Comparison of uptake and predictors of adherence in primary and secondary prevention of cardiovascular disease in a community-based cardiovascular prevention programme (MyAction Westminster)

Outcomes in Patients with Minor Stroke: Diagnosis and Management in the Post-thrombectomy Era

In the era of mechanical thrombectomy and better preventative strategies, a higher number of patients are being discharged home from the hospital with the so-called minor strokes. This has significantly changed the landscape of stroke recovery. Unfortunately, while symptoms may be categorized as mild compared to individuals with higher NIH Stroke Scale scores, the physical, cognitive, and emotional sequelae can be disabling and result in failure to return to work and poor quality of life in a population with significant potential to recover fully. In this review, we discuss the current state of minor stroke, the most common pattern of resulting deficits, what is known about the underlying pathophysiology that leads to a relatively global pattern of impaired cognition following an infarct in any location, and special considerations for treatment based on this population's unique needs. Raising awareness of the current morbidity associated with minor stroke, the need for a uniform definition that allows for comparisons of individuals across studies, and further research focused on this population to optimize outcomes, has the potential to significantly improve recovery.

Bridging Care Transition After Hospitalization for Atrial Fibrillation and Coronary Interventions

ABSTRACT

Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community-hospital-integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.

Pharmacist-led cardiovascular risk prevention in Western Canada: a qualitative study

OBJECTIVES

Preventing cardiovascular diseases (CVD) is a public health and policy priority, including for employers. A novel CVD risk management programme that included medication management was delivered by pharmacists to employees of a Canadian university. This qualitative study describes the experiences and perceptions of participants who received individual health consultations in this programme.

METHODS

A qualitative study design using free-text responses was adopted. Data (5658 words) came from evaluation surveys completed by 119 programme participants were iteratively coded and thematically analysed.

KEY FINDINGS

We identified four themes characterising participant experiences of pharmacist-led CVD prevention. Theme one was labelled self-efficacy because personalised health information and advice on CVD risk factor management empowered participants to make improvements for their health. Participants expressed a range of positive responses about the longer consultations, supportive communication and safe setting of their pharmacist-led encounters; hence, Theme two is labelled pharmacists' interpersonal skills. The wider context of the programme included a number of enabling factors (Theme three) that either supported or limited participant engagement in the programme. A number of changes to behaviour and health measures were identified and participant suggestions to expand and continue the programme further contributed to perceptions of positive programme impact (Theme four).

CONCLUSIONS

This study raises questions about how external resources and broader determinants might enable, or hinder, future programme success and sustainability. It also highlights the need for greater understanding and communication of the importance of primary prevention and the role of pharmacists in CVD risk reduction and workplace health promotion.

Influences on NHS Health Check behaviours: a systematic review

Background

National Health Service Health Checks were introduced in 2009 to reduce cardiovascular disease (CVD) risks and events. Since then, national evaluations have highlighted the need to maximise the programme’s impact by improving coverage and outputs. To address these challenges it is important to understand the extent to which positive behaviours are influenced across the NHS Health Check pathway and encourage the promotion or minimisation of behavioural facilitators and barriers respectively. This study applied behavioural science frameworks to: i) identify behaviours and actors relevant to uptake, delivery and follow up of NHS Health Checks and influences on these behaviours and; ii) signpost to example intervention content.

Methods

A systematic review of studies reporting behaviours related to NHS Health Check-related behaviours of patients, health care professionals (HCPs) and commissioners. Influences on behaviours were coded using theory-based models: COM-B and Theoretical Domains Framework (TDF). Potential intervention types and behaviour change techniques (BCTs) were suggested to target key influences.

Results

We identified 37 studies reporting nine behaviours and influences for eight of these. The most frequently identified influences were physical opportunity including HCPs having space and time to deliver NHS Health Checks and patients having money to adhere to recommendations to change diet and physical activity. Other key influences were motivational, such as beliefs about consequences about the value of NHS Health Checks and behaviour change, and social, such as influences of others on behaviour change. The following techniques are suggested for websites or smartphone apps: Adding objects to the environment, e.g. provide HCPs with electronic schedules to guide timely delivery of Health Checks to target physical opportunity, Social support (unspecified), e.g. include text suggesting patients to ask a colleague to agree in advance to join them in taking the ‘healthy option’ lunch at work; Information about health consequences, e.g. quotes and/or videos from patients talking about the health benefits of changes they have made.

