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Arshed M, Mahmud A, Minhat HS, Lim PY, Zakar R. Effectiveness of a Multifaceted Mobile Health Intervention (Multi-Aid-Package) in Medication Adherence and Treatment Outcomes Among Patients With Hypertension in a Low- to Middle-Income Country: Randomized Controlled Trial. JMIR Mhealth Uhealth 2024; 12:e50248. [PMID: 38896837 PMCID: PMC11222770 DOI: 10.2196/50248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/31/2024] [Accepted: 04/30/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND The high prevalence of uncontrolled hypertension in Pakistan is predominantly attributed to poor medication adherence. As more than 137 million people in Pakistan use cell phones, a suitable mobile health (mHealth) intervention can be an effective tool to overcome poor medication adherence. OBJECTIVE We sought to determine whether a novel mHealth intervention is useful in enhancing antihypertensive therapy adherence and treatment outcomes among patients with hypertension in a low- to middle-income country. METHODS A 6-month parallel, single-blinded, superiority randomized controlled trial recruited 439 patients with hypertension with poor adherence to antihypertensive therapy and access to smartphones. An innovative, multifaceted mHealth intervention (Multi-Aid-Package), based on the Health Belief Model and containing reminders (written, audio, visual), infographics, video clips, educational content, and 24/7 individual support, was developed for the intervention group; the control group received standard care. The primary outcome was self-reported medication adherence measured using the Self-Efficacy for Appropriate Medication Adherence Scale (SEAMS) and pill counting; the secondary outcome was systolic blood pressure (SBP) change. Both outcomes were evaluated at baseline and 6 months. Technology acceptance feedback was also assessed at the end of the study. A generalized estimating equation was used to control the covariates associated with the probability of affecting adherence to antihypertensive medication. RESULTS Of 439 participants, 423 (96.4%) completed the study. At 6 months post intervention, the median SEAMS score was statistically significantly higher in the intervention group compared to the controls (median 32, IQR 11 vs median 21, IQR 6; U=10,490, P<.001). Within the intervention group, there was an increase in the median SEAMS score by 12.5 points between baseline and 6 months (median 19.5, IQR 5 vs median 32, IQR 11; P<.001). Results of the pill-counting method showed an increase in adherent patients in the intervention group compared to the controls (83/220, 37.2% vs 2/219, 0.9%; P<.001), as well as within the intervention group (difference of n=83, 37.2% of patients, baseline vs 6 months; P<.001). There was a statistically significant difference in the SBP of 7 mmHg between the intervention and control groups (P<.001) at 6 months, a 4 mmHg reduction (P<.001) within the intervention group, and a 3 mmHg increase (P=.314) within the controls. Overall, the number of patients with uncontrolled hypertension decreased by 46 in the intervention group (baseline vs 6 months), but the control group remained unchanged. The variables groups (adjusted odds ratio [AOR] 1.714, 95% CI 2.387-3.825), time (AOR 1.837, 95% CI 1.625-2.754), and age (AOR 1.618, 95% CI 0.225-1.699) significantly contributed (P<.001) to medication adherence. Multi-Aid-Package received a 94.8% acceptability score. CONCLUSIONS The novel Multi-Aid-Package is an effective mHealth intervention for enhancing medication adherence and treatment outcomes among patients with hypertension in a low- to middle-income country. TRIAL REGISTRATION ClinicalTrials.gov NCT04577157; https://clinicaltrials.gov/study/NCT04577157.
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Affiliation(s)
- Muhammad Arshed
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
- University Institute of Public Health, Faculty of Allied Health Sciences, University of Lahore, Punjab, Lahore, Pakistan
| | - Aidalina Mahmud
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Halimatus Sakdiah Minhat
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Poh Ying Lim
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Rubeena Zakar
- Department of Public Health, Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
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Lindsay S, Ragunathan S, Kingsnorth S, Zhou C, Kakonge L, Cermak C, Hickling A, Wright FV. Understanding the benefits and challenges of outpatient virtual care during the COVID-19 pandemic in a Canadian pediatric rehabilitation hospital. Disabil Rehabil 2024; 46:2396-2404. [PMID: 37306595 DOI: 10.1080/09638288.2023.2221902] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/01/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE The evolving virtual health care experience highlights the potential of technology to serve as a way to enhance care. Having virtual options for assessment, consultation and intervention were essential during the coronavirus (COVID-19) pandemic, especially for children with disabilities and their families. The purpose of our study was to describe the benefits and challenges of outpatient virtual care during the pandemic within pediatric rehabilitation. METHODS This qualitative study, part of a larger mixed methods project, involved in-depth interviews with 17 participants (10 parents, 2 youth, 5 clinicians) from a Canadian pediatric rehabilitation hospital. We analyzed the data using a thematic approach. RESULTS Our findings demonstrated three main themes: (1) benefits of virtual care (e.g., continuity of care, convenience, stress reduction and flexibility, and comfort within the home environment and enhanced rapport); (2) challenges related to virtual care (e.g., technical difficulties and lack of technology, environmental distractions and constraints, communication difficulty, and health impacts); and (3) advice for the future of virtual care (i.e., offering choice to families, enhanced communication and addressing health equity issues). CONCLUSIONS Clinicians and hospital leaders should consider addressing the modifiable barriers in accessing and delivering virtual care to optimize its effectiveness.
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Affiliation(s)
- Sally Lindsay
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | | | - Shauna Kingsnorth
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | - Chuanlin Zhou
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Lisa Kakonge
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Speech-Language Pathology, University of Toronto, Toronto, Canada
- School of Rehabilitation Science, McMaster University, Toronto, Canada
| | - Carly Cermak
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Andrea Hickling
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada
| | - F Virginia Wright
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
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Yin X, Huang C, Lin B. Application of intensive management of risk awareness combined with cardiac rehabilitation nursing in elderly patients with acute myocardial infarction and heart failure. Medicine (Baltimore) 2024; 103:e37381. [PMID: 38758887 PMCID: PMC11098228 DOI: 10.1097/md.0000000000037381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/05/2024] [Indexed: 05/19/2024] Open
Abstract
The aim of this study is to assess the impact of intensive risk awareness management along with cardiac rehabilitation nursing in elderly patients with acute myocardial infarction and heart failure. We selected 101 elderly patients with acute myocardial infarction and heart aging treated from January 2022 to March 2023. They were divided into control and observation groups based on hospitalization numbers. The control group (n = 50) received routine nursing, while the observation group (n = 51) received intensive risk awareness management and cardiac rehabilitation nursing. We compared medication possession ratio (MPR), cardiac function, self-care ability scale scores, quality-of-life, incidents, and satisfaction between the 2 groups. Before intervention, there was no significant difference in MPR values between the 2 groups (P > .05). After intervention, MPR values increased in both groups, with a greater increase in the observation group (P < .05). Cardiac function showed no significant difference before intervention (P > .05), but after intervention, the observation group had lower left ventricular end-systolic and diastolic diameters and higher left ventricular ejection fraction compared to the control group (P < .05). Self-care skills, health knowledge, self-responsibility, and self-concept scores improved in both groups after intervention, with higher scores in the observation group (P < .05). The observation group had higher scores in various quality-of-life domains (P < .05). The total incidence of adverse events was lower in the observation group (5.88%) compared to the control group (20.00%) (P < .05). Patient satisfaction was significantly higher in the observation group (96.08%) than in the control group (84.00%) (P < .05). Intensive risk awareness management combined with cardiac rehabilitation nursing in elderly patients with acute myocardial infarction and heart aging can enhance medication compliance, improve quality-of-life, enhance self-care abilities, boost cardiac function, reduce incidents, and increase patient satisfaction.
