Comparing Interventions in Older Unpartnered Adults after Myocardial Infarction

Social network interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease

BACKGROUND

Globally, cardiovascular diseases (CVD, that is, coronary heart (CHD) and circulatory diseases combined) contribute to 31% of all deaths, more than any other cause. In line with guidance in the UK and globally, cardiac rehabilitation programmes are widely offered to people with heart disease, and include psychosocial, educational, health behaviour change, and risk management components. Social support and social network interventions have potential to improve outcomes of these programmes, but whether and how these interventions work is poorly understood.  OBJECTIVES: To assess the effectiveness of social network and social support interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease. The comparator was usual care with no element of social support (i.e. secondary prevention alone or with cardiac rehabilitation).  SEARCH METHODS: We undertook a systematic search of the following databases on 9 August 2022: CENTRAL, MEDLINE, Embase, and the Web of Science. We also searched ClinicalTrials.gov and the WHO ICTRP. We reviewed the reference lists of relevant systematic reviews and included primary studies, and we contacted experts to identify additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of social network or social support interventions for people with heart disease. We included studies regardless of their duration of follow-up, and included those reported as full text, published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened all identified titles. We retrieved full-text study reports and publications marked 'included', and two review authors independently screened these, and conducted data extraction. Two authors independently assessed risk of bias, and assessed the certainty of the evidence using GRADE. Primary outcomes were all-cause mortality, cardiovascular-related mortality, all-cause hospital admission, cardiovascular-related hospital admission, and health-related quality of life (HRQoL) measured at > 12 months follow-up.  MAIN RESULTS: We included 54 RCTs (126 publications) reporting data for a total of 11,445 people with heart disease. The median follow-up was seven months and median sample size was 96 participants. Of included study participants, 6414 (56%) were male, and the mean age ranged from 48.6 to 76.3 years. Studies included heart failure (41%), mixed cardiac disease (31%), post-myocardial infarction (13%), post-revascularisation (7%), CHD (7%), and cardiac X syndrome (1%) patients. The median intervention duration was 12 weeks. We identified notable diversity in social network and social support interventions, across what was delivered, how, and by whom.  We assessed risk of bias (RoB) in primary outcomes at > 12 months follow-up as either 'low' (2/15 studies), 'some concerns' (11/15), or 'high' (2/15). 'Some concerns' or 'high' RoB resulted from insufficient detail on blinding of outcome assessors, data missingness, and absence of pre-agreed statistical analysis plans. In particular, HRQoL outcomes were at high RoB. Using the GRADE method, we assessed the certainty of evidence as low or very low across outcomes. Social network or social support interventions had no clear effect on all-cause mortality (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.49 to 1.13, I2 = 40%) or cardiovascular-related mortality (RR 0.85, 95% CI 0.66 to 1.10, I2 = 0%) at > 12 months follow-up. The evidence suggests that social network or social support interventions for heart disease may result in little to no difference in all-cause hospital admission (RR 1.03, 95% CI 0.86 to 1.22, I2 = 0%), or cardiovascular-related hospital admission (RR 0.92, 95% CI 0.77 to 1.10, I2 = 16%), with a low level of certainty. The evidence was very uncertain regarding the impact of social network interventions on HRQoL at > 12 months follow-up (SF-36 physical component score: mean difference (MD) 31.53, 95% CI -28.65 to 91.71, I2 = 100%, 2 trials/comparisons, 166 participants; mental component score MD 30.62, 95% CI -33.88 to 95.13, I2 = 100%, 2 trials/comparisons, 166 participants).  Regarding secondary outcomes, there may be a decrease in both systolic and diastolic blood pressure with social network or social support interventions. There was no evidence of impact found on psychological well-being, smoking, cholesterol, myocardial infarction, revascularisation, return to work/education, social isolation or connectedness, patient satisfaction, or adverse events.  Results of meta-regression did not suggest that the intervention effect was related to risk of bias, intervention type, duration, setting, and delivery mode, population type, study location, participant age, or percentage of male participants.  AUTHORS' CONCLUSIONS: We found no strong evidence for the effectiveness of such interventions, although modest effects were identified in relation to blood pressure. While the data presented in this review are indicative of potential for positive effects, the review also highlights the lack of sufficient evidence to conclusively support such interventions for people with heart disease. Further high-quality, well-reported RCTs are required to fully explore the potential of social support interventions in this context. Future reporting of social network and social support interventions for people with heart disease needs to be significantly clearer, and more effectively theorised, in order to ascertain causal pathways and effect on outcomes.

