Chances of survival after major surgery may be better among married vs unmarried persons,1,2 but little is known regarding the association between marital status and postoperative function. Characterizing the association between marital status and postoperative function may be useful for counseling patients and identifying at-risk groups that may benefit from targeted interventions aimed at improving functional recovery.
Methods
We used data from the University of Michigan Health and Retirement Study (http://hrsonline.isr.umich.edu), a longitudinal panel survey that has enrolled 29 053 adults 50 years of age or older since 1998. The Health and Retirement Study participants undergo interviews every 2 years regarding health, functioning, medical care, and family structure. We used data from the 2004, 2006, 2008, and 2010 waves of the Health and Retirement Study; our sample included surviving participants who reported having undergone cardiac surgery in the interval since the preceding interview and deceased participants for whom proxies reported a cardiac surgery since the last interview. This study was exempted from review by the University of Pennsylvania institutional review board. Participants in the Health and Retirement Study provided written informed consent at the time of enrollment.
We collected information on marital status, age, sex, and comorbidities as recorded at enrollment and in the last interview before surgery. We also collected information on preoperative dependence in 6 activities of daily living: dressing, ambulation, bathing, eating, toileting, and getting in and out of bed. Our end point was a combined outcome of death or new dependence in 1 or more activities of daily living at the postsurgery interview. We used the χ2 test and the Kruskal-Wallis test to compare the distribution of patient characteristics at baseline, and we used logistic regression to test the association of marital status with postoperative death or new functional dependence after accounting for baseline characteristics. We used P < .05 to indicate statistical significance.
Results
Our study sample included 1576 participants; at the time of the baseline interview, 1026 (65.1%) were married, 184 (11.7%) were divorced or separated, 331 (21.0%) were widowed, and 35 (2.2%) were never married. Married participants were more likely to be male and to demonstrate lower degrees of comorbidity and disability before surgery (Table 1). Forty-five patients (2.9%) died before the next Health and Retirement Study interview; 326 (20.7%) survived but developed new dependence in at least 1 activity of daily living. At the postsurgery interview, 199 of the 1016 married participants (19.4%), 53 of the 184 divorced or separated individuals (28.8%), 112 of the 331 widowed participants (33.8%), and 7 of the 35 participants who had never been married (20.0%) had either died or developed a new disability (P < .001); we did not observe statistically significant differences in mortality according to marital status. Marital status remained significantly associated with death or a new functional disability after accounting for baseline characteristics (Table 2). Compared with participants who were married at baseline, the odds ratio for death or a new functional disability was 1.55 among divorced or separated participants (95% CI, 1.06-2.28; P = .02) and 1.60 among participants who were widowed at baseline (95% CI, 1.15-2.23; P = .01).
Table 1.
Baseline Characteristics and Status at the First Scheduled Postoperative Interview for 1567 HRS Participants Undergoing Cardiac Surgery Between 2002 and 2010, by Marital Status
| Participants, No. (%) |
|||||
|---|---|---|---|---|---|
| Characteristic or Status | Married (n = 1026) | Separated or Divorced (n = 184) | Widowed (n = 331) | Never Married (n = 35) | P Value |
| Median age (IQR), y | 69 (63-75) | 67 (60-72) | 77 (71-83) | 69 (56-73) | <.001 |
| Male sex | 760 (74.1) | 87 (47.3) | 92 (27.8) | 22 (62.9) | <.001 |
| Congestive heart failure | 84 (8.2) | 22 (12.0) | 51 (15.4) | 1 (2.9) | .001 |