Conclusions

Through the application of behavioural science we identified key behaviours and their influences which informed recommendations for intervention content. To ascertain the extent to which this reflects existing interventions we recommend a review of relevant evidence.

Development and Psychometric Evaluation of the Cardiac Rehabilitation Adherence Tool (CRAT)

Patients with cardiac diseases can achieve the greatest benefit from cardiac rehabilitation through modification of their unhealthy behaviors. This study aimed to develop and examine the psychometric properties of the Cardiac Rehabilitation Adherence Tool (CRAT), which was designed to assess patients' adherence to cardiac rehabilitation. In this instrument development study, the items of the CRAT were extracted through a comprehensive literature review. The CRAT was assessed in terms of validity and reliability. Exploratory factor analysis was conducted to assess its construct validity, which led to the development of a tool containing 57 items and five dimensions including "acceptance of the rehabilitation center", "being interested in health", "feeling a need", "personal control over the situation", and "encouragement and advice." These five factors accounted for 45.23% of the observed variance. The Cronbach's alpha was 0.935. The test-retest method supported the stability of the instrument (r = 0.95). Health care professionals can use the CRAT to examine factors influencing the patient's decision to leave cardiac rehabilitation and design strategies for improving their adherence to the rehabilitation program.

Interventions to promote patient utilisation of cardiac rehabilitation

BACKGROUND

International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation.

OBJECTIVES

First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations.

SEARCH METHODS

Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics.

MAIN RESULTS

Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.

AUTHORS' CONCLUSIONS

Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

Predictors of completion of a psychological-behavioral intervention in acute coronary syndrome patients

OBJECTIVE

Dropout from health behavior interventions in patients with heart disease is a major clinical issue that can impact recovery and prognosis. Positive psychology (PP)-based treatments have the potential to promote health behaviors, but predictors of PP intervention completion have not been examined in persons with heart disease.

METHODS

Among 128 patients receiving a phone-based PP intervention to promote physical activity among acute coronary syndrome (ACS) patients, numerous baseline sociodemographic, medical, and psychological variables, along with self-reported pre/post improvements in happiness and optimism (on 0-10 Likert scales) associated with an initial PP exercise, were examined as potential predictors of intervention completion. Logistic and linear regression analyses were used to assess relationships between these predictors and (a) intervention completion (at least 4 of 8 sessions completed) and (b) number of total sessions completed.

RESULTS

No patient characteristic was associated with greater likelihood of completing the PP intervention. However, immediate pre-post change in optimism following the initial exercise was associated with intervention completion (odds ratio = 1.98; 95% confidence interval: 1.28-3.05; p = .002; mean post-exercise increase in optimism 0.79 [SD 1.52] in completers vs. mean optimism decrease of 0.59 [SD 1.42] in non-completers).

CONCLUSIONS

Pre-post change in optimism with a single PP activity predicted completion of an 8-week PP-based health behavior intervention in post-ACS patients. This information could be used clinically by having potential enrollees complete a single PP activity to assess intervention fit.

Local authority commissioning of NHS Health Checks: A regression analysis of the first three years

In April 2013, the public health function was transferred from the NHS to local government, making local authorities (LAs) responsible for commissioning the NHS Health Check programme. The programme aims to reduce preventable mortality and morbidity in people aged 40-74. The national five-year ambition is to invite all eligible individuals and to achieve an uptake of 75%. This study evaluates the effects of LA expenditure on the programme's invitation rates (the proportion of the eligible population invited to a health check), coverage rates (the proportion of the eligible population who received a health check) and uptake rates (attendance by those who received a formal invitation letter) in the first three years of the reforms. We ran negative binomial panel models and controlled for a range of confounders. Over 2013/14-2015/16, the invitation rate, coverage rate and uptake rate averaged 57% 28% and 49% respectively. Higher per capita spend on the programme was associated with increases in both the invitation rate and coverage rate, but had no effect on the uptake rate. When we controlled for the LA invitation rate, the association between spend and coverage rate was smaller but remained statistically significant. This suggests that alternatives to formal invitation, such as opportunistic approaches in work places or sports centres, may be effective in influencing attendance.