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Affiliation(s)
- Xiaoli Yin
- Department of Cardiology, Wannan Rehabilitation Hospital, Wuhu, Anhui, China
| | - Cuiping Huang
- Department of Cardiology, Wannan Rehabilitation Hospital, Wuhu, Anhui, China
| | - Binglai Lin
- Department of Cardiology, Wannan Rehabilitation Hospital, Wuhu, Anhui, China
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Gallegos-Rejas VM, Rawstorn JC, Gallagher R, Mahoney R, Thomas EE. Key features in telehealth-delivered cardiac rehabilitation required to optimize cardiovascular health in coronary heart disease: a systematic review and realist synthesis. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:208-218. [PMID: 38774382 PMCID: PMC11104477 DOI: 10.1093/ehjdh/ztad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 05/24/2024]
Abstract
Telehealth-delivered cardiac rehabilitation (CR) programmes can potentially increase participation rates while delivering equivalent outcomes to facility-based programmes. However, key components of these interventions that reduce cardiovascular risk factors are not yet distinguished. This study aims to identify features of telehealth-delivered CR that improve secondary prevention outcomes, exercise capacity, participation, and participant satisfaction and develop recommendations for future telehealth-delivered CR. The protocol for our review was registered with the Prospective Register of Systematic Reviews (#CRD42021236471). We systematically searched four databases (PubMed, Scopus, EMBASE, and Cochrane Database) for randomized controlled trials comparing telehealth-delivered CR programmes to facility-based interventions or usual care. Two independent reviewers screened the abstracts and then full texts. Using a qualitative review methodology (realist synthesis), included articles were evaluated to determine contextual factors and potential mechanisms that impacted cardiovascular risk factors, exercise capacity, participation in the intervention, and increased satisfaction. We included 37 reports describing 26 randomized controlled trials published from 2010 to 2022. Studies were primarily conducted in Europe and Australia/Asia. Identified contextual factors and mechanisms were synthesized into four theories required to enhance participant outcomes and participation. These theories are as follows: (i) early and regular engagement; (ii) personalized interventions and shared goals; (iii) usable, accessible, and supported interventions; and (iv) exercise that is measured and monitored. Providing a personalized approach with frequent opportunities for bi-directional interaction was a critical feature for success across telehealth-delivered CR trials. Real-world effectiveness studies are now needed to complement our findings.
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Affiliation(s)
- Victor M Gallegos-Rejas
- Centre for Online Health, The University of Queensland, Ground Floor Building 33, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Ground Floor Building 33, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia
| | - Jonathan C Rawstorn
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Robyn Gallagher
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Western Ave, Camperdown, NSW 2050, Australia
| | - Ray Mahoney
- CSIRO Health & Biosecurity, Australian e-Health Research Centre, Surgical, Treatment and Rehabilitation Service—STARS Level 7, 296 Herston Rd, Herston 4029, Australia
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Emma E Thomas
- Centre for Online Health, The University of Queensland, Ground Floor Building 33, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Ground Floor Building 33, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia
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Gebremichael LG, Champion S, Nesbitt K, Pearson V, Bulamu NB, Dafny HA, Sajeev S, Pinero de Plaza MA, Ramos JS, Suebkinorn O, Gulyani A, Bulto LN, Beleigoli A, Hendriks JM, Hines S, Clark RA. Effectiveness of cardiac rehabilitation programs on medication adherence in patients with cardiovascular disease: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 20:200229. [PMID: 38188637 PMCID: PMC10770721 DOI: 10.1016/j.ijcrp.2023.200229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/20/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Background Education to improve medication adherence is one of the core components of cardiac rehabilitation (CR) programs. However, the evidence on the effectiveness of CR programs on medication adherence is conflicting. Therefore, we aimed to summarize the effectiveness of CR programs versus standard care on medication adherence in patients with cardiovascular disease. Methods A systematic review and meta-analysis was conducted. Seven databases and clinical trial registries were searched for published and unpublished articles from database inception to 09 Feb 2022. Only randomised controlled trials and quasi-experimental studies were included. Two independent reviewers conducted the screening, extraction, and appraisal. The JBI methodology for effectiveness reviews and PRISMA 2020 guidelines were followed. A statistical meta-analysis of included studies was pooled using RevMan version 5.4.1. Results In total 33 studies were included with 16,677 participants. CR programs increased medication adherence by 14 % (RR = 1.14; 95 % CI: 1.07 to 1.22; p = 0.0002) with low degree of evidence certainty. CR also lowered the risk of dying by 17 % (RR = 0.83; 95 % CI: 0.69 to 1.00; p = 0.05); primary care and emergency department visit by mean difference of 0.19 (SMD = -0.19; 95 % CI: -0.30 to -0.08; p = 0.0008); and improved quality of life by 0.93 (SMD = 0.93; 95 % CI: 0.38 to 1.49; p = 0.0010). But no significant difference was observed in lipid profiles, except with total cholesterol (SMD = -0.26; 95 % CI: -0.44 to -0.07; p = 0.006) and blood pressure levels. Conclusions CR improves medication adherence with a low degree of evidence certainty and non-significant changes in lipid and blood pressure levels. This result requires further investigation.
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Affiliation(s)
- Lemlem Gebremedhin Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - Stephanie Champion
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - Vincent Pearson
- JBI, School of Public Health, The University of Adelaide, Australia
| | - Norma B. Bulamu
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Hila A. Dafny
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - Shelda Sajeev
- Centre for Artificial Intelligence Research and Optimisation (AIRO), Torrens University, Adelaide, South Australia, Australia
- College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Maria Alejandra Pinero de Plaza
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
- National Health and Medical Research Council, Transdisciplinary Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Joyce S. Ramos
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Orathai Suebkinorn
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Aarti Gulyani
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Lemma N. Bulto
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - Jeroen M. Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sonia Hines
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
- Flinders Rural and Remote Health, NT. College of Medicine and Public Health, Flinders University, Australia
| | - Robyn A. Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
| | - On behalf of the NHMRC CHAP Project Team
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Australia
- JBI, School of Public Health, The University of Adelaide, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Centre for Artificial Intelligence Research and Optimisation (AIRO), Torrens University, Adelaide, South Australia, Australia
- College of Science and Engineering, Flinders University, Adelaide, SA, Australia
- National Health and Medical Research Council, Transdisciplinary Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
- Flinders Rural and Remote Health, NT. College of Medicine and Public Health, Flinders University, Australia
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Shuldiner J, Lam E, Shah N, Grimshaw J, Desveaux L, Heisey R, Taccone MS, Taljaard M, Thavorn K, Hodgson D, Gupta S, Lofters A, Ivers N, Nathan PC. Protocol for the ONLOOP trial: pragmatic randomized trial evaluating a province-wide system of personalized reminders for evidence-based surveillance tests in adult survivors of childhood cancer in Ontario. Implement Sci 2024; 19:19. [PMID: 38395903 PMCID: PMC10885391 DOI: 10.1186/s13012-024-01347-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Childhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time. METHODS This is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP's impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants' consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later. The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed. DISCUSSION The results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population. TRIAL REGISTRATION ClinicalTrials.gov NCT05832138.
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Affiliation(s)
- Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville St., Toronto, ON, M5S 1B2, Canada.
| | - Emily Lam
- The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Nida Shah
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville St., Toronto, ON, M5S 1B2, Canada
| | - Jeremy Grimshaw
- University of Ottawa, Ottawa Hospital Research Institute, 501 Smyth Road, Room 1286, Ottawa, ON, K1H 8L6, Canada
| | - Laura Desveaux
- Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B, Canada
| | - Ruth Heisey
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Michael S Taccone
- The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health-University of Ottawa, Clinical Epidemiology-Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - David Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, Toronto, ON, Canada
| | - Sumit Gupta
- The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Aisha Lofters
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville St., Toronto, ON, M5S 1B2, Canada
| | - Noah Ivers
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Paul C Nathan
- The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Marselin A, Amalia L, Dinarti LK. The interventions to improve medication adherence in coronary heart disease patient: A systematic review. J Saudi Heart Assoc 2023; 35:259-278. [PMID: 38116401 PMCID: PMC10727132 DOI: 10.37616/2212-5043.1356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/05/2023] [Accepted: 10/13/2023] [Indexed: 12/21/2023] Open
Abstract
Objective The clinical outcome and quality of life of CHD patients are greatly influenced by medication adherence. Non-adherence of CHD patients to treatment results in sub-optimal clinical outcomes and increasing costs. This study aims to describe effectiveness of the intervention to improve the medication adherence in CHD patients. Methods Systematic review methodology was used in this study. Scopus and PubMed were used to search the relevant article systematically. The outcome measured was medication adherence in coronary heart disease patients. Results Final screening was 31 articles that met the inclusion criteria in this study of 788 articles. Selection processes the article used the PRISMA guideline. Most of the articles (15 articles) use interventions that utilize information technology (IT) as known with m-health in the form of text messages, website, and smartphone-based applications in increasing medication adherence in CHD patients. The non m-health interventions developed are in the form of self-efficacy programs, monitoring and education by health workers or care workers, pharmacy care by clinical pharmacists, and the use of drugs in the form of multi-capsules. The results of most intervention with m-health can improve the medication adherence in CHD patient effectively. Education and motivation program by professional health care and multi-capsules also increasing the medication adherence in the intervention control. There was a decrease of medication adherence in some articles with long time follow-up that can be attention for the professional health care to manage the patient adherent. Conclusion The medication adherence in CHD patient can be improve by various program. Modification of m-health and non m-health intervention can be resolved to increase the communication, motivation, and knowledge about medication adherence in CHD patients.