| Prior myocardial infarction | 77 (7.5) | 16 (8.7) | 40 (12.1) | 3 (8.6) | .08 |
| Diabetes mellitus | 294 (28.7) | 55 (30.0) | 110 (33.2) | 13 (37.1) | .34 |
| Angina | 180 (17.5) | 36 (19.6) | 86 (26.0) | 6 (17.1) | .01 |
| Prior stroke | 103 (10.0) | 14 (7.6) | 65 (19.6) | 4 (11.4) | <.001 |
| Cancer | 129 (14.5) | 24 (13.0) | 43 (13.0) | 3 (8.6) | .68 |
| Current smoker | 114 (11.1) | 43 (23.4) | 35 (10.6) | 6 (17.1) | <.001 |
| Chronic lung disease | 119 (11.6) | 42 (22.8) | 46 (13.9) | 1 (2.9) | <.001 |
| Any ADL disability at baseline | 161 (15.7) | 45 (24.5) | 96 (29.0) | 6 (17.1) | <.001 |
| Status at first scheduled HRS interview after surgery | |||||
| Died prior to interview | 23 (2.2) | 8 (4.4) | 12 (3.6) | 2 (5.7) | .20 |
| Alive with new dependence in ≥1 ADL | 176 (17.2) | 45 (24.5) | 100 (30.2) | 5 (14.3) | <.001 |
| ADL domain with new dependence reported | |||||
| Dressing | 84 (8.2) | 18 (9.8) | 36 (10.9) | 2 (5.7) | .43 |
| Ambulation | 70 (6.8) | 16 (8.7) | 42 (12.7) | 2 (5.7) | .01 |
| Eating | 36 (3.5) | 7 (3.8) | 19 (5.7) | 0 (0) | .24 |
| Bathing | 64 (6.2) | 22 (12.0) | 42 (12.7) | 0 (0) | <.001 |
| Toileting | 49 (4.8) | 12 (6.5) | 31 (9.4) | 1 (2.9) | .02 |
| Getting in/out of bed | 59 (5.8) | 15 (8.2) | 30 (9.1) | 1 (2.9) | .12 |
| Died or developed any new ADL dependence | 199 (19.4) | 53 (28.8) | 112 (33.8) | 7 (20.0) | <.001 |
Abbreviations: ADL, activities of daily living; HRS, Health and Retirement Study; IQR, interquartile range.
Table 2.
Predictors of Death or New ADL Disability at the Earliest Follow-up Within 2 Years of Cardiac Surgery Among 1567 Participants in the Health and Retirement Study
| Predictor | Odds Ratio (95% CI) | P Value |
|---|---|---|
| Marital status | ||
| Married | 1 [Reference] | |
| Divorced or separated | 1.55 (1.06-2.28) | .02 |
| Widowed | 1.60 (1.15-2.23) | .01 |
| Never married | 1.04 (0.43-2.48) | .93 |
| Age | 1.01 (1.00-1.03) | .05 |
| Sex | ||
| Male | 1 [Reference] | |
| Female | 1.01 (0.77-1.33) | .94 |
| Congestive heart failure | 1.09 (0.74-1.62) | .66 |
| Prior myocardial infarction | 1.11 (0.72-1.70) | .63 |
| Diabetes mellitus | 1.27 (0.97-1.65) | .08 |
| Angina | 1.40 (1.03-1.90) | .03 |
| Prior stroke | 1.03 (0.71-1.48) | .89 |
| Cancer | 1.09 (0.77-1.54) | .63 |
| Current smoker | 1.00 (0.68-1.46) | .98 |
| Chronic lung disease | 1.21 (0.85-1.71) | .30 |
| Any ADL disability at baseline | 2.91 (2.19-3.85) | <.001 |
Abbreviation: ADL, activities of daily living.
Discussion
Among the 1576 adults 50 years of age or older, those who were divorced, separated, or widowed had an approximately 40% greater odds of dying or developing a new functional disability during the first 2 years after cardiac surgery compared with the married participants. These findings extend prior work suggesting postoperative survival advantages for married people1,2 and may relate to the role of social supports in influencing patients’ choices of hospitals3 and their self-care.4 Our study is limited by the possibility that the married and unmarried participants may have differed in ways that were not observable in the study data. Nonetheless, our findings persisted in multivariate models that controlled for multiple baseline factors, suggesting that marital status is a predictor of survival and functional recovery after cardiac surgery. Further research is needed to define the mechanisms linking marital status and postoperative outcomes.
Acknowledgments
Funding/Support: This work was supported by the National Institutes of Health, Bethesda, Maryland (grant K08AG043548 to Dr Neuman and grant K24-AG047908 to Dr Werner).
Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
Author Contributions: Dr Neuman had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Neuman.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Both authors.
Obtained funding: Both authors.
Administrative, technical, or material support: Neuman.
Study supervision: Both authors.
Conflict of Interest Disclosures: None reported.
References
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