Impact of a telehealth intervention to augment home health care on functional and recovery outcomes of elderly patients undergoing coronary artery bypass grafting

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.

OBJECTIVES

To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

MAIN RESULTS

We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.

Effectiveness of Communication Strategies in the Management of Chronic Postsurgical Pain: Protocol for a Systematic Review and Meta-Analysis

Purpose

To describe the details of a systematic review to assess the current evidence about the efficacy of communication strategies on the prevention of chronic postsurgical pain (CPSP).

Methods

The protocol for this systematic review was based on the Cochrane Handbook methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations. A systematic search of the literature on electronic databases Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science (from the inception to 19 June 2022) was carried out using predefined search terms to identify relevant studies. This review will include randomized clinical trials or observational studies. The search strategy consisted of keywords and index terms related to "clinician", "communication" or "post-surgical pain". Inclusion criteria are as follows: randomized clinical trials or observational studies using a parallel group design that assess the efficacy of communication interventions in patients undergoing surgery and that assess pain and pain-related disability. We considered interventions that included any type of written, verbal, and non-verbal communication in combination with other interventions or without. Control groups may include no communication intervention or another intervention distinctly different. We excluded studies with follow-up duration of less than 3 months, patients aged <18 years, and studies for which no reviewer had language proficiency (eg, Chinese, Korean). Descriptive statistics will be used to summarize quantitative findings. Meta-analysis will only be considered if at least three studies used the same outcome with comparable interventions, as we expect a wide heterogeneity of study population and settings.

Conclusion

This systematic review and meta-analysis will be an important source for clinicians and researchers to understand the influence of communication to prevent CPSP.

Study Registration

This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Registration number: CRD42021241596.

Health Information Technology Adoption at U.S. Home Health Care Agencies: Results from a Multi-Methods Study

Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; (4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR; an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.

Home healthcare patient, caregiver and provider perspectives on use of unscheduled acute care and the usability and acceptability of on-demand telehealth solutions

BACKGROUND/OBJECTIVES

Home health care (HHC) agencies provide an important role in helping to transition patients from acute care to independent residential living. Telehealth has the potential to transform care delivery in HHC, however the majority of studies in HHC have focused on the use of telemonitoring for patients with specific chronic conditions. The objective of this study was to examine reasons HHC patients use acute care services and assess the acceptability of on-demand telehealth services among HHC patients, caregivers and personnel to help alleviate the need for seeking in-person acute care. Design/Setting/Participants/Measures: This study was a secondary analysis of qualitative data from in-depth interviews of 30 HHC personnel, patients and caregivers from a Medicare-certified HHC agency affiliated with a large healthcare system from January through May 2020. A conventional content analysis approach was used to identify themes.

RESULTS

Themes associated with reasons for seeking acute care included: sense of urgency, behavioral and psychosocial factors, and access to care. Participants described their perceptions of the benefits, usability and acceptability and barriers to using telehealth. Patients and HHC personnel agreed that on-demand telehealth should not replace in-person visits but all identified roles that on-demand telehealth services could play in improving communication and access to care. The biggest barriers to use of telehealth identified by HHC personnel were cost, access and ability to use technology by HHC patients.

CONCLUSION

This study identified reasons HHC patients seek unscheduled acute care and the usability and acceptability of on-demand telehealth services to increase access to care among HHC patients. These findings underscore the need to improve communication and coordination between patients, HHC personnel, and primary care providers and the role that on-demand telehealth services can have in transforming HHC.

Impact of the integrated comprehensive care program post-thoracic surgery: A propensity score-matched study

OBJECTIVE

Thoracic surgery is associated with significant rates of postoperative morbidity and postdischarge return to the hospital or emergency department (ED). This study aims to assess the impact of a novel integrated patient-centered, hospital-based multidisciplinary community program (Integrated Comprehensive Care [ICC]) on postdischarge outcomes in patients undergoing thoracic surgery compared to routine care.

METHODS

This was a retrospective cohort study of patients who underwent surgical resection for lung malignancies at a tertiary care center from 2010 to 2014. Patients were divided into 2 cohorts based on their enrollment in the ICC program (intervention cohort; 2012-2014) or routine postoperative care (control cohort; 2010-2012). Propensity score matching was performed to match the 2 cohorts. The impact of the ICC program on postoperative length of stay (LOS), rate of ED visits, readmissions, and mortality within the first 60 days was assessed.

RESULTS

Of the 1288 patients included in this study, 658 (51.1%) were male patients with mean age of 64 years (standard deviation 14.1 years). After propensity score matching, 478 patients were enrolled in the ICC cohort and 592 were enrolled as controls. The ICC cohort had significantly shorter LOS (4 days, vs 5 days in controls, P = .001), lower rate of 60-day ED visits (9.8% vs 28.4% in controls, P < .001), and readmissions (6.9% vs 8.6% in controls, P < .001). The 60-day mortality was also significantly lower in the ICC cohort compared with the control group (0.6% vs 0.8% in controls, P < .001).

CONCLUSIONS

The ICC program is associated with shorter LOS, fewer ED visits and readmissions after discharge, and ultimately may decrease postoperative mortality.