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Affiliation(s)
- Amanda Marselin
- School of Pharmacy, Institut Teknologi Bandung,
Indonesia
- Pharmacy Program, STIKES Notokusumo, Yogyakarta,
Indonesia
| | - Lia Amalia
- School of Pharmacy, Institut Teknologi Bandung,
Indonesia
| | - Lucia K. Dinarti
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta,
Indonesia
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Bahit MC, Korjian S, Daaboul Y, Baron S, Bhatt DL, Kalayci A, Chi G, Nara P, Shaunik A, Gibson CM. Patient Adherence to Secondary Prevention Therapies After an Acute Coronary Syndrome: A Scoping Review. Clin Ther 2023; 45:1119-1126. [PMID: 37690915 DOI: 10.1016/j.clinthera.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/05/2023] [Accepted: 08/16/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Adherence to guideline-recommended, long-term secondary preventative therapies among patients with acute coronary syndrome (ACS) is fundamental to improving long-term outcomes. The purpose of this scoping review was to provide a broad synopsis of pertinent studies in a structured and comprehensive way regarding factors that influence patient adherence to medical therapy after ACS. METHODS Relevant articles focusing on adherence to medical therapy after ACS were retrieved from the EMBASE and MEDLINE databases (search date, September 7, 2021). Studies were independently screened, and relevant information was extracted. FINDINGS A total of 58 studies were identified by using the EMBASE and MEDLINE databases. Adherence to secondary prevention was moderate to low and steadily decreased over time. Nearly 30% of patients discontinued one or more medications within 90 days of their primary ACS, and adherence decreased to 50% to 60% at 1 year postdischarge. There were no major differences in adherence between drug classes. Factors influencing patient adherence can be broadly divided into 3 categories: patient related, health care system related, and disease related. Patients managed with percutaneous coronary interventions were more adherent to follow-up treatment than medically managed patients. Depression was reported as a major psychological factor that negatively affected adherence. Improved adherence was observed when higher levels of patient education and provider engagement were delivered during postdischarge follow-up, particularly when scheduled early. Notably, the incidence of major adverse cardiovascular events was lower in hospitals with high 90-day medication adherence than those with moderate or low adherence. IMPLICATIONS Patient nonadherence to guideline-recommended long-term pharmacologic secondary preventative therapies after ACS is multifactorial. A comprehensive multifaceted approach should be implemented to improve adherence and clinical outcomes. This approach should include key interventions such as early follow-up visits, high medication adherence at 90 days, patient engagement and education, and development of novel interventions that support the 3 broad categories influencing patient adherence as discussed in this review.
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Affiliation(s)
| | - Serge Korjian
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yazan Daaboul
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne Baron
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Arzu Kalayci
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Nara
- CSL Behring, King of Prussia, Pennsylvania, USA
| | | | - C Michael Gibson
- PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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9
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Zhong W, Liu R, Cheng H, Xu L, Wang L, He C, Wei Q. Longer-Term Effects of Cardiac Telerehabilitation on Patients With Coronary Artery Disease: Systematic Review and Meta-Analysis. JMIR Mhealth Uhealth 2023; 11:e46359. [PMID: 37505803 PMCID: PMC10422170 DOI: 10.2196/46359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/19/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Cardiac telerehabilitation offers a flexible and accessible model for patients with coronary artery disease (CAD), effectively transforming the traditional cardiac rehabilitation (CR) approach. OBJECTIVE This systematic review and meta-analysis aimed to evaluate the long-term effectiveness of cardiac telerehabilitation. METHODS We searched randomized controlled trials (RCTs) in 7 electronic databases: PubMed, Web of Science, EMBASE, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, the China National Knowledge Infrastructure, and WANFANG. The primary outcome focused on cardiopulmonary fitness. For secondary outcomes, we examined cardiovascular risk factors (blood pressure, BMI, and serum lipids), psychological scales of depression and anxiety, quality of life (QoL), cardiac telerehabilitation adherence, and adverse events. RESULTS In total, 10 RCTs fulfilled the predefined criteria, which were reviewed in our meta-analysis. The results showed that after cardiac telerehabilitation, there was a significant difference in the improvement in long-term peak oxygen uptake compared to center-based CR (mean difference [MD] 1.61, 95% CI 0.38-2.85, P=.01), particularly after 6-month rehabilitation training (MD 1.87, 95% CI 0.34-3.39, P=.02). The pooled effect size of the meta-analysis indicated that there were no significant differences in the reduction in cardiovascular risk factor control. There was also no practical demonstration of anxiety scores or depression scores. However, cardiac telerehabilitation demonstrated an improvement in the long-term QoL of patients (MD 0.92, 95% CI 0.06-1.78, P=.04). In addition, the study reported a high completion rate (80%) for cardiac telerehabilitation interventions. The incidence of adverse events was also low during long-term follow-up. CONCLUSIONS Cardiac telerehabilitation proves to be more effective in improving cardiopulmonary fitness and QoL during the long-term follow-up for patients with CAD. Our study highlights monitoring-enabled and patient-centered telerehabilitation programs, which play a vital role in the recovery and development of CAD and in the long-term prognosis of patients.
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Affiliation(s)
- Wen Zhong
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Rui Liu
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Hongxin Cheng
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Lin Xu
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Lu Wang
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Chengqi He
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Quan Wei
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
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10
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Aljehani R, Grace SL, Aburub A, Turk-Adawi K, Ghisi GLDM. Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers. Healthcare (Basel) 2023; 11:healthcare11081196. [PMID: 37108029 PMCID: PMC10138187 DOI: 10.3390/healthcare11081196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/07/2023] [Accepted: 03/07/2023] [Indexed: 04/29/2023] Open
Abstract
Cardiac rehabilitation (CR) utilization is low, particularly in Arabic-speaking countries. This study aimed to translate and psychometrically validate the CR Barriers Scale in Arabic (CRBS-A), as well as strategies to mitigate them. The CRBS was translated by two bilingual health professionals independently, followed by back-translation. Next, 19 healthcare providers, followed by 19 patients rated the face and content validity (CV) of the pre-final versions, providing input to improve cross-cultural applicability. Then, 207 patients from Saudi Arabia and Jordan completed the CRBS-A, and factor structure, internal consistency, construct, and criterion validity were assessed. Helpfulness of mitigation strategies was also assessed. For experts, item and scale CV indices were 0.8-1.0 and 0.9, respectively. For patients, item clarity and mitigation helpfulness scores were 4.5 ± 0.1 and 4.3 ± 0.1/5, respectively. Minor edits were made. For the test of structural validity, four factors were extracted: time conflicts/lack of perceived need and excuses; preference to self-manage; logistical problems; and health system issues and comorbidities. Total CRBS-A α was 0.90. Construct validity was supported by a trend for an association of total CRBS with financial insecurity regarding healthcare. Total CRBS-A scores were significantly lower in patients who were referred to CR (2.8 ± 0.6) vs. those who were not (3.6 ± 0.8), confirming criterion validity (p = 0.04). Mitigation strategies were considered very helpful (mean = 4.2 ± 0.8/5). The CRBS-A is reliable and valid. It can support identification of top barriers to CR participation at multiple levels, and then strategies for mitigating them can be implemented.