Implications of prescribing a fixed-dose combination in clinical cardiology practice: a retrospective observational study using a single medical centre database in Korea

Objective

Fixed-dose combination (FDC) prescribing enhances adherence to medication. However, there are limited data regarding the usefulness of FDC drugs across different risk groups. The aim of this study was to explore the relationship between FDC discontinuation and clinical outcomes.

Methods

From January 2008 to December 2014, patients with FDC prescriptions who visited a cardiology outpatient clinic at a tertiary university hospital in Daegu, Republic of Korea were retrospectively identified. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk score and 20 conventional cardiovascular (CV) risk factors were assessed. Patients were classified according to FDC continuation, together with a tertile of 20 risks. CV events were defined as the composite of admission for worsening heart failure or diabetes, stroke, ischaemic heart disease, and CV death.

Results

502 patients were prescribed with one of the following FDC products: calcium channel blocker (CCB) plus angiotensin receptor blockers (ARB), CCB plus statins, and ARB plus diuretics. During follow-up (mean 2.8±2.4 years), 203 discontinuations (40.4%) occurred. FDC-discontinued patients had lower ASCVD risk scores (24.8% vs. 28.8%, p<0.001), and patients with <6 risk factors discontinued FDC frequently. During follow-up, 57 events (11.4%) were reported: 30 (14.8%) in FDC-discontinued patients and 27 (9.1%) in FDC-continued patients (p=0.062). In multivariate models accounting for events, FDC discontinuation (p<0.001) and high ASCVD risk score (p=0.017) were associated with CV events.

Conclusions

FDC discontinuation was common among patients attending the cardiology outpatient clinic. Our analyses suggest that FDC discontinuation in patients at high ASCVD risk may have an impact on CV event rates.

Determinants of Dropout and Nonadherence in a Dementia Prevention Randomized Controlled Trial: The Prevention of Dementia by Intensive Vascular Care Trial

OBJECTIVES

To explore and compare sociodemographic, clinical, and neuropsychiatric determinants of dropout and nonadherence in older people participating in an open-label cluster-randomized controlled trial-the Prevention of Dementia by Intensive Vascular care (preDIVA) trial-over 6 years.

DESIGN

Secondary analysis.

SETTING

One hundred sixteen general practices in the Netherlands.

PARTICIPANTS

Community-dwelling individuals aged 70 to 78 (N = 2,994).

INTERVENTION

Nurse-led multidomain intervention targeting cardiovascular risk factors to prevent dementia.

MEASUREMENTS

The associations between participant baseline sociodemographic (age, sex, education), clinical (medical history, disability, cardiovascular risk), neuropsychiatric (depressive symptoms (Geriatric Depression Scale-15), and cognitive (Mini-Mental State Examination)) characteristics and dropout from the trial and nonadherence to the trial intervention were explored using multilevel logistic regression models.

RESULTS

Older age, poorer cognitive function, more symptoms of depression, and greater disability were the most important determinants of dropout of older people. The presence of cardiovascular risk factors was not associated with dropout but was associated with nonadherence. Being overweight was a risk factor for nonadherence, whereas people with high blood pressure or a low level of physical exercise adhered better to the intervention. The association between poorer cognitive function and symptoms of depression and dropout was stronger in the control group than in the intervention group, and vice versa for increased disability.

CONCLUSION

In a large dementia prevention trial with 6-year follow-up, dropout was associated with older age, poorer cognitive function, symptoms of depression, and disability at baseline. These findings can help to guide the design of future dementia prevention trials in older adults. The associations found between cardiovascular risk factors and nonadherence need to be confirmed in other older populations receiving cardiovascular prevention interventions.