Continuity of Nursing Care in Patients with Coronary Artery Disease: A Systematic Review

Coronary artery disease is the leading cause of death worldwide and patient continuity of care is essential. Health professionals can help in the transition stage by providing resources to achieve pharmacological treatment adherence, as well as social and emotional support. The objective was to analyse the effects of nursing interventions based on continuity of care in patients with coronary artery disease after hospital discharge. A systematic review of randomised controlled trials and quasi-experimental studies was carried out. Cochrane, CINAHL, Health & medical collection, Medline, and Scopus databases were consulted in January 2022. PRISMA guidelines were followed with no time limits. In total, 16 articles were included with a total of 2950 patients. Nurse-led continuity of care programs improved the monitoring and control of the disease. Positive effects were found in the quality of life of patients, and in mental health, self-efficacy, and self-care capacity dimensions. Clinical parameters such as blood pressure and lipid levels decreased. The continuity of care provided by nurses had a positive influence on the quality of life of patients with coronary artery disease. Nurse-led care focused on the needs and resources, including continuity of care, plays a key role.

Defining and measuring health equity in research on task shifting in high-income countries: A systematic review

Introduction

Task shifting interventions have been implemented to improve health and address health inequities. Little is known about how inequity and vulnerability are defined and measured in research on task shifting. We conducted a systematic review to identify how inequity and vulnerability are identified, defined and measured in task shifting research from high-income countries.

Methods and analysis

We implemented a novel search process to identify programs of research concerning task shifting interventions in high-income countries. We searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL to identify articles published from 2004 to 2016. Each program of research incorporated a "parent" randomized trial and "child" publications or sub-studies arising from the same research group. Two investigators extracted (1) study details, (2) definitions and measures of health equity or population vulnerability, and (3) assessed the quality of the reporting and measurement of health equity and vulnerability using a five-point scale developed for this study. We summarized the findings using a narrative approach.

Results

Fifteen programs of research met inclusion criteria, involving 15 parent randomized trials and 62 child publications. Included programs of research were all undertaken in the United States, among Hispanic- (5/15), African- (2/15), and Korean-Americans (1/15), and low socioeconomic status (2/15), rural (2/15) and older adult populations (2/15). Task shifting interventions included community health workers, peers, and a variety of other non-professional and lay workers to address a range of non-communicable diseases. Some research provided robust analyses of the affected populations' health inequities and demonstrated how a task shifting intervention redressed those concerns. Other studies provided no such definitions and measured only biomedical endpoints.

Conclusion

Included studies vary substantially in the definition and measurement of health inequity and vulnerability. A more precise theoretical and evaluative framework for task shifting is recommended to effectively achieve the goal of equitable health.

The effect of a peer support intervention on early recovery outcomes in men recovering from coronary bypass surgery: A randomized controlled trial

BACKGROUND AND AIM

Examine the effect of a professionally-guided telephone peer support intervention on recovery outcomes including depression, perceived social support, and health services utilization after coronary artery bypass graft surgery (CABG).

METHODS

A randomized controlled trial was conducted with post-coronary artery bypass graft surgery men ( N=185) who were randomized before hospital discharge. The intervention arm received telephone-based peer support through weekly telephone calls from a peer volunteer over six weeks, initiated within 3-4 days of discharge.