Development of family-based follow-up care system for patients with burn in Iran: Participatory action research

Aim

After the discharge of patients with burns, quality of life, psychological and social adjustment, performance and their follow-up are ambiguous. Therefore, we decided to improve the status of family-based care programmes in patients with the burn.

Design

Participatory action research.

Methods

The participatory action research was conducted between the Faculty of Nursing, Sina Hospital's managers and multidisciplinary burn teams from 2017-2018. The procedure for data collection included focus group meetings with key informants, interviews, observation, and questionnaire. Qualitative data were analysed using the qualitative content analysis and qualitative data were analysed by SPSSv.24.

Results

The study, comprised of four phases, started in May 2017 and completed in 9 months. The results of quantitative showed that quality of life has a statistically significant difference before and after the action. The qualitative data resulted were grouped into 3 categories and 28 subcategories and were analysed in the SWOT Matrix. All the multidisciplinary burn teams together with the managers as a team working of the care providers and the academic researcher resulted in enablers the changes in providing health education and services as well as improving the quality of life of patients and their families.

"Celebrating old age": an obsolete expression during the COVID-19 pandemic? Medical, social, psychological, and religious consequences of home isolation and loneliness among the elderly

Since epidemiological arguments favouring self-isolation during the COVID-19 pandemic are widely recommended, the consequences of social isolation/loneliness of older people considered to be at higher risk for severe illness are neglected. We identified and described medical, social, psychological, and religious issues, indirectly generated by the COVID-19 lockdown. Mortality induced by SARS-CoV-2 and death from other "neglected" issues were put in balance. Arguments for strict lockdown from most European countries are compared with a relaxed approach, as has been applied in Sweden. Social isolation affects disproportionally the elderly, transforming it into a public health concern. One witnesses openly ageist discourse, while painful decisions to prioritising ventilation for younger patients deepens the sense of hopelessness. Fear has led to anxiety disorders and depression. Various religious practices provide resources for coping with isolation/overcoming loneliness. Higher levels of mortality/morbidity due to "COVID-19 versus non-COVID-19" polarisation oblige the healthcare community to find ways to provide proper care for its elders.

Characterizing Patient-Centered Postoperative Recovery After Adult Cardiac Surgery: A Systematic Review

Background

Improving postoperative recovery is important, with a national focus on postacute care, but the volume and quality of evidence in this area are not well characterized. We conducted a systematic review to characterize studies on postoperative recovery after adult cardiac surgery using patient‐reported outcome measures.

Methods and Results

From MEDLINE and Web of Science, studies were included if they prospectively assessed postoperative recovery on adult patients undergoing cardiac surgery using patient‐reported outcome measures. Six recovery domains were defined by prior literature: nociceptive symptoms, mental health, physical function, activities of daily living, sleep, and cognitive function. Of the 3432 studies, 105 articles met the inclusion criteria. The studies were small (median sample size, 119), and mostly conducted in single‐center settings (n=81; 77%). Study participants were predominantly men (71%) and white (88%). Coronary artery bypass graft was included in 93% (n=98). Studies commonly selected for elective cases (n=56; 53%) and patients with less comorbidity (n=67; 64%). Median follow‐up duration was 91 (interquartile range, 42–182) days. Studies most commonly assessed 1 domain (n=42; 40%). The studies also varied in the instruments used and differed in their reporting approach. Studies commonly excluded patients who died during the follow‐up period (n=48; 46%), and 45% (n=47) did not specify how those patients were analyzed.

Conclusions

Studies of postoperative patient‐reported outcome measures are low in volume, most often single site without external validation, varied in their approach to missing data, and narrow in the domains and diversity of patients. The evidence base for postoperative patient‐reported outcome measures needs to be strengthened.

Electronic Health Program to Empower Patients in Returning to Normal Activities After General Surgical and Gynecological Procedures: Intervention Mapping as a Useful Method for Further Development

Background

Support for guiding and monitoring postoperative recovery and resumption of activities is usually not provided to patients after discharge from the hospital. Therefore, a perioperative electronic health (eHealth) intervention (“ikherstel” intervention or “I recover” intervention) was developed to empower gynecological patients during the perioperative period. This eHealth intervention requires a need for further development for patients who will undergo various types of general surgical and gynecological procedures.

Objective

This study aimed to further develop the “ikherstel” eHealth intervention using Intervention Mapping (IM) to fit a broader patient population.

Methods

The IM protocol was used to guide further development of the “ikherstel” intervention. First, patients’ needs were identified using (1) the information of a process evaluation of the earlier performed “ikherstel” study, (2) a review of the literature, (3) a survey study, and (4) focus group discussions (FGDs) among stakeholders. Next, program outcomes and change objectives were defined. Third, behavior change theories and practical tools were selected for the intervention program. Finally, an implementation and evaluation plan was developed.

Results

The outcome for an eHealth intervention tool for patients recovering from abdominal general surgical and gynecological procedures was redefined as “achieving earlier recovery including return to normal activities and work.” The Attitude-Social Influence-Self-Efficacy model was used as a theoretical framework to transform personal and external determinants into change objectives of personal behavior. The knowledge gathered by needs assessment and using the theoretical framework in the preparatory steps of the IM protocol resulted in additional tools. A mobile app, an activity tracker, and an electronic consultation (eConsult) will be incorporated in the further developed eHealth intervention. This intervention will be evaluated in a multicenter, single-blinded randomized controlled trial with 18 departments in 11 participating hospitals in the Netherlands.

