL. It is important to note that overall scores are
relatively high at this measurement point, for example, for
the total study population, the mean score for physical
HRQL is 5.58, for emotional HRQL is 5.51, for social
HRQL is 5.96, and for global HRQL is 5.64, whereas the
maximum score is 7 for all scales.
T-tests revealed significant sex differences (research
question 2b) in favour of men for the total patient
sample at T1 on physical (t = 12.49; df = 6286; P < 001),
emotional (t = 14.44; df = 6286; P < 0.001), social
(t = 7.94; df = 6286; P < 0.001), and global HRQL scores
(t = 12.96; df = 6286; P < 0.001). Similar significant sex
differences were found for HS, MI + , and AP + patients,
but for ICD and HF patients no significant differences
were found.
At T2, there was a significant sex difference in favour of
men for the global patient population on the physical
(t = 3.45, df = 1652, P < 0.001), emotional (t = 4.97;
df = 1652; P < 0.001), and the global HRQL scales
(t = 3.42; df = 1652; P < 0.001), but not on the social
HRQL scale. Similar sex differences were found for HS

Table 1 Number (N) of patients at T1 and T2, divided in sex and age groups, for the total patient sample and the five diagnostic categories
T1 T1 T2 T2

Sex Age (years) Sex Age (years)

W M N < 65 65–75 > 75 W M N < 65 65–75 > 75

All patients 1670 5079 6749 4079 1923 594 396 1258 1654 1026 491 107
Implantable cardioverter defibrillator 31 108 139 99 32 5 6 28 34 24 8 2
Heart surgery 544 1904 2448 1209 902 265 166 511 677 335 276 54
Myocardial infarction ± PCI 673 2049 2722 1806 39 228 141 489 630 453 131 34
Angina pectoris ± PCI 273 790 1063 728 257 57 54 176 230 161 56 9
Heart failure 53 81 134 74 37 20 11 23 34 20 7 5

PCI, percutaneous coronary intervention; M, men; W, women.

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 MacNew quality of life questionnaire Maes et al. 519

Table 2 MacNew scores (standard deviations) and change (t scores and SRM) between entry (T1) and end (T2) of cardiac rehabilitation for
the total sample and different patient groups
Physical HRQL Emotional HRQL Social HRQL Global HRQL

T1 T2 T1 T2 T1 T2 T1 T2

All (N = 1654) 4.77 5.58 4.98 5.51 5.32 5.96 5.02 5.64
(1.08) (0.95) (1.11) (0.96) (1.04) (0.89) (0.95) (0.85)
t = – 35.22** t = – 23.72** t = – 28.47** t = – 32.92**
SRM = 0.82 SRM = 0.56 SRM = 0.70 SRM = 0.81
Implantable cardioverter defibrillator (N = 34) 4.56 5.22 4.89 5.37 5.09 5.66 4.88 5.38
(1.07) (0.94) (1.14) (1.04) (1.11) (1.03) (0.99) (0.86)
t = – 4.54** t = – 2.90* t = – 3.91** t = – 4.03**
SRM = 0.77 SRM = 0.50 SRM = 0.67 SRM = 0.68
Heart surgery (N = 677) 4.71 5.65 5.05 5.61 5.24 6.00 5.02 5.72
(1.04) (0.92) (1.07) (0.91) (1.01) (0.84) (0.91) (0.80)
t = – 26.44** t = – 16.54** t = – 22.07** t = – 24.53**
SRM = 1.02 SRM = 0.63 SRM = 0.84 SRM = 0.95
Myocardial infarction ± PCI (N = 630) 4.91 5.60 5.02 5.48 5.44 5.97 5.11 5.64
(1.09) (0.97) (1.11) (0.99) (1.04) (0.90) (0.95) (0.87)
t = – 19.14** t = – 12.63** t = – 14.64** t = – 17.66**
SRM = 0.76 SRM = 0.51 SRM = 0.58 SRM = 0.71
Angina pectoris ± PCI (N = 230) 4.78 5.51 4.76 5.40 5.41 5.97 4.95 5.58
(1.11) (0.91) (1.12) (0.94) (1.01) (0.86) (0.97) (0.82)
t = – 11.69** t = – 10.56** t = – 9.64** t = – 12.06**
SRM = 0.77 SRM = 0.70 SRM = 0.63 SRM = 0.80
Heart failure (N = 34) 4.26 5.08 4.76 5.24 4.77 5.44 4.63 5.24
(0.90) (1.01) (1.15) (1.01) (1.22) (1.16) (0.94) (0.98)
t = – 5.26** t = – 2.96* t = – 3.37* t = – 4.18**
SRM = 0.90 SRM = 0.51 SRM = 0.58 SRM = 0.72

*P < 0.01; **P < 0.001. HRQL, health-related quality of life; PCI, percutaneous coronary intervention; SRM, standardized response mean; ± , with or without.