RESULTS

Although a significant difference was detected in pre-intervention depression scores at discharge, there were no differences between groups in changes in depression scores at six weeks ( p=0.08), 12 weeks (0.49) or over time ( p=0.51); and no significant differences in perceived social support scores over time ( p=0.94). At 12 weeks, the intervention group had significantly lower incidence of health services utilization (family physician ( p=0.02) and emergency room ( p=0.04)).

CONCLUSIONS

Healthcare providers need to continue to investigate novel interventions to enhance social support and reduce depression in cardiac patients.

A Community-Based Participatory Research Intervention to Promote Physical Activity Among Rural Children: Theory and Design

The overall objective of Project SHAPE (Shaping Health using Activity Photovoice and E-Video) was to improve physical activity levels of rural, medically underserved children by designing and implementing a culturally relevant physical activity intervention. This objective was met by using a community-based participatory research approach to design and implement an intervention that would positively affect the psychosocial constructs related to increasing physical activity, which, in turn, would lead to increases in the time spent in daily physical activity. This article describes the unique design of the intervention including its theoretical framework, its interrelated components, and the logistics involved.

Experiences of peer support in self-management interventions among people with ischemic heart disease: a systematic review protocol

The objective of this review is to identify, appraise and synthesize the best available evidence regarding people with ischemic heart disease and their experiences with peer support in self-management interventions.More specifically, the review question is: How do people with ischemic heart disease experience peer support in structured self-management interventions led or co-led by peers?

Description of Advanced Practice Nurses Interventions Through the Nursing Interventions Classification in Different Care Settings for Older People: A Qualitative Study

PURPOSE

To identify the interventions provided by advanced practice nurses to older people in different contexts with standardized nursing language.

DATA SOURCE

This is a qualitative study. Content analysis was applied to the texts of experimental research papers about advanced practice nursing for older people. Deductive coding through the Nursing Intervention Classification was carried out.

DATA SYNTHESIS

Seventy-three interventions codified with the Nursing Intervention Classification were extracted, mainly related to the behavioral and healthcare system domains, which could be explained due to the need for improving the psychosocial functioning and self-care of these patients to preserve their quality of life.

CONCLUSION AND IMPLICATION FOR NURSING PRACTICE

Advanced practice nurses interventions can be better described, reported, and analyzed along different contexts with standardized languages.

Peer-delivered physical activity interventions: an overlooked opportunity for physical activity promotion

The purpose of this systematic review was to catalogue and synthesize published studies that have examined the effects of peer-delivered physical activity interventions on physical activity behavior. Ten published studies were identified that met the inclusion criteria. The following information was extracted from each study: study design and duration; characteristics of the sample, peers, and interventions; and physical activity outcomes. In all articles reporting within-groups analyses, peer-delivered interventions led to increases in physical activity behavior. When compared to alternatives, peer-delivered interventions were just as effective as professionally delivered interventions and more effective than control conditions for increasing physical activity. Only three studies included measures of social cognitive variables, yielding some evidence that peers may enhance self-efficacy and self-determined forms of motivation. Based on these findings, interventionists are encouraged to include peer mentors in their intervention delivery models. Investigators are encouraged to pursue a more comprehensive understanding of factors that can explain and maximize the impact of peer-delivered activity interventions.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Social determinants and heat shock protein-70 among African American and non-Hispanic white women with atherosclerosis: a pilot study