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Affiliation(s)
- Raghdah Aljehani
- Rehabilitation Department, King Abdullah Medical City, Makkah 24246, Saudi Arabia
| | - Sherry L Grace
- Faculty of Health, York University, Toronto, ON M3J 1P3, Canada
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M4G 2V6, Canada
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON M5G 2C4, Canada
| | - Aseel Aburub
- Department of Physiotherapy, Applied Science Private University, Amman 11931, Jordan
| | - Karam Turk-Adawi
- College of Health Sciences, QU Health, Qatar University, Doha 2713, Qatar
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11
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Livori AC, Pol D, Levkovich B, Oqueli E. Optimising adherence to secondary prevention medications following acute coronary syndrome utilising telehealth cardiology pharmacist clinics: a matched cohort study. Int J Clin Pharm 2023:10.1007/s11096-023-01562-4. [PMID: 36940081 PMCID: PMC10026199 DOI: 10.1007/s11096-023-01562-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 02/19/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Adherence to secondary prevention medications following acute coronary syndromes (ACS) is a predictor of future major adverse cardiovascular events. Underutilisation of these medications is associated with higher risk of major adverse cardiovascular events globally. AIM To explore the effects of a telehealth cardiology pharmacist clinic on patient adherence to secondary prevention medications in the 12 months following ACS. METHOD Retrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of pharmacist clinic with 12-month follow up. Patients who received percutaneous coronary intervention for ACS were consulted by the pharmacist at 1, 3- and 12-months. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence in adherence at 12 months post ACS. Secondary outcomes included major adverse cardiovascular events at 12 months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records. RESULTS There were 156 patients in this study (78 matched pairs). Analysis of adherence at 12 months demonstrated an absolute increase in adherence by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medical therapy (less than 3 ACS medication groups at 12 months) reduced by 23% (31 vs. 8%, p = 0.004). CONCLUSION This novel intervention significantly improved adherence to secondary prevention medications at 12 months, a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up improves adherence and patient outcomes.
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Affiliation(s)
- Adam C Livori
- Pharmacy Department, Grampians Health Ballarat, 1 Drummond St Nth, Ballarat, VIC, 3350, Australia.
- Centre for Medicine Use and Safety, Monash University, Clayton, VIC, Australia.
| | - Derk Pol
- Pharmacy Department, Grampians Health Ballarat, 1 Drummond St Nth, Ballarat, VIC, 3350, Australia
- Monash Heart, Clayton, VIC, Australia
- Latrobe Regional Hospital, Traralgon, VIC, Australia
| | - Bianca Levkovich
- Pharmacy Department, Grampians Health Ballarat, 1 Drummond St Nth, Ballarat, VIC, 3350, Australia
- Centre for Medicine Use and Safety, Monash University, Clayton, VIC, Australia
| | - Ernesto Oqueli
- Pharmacy Department, Grampians Health Ballarat, 1 Drummond St Nth, Ballarat, VIC, 3350, Australia
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia
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12
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Arshed M, Mahmud AB, Minhat HS, Ying LP, Umer MF. Effectiveness of mHealth Interventions in Medication Adherence among Patients with Cardiovascular Diseases: A Systematic Review. Diseases 2023; 11:diseases11010041. [PMID: 36975590 PMCID: PMC10047328 DOI: 10.3390/diseases11010041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/30/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
mHealth interventions have been reported to improve adherence to long-term therapies in chronic conditions. Therefore, this study aimed at determining the effectiveness of mHealth interventions in medication adherence among patients with cardiovascular diseases (CVDs), a leading cause of mortality globally. Relying on our inclusion criteria and the PRISMA recommendations, a literature search was carried out in the PubMed, Medline, and ProQuest databases for primary studies that investigated the impact of mHealth on medication adherence for cardiovascular disease (CVD) between 2000–2021. A total of 23 randomized controlled trials with 34,915 participants matched the selection criteria. The mHealth interventions used included text messages, mobile phone applications, and voice calls, which were used either as a single intervention or combined. Additionally, studies on enhancing drug adherence had contradictory findings: most of the studies elaborated positive results; however, six studies were unable to reveal any significant effect. Finally, a risk bias analysis revealed varying outcomes across all studies. This review, as a whole, supported the notion that mHealth interventions can be effective in improving adherence to CVD medication even though they could not improve adherence to all CVD medications when compared with controls. Further trials with more refined designs integrated with comprehensive interventions are needed to produce better health outcomes.
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Affiliation(s)
- Muhammad Arshed
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM), Serdang 43400, Selangor Darul Ehsan, Malaysia
| | - Aidalina Binti Mahmud
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM), Serdang 43400, Selangor Darul Ehsan, Malaysia
| | - Halimatus Sakdiah Minhat
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM), Serdang 43400, Selangor Darul Ehsan, Malaysia
| | - Lim Poh Ying
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM), Serdang 43400, Selangor Darul Ehsan, Malaysia
| | - Muhammad Farooq Umer
- Department of Dental Public Health, College of Dentistry, King Faisal University, Hofuf 31982, Saudi Arabia
- Correspondence: ; Tel.: +966-590536962
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13
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Grace SL. Evidence is indisputable that cardiac rehabilitation provides health benefits and event reduction: time for policy action. Eur Heart J 2023; 44:470-472. [PMID: 36746185 DOI: 10.1093/eurheartj/ehac690] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Sherry L Grace
- York University, Faculty of Health, 4700 Keele Street, KaHS Bethune 368, Toronto M3J 1P3, Canada.,KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada
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14
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Renke G, Gapanowicz DP, Pereira MB, Mattos F, Ribeiro-Alves M, Assad M, Moreira ASB. Long-Term Association between Intensive Medical Treatment and the Incidence of Cardiovascular Outcomes in Patients with Dyslipidemia: an Observational Study. Cardiol Ther 2022; 11:575-587. [PMID: 36223067 PMCID: PMC9555270 DOI: 10.1007/s40119-022-00282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/29/2022] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION The management of patients with dyslipidemia (DLP) requires intensive medical follow-up as an essential part of treatment and to reduce the risk of cardiovascular (CV) outcomes. The aim of this study was to evaluate whether adherence to medical treatment changed the prevalence of CV disease events in a retrospective 7-year follow-up analysis. METHODS This retrospective study involved 92 patients divided into two groups according to their adherence: the REG group with 64 patients who had medical appointments from 2012 to 2018, and the DROP group, with 28 patients who had medical appointments in 2012 but did not complete regular appointments until 2018. Cox proportional hazard models were fitted to estimate hazard ratios associated with CV outcomes as primary endpoints. RESULTS We observed a total of 32 cases of acute myocardial infarction (AMI) in the study population, 17 (338.41 pY) in the REG group and 15 (62.97 pY) in the DROP group. An increased hazard of AMIs was observed in the DROP group compared with the REG group by follow-up time (p < 0.001). We found that previous events of AMI and congestive heart failure (CHF) were associated with progression to treatment dropout (p < 0.05) and that two drugs were considered a risk factor for treatment dropout, diuretics and fibrates (p < 0.05). CONCLUSIONS A reduced hazard of AMI was observed in patients who complete a greater number of medical appointments and receive multidisciplinary treatment on a regular basis.
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Affiliation(s)
- Guilherme Renke
- National Institute of Cardiology, Brazilian Ministry of Health, Rua das Laranjeiras, 374. Laranjeiras, Rio de Janeiro, Brazil.