patients. For MI + patients, a similar sex difference was
found for emotional HRQL. Finally, male AP + patients
scored higher than female patients on social HRQL only.
No differences were calculated for ICD and HF because
of small sample sizes.
ANOVAs were used to explore differences between the
three age groups (research question 2c): those younger
than 65 years, from 65 to 75 years, and older than 75 years.
At T1, significant differences were found in the total
patient sample between age groups for the global HRQL
score [F(2, 6146) = 11.43; P < 0.001], physical [F(2,
6146) = 3.56; P < 0.05], emotional [F(2, 6146) = 13.07;
P < 0.001], and social HRQL [F(2, 6146) = 9.93;
P < 0.001]. Post-hoc tests (Bonferroni and Games–Howell)
revealed significant differences between patients younger
than 65 years and between 65 and 75 years in favour of the
latter for the global HRQL scale and all three subscales.
With the exception of a significant difference between
patients younger than 65 years and older than 75 years for
social HRQL in favour of patients older than 75 years, no
other significant differences were found. Comparable
significant differences were found for MI + patients. For
AP + patients, significant differences were found between
patients younger than 65 years and those between 65 and
75 years only. For HS patients, no significant age
differences were found. Differences for ICD and HF were
not calculated because of the small sample sizes.
At T2, significant age differences were found for AP +
patients only on global HRQL [F(2,223) = 9.18;
P < 0.001], physical [F(2,223) = 6.16; P < 0.01], emo-
tional [F(2, 223) = 10.60; P < 0.001], and social HRQL
scores [F(2, 223) = 5.75; P < 0.01]. Post-hoc tests
revealed that patients between the ages of 65 and
75 years scored significantly higher on all HRQL scales
than those younger than 65 years, whereas patients older
than 75 years scored also significantly higher on global
and emotional HRQL than patients younger than 65
years. Differences for ICD and HF were not calculated
because of sample size.
Research question 3: sensitiveness for change
Significant improvement was found for the total cardiac
rehabilitation patient sample and for each of the five
diagnostic subcategories (ICD, HS, MI + , AP + , and
HF) separately on physical, emotional, social, and global
HRQL. The SRM’s or effect sizes range from moderate
to high (Table 2).
Discussion
The total HRQL scale and the three subscales (physical,
emotional, and social HRQL) of the MacNew have high
internal consistencies at both measurement points, and
discriminate well and in the expected direction between
the diagnostic groups, sex, and age at the start of cardiac
rehabilitation. Results show that, as expected, at T1
MI + and HS patients have the highest scores after
AP + patients, who score, in turn, higher than ICD and
HF patients, but at T2 several of these differences
disappear. In addition, as expected, in the total sample,
at both measurement moments, men score higher than
women. Comparable sex differences are found for MI+,

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 520 European Journal of Cardiovascular Prevention and Rehabilitation 2008, Vol 15 No 5
HS (T1 and T2), and AP + (T1 only) patients. Finally, at
T1, in the total sample, patients younger than 65 years
score lower than patients in between 65 and 75 years of
age, but generally do not differ in score from patients
older than 75 years, possibly because of the small number
of patients in this last group. This is also true for MI +
and AP + patients. At T2, however, with the exception of
AP + patients, no significant age differences were found.
The MacNew also seems to be a suitable evaluation
instrument for cardiac rehabilitation, as all subscales are
responsive enough to capture changes over this period:
SRM’s for physical, emotional, social, and global HRQL
range from moderate to strong for the total sample and
the various diagnostic groups. These results for the first
time show that the MacNew is a HRQL questionnaire
with the capacity to evaluate relevant changes for all
diagnostic groups during cardiac rehabilitation.
It seems, however, that the MacNew lost some of its
discriminating power at the end of the cardiac rehabilita-
tion period. At this stage, the scores differentiate less
between the different diagnostic groups, age, and even
sex, possibly because of ceiling effects and type II errors
owing to multiple Bonferroni post-hoc tests. As a
consequence, it is advisable to complement the MacNew
with other psychosocial assessment instruments for
diagnostic purposes at the end of cardiac rehabilitation.
As anxiety and depression are linked to social reintegra-
tion problems, lower quality of life and possibly disease
progression [4,8], brief anxiety, and depression measures
would be good candidates.
As the MacNew was not developed for this, additional
screening for anxiety and depression by means of other
instruments is also advised at entry of cardiac rehabilita-
tion. For this purpose, the depression and anxiety scales
of the SCL-90 and the Hospital Anxiety and Depression
Scale are frequently used, next to the Beck Depression
Inventory and the Hamilton Depression Rating Scale for
depression and the State Trait Anxiety Inventory for
anxiety, but they lack validity for a cardiac rehabilitation
population [4,16]. Among these measures, the Hospital
Anxiety and Depression Scale seems to be the most
suitable, as it has been developed for medically ill
patients [17]. Both from a clinical and pragmatic
perspective, however, brief measures that are based
on DSM IV criteria and have good construct validity
in a cardiac population, such as the Depression in the
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Medically Ill-10 (DMI-10) or Depression in the Medi-
cally Ill-18, are more promising [18].
In conclusion, despite its discriminating power at entry of
cardiac rehabilitation and its responsiveness during the
cardiac rehabilitation period, assessment with the Mac-
New should be complemented by brief measures of
anxiety and depression, which are valid for cardiac
rehabilitation patients, both at entry and at the end of
cardiac rehabilitation.
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