African American (AA) women are nearly twice as likely as non-Hispanic White (NHW) women to develop atherosclerosis associated with cardiovascular disease. Compelling evidence demonstrates that stress-related biomarkers, such as heat shock protein-70 (HSP70), are associated with increased atherosclerosis risk. Yet little is known about how social factors such as perceived discrimination, subjective social status, and socioeconomic status contribute to the levels of these biomarkers in women with atherosclerosis. The aims of this pilot study were to (1) describe perceived everyday discrimination, subjective social status, perceived stress, and HSP70 level in AA and NHW women diagnosed with coronary or carotid artery disease requiring intervention and (2) determine the extent to which perceived discrimination, subjective social status, and perceived stress are associated with HSP70 level, controlling for age, education, and race. The sample for this cross-sectional, descriptive pilot study consisted of 10 AA and 21 NHW women admitted to the hospital for elective percutaneous cardiac intervention or carotid endarterectomy. Participants completed questionnaires measuring psychosocial variables and provided blood samples for analysis of HSP70. Race, age, education, perceived stress, perceived discrimination, and subjective social status significantly (p = .022) explained 34% of the variance in HSP70 levels. However, only subjective social status (p = .031) and AA race (p = .031) were significant independent predictors of HSP70 levels, with lower subjective social status and AA race associated with higher HSP70. Although larger studies are needed to confirm these results, findings imply that race and subjective social status may play an important role in predicting stress biomarker levels.

The clinical nurse specialist in chronic diseases

BACKGROUND/RATIONALE

The number of individuals with chronic illness is growing at an astonishing rate because of the rapid aging of the population and the increased longevity of persons with chronic conditions. Nurses in clinical nurse specialist (CNS) roles are well positioned and ideally suited to meet the needs of a growing population with chronic diseases; yet, to date, there has been no critical review of the CNS in chronic diseases.

PURPOSE/OBJECTIVES

This article provides a critical review of the literature in order to better define and understand the CNS related to patients living with chronic illnesses (cardiovascular and oncology).

DESCRIPTION OF THE PROJECT/INNOVATION

Using the guidelines of DiCenso et al (2005) for evaluating health services interventions, the literature was appraised in order to identify the characteristics of CNS roles, and the strengths and limitations of research about the effectiveness of CNS in chronic disease management.

IMPLICATIONS

Clinical nurse specialists with master's-level preparation provided high-quality and cost-effective care to patients with chronic diseases. The CNSs had a positive impact on patient, family, and healthcare team outcomes. Further evaluation of the CNS role in the research domain of practice is recommended.

The effects of a cardiac rehabilitation program tailored for women on their perceptions of health: a randomized clinical trial

PURPOSE

The aim of this study was to compare the effects of a cardiac rehabilitation (CR) program tailored for women with a traditional program on perceptions of health among women with coronary heart disease.

METHODS

This 2-group randomized clinical trial compared the perceptions of health among 92 women completing a traditional 12-week CR program with those of 133 women completing a tailored program that included motivational interviewing guided by the transtheoretical model of behavior change. Perceptions of health were measured using the SF-36 Health Survey at baseline, postintervention, and at 6-month follow-up. Analysis of variance was used to compare changes in SF-36 Health Survey subscale scores over time.

RESULTS

The group-by-time interaction was significant for the general health (F2,446 = 3.80, P = .023), social functioning (F2,446 = 4.85, P = .008), vitality (F2,446 = 5.85, P = .003), and mental health (F2,446 = 3.61, P = .028) subscales, indicating that the pattern of change was different between the 2 groups. Of the 4 subscales on which there were significant group-by-time interactions, the tailored group demonstrated improved scores over time on all 4 subscales, while the traditional group improved on only the emotional role limitations and vitality subscales.

CONCLUSIONS

A tailored CR program improved general health perceptions, mental health, vitality, and social functioning in women when compared with traditional CR. To the extent that perceptions of health contribute to healthy behaviors fostered in CR programs, tailoring CR programs to alter perceptions of health may improve adherence.