Conclusions

The intervention is extended to patients undergoing general surgical procedures and for malignant indications. New intervention tools such as a mobile app, an activity tracker, and an eConsult were developed.

Trial Registration

Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5686 

Self-Management Interventions for Women With Cardiac Pain: A Systematic Review and Meta-analysis

BACKGROUND

Cardiac pain is considered the primary indicator of coronary artery disease (CAD). Existing reviews lack appropriate numbers of women or sex-based subgroup analyses, or both; thus, the benefits of self-management (women with cardiac pain actively participating in their own care and treatment) remain uncertain.

METHODS

Using methods described by the Evidence for Policy and Practice Information and Co-ordinating Centre at the Institute of Education, 7 databases were systematically searched to examine and synthesize the evidence on self-management interventions for women with cardiac pain and cardiac pain equivalents, such as fatigue, dyspnea, and exhaustion.

RESULTS

Our search yielded 22,402 article titles and abstracts. Of these, 57 randomized controlled trials were included in a final narrative synthesis, comprising data from 13,047 participants, including 5299 (41%) women. Self-management interventions targeting cardiac pain in women compared with a control population reduced (1) cardiac pain frequency and cardiac pain proportion (obstructive and nonobstructive CAD), (2) fatigue at 12 months, and (3) dyspnea at 2 months. There was no evidence of group differences in postprocedural (percutaneous coronary intervention or cardiac surgery) pain. Results indicated that self-management interventions for cardiac pain were more effective if they included a greater proportion of women (standardized mean difference [SMD], -0.01; standard error, 0.003; P = 0.02), goal setting (SMD, -0.26; 95% confidence interval [CI], -0.49 to -0.03), and collaboration/support from health care providers (SMD, -0.57; 95% CI, -1.00 to -0.14).

CONCLUSIONS

The results of this review suggest that self-management interventions reduce cardiac pain and cardiac pain equivalents.

E-coaching: New future for cardiac rehabilitation? A systematic review

OBJECTIVE

To provide an evidence-based overview of the effectiveness of e-coaching as a cardiac rehabilitation program (CRP).

METHODS

Pubmed, Embase, PEDro and CINAHL were searched to identify relevant RCTs. The e-coaching programs were divided into basic or complex depending on their content. Two reviewers independently assessed the methodological quality and extracted the data. A best-evidence synthesis was used to summarize the results.

RESULTS

19 RCTs were included. Detailed descriptions of the e-coaching programs were lacking. Complex e-coaching was more effective than usual-care for physical capacity (moderate evidence for short-, and mid-term; strong evidence for long-term), for clinical status (limited evidence for short- and mid-term; moderate evidence for the long-term), and for psychosocial health (moderate evidence for short-term; strong evidence for mid-, and long-term). For basic e-coaching only limited or no evidence for effectiveness was found.

CONCLUSION

Promising results were found for the effectiveness of complex e-coaching as a CRP to improve a patients' physical capacity, clinical status and psychosocial health.

PRACTICE IMPLICATIONS

The content of the e-coaching programs were not clearly described. This makes it difficult to identify which components of e-coaching are most effective and should be further developed to deliver the most optimal care for cardiac rehabilitation patients.

Patient education in the management of coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation.

OBJECTIVES

1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables.

MAIN RESULTS

This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains.

AUTHORS' CONCLUSIONS

We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.

Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial

Background

Due to the strong reduction in the length of hospital stays in the last decade, the period of in-hospital postoperative care is limited. After discharge from the hospital, guidance and monitoring on recovery and resumption of (work) activities are usually not provided. As a consequence, return to normal activities and work after surgery is hampered, leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption.

Objective

With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures, leading to accelerated recovery and to a reduction in costs in comparison to usual care.

Methods

This is a multicenter randomized, single-blinded, controlled trial. At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication will be included. Patients will be randomized to an intervention or control group. The intervention group will have access to an innovative, perioperative eHealth care program. This intervention program consists of a website, mobile phone app, and activity tracker. It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery. The control group will receive usual care and will have access to a nonintervention (standard) website consisting of the digital information brochure about the surgical procedure being performed. Patients are asked to complete questionnaires at 5 moments during the first 6 months after surgery. The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning item bank version 1.2. Secondary outcomes include social participation, self-rated health, duration of return to work, physical activity, length of recovery, pain intensity, and patient satisfaction. In addition, an economic evaluation alongside this randomized controlled trial will be performed from the societal and health care perspective. All statistical analyses will be conducted according to the intention-to-treat principle.

Results

The enrollment of patients started in September 2015. The follow-up period will be completed in February 2017. Data cleaning and analyses have not begun as of the time this article was submitted.

Conclusions

We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower.

ClinicalTrial

Netherlands Trial Registry NTC4699; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4699 (Archived by WebCite at http://www.webcitation.org/6mcCBZmwy)

The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review

Telehealth, the delivery of health care services at a distance using information and communications technology, is one means of redressing inequalities in cardiovascular outcomes for disadvantaged groups in Australia. This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.