- Nutrindo Ideais Performance and Nutrition Research Centre, Rio de Janeiro, Brazil.
| | - Débora Pinto Gapanowicz
- National Institute of Cardiology, Brazilian Ministry of Health, Rua das Laranjeiras, 374. Laranjeiras, Rio de Janeiro, Brazil
| | | | - Fernanda Mattos
- Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Ribeiro-Alves
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Marcelo Assad
- National Institute of Cardiology, Brazilian Ministry of Health, Rua das Laranjeiras, 374. Laranjeiras, Rio de Janeiro, Brazil
| | - Annie Seixas Bello Moreira
- National Institute of Cardiology, Brazilian Ministry of Health, Rua das Laranjeiras, 374. Laranjeiras, Rio de Janeiro, Brazil
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15
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Kottke TE, Gupta AK, Thomas RJ. Failing Cardiovascular Health. J Am Coll Cardiol 2022; 80:152-154. [DOI: 10.1016/j.jacc.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 10/17/2022]
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16
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Miralles-Resurreccion KV, Grace SL, Cuenza LR. Trends in cardiac rehabilitation enrollment post-coronary artery bypass grafting upon implementation of automatic referral in Southeast Asia: A retrospective cohort study. J Cardiovasc Thorac Res 2022; 14:84-89. [PMID: 35935385 PMCID: PMC9339729 DOI: 10.34172/jcvtr.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cardiac rehabilitation (CR) is an effective but underutilized intervention. Strategies have been identified to increase its use, but there is paucity of data testing them in low-resource settings. We sought to determine the effect of automatic referral post-coronary artery bypass graft (CABG) surgery on CR enrollment.
Methods: This is a retrospective cohort study assessing cardiac patients referred to CR at a tertiary center in Southeast Asia from 2013 to 2019. The paper-based pathway was introduced at the end of 2012. The checklist with automatic CR referral on the third day post-operation prompted a nurse to educate the patient about CR, initiate phase 1 and encourage enrollment in phase 2. Patients who were not eligible for the pathway for administrative or clinical reasons were referred at the discretion of the attending physician (i.e., usual care). Enrollment was defined as attendance at≥1 CR visit. Results: Of 4792 patients referred during the study period, 394 enrolled in CR. Significantly more patients referred automatically enrolled compared to usual care (225 [11.8%] vs. 169 [5.8%]; OR=2.2, 95% CI=1.8-2.7), with increases up to 23.4% enrollment in 2014 (vs. average enrollment rate of 5.9% under usual referral). Patients who enrolled following automatic referral were significantly younger and more often employed (both P<0.001); no other differences were observed. Conclusion: In a lower-resource, Southeast Asian setting, automatic CR referral is associated with over two times greater enrollment in phase 2 CR, although efforts to maintain this effect are required.
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Affiliation(s)
| | - Sherry L. Grace
- York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada
| | - Lucky R. Cuenza
- Section of Cardiac Rehabilitation, Philippine Heart Center, Quezon City, Philippines
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17
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McCleary N, Ivers NM, Schwalm JD, Witteman HO, Taljaard M, Desveaux L, Bouck Z, Grace SL, Grimshaw JM, Presseau J. Impacts of two behavior change interventions on determinants of medication adherence: process evaluation applying the health action process approach and habit theory alongside a randomized controlled trial. J Behav Med 2022; 45:659-673. [PMID: 35596020 DOI: 10.1007/s10865-022-00327-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
Abstract
Investigating the mechanisms of behavior change interventions provides a more fulsome understanding of how and why interventions work (or don't work). We assessed mechanisms of two interventions (mailouts alone, and mailouts plus telephone support, informed by the Health Action Process Approach (HAPA) and Habit Theory), designed to increase medication adherence after myocardial infarction. We conducted a process evaluation alongside a pragmatic trial. Medication adherence was assessed via self-report at 12-months in the trial, and participants in all trial groups were invited to contemporaneously complete an additional questionnaire assessing targeted mechanisms (HAPA constructs and automaticity). We used multiple regression-based mediation models to investigate indirect effects. Of 589 respondents, 497 were analyzed (92 excluded due to missing data). Mailouts plus telephone support had statistically significant but small effects on intention, social support, action planning, coping planning, and automaticity. There were no indirect effects of interventions on medication adherence via these constructs. Therefore, while this intervention led to changes in proposed mechanisms, these changes were not great enough to lead to behavior change. Refinements (and subsequent evaluation) of the interventions are warranted, and our findings indicate that this could involve offering more intensive support to form plans and identify cues for taking medications, in addition to providing physical supports to encourage self-monitoring, feedback, and habit formation. Trial registration: ClinicalTrials.gov: NCT02382731.
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Affiliation(s)
- Nicola McCleary
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, K1H 8L6, Ottawa, Ontario, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Noah M Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - J-D Schwalm
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Division of Cardiology, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Holly O Witteman
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, K1H 8L6, Ottawa, Ontario, Canada.,Department of Family and Emergency Medicine, Laval University, Québec City, QC, Canada
| | - Monica Taljaard
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, K1H 8L6, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Laura Desveaux
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Toronto, ON, Canada.,KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Jeremy M Grimshaw
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, K1H 8L6, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Justin Presseau
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, K1H 8L6, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,School of Psychology, University of Ottawa, Ottawa, ON, Canada
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18
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Wang K, Qi Y, Gu R, Dai Q, Shan A, Li Z, Gong C, Chang L, Hao H, Duan J, Xu J, Hu J, Mu D, Zhang N, Lu J, Wang L, Wu H, Li L, Kang L, Xu B. Renal Denervation Attenuates Adverse Remodeling and Intramyocardial Inflammation in Acute Myocardial Infarction With Ischemia–Reperfusion Injury. Front Cardiovasc Med 2022; 9:832014. [PMID: 35571187 PMCID: PMC9095912 DOI: 10.3389/fcvm.2022.832014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Inhibition of sympathetic activity and renin–angiotensin system with renal denervation (RDN) was proved to be effective in managing refractory hypertension, and improving left ventricular (LV) performance in chronic heart failure. The inhibition of sustained sympathetic activation prevents or delays the development of cardiac fibrosis and dysfunction that occurs after myocardial infarction and ischemia–reperfusion (I/R) injury. The translational efficiency of RDN remains to be defined in preclinical animal studies. Objectives This study investigated the therapeutic role of RDN in adverse remodeling and intramyocardial inflammation in myocardial ischemia–reperfusion (MI/R) injury. Methods Herein, 15 minipigs were subjected to 90-min percutaneous occlusion of the left anterior descending artery followed by reperfusion. Eight animals received simultaneous RDN using catheter-based radiofrequency ablation (MI/R-RDN). Cardiac function and infarct volume were measured in vivo, followed by histological and biochemical analyses. Results The infarct volume in I/R-RDN pigs reduced at 30 days postreperfusion, compared to I/R-Sham animals. The levels of catecholamine and cytokines in the serum, kidney cortex, the border, and infarcted regions of the heart were significantly reduced in I/R-RDN group. Moreover, the gene expression of collagen and the protein expression of adrenergic receptor beta 1 in heart were also decreased in I/R-RDN mice. Additionally, RDN therapy alleviated myocardial oxidative stress. Conclusion RDN is an effective therapeutic strategy for counteracting postreperfusion myocardial injury and dysfunction, and the application of RDN holds promising prospects in clinical practice.
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Piekarz H, Langran C, Raza A, Donyai P. Medication-taking for secondary prevention of acute myocardial infarction: a thematic meta-synthesis of patient experiences. Open Heart 2022; 9:openhrt-2021-001939. [PMID: 35246500 PMCID: PMC8900060 DOI: 10.1136/openhrt-2021-001939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/08/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To collate existing qualitative research examining patients’ medication-taking experiences in secondary prevention of acute myocardial infarction (AMI) and produce new knowledge, a systematic review and meta-synthesis of patient qualitative studies was conducted. Method A systematic review found nine reports suitable for inclusion. Themes found by the report authors and report characteristic data were extracted. Reports were assessed for quality. A meta-synthesis using thematic coding and constant comparison method produced higher order themes, and these were used to construct a statement organised by theme using specific examples from the included studies. Results All patients discussed their medication-taking in thematic categories of beliefs about medication and illness, personal ability and interpersonal factors. Themes differed between classes of medication and between patients, suggesting tailored interventions to medications and individual patients would be appropriate. Some themes overlapped with those discussed by the broader group of cardiovascular patients, but some themes were unique to this myocardial infarction patient group, again indicating that a tailored approach is appropriate for this patient group. Conclusion The themes of beliefs about medication and illness, personal ability and interpersonal support provide tangible starting points for addressing adherence issues. The concept of medication-taking had unique elements within the post-AMI group of patients, and between classes of medication. While these themes were grouped into more generalised higher-order constructs, there were differences between patients within the themed group, indicating that themes are useful as a guide, but individual-level patient support is appropriate.