Classifying subgroups of patients with symptoms of acute coronary syndromes: A cluster analysis

The purpose of the study was to identify subgroups of patients presenting with acute coronary syndromes based on symptom clusters. Two hundred fifty-six patients completed a symptom assessment in their hospital rooms. Latent class cluster analysis and analysis of variance were used to classify subgroups of patients according to selected clinical characteristics. Four subgroups were identified and labeled as Heavy Symptom Burden, Chest Pain Only, Sweating and Weak, and Short of Breath and Weak (model fit χ(2) [130,891, n = 256] = 867.5, p = 1.00). The largest group of patients experienced classic symptoms of chest pain and shortness of breath but not sweating. Younger patients were more likely to cluster in the Heavy Symptom Burden group (F = 5.08, p = .002). Interpretation of the clinical significance of these groupings requires further study.

Effects of befriending on depressive symptoms and distress: systematic review and meta-analysis

BACKGROUND

High rates of emotional distress and depressive symptoms in the community can reflect difficult life events and social circumstances. There is a need for appropriate, low-cost, non-medical interventions for many individuals. Befriending is an emotional support intervention commonly offered by the voluntary sector.

AIMS

To examine the effectiveness of befriending in the treatment of emotional distress and depressive symptoms.

METHOD

Systematic review of randomised trials of interventions focused on providing emotional support to individuals in the community.

RESULTS

Compared with usual care or no treatment, befriending had a modest but significant effect on depressive symptoms in the short term (standardised mean difference SMD = -0.27, 95% CI -0.48 to -0.06, nine studies) and long term (SMD = -0.18, 95% CI -0.32 to -0.05, five studies).

CONCLUSIONS

Befriending has a modest effect on depressive symptoms and emotional distress in varied patient groups. Further exploration of active ingredients, appropriate target populations and optimal methods of delivery is required.

A systematic review of the effectiveness of peer-based interventions on health-related behaviors in adults

We reviewed 25 randomized clinical trials that assessed the effect of peer-based interventions on health-related behaviors in adults. Effect sizes were calculated as odds ratios or standardized mean differences. We grouped most of the studies by 7 measured outcomes, with effect sizes ranging from -0.50 to 2.86. We found that peer-based interventions facilitated important changes in health-related behaviors, including physical activity, smoking, and condom use, with a small- to medium-sized effect. However, the evidence was mixed, possibly because of the heterogeneity we found in methods, dose, and other variables between the studies. Interventions aimed at increasing breastfeeding, medication adherence, women's health screening, and participation in general activities did not produce significant changes.

Peer support telephone calls for improving health

BACKGROUND

Peer support telephone calls have been used for a wide range of health-related concerns. However, little is known about their effects.

OBJECTIVES

To assess the effects of peer support telephone calls in terms of physical (e.g. blood pressure), psychological (e.g. depressive symptoms), and behavioural health outcomes (e.g. uptake of mammography) and other outcomes.

SEARCH STRATEGY

We searched: The Cochrane Library databases (CENTRAL, DARE, CDSR) (issue 4 2007); MEDLINE (OVID) (January 1966 to December 2007); EMBASE (OVID) (January 1985 to December 2007); CINAHL (Athens) (January 1966 to December 2007), trials registers and reference lists of articles, with no language restrictions.

SELECTION CRITERIA

Randomised controlled trials of peer support interventions delivered by telephone call.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. We present results narratively and in tabular format. Meta-analysis was not possible due to heterogeneity between studies.

MAIN RESULTS

We included seven studies involving 2492 participants.Peer support telephone calls were associated with an increase in mammography screening, with 49% of women in the intervention group and 34% of women in the control group receiving a mammogram since the start of the intervention (P </ = 0.001). In another study, peer telephone support calls were found to maintain mammography screening uptake for baseline adherent women (P = 0.029).Peer support telephone calls for post myocardial infarction patients were associated at six months with a change in diet in the intervention and usual care groups of 54% and 44% respectively (P = 0.03). In another study for post myocardial infarction patients there were no significant differences between groups for self-efficacy, health status and mental health outcomes.Peer support telephone calls were associated with greater continuation of breastfeeding in mothers at 3 months post partum (P = 0.01).Peer support telephone calls were associated with reduced depressive symptoms in mothers with postnatal depression (Edinburgh Postnatal Depression Scale (EPDS) > 12). The peer support intervention significantly decreased depressive symptomatology at the 4-week assessment (odds ratio (OR) 6.23 (95% confidence interval (CI) 1.15 to 33.77; P = 0.02)) and 8-week assessment (OR 6.23 (95% CI 1.40 to 27.84; P = 0.01). One study investigated the use of peer support for patients with poorly controlled diabetes. There were no significant differences between groups for self-efficacy, HbA1C, cholesterol level and body mass index.