The Effect of Perioperative E-Health Interventions on the Postoperative Course: A Systematic Review of Randomised and Non-Randomised Controlled Trials

BACKGROUND

E-health interventions have become increasingly popular, including in perioperative care. The objective of this study was to evaluate the effect of perioperative e-health interventions on the postoperative course.

METHODS

We conducted a systematic review and searched for relevant articles in the PUBMED, EMBASE, CINAHL and COCHRANE databases. Controlled trials written in English, with participants of 18 years and older who underwent any type of surgery and which evaluated any type of e-health intervention by reporting patient-related outcome measures focusing on the period after surgery, were included. Data of all included studies were extracted and study quality was assessed by using the Downs and Black scoring system.

FINDINGS

A total of 33 articles were included, reporting on 27 unique studies. Most studies were judged as having a medium risk of bias (n = 13), 11 as a low risk of bias, and three as high risk of bias studies. Most studies included patients undergoing cardiac (n = 9) or orthopedic surgery (n = 7). All studies focused on replacing (n = 11) or complementing (n = 15) perioperative usual care with some form of care via ICT; one study evaluated both type of interventions. Interventions consisted of an educational or supportive website, telemonitoring, telerehabilitation or teleconsultation. All studies measured patient-related outcomes focusing on the physical, the mental or the general component of recovery. 11 studies (40.7%) reported outcome measures related to the effectiveness of the intervention in terms of health care usage and costs. 25 studies (92.6%) reported at least an equal (n = 8) or positive (n = 17) effect of the e-health intervention compared to usual care. In two studies (7.4%) a positive effect on any outcome was found in favour of the control group.

CONCLUSION

Based on this systematic review we conclude that in the majority of the studies e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative care for patients who have undergone various forms of surgery. However, due to the low or moderate quality of many studies, the results should be interpreted with caution.

Internet-based interventions for the secondary prevention of coronary heart disease

BACKGROUND

The Internet could provide a means of delivering secondary prevention programmes to people with coronary heart disease (CHD).

OBJECTIVES

To determine the effectiveness of Internet-based interventions targeting lifestyle changes and medicines management for the secondary prevention of CHD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, in December 2014. We also searched six other databases in October 2014, and three trials registers in January 2015 together with reference checking and handsearching to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating Internet-delivered secondary prevention interventions aimed at people with CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data according to the Cochrane Handbook for Systematic Reviews of Interventions. We assessed evidence quality using the GRADE approach and presented this in a 'Summary of findings' table.

MAIN RESULTS

Eighteen trials met our inclusion criteria. Eleven studies are complete (1392 participants), and seven are ongoing. Of the completed studies, seven interventions are broad, targeting the lifestyle management of CHD, and four focused on physical activity promotion. The comparison group in trials was usual care (n = 6), minimal intervention (n = 3), or traditional cardiac rehabilitation (n = 2).We found no effects of Internet-based interventions for all-cause mortality (odds ratio (OR) 0.27, 95% confidence interval (CI) 0.04 to 1.63; participants = 895; studies = 6; low-quality evidence). There was only one case of cardiovascular mortality in a control group (participants = 895; studies = 6). No incidences of non-fatal re-infarction were reported across any of the studies. We found no effects for revascularisation (OR 0.69, 95% CI 0.37 to 1.27; participants = 895; studies = 6; low-quality evidence).We found no effects for total cholesterol (mean difference (MD) 0.00, 95% CI -0.27 to 0.28; participants = 439; studies = 4; low-quality evidence), high-density lipoprotein (HDL) cholesterol (MD 0.01, 95% CI -0.06 to 0.07; participants = 437; studies = 4; low-quality evidence), or triglycerides (MD 0.01, 95% CI -0.17 to 0.19; participants = 439; studies = 4; low-quality evidence). We did not pool the data for low-density lipoprotein (LDL) cholesterol due to considerable heterogeneity. Two out of six trials measuring LDL cholesterol detected favourable intervention effects, and four trials reported no effects. Seven studies measured systolic and diastolic blood pressure; we did not pool the data due to substantial heterogeneity. For systolic blood pressure, two studies showed a reduction with the intervention, but the remaining studies showed no effect. For diastolic blood pressure, two studies showed a reduction with the intervention, one study showed an increase with the intervention, and the remaining four studies showed no effect.Five trials measured health-related quality of life (HRQOL). We could draw no conclusions from one study due to incomplete reporting; one trial reported no effect; two studies reported a short- and medium-term effect respectively; and one study reported both short- and medium-term effects.Five trials assessed dietary outcomes: two reported favourable effects, and three reported no effects. Eight studies assessed physical activity: five of these trials reported no physical activity effects, and three reported effectiveness. Trials are yet to measure the impact of these interventions on compliance with medication.Two studies measured healthcare utilisation: one reported no effects, and the other reported increased usage of healthcare services compared to a control group in the intervention group at nine months' follow-up. Two trials collected cost data: both reported that Internet-delivered interventions are likely to be cost-effective.In terms of the risk of bias, the majority of studies reported appropriate randomisation and appropriate concealment of randomisation processes. A lack of blinding resulted in a risk of performance bias in seven studies, and a risk of detection bias in five trials. Two trials were at risk of attrition bias, and five were at risk for reporting bias.