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Affiliation(s)
- Hannah Piekarz
- Department of Pharmacy, University of Reading School of Chemistry Food and Pharmacy, Reading, UK
| | - Catherine Langran
- Department of Pharmacy, University of Reading School of Chemistry Food and Pharmacy, Reading, UK
| | - Amna Raza
- Department of Pharmacy, University of Reading School of Chemistry Food and Pharmacy, Reading, UK
| | - Parastou Donyai
- Department of Pharmacy, University of Reading School of Chemistry Food and Pharmacy, Reading, UK
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20
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Arutyunov GP, Arutyunov AG, Ageev FT, Fofanova TV. Use of digital technology tools to characterize adherence to prescription-grade omega-3 polyunsaturated fatty acid therapy in post-myocardial or hypertriglyceridemic patients: Primary results of the DIAPAsOn prospective observational study (Preprint). JMIR Cardio 2022; 6:e37490. [PMID: 35877173 PMCID: PMC9361151 DOI: 10.2196/37490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background Maintaining sustained adherence to medication for optimal management of chronic noninfectious diseases, such as atherosclerotic vascular disease, is a well-documented therapeutic challenge. Objective The DIAPAsOn study was a 6-month, multicenter prospective observational study in the Russian Federation that examined adherence to a preparation of highly purified omega-3 polyunsaturated fatty acids (Omacor) in 2167 adult patients with a history of recent myocardial infarction or endogenous hypertriglyceridemia. Methods A feature of DIAPAsOn was the use of a bespoke electronic patient engagement and data collection system to monitor adherence. Adherence was also monitored by enquiry at clinic visits. A full description of the study’s aims and methods has appeared in JMIR Research Protocols. Results The net average reduction from baseline in both total and low-density lipoprotein cholesterol was approximately 1 mmol/L and the net average increase in high-density lipoprotein cholesterol was 0.2 (SD 0.53) mmol/L (P<.001 for all outcomes vs baseline). The mean triglyceride level was 3.0 (SD 1.3) mmol/L at visit 1, 2.0 (SD 0.9) mmol/L at visit 2, and 1.7 (SD 0.7) mmol/L at visit 3 (P<.001 for later visits vs visit 1). The percentage of patients with a triglyceride level <1.7 mmol/L rose from 13.1% (282/2151) at baseline to 54% (1028/1905) at the end of the study. Digital reporting of adherence was registered by 8.3% (180/2167) of patients; average scores indicted poor adherence. However, a clinic-based enquiry suggested high levels of adherence. Data on health-related quality of life accrued from digitally engaged patients identified improvements among patients reporting high adherence to study treatment, but patient numbers were small. Conclusions The lipid and lipoprotein findings indicate that Omacor had nominally favorable effects on the blood lipid profile. Less than 10% of patients enrolled in DIAPAsOn used the bespoke digital platform piloted in the study, and the level of self-reported adherence to medication by these patients was also low. Reasons for this low uptake and adherence are unclear. Better adherence was recorded in clinical reports. Trial Registration ClinicalTrials.gov NCT03415152; https://clinicaltrials.gov/ct2/show/NCT03415152
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Affiliation(s)
- Gregory P Arutyunov
- Department of Internal Medicine, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Alexander G Arutyunov
- Department of Internal Medicine, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Fail T Ageev
- Department of Outpatient Medical and Diagnostic Technologies of the Research Institute of Cardiology named after A.L. Myasnikov, Federal State Budgetary Institution National Medical Research Center of Cardiology named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Tatiana V Fofanova
- Department of Outpatient Medical and Diagnostic Technologies of the Research Institute of Cardiology named after A.L. Myasnikov, Federal State Budgetary Institution National Medical Research Center of Cardiology named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, Moscow, Russian Federation
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21
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Branda ME, Kunneman M, Meza-Contreras AI, Shah ND, Hess EP, LeBlanc A, Linderbaum JA, Nelson DM, Mc Donah MR, Sanvick C, Van Houten HK, Coylewright M, Dick SR, Ting HH, Montori VM. Shared Decision-Making for Patients Hospitalized with Acute Myocardial Infarction: A Randomized Trial. Patient Prefer Adherence 2022; 16:1395-1404. [PMID: 35673524 PMCID: PMC9167591 DOI: 10.2147/ppa.s363528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Adherence to guideline-recommended medications after acute myocardial infarction (AMI) is suboptimal. Patient fidelity to treatment regimens may be related to their knowledge of the risk of death following AMI, the pros and cons of medications, and to their involvement in treatment decisions. Shared decision-making may improve both patients' knowledge and involvement in treatment decisions. METHODS In a pilot trial, patients hospitalized with AMI were randomized to the use of the AMI Choice conversation tool or to usual care. AMI Choice includes a pictogram of the patient's estimated risk of mortality at 6 months with and without guideline-recommended medications, ie, aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors. Primary outcomes were patient knowledge and conflict with the decision made assessed via post-encounter surveys. Secondary outcomes were patient involvement in the decision-making process (observer-based OPTION12 scale) and 6-month medication adherence. RESULTS Patient knowledge of the expected survival benefit from taking medications was significantly higher (62% vs 16%, p<0.0001) in the AMI Choice group (n = 53) compared to the usual care group (n = 53). Both groups reported similarly low levels of conflict with the decision to start the medications (13 (SD 24.2) vs 16 (SD 22) out of 100; p=0.16). The extent to which clinicians in the AMI Choice group involved their patients in the decision-making process was high (OPTION12 score 53 out of 100, SD 12). Medication adherence at 6-months was relatively high in both groups and not different between groups. CONCLUSION The AMI Choice conversation tool improved patients' knowledge of their estimated risk of short-term mortality after an AMI and the pros and cons of treatments to reduce this risk. The effect on patient fidelity to recommended medications of using this SDM tool and of SDM in general should be tested in larger trials enrolling patients at high risk for nonadherence. TRIAL REGISTRATION NUMBER NCT00888537.