AUTHORS' CONCLUSIONS

Whilst this review provides some evidence that peer support telephone calls can be effective for certain health-related concerns, few of the studies were of high quality and so results should be interpreted cautiously. There were many methodological limitations thus limiting the generalisability of findings. Overall, there is a need for further well designed randomised controlled studies to clarify the cost and clinical effectiveness of peer support telephone calls for improvement in health and health-related behaviour.

Cluster analysis of elderly cardiac patients' prehospital symptomatology

BACKGROUND

Chest pain routinely brings patients into the healthcare system, and elderly patients may present with more complex symptoms presaging ischemic heart changes than do younger patients.

OBJECTIVE

To examine, using cluster analysis, how elderly patients experiencing an ischemic coronary heart disease cluster based on presenting symptoms in the week before hospitalization and how they vary in terms of their general physical and mental health, mood states, and quality of life.

METHODS

Elderly (age >or=65 years), unpartnered patients (N = 247) admitted with ischemic coronary heart disease to one of five university medical centers were inducted into a clinical trial; only baseline data are reported. Interviews assessed cardiac symptoms, medical history, general physical and mental health, mood states, and quality of life. Patients were clustered (grouped) using squared Euclidean distances and weighted average linkage. Characteristics of patients were examined using analysis of variance and chi-squared analyses.

RESULTS

Three clusters (groups) were identified: (a) Classic Acute Coronary Syndrome (severe ischemic pain; 22%), (b) Weary (severe fatigue, sleep disturbance, and shortness of breath; 29%), and (c) Diffuse Symptoms (mild symptomatology; 49%). Post hoc tests revealed that the Weary group was more likely to have a history of heart failure; they also exhibited significantly more psychological distress and lower quality of life than the other subgroups.

CONCLUSION

Cluster analysis proved useful in grouping patients based on their symptom experience, but further research is needed to clarify the relationships among identified symptoms, psychological distress, and health outcomes; develop interventions for Weary patients; and extend the findings of this study.

Self-management education programmes by lay leaders for people with chronic conditions

BACKGROUND

Lay-led self-management programmes are becoming widespread in the attempt to promote self-care for people with chronic conditions.

OBJECTIVES

To assess systematically the effectiveness of lay-led self-management programmes for people with chronic conditions.

SEARCH STRATEGY

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2005, Issue 1), MEDLINE (January 1986 to May 2006), EMBASE (January 1986 to June 2006), AMED (January 1986 to June 2006), CINAHL (January 1986 to June 2006), DARE (1994 to July 2006, National Research Register (2000 to July 2006), NHS Economic Evaluations Database (1994 to July 2006), PsycINFO (January 1986 to June 2006), Science Citation Index (January 1986 to July 2006), reference lists and forward citation tracking of included studies. We contacted principal investigators and experts in the field. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing structured lay-led self-management education programmes for chronic conditions against no intervention or clinician-led programmes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Results of RCTs were pooled using a random-effects model with standardised mean differences (SMDs) or weighted mean differences (WMDs) for continuous outcomes.

MAIN RESULTS

We included seventeen trials involving 7442 participants. The interventions shared similar structures and components but studies showed heterogeneity in conditions studied, outcomes collected and effects. There were no studies of children and adolescents, only one study provided data on outcomes beyond six months, and only two studies reported clinical outcomes.