AUTHORS' CONCLUSIONS

In general, evidence was of low quality due to lack of blinding, loss to follow-up, and uncertainty around the effect size. Few studies measured clinical events, and of those that did, a very small number of events were reported, and therefore no firm conclusions can be made. Similarly, there was no clear evidence of effect for cardiovascular risk factors, although again the number of studies reporting these was small. There was some evidence for beneficial effects on HRQOL, dietary outcomes, and physical activity, although firm conclusions cannot yet be made. The effects on healthcare utilisation and cost-effectiveness are also inconclusive, and trials are yet to measure the impact of Internet interventions on compliance with medication. The comparison groups differed across trials, and there were insufficient studies with usable data for subgroup analyses. We intend to study the intensity of comparison groups in future updates of this review when more evidence is available. The completion of the ongoing trials will add to the evidence base.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Home telehealth for chronic disease management: selected findings of a narrative synthesis

BACKGROUND

Chronic disease has become an increasingly important issue for individuals and healthcare organizations across Canada. Home telehealth may have the potential to alleviate the economic and social challenges associated with rising rates of chronic disease. An aim of this review was to gather and synthesize the evidence on the effectiveness of home telehealth in chronic disease management.

MATERIALS AND METHODS

We searched the Medline, EMBASE, Web of Science, CINAHL, and PAIS databases for studies published in English from January 1, 2005, and December 31, 2010. Academic publications, white papers, and gray literature were all considered eligible for inclusion, provided an original research element was present. Articles were screened for relevance.

RESULTS

One hundred one articles on quantitative or mixed-methods studies reported the effects of home telehealth on disease state, symptoms, and quality of life in chronic disease patients. Studies were consistent in finding that home telehealth was equivalent or superior to usual care.

CONCLUSIONS

The literature strongly supports the use of home telehealth as an equally effective alternative to usual care. The circumstances under which home telehealth emerges as significantly better than usual care have not been extensively researched. Further research into factors affecting the effectiveness of home telehealth would support more widespread realization of telehealth's potential benefits.

A Systematic Review of Web-Based Educational Interventions

A complement to in-hospital educational interventions is web-based patient education accessed during the home recovery period. While findings demonstrate the effectiveness of web-based patient education interventions on patient outcomes, they fall short of identifying the characteristics that are associated with desired outcomes. The purpose of this systematic review was to determine the characteristics of web-based patient education interventions that are associated with producing changes in self-care behaviors. A systematic review involving 19 studies was conducted to determine the most effective components of a web-based intervention. Findings suggest that the most effective form of web-based patient education is one that is interactive and allows patients to navigate the online system on their own. The findings from this systematic review allow for the design of a web-based educational intervention that will promote increased performance of self-care behaviors during the home recovery period.

Cardiovascular disease self-care interventions

Background. Cardiovascular disease (CVD) is a major cause of increased morbidity and mortality globally. Clinical practice guidelines recommend that individuals with CVD are routinely instructed to engage in self-care including diet restrictions, medication adherence, and symptom monitoring. Objectives. To describe the nature of nurse-led CVD self-care interventions, identify limitations in current nurse-led CVD self-care interventions, and make recommendations for addressing them in future research. Design. Integrative review of nurse-led CVD self-care intervention studies from PubMed, MEDLINE, ISI Web of Science, and CINAHL. Primary studies (n = 34) that met the inclusion criteria of nurse-led RCT or quasiexperimental CVD self-care intervention studies (years 2000 to 2012) were retained and appraised. Quality of the review was assured by having at least two reviewers screen and extract all data. Results. A variety of self-care intervention strategies were studied among the male (57%) and Caucasian (67%) dominated samples. Combined interventions were common, and quality of life was the most frequent outcome evaluated. Effectiveness of interventions was inconclusive, and in general results were not sustained over time. Conclusions. Research is needed to develop and test tailored and inclusive CVD self-care interventions. Attention to rigorous study designs and methods including consistent outcomes and measurement is essential.

Using Information and Communication Technology in Home Care for Communication between Patients, Family Members, and Healthcare Professionals: A Systematic Review

Introduction. Information and communication technology (ICT) are becoming a natural part in healthcare both for delivering and giving accessibility to healthcare for people with chronic illness living at home. Aim. The aim was to review existing studies describing the use of ICT in home care for communication between patients, family members, and healthcare professionals. Methods. A review of studies was conducted that identified 1,276 studies. A selection process and quality appraisal were conducted, which finally resulted in 107 studies. Results. The general results offer an overview of characteristics of studies describing the use of ICT applications in home care and are summarized in areas including study approach, quality appraisal, publications data, terminology used for defining the technology, and disease diagnosis. The specific results describe how communication with ICT was performed in home care and the benefits and drawbacks with the use of ICT. Results were predominated by positive responses in the use of ICT. Conclusion. The use of ICT applications in home care is an expanding research area, with a variety of ICT tools used that could increase accessibility to home care. Using ICT can lead to people living with chronic illnesses gaining control of their illness that promotes self-care.

Physician assistant home visit program to reduce hospital readmissions

OBJECTIVE

A physician assistant home care (PAHC) program providing house calls was initiated to decrease hospital readmission rates. We evaluated the 30-day readmission rates and diagnoses before and during PAHC to identify determinants of readmission and interventions to reduce readmissions.