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Affiliation(s)
- Megan E Branda
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Alejandra I Meza-Contreras
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Annie LeBlanc
- Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Jane A Linderbaum
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Danika M Nelson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | - Holly K Van Houten
- Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA
| | - Megan Coylewright
- Section of Cardiovascular Medicine, Erlanger Heart and Lung Institute, Chattanooga, TN, USA
| | - Sara R Dick
- Education Project Management Office, Mayo Clinic, Rochester, MN, USA
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Correspondence: Victor M Montori, 200 First Street SW, Rochester, MN, 55905, USA, Tel +1 507-284-2511, Email
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22
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Wilton SB, Bennett MT, Parkash R, Kavanagh K, Jolicoeur EM, Halperin F, Jolly U, Leong-Sit P, Sas R, Chew DS, Singh S, Frisbee S, MacLachlan R, Manlucu J. Variability in Reassessment of Left Ventricular Ejection Fraction After Myocardial Infarction in the Acute Myocardial Infarction Quality Assurance Canada Study. JAMA Netw Open 2021; 4:e2136830. [PMID: 34854904 PMCID: PMC8640891 DOI: 10.1001/jamanetworkopen.2021.36830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Persistently depressed left ventricular ejection fraction (LVEF) after myocardial infarction (MI) is associated with adverse prognosis and directs the use of evidence-based treatments to prevent sudden cardiac death and/or progressive heart failure. OBJECTIVE To assess adherence with guideline-recommended LVEF reassessment and to study the evolution of LVEF over 6 months of follow-up. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter cohort study at Canadian academic and community hospitals with on-site cardiac catheterization services. Patients with type 1 acute MI and LVEF less than or equal to 45% during the index hospitalization were enrolled between January 2018 and August 2019 and were followed-up for 6 months. Data analysis was performed from May 2020 to September 2021. EXPOSURES Baseline clinical factors, in-hospital care and LVEF, and site-specific features. MAIN OUTCOMES AND MEASURES The main outcomes were receipt of repeat LVEF assessment by 6 months and the presence of a persistent LVEF reduction at 2 thresholds: LVEF less than or equal to 40%, prompting consideration of additional medical therapy for heart failure, or LVEF less than or equal to 35%, prompting referral for implanted cardioverter defibrillator in addition to medical therapy. RESULTS This study included 501 patients (mean [SD] age, 63.3 [13.0] years; 113 women [22.6%]). Overall, 370 patients (73.4%) presented with STEMI, and 454 (90.6%) had in-hospital revascularization. The median (IQR) baseline LVEF was 40% (34%-43%). Of 458 patients (91.4%) who completed the 6-month follow-up, 303 (66.2%; 95% CI, 61.7%-70.5%) had LVEF reassessment, with a range of 46.7% to 90.0% across sites (χ213 = 19.6; P = .11). Participants from community hospitals were more likely than those from academic hospitals to undergo LVEF reassessment (73.6% vs 63.2%; χ21 = 4.50; P = .03), as were those with worse LVEF at baseline. Follow-up LVEF improved by an absolute median (IQR) of 8% (3%-15%). However, 103 patients (34.1%) met the definitions of clinically relevant LVEF reduction, including 52 patients (17.2%) with LVEF less than or equal to 35% and 51 patients (16.9%) with LVEF of 35.1% to 40.0%. CONCLUSIONS AND RELEVANCE In this cohort study, approximately 1 in 3 patients with at least mild LVEF reduction after acute MI did not undergo indicated LVEF reassessment within 6 months, suggesting that programs to improve the quality of post-MI care should include measures to ensure that indicated repeat cardiac imaging is performed. In those with follow-up imaging, clinically relevant persistent LVEF reduction was identified in more than one-third of patients.
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Affiliation(s)
- Stephen B. Wilton
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T. Bennett
- Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ratika Parkash
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Katherine Kavanagh
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - E. Marc Jolicoeur
- Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Frank Halperin
- Division of Cardiology, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Umjeet Jolly
- Division of Cardiology, St Mary’s General Hospital, Kitchener, Ontario, Canada
| | - Peter Leong-Sit
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Rozsa Sas
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Derek S. Chew
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Singh
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Stephanie Frisbee
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | | | - Jaimie Manlucu
- Division of Cardiology, Western University, London, Ontario, Canada
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23
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Dibben G, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2021; 11:CD001800. [PMID: 34741536 PMCID: PMC8571912 DOI: 10.1002/14651858.cd001800.pub4] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD. SEARCH METHODS We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease. DATA COLLECTION AND ANALYSIS We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point). MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs). AUTHORS' CONCLUSIONS This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.
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Affiliation(s)
- Grace Dibben
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - James Faulkner
- Faculty Health and Wellbeing, School of Sport, Health and Community, University of Winchester, Winchester, UK
| | - Neil Oldridge
- College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Karen Rees
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Ann-Dorthe Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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24
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Bond Z, Scanlon T, Judah G. Systematic Review of RCTs Assessing the Effectiveness of mHealth Interventions to Improve Statin Medication Adherence: Using the Behaviour-Change Technique Taxonomy to Identify the Techniques That Improve Adherence. Healthcare (Basel) 2021; 9:1282. [PMID: 34682962 PMCID: PMC8535703 DOI: 10.3390/healthcare9101282] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/16/2022] Open
Abstract
Statin non-adherence is a common problem in the management of cardiovascular disease (CVD), increasing patient morbidity and mortality. Mobile health (mHealth) interventions may be a scalable way to improve medication adherence. The objectives of this review were to assess the literature testing mHealth interventions for statin adherence and to identify the Behaviour-Change Techniques (BCTs) employed by effective and ineffective interventions. A systematic search was conducted of randomised controlled trials (RCTs) measuring the effectiveness of mHealth interventions to improve statin adherence against standard of care in those who had been prescribed statins for the primary or secondary prevention of CVD, published in English (1 January 2000-17 July 2020). For included studies, relevant data were extracted, the BCTs used in the trial arms were coded, and a quality assessment made using the Risk of Bias 2 (RoB2) questionnaire. The search identified 17 relevant studies. Twelve studies demonstrated a significant improvement in adherence in the mHealth intervention trial arm, and five reported no impact on adherence. Automated phone messages were the mHealth delivery method most frequently used in effective interventions. Studies including more BCTs were more effective. The BCTs most frequently associated with effective interventions were "Goal setting (behaviour)", "Instruction on how to perform a behaviour", and "Credible source". Other effective techniques were "Information about health consequences", "Feedback on behaviour", and "Social support (unspecified)". This review found moderate, positive evidence of the effect of mHealth interventions on statin adherence. There are four primary recommendations for practitioners using mHealth interventions to improve statin adherence: use multifaceted interventions using multiple BCTs, consider automated messages as a digital delivery method from a credible source, provide instructions on taking statins, and set adherence goals with patients. Further research should assess the optimal frequency of intervention delivery and investigate the generalisability of these interventions across settings and demographics.
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Affiliation(s)
| | | | - Gaby Judah
- Department of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London, London W2 1NY, UK; (Z.B.); (T.S.)
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25
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Shepherd S, Ivers N, Natarajan MK, Grimshaw J, Taljaard M, Bouck Z, Schwalm JD. Immigrants, Ethnicity, and Adherence to Secondary Cardiac Prevention Therapy: A Substudy of the ISLAND Trial. CJC Open 2021; 3:913-923. [PMID: 34401698 PMCID: PMC8348195 DOI: 10.1016/j.cjco.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
Background The objective of this study was to evaluate adherence to guideline-recommended cardiac secondary prevention therapies by immigration and ethnicity. Methods We conducted a retrospective substudy of the Interventions Supporting Long-Term Adherence and Decreasing Cardiovascular Events (ISLAND) randomized controlled trial. A cohort of 1642 participants was analyzed. Patients were categorized based on their self-reported immigrant status as being Canadian or foreign born and based on their visual minority status (as European or a visual minority). We used logistic regression to examine associations between these patient characteristics of interest and patient adherence to statin medication 1 year after myocardial infarction (MI) and completion of cardiac rehabilitation, adjusting for age, sex, and comorbidities. Results The dataset included outcome data on 1049 (64%) Canadian-born patients and 593 (36%) immigrants. There were 347 (21%) who identified as a visual minority. We report a nonsignificant trend in statin adherence 1 year after MI favouring foreign-born participants compared with Canadian-born participants (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.91-1.68). Visual minorities were found to have no significant difference in statin adherence 1 year after MI compared with participants of European ethnicity (OR, 1.04; 95% CI, 0.72-1.51). Neither immigration status (OR, 0.91; 95% CI, 0.72-1.15) nor visual minority status (OR, 0.97; 95% CI, 0.73-1.28) were associated with cardiac rehabilitation completion. Conclusions Our findings offer limited support that immigrants with > 10 years of Canadian residency exposure experience greater adherence to statins 1 year after MI. Further research is required to better inform our understanding of secondary prevention strategy among immigrant populations.
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Affiliation(s)
- Shaun Shepherd
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Noah Ivers
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jeremy Grimshaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Zachary Bouck
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - J D Schwalm
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada
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26
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Abstract
Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases.
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Affiliation(s)
- Steven T Simon
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vinay Kini
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew E Levy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - P Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO, USA
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27
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Östbring MJ, Eriksson T, Petersson G, Hellström L. Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease: the MIMeRiC randomized controlled trial. BMC Cardiovasc Disord 2021; 21:367. [PMID: 34334142 PMCID: PMC8327441 DOI: 10.1186/s12872-021-02178-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/23/2021] [Indexed: 01/22/2023] Open
Abstract
Background In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence. Methods This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient’s clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use. Results 316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin–angiotensin–aldosterone system inhibitors. Conclusions Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health. Trial registration: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02178-0.