PRIMARY OUTCOMES

Health status: There was a small, statistically-significant reduction in: pain (11 studies, SMD -0.10 (95% confidence interval (CI) -0.17 to -0.04)); disability (8 studies, SMD -0.15 (95% CI -0.25 to -0.05); and fatigue (7 studies, SMD -0.16 (95% CI -0.23 to -0.09); and small, statistically-significant improvement in depression (6 studies, SMD -0.16 95% CI -0.24 to -0.07). There was a small (but not statistically- or clinically-significant) improvement in psychological well-being (5 studies; SMD -0.12 (95% CI -0.33 to 0.09)); but no difference between groups for health-related quality of life (3 studies; WMD -0.03 (95% CI -0.09 to 0.02). Six studies showed a statistically-significant improvement in self-rated general health (WMD -0.20 (95% CI -0.31 to -0.10). Health behaviours: 7 studies showed a small, statistically-significant increase in self-reported aerobic exercise (SMD -0.20 (95% CI -0.27 to -0.12)) and a moderate increase in cognitive symptom management (4 studies, WMD -0.55 ( 95% CI -0.85 to -0.26)). Healthcare use: There were no statistically-significant differences between groups in physician or general practitioner attendance (9 studies; SMD -0.03 (95% CI -0.09 to 0.04)). There were also no statistically-significant differences between groups for days/nights spent in hospital (6 studies; WMD -0.32 (95% CI -0.71 to 0.07)). Self-efficacy: (confidence to manage condition) showed a small statistically-significant improvement (10 studies): SMD -0.30, 95% CI -0.41 to -0.19. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

Lay-led self-management education programmes may lead to small, short-term improvements in participants' self-efficacy, self-rated health, cognitive symptom management, and frequency of aerobic exercise. There is currently no evidence to suggest that such programmes improve psychological health, symptoms or health-related quality of life, or that they significantly alter healthcare use. Future research on such interventions should explore longer term outcomes, their effect on clinical measures of disease and their potential role in children and adolescents.

The Effects of a Collaborative Peer Advisor/Advanced Practice Nurse Intervention

BACKGROUND

After the cardiovascular events of myocardial infarction (MI) and coronary artery bypass surgery (CABS), unpartnered older adults are a vulnerable group that may benefit from interventions to improve health outcomes. The purpose of this analysis is to determine if a community-based collaborative peer advisor/advanced practice nurse intervention increased participation in cardiac rehabilitation programs and reduced hospital readmissions after MI and CABS and determine whether the type of cardiovascular event influenced rehospitalization.

SUBJECTS AND METHODS

This study was a randomized clinical trial that enrolled 247 unpartnered older adults who were single, widowed, or divorced. Subjects were randomized into 4 groups: standard of care group for MI and for CABS and standard of care plus the treatment groups for MI and for CABS, for 12 weeks after discharge. There were 163 women/84 men, with a mean age of 76.4 years, who were admitted for MI (n = 93) or CABS (n = 154) and who were enrolled from 5 academic medical centers. The treatment consisted of a community-based intervention of a home visit within 72 hours and telephone calls at 2, 6, and 10 weeks from an advanced practice nurse and 12 weekly telephone calls from a peer advisor. Participation in a cardiac rehabilitation program and rehospitalizations were collected at 6 weeks and 3, 6, and 12 months by telephone interview.

RESULTS AND CONCLUSIONS

There were significantly more participants in cardiac rehabilitation programs after 3 months in the treatment group, and this increase was seen up to 1 year after MI and CABS. There were no statistical differences, although there were fewer rehospitalizations between 3 and 6 months after MI and CABS in the treatment group compared with the standard of care group. Overall, the evidence from this study suggests that a community-based collaborative peer advisor/advanced practice nurse intervention can play a role in promoting active participation in cardiac rehabilitation programs and fewer rehospitalizations in unpartnered older adults after MI and CAGS.