METHODS

Patients who underwent cardiac surgery were evaluated postoperatively for 13 months as pre-PAHC (control group) and 13 months with PAHC. Physician assistants made house calls on days 2 and 5 following hospital discharge for the PAHC group. Both groups were seen in the office postoperatively. We retrospectively reviewed the charts of 26 months of readmissions. Readmission rates for the control and PAHC groups were compared, as were the reasons for readmissions. Readmission diagnoses were categorized as infectious, cardiac, gastrointestinal, vascular, pulmonary, neurologic, and other. Also noted were the interventions made during the home visits.

RESULTS

There were 361 patients (51%) in the control group and 340 patients (49%) in the PAHC group. Overall readmission rate for the control group was 16% (59 patients) and 12% (42 patients) for the PAHC group, a 25% reduction in the rate of readmissions (P = .161). The rate of infection-related readmissions was reduced from 44% (26 patients) to 19% (8 patients) (P = .010). Home interventions included adjustment of medications (90%), ordering of imaging studies (7%), and administering direct wound care (2%).

CONCLUSIONS

The 30-day readmission rate was reduced by 25% in patients receiving PAHC visits. The most common home intervention was medication adjustment, most commonly to diuretic agents, medications for hypoglycemia, and antibiotics.

Health-enabling technologies for the elderly--an overview of services based on a literature review

BACKGROUND

Services for the elderly based on health-enabling technologies promise to contribute significantly to the efficiency and effectiveness of future health care. Due to this promise, over the last years the scientific community has designed a complex variety of these valuable innovations. A systematic overview of the developed services would help to better understand their opportunities and limitations.

OBJECTIVE

To obtain a systematic overview of services for the elderly based on health-enabling technologies and to identify archetypical service categories.

METHODS

We conducted a literature review using PubMed and retrieved 1447 publications. We stepwise reduced this list to 27 key publications that describe typical service archetypes.

RESULTS

We present six archetypical service categories, namely handling adverse conditions, assessing state of health, consultation and education, motivation and feedback, service ordering and social inclusion and describe their implementation in current research projects.

The impact of discharge plan upon re-admission, satisfaction with nursing care and the ability to self-care for coronary artery bypass graft surgery patients

BACKGROUND AND AIM

Grafting coronary arteries and post operative recovery has many challenges, which can be ameliorated through continues care and an appropriate discharge plan. Therefore, the current study was undertaken aiming to evaluate the impact of discharge plan on satisfaction with nursing care, ability to self-care, and incidence of re-admission.

METHOD

This is a quasi experimental study involving patients who were due to undergo coronary artery bypass graft in Chamran Hospital in 2010. In the intervention group, the discharge plan was initiated at the time of admission and continued for 2 weeks after discharge by home visit and telephone follow ups. Satisfaction with nursing care was assessed 2 days after discharge, whilst patients' ability for self-care was measured 6 weeks and 3 months post discharge and the incidence of re-admission was determined at the 3 months point.

FINDINGS

Satisfaction levels with nursing care and the ability to take self-care were higher in intervention group comparing with control group (p < 0.001). There was a significant difference for self-care ability between pre test and post test in both groups but the improvement was more pronounced for the intervention group (p = 0.04). There was no significant difference between the two groups in terms of re-admission incidence after 3 months (p = 0.15).

DISCUSSION AND CONCLUSION

The results indicate that the discharge plan, as a method of continual care plan, can lead to higher satisfaction levels and enhanced self-care abilities of patients. Such discharge plan can therefore be utilised as an effective method of continuous care for patients who are going to undergo coronary artery bypass graft.

Patient education in the management of coronary heart disease

BACKGROUND

Cardiac rehabilitation (CR) is a complex multifaceted intervention consisting of three core modalities: education, exercise training and psychological support. Whilst exercise and psychological interventions for patients with coronary heart disease (CHD) have been the subject of Cochrane systematic reviews, the specific impact of the educational component of CR has not previously been investigated.

OBJECTIVES

1. Assess effects of patient education on mortality, morbidity, health-related quality of life (HRQofL) and healthcare costs in patients with CHD.2. Explore study level predictors of the effects of patient education (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

The following databases were searched: The Cochrane Library, (CENTRAL, CDSR, DARE, HTA, NHSEED), MEDLINE (OVID), EMBASE (OVID), PsycINFO (EBSCOhost) and CINAHL (EBSCOhost). Previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies and extracted data. Attempts were made to contact all study authors to obtain relevant information not available in the published manuscript. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. For continuous variables, mean differences and 95% CI were calculated for each outcome.

MAIN RESULTS

Thirteen RCTs involving 68,556 subjects with CHD and follow-up from six to 60 months were found. Overall, methodological quality of included studies was moderate to good. Educational 'dose' ranged from a total of two clinic visits to a four-week residential stay with 11 months of follow-up sessions. Control groups typically received usual medical care. There was no strong evidence of an effect of education on all-cause mortality (Relative Risk (RR): 0.79, 95% CI 0.55 to 1.13), cardiac morbidity (subsequent myocardial infarction RR: 0.63, 95% CI 0.26 to 1.48, revascularisation RR: 0.58, 95% CI 0.19 to 1.71) or hospitalisation (RR: 0.83, 95% CI:0.65 to 1.07). Whilst some HRQofL domain scores were higher with education, there was no consistent evidence of superiority across all domains. Different currencies and years studies were performed making direct comparison of healthcare costs challenging, although there is evidence to suggest education may be cost-saving by reducing subsequent healthcare utilisation.This review had insufficient power to exclude clinically important effects of education on mortality and morbidity of patients with CHD.

AUTHORS' CONCLUSIONS

We did not find strong evidence that education reduced all cause mortality, cardiac morbidity, revascularisation or hospitalisation compared to control. There was some evidence to suggest that education may improve HRQofL and reduce overall healthcare costs. Whilst our findings are generally supportive of current guidelines that CR should include not only exercise and psychological interventions, further research into education is needed.

Gender differences in recovery outcomes after an early recovery symptom management intervention

BACKGROUND

Despite known gender differences in recovery, few studies have examined symptom management (SM) interventions or responses by gender after coronary artery bypass surgery (CABS).

OBJECTIVE

The purpose of this subanalysis was to describe and evaluate differences in response by gender to an SM intervention on the presence and burden of symptoms, physical activity, and physical functioning in elderly CABS patients during the early discharge period (3 and 6 weeks after CABS, and 3 and 6 months after CABS).

METHODS

The parent study whose data were analyzed to examine gender differences involved a two-group, randomized clinical trial design. The 6-week early recovery SM telehealth intervention was delivered by the Health Buddy. Measures included the Cardiac Symptom Survey, a Modified 7-Day Activity Interview, an RT3 accelerometer, an Activity Diary, and the Medical Outcomes Study Short Form 36. This study was not powered for a gender × group analysis, and we used descriptive statistics, χ(2) tests, t tests, and analysis of variance for statistical analyses.

RESULTS

Subjects (n = 232) included 192 men and 40 women, with a mean age of 71.2 SD, 7 years. The intervention group consisted of 86 men and 23 women, and the usual care (UC) group consisted of 106 men and 17 women. Data trends suggest that the SM intervention exerted greater impact on women than on men for symptoms such as fatigue, depression, sleep problems, and pain. Again, men exhibited higher levels of physical activity than did women. However, women in the SM group generally had higher scores than did women in the UC group.

CONCLUSION

Although the parent study found no effect of an early recovery SM intervention, this exploratory secondary analysis indicated that women in the intervention group demonstrated more improvement in measures of physical activity than did those in the UC group. Further study, using a larger sample, is necessary to test these preliminary results.

Technology-enhanced practice for patients with chronic cardiac disease: home implementation and evaluation

OBJECTIVE

This 3-year field experiment engaged 60 nurses and 282 patients in the design and evaluation of an innovative home-care nursing model, referred to as technology-enhanced practice (TEP).

METHODS

Nurses using TEP augmented the usual care with a web-based resource (HeartCareII) that provided patients with self-management information, self-monitoring tools, and messaging services.

RESULTS

Patients exposed to TEP demonstrated better quality of life and self-management of chronic heart disease during the first 4 weeks, and were no more likely than patients in usual care to make unplanned visits to a clinician or hospital. Both groups demonstrated the same long-term symptom management and achievements in health status.

CONCLUSION

This project provides new evidence that the purposeful creation of patient-tailored web resources within a hospital portal is possible; that nurses have difficulty with modifying their practice routines, even with a highly-tailored web resource; and that the benefits of this intervention are more discernable in the early postdischarge stages of care.

Symptom burden clusters and their impact on psychosocial functioning following coronary artery bypass surgery

Although there is extensive literature on symptoms experienced by patients after coronary artery bypass surgery (CABS), there is a paucity of data on symptom clusters and their impact on functional outcomes. The purpose of these descriptive, secondary analyses was to identify and describe cluster subgroups of 226 elderly CABS patients at discharge and to examine the cluster's impact on psychosocial functioning over time (baseline, 6 weeks, and 3 months) using the 36-item Medical Outcome Study Short Form subscales. Cluster analysis revealed a 3-cluster solution with low, low-moderate, and moderate symptom burden clusters. Significant differences were detected for Duke Activity Status Index (F(2,223) = 5.12, P = .007), Barnason Efficacy Expectation Scale (F(2,223) = 9.60, P < .0001), Hospital Anxiety and Depression Scale (F(2,219) = 15.14, P < .0001), and New York Heart Association classification (chi = 17.44, P = .008). Significant differences were noted on all variables between the low and moderate symptom burden clusters with differences between the low-moderate and moderate clusters for only the Barnason Efficacy Expectation Scale and the Hospital Anxiety and Depression Scale. Those in the moderate symptom burden cluster had more symptoms, anxiety, and depression along with lower self-efficacy and physiological functioning than those in the other 2 clusters. There was no interaction or simple main effects for the role-emotional or social subscales as measured by the 36-item Medical Outcome Study Short Form. There was no significant interaction for mental functioning by time and cluster (F(4,641) = .30, P = .88); however, there was a simple main effect for cluster (F(2,641) = 4.11, P = .02). Follow-up analysis indicated significant differences between the low and low-moderate clusters, indicating that those with low symptom burden had significantly better mental health functioning than those with moderate symptom burden. Findings provide a foundation of knowledge on symptom clusters in CABS populations and may be useful to clinicians to identify patients at risk for slowed or delayed recovery and for early intervention.

Home telecare technologies for the elderly

There are many home telecare technologies which have been developed specifically for chronic diseases and there are some more generic technologies that could be used as well. For home telecare, the equipment must be certified, the operational routines must be reformed, the infrastructure must be in place, the market must be prepared, the health authorities must be convinced that the system will work and the cost-effectiveness must be evaluated. Organizational and societal changes, such as cost reduction policies and an aging population, are the main driving forces for the development of home telecare, especially for elderly patients. At the moment there is no holistic model for scientific evaluation from different perspectives (e.g. clinical, legal, technical). We suggest that more research on home telecare and its effects needs to be conducted, in order to provide evidence for optimizing the use of this promising technique.

Infection, rejection, and hospitalizations in transplant recipients using telehealth

CONTEXT

Telehealth technology serves individuals who live in geographical areas that prohibit easy access to specialized health care and can provide transplant recipients with access to transplant center personnel for adjunctive follow-up care.

OBJECTIVE

To compare infection, rejection, and hospitalization events in subjects randomized to telehealth or to standard posttransplant care. STUDY DESIGN, STUDY PARTICIPANTS, SETTING AND RESEARCH PROCEDURE: This longitudinal prospective study compared transplant outcomes (infections, rejections, and hospitalizations) of 106 subjects who were randomized to either the telehealth (n = 53) or standard care (n = 53) group and met the 6-month study end point. Sex, race, and transplant type were evenly distributed within the 2 groups. Subjects received primary follow-up care from nurse practitioners. The telehealth visits were conducted via live interactive sessions with digitized equipment used to perform physical examinations.

MAIN OUTCOMES

Infections, rejections, and hospitalizations were summarized for each of the groups. Subgroup analyses were performed by sex, transplant type, and time since transplant.

RESULTS

No differences were found between the telehealth and standard care groups for infections, rejections, or hospitalizations at the 6-month data end point. Overall, females had twice as many infections as males (P = .01). In this analysis, group assignment did not affect study outcomes.

CONCLUSIONS

The rates of infection, rejection, and hospitalization in a sample of primarily long-term transplant patients did not differ between patients who received telehealth follow-up and patients who received standard care, indicating that this delivery system can be used to provide follow-up care after transplant.

Home-based telehealth: a review and meta-analysis

We conducted a systematic review to identify studies on the effect of home telehealth on clinical care outcomes. The search was restricted to peer-reviewed publications (published between 2001 and 2007) about studies conducted in home or residential settings. The search yielded 154 potential articles and dissertations. A total of 29 articles met the inclusion criteria and were included in a meta-analysis. The weighted mean effect size for the overall meta-analysis was 0.50, and the z-statistic was 3.0, indicating that telehealth had a moderate, positive and significant effect (P < or = 0.01) on clinical outcomes. Subanalyses also indicated positive significant effects of telehealth for some disease categories (heart disease and psychiatric conditions), but not others (diabetes), patient populations and telehealth interventions. Overall, the meta-analysis indicated that telehealth positively affects clinical outcomes of care, even in different patient populations.

Infection, Rejection, and Hospitalizations in Transplant Recipients Using Telehealth

Context

Telehealth technology serves individuals who live in geographical areas that prohibit easy access to specialized health care and can provide transplant recipients with access to transplant center personnel for adjunctive follow-up care.

Objective

To compare infection, rejection, and hospitalization events in subjects randomized to telehealth or to standard posttransplant care.

Study Design, Study Participants, Setting and Research Procedure

This longitudinal prospective study compared transplant outcomes (infections, rejections, and hospitalizations) of 106 subjects who were randomized to either the telehealth (n=53) or standard care (n=53) group and met the 6-month study end point. Sex, race, and transplant type were evenly distributed within the 2 groups. Subjects received primary follow-up care from nurse practitioners. The telehealth visits were conducted via live interactive sessions with digitized equipment used to perform physical examinations.

Main Outcomes

Infections, rejections, and hospitalizations were summarized for each of the groups. Subgroup analyses were performed by sex, transplant type, and time since transplant.

Results

No differences were found between the telehealth and standard care groups for infections, rejections, or hospitalizations at the 6-month data end point. Overall, females had twice as many infections as males ( P = .01). In this analysis, group assignment did not affect study outcomes.

Conclusions

The rates of infection, rejection, and hospitalization in a sample of primarily long-term transplant patients did not differ between patients who received telehealth follow-up and patients who received standard care, indicating that this delivery system can be used to provide follow-up care after transplant.

Use of a Telehealth Device to Deliver a Symptom Management Intervention to Cardiac Surgical Patients

A variety of approaches can provide cardiac patients with needed follow-up care. However, with the explosion of telehealth capabilities, clinicians are more ready to explore other methods to integrate the use of telehealth devices into the delivery of effective nursing interventions. This article summarizes the development of a symptom management intervention for coronary artery bypass graft patients using the Health Buddy to deliver a nursing intervention in the early recovery period after hospital discharge. Considerations used to design the symptom management intervention and selection of this telehealth modality are discussed. This overview can help clinicians and researchers gain perspective on how to evaluate telehealth modalities to aid in the delivery of interventions for cardiac and other clinical populations.