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Affiliation(s)
- Malin Johansson Östbring
- eHealth Institute, Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden. .,Pharmaceutical Department, Region Kalmar County, Building 2, floor 2, County Council Hospital, 391 85, Kalmar, Sweden.
| | - Tommy Eriksson
- Department of Biomedical Science, and Biofilm - Research Center for Biointerfaces, Malmö University, Malmö, Sweden
| | - Göran Petersson
- eHealth Institute, Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden
| | - Lina Hellström
- eHealth Institute, Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden.,Pharmaceutical Department, Region Kalmar County, Building 2, floor 2, County Council Hospital, 391 85, Kalmar, Sweden
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Giannopoulos G, Karageorgiou S, Vrachatis D, Anagnostopoulos I, Kousta MS, Lakka E, Giotaki S, Raisakis K, Sianos G, Toutouzas K, Cleman M, Deftereos S. A stand-alone structured educational programme after myocardial infarction: a randomised study. Heart 2021; 107:1047-1053. [PMID: 33483355 DOI: 10.1136/heartjnl-2020-318414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/27/2020] [Accepted: 12/30/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Acute myocardial infarction (MI) is a major clinical manifestation of coronary artery disease. Post-MI morbidity and mortality can be reduced by lifestyle changes and aggressive risk factor modification. These changes can be applied more effectively if the patient is actively involved in the process. The hypothesis of this study was that an educational programme in post-MI patients could lead to reduced incidence of cardiovascular events. METHODS Post-MI patients were prospectively randomised into two groups. Patients in the intervention arm were scheduled to attend an 8-week-long educational programme on top of usual treatment, while controls received optimal treatment. The primary endpoint was the composite of all-cause death, MI, cerebrovascular event and unscheduled hospitalisation for cardiovascular causes. Endpoint adjudication was blinded. RESULTS 329 patients (238 men) were included, with a mean follow-up time of 17±4 months. In the primary analysis, mean primary end point-free survival time was 597 days (95% CI 571 to 624) in controls, compared with 663 days (95% CI 638 to 687) in the intervention group (p<0.001). The HR in the univariate Cox regression analysis was 0.48 (95% CI 0.32 to 0.73; p=0.001). The raw rates of the primary endpoint were 20.8% (6 deaths, 13 MIs, 2 strokes and 14 hospitalisations) vs 36.6% (8 deaths, 22 MIs, 7 strokes and 22 hospitalisations), respectively (OR 0.46, 95% CI 0.28 to 0.74; p=0.002). CONCLUSION These results suggest that a relatively short adult education programme offered to post-MI patients has beneficial effects, resulting in reduced risk of cardiovascular events. TRIAL REGISTRATION NUMBER NCT04007887.
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Affiliation(s)
| | - Sofia Karageorgiou
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Dimitrios Vrachatis
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | | | - Maria S Kousta
- Department of Cardiology, Athens General Hospital "G. Gennimatas", Athens, Greece
| | - Eleni Lakka
- Department of Cardiology, Athens General Hospital "G. Gennimatas", Athens, Greece
| | - Sotiria Giotaki
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | | | - Georgios Sianos
- 1st Department of Cardiology, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Konstantinos Toutouzas
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Michael Cleman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Spyridon Deftereos
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
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29
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Wolfenden L, Foy R, Presseau J, Grimshaw JM, Ivers NM, Powell BJ, Taljaard M, Wiggers J, Sutherland R, Nathan N, Williams CM, Kingsland M, Milat A, Hodder RK, Yoong SL. Designing and undertaking randomised implementation trials: guide for researchers. BMJ 2021; 372:m3721. [PMID: 33461967 PMCID: PMC7812444 DOI: 10.1136/bmj.m3721] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.
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Affiliation(s)
- Luke Wolfenden
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family Medicine and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St Louis, St Louis, MI, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Wiggers
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Rachel Sutherland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Kingsland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Andrew Milat
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca K Hodder
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Sze Lin Yoong
- Swinburne University of Technology, School of Health Sciences, Faculty Health, Arts and Design, Hawthorn, VIC, Australia
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30
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Bhatia RS, Chu C, Pang A, Tadrous M, Stamenova V, Cram P. Virtual care use before and during the COVID-19 pandemic: a repeated cross-sectional study. CMAJ Open 2021; 9:E107-E114. [PMID: 33597307 PMCID: PMC8034297 DOI: 10.9778/cmajo.20200311] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic is thought to have increased use of virtual care, but population-based studies are lacking. We aimed to assess the uptake of virtual care during the COVID-19 pandemic using comprehensive population-based data from Ontario. METHODS This was a repeated cross-sectional study design. We used administrative data to evaluate changes in in-person and virtual visits among all residents of Ontario before (2012-2019) and during (January-August 2020) the COVID-19 pandemic. We included all patients who had an ambulatory care visit in Ontario. We excluded claims for patients who were not Ontario residents or had an invalid or missing health card number. We compared monthly or quarterly virtual care use across age groups, neighbourhood income quintiles and chronic disease subgroups. We also examined physician characteristics that may have been associated with virtual care use. RESULTS Among all residents of Ontario (population 14.6 million), virtual care increased from 1.6% of total ambulatory visits in the second quarter of 2019 to 70.6% in the second quarter of 2020. The proportion of physicians who provided 1 or more virtual visits per year increased from 7.0% in the second quarter of 2019 to 85.9% in the second quarter of 2020. The proportion of Ontarians who had a virtual visit increased from 1.3% in 2019 to 29.2% in 2020. Older patients were the highest users of virtual care. The proportion of total virtual visits that were provided to patients residing in rural areas (v. urban areas) declined significantly between 2012 and 2020, reflecting a shift in virtual care to a service increasingly used in urban centres. The rates of virtual care use increased similarly across all conditions and across all income quintiles. INTERPRETATION Our findings show that Ontario's approach to virtual care led to broad adoption across all provider groups, patient age, types of chronic diseases and neighborhood income. These findings have policy implications, including use of virtual care billing codes, for the ongoing use of virtual care during the second wave of the pandemic and beyond.
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Affiliation(s)
- R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia, Chu, Tadrous, Stamenova), Women's College Hospital; ICES Central (Bhatia, Pang); Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network; Department of Medicine (Cram), University of Toronto, Toronto, Ont.
| | - Cherry Chu
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia, Chu, Tadrous, Stamenova), Women's College Hospital; ICES Central (Bhatia, Pang); Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network; Department of Medicine (Cram), University of Toronto, Toronto, Ont
| | - Andrea Pang
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia, Chu, Tadrous, Stamenova), Women's College Hospital; ICES Central (Bhatia, Pang); Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network; Department of Medicine (Cram), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia, Chu, Tadrous, Stamenova), Women's College Hospital; ICES Central (Bhatia, Pang); Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network; Department of Medicine (Cram), University of Toronto, Toronto, Ont
| | - Vess Stamenova
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia, Chu, Tadrous, Stamenova), Women's College Hospital; ICES Central (Bhatia, Pang); Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network; Department of Medicine (Cram), University of Toronto, Toronto, Ont
| | - Peter Cram
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia, Chu, Tadrous, Stamenova), Women's College Hospital; ICES Central (Bhatia, Pang); Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network; Department of Medicine (Cram), University of Toronto, Toronto, Ont
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Suskin NG, Huitema AA, Hartley T, McKelvie RS. Sex, Depression, and More in Cardiac Rehabilitation. Can J Cardiol 2020; 37:357-358. [PMID: 33290825 DOI: 10.1016/j.cjca.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Neville G Suskin
- St Joseph's Health Care London, London, Ontario, Canada; Western University, London, Ontario, Canada.
| | - Ashlay A Huitema
- St Joseph's Health Care London, London, Ontario, Canada; Western University, London, Ontario, Canada
| | - Tim Hartley
- St Joseph's Health Care London, London, Ontario, Canada
| | - Robert S McKelvie
- St Joseph's Health Care London, London, Ontario, Canada; Western University, London, Ontario, Canada
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Makris E, Hu L, Jones GB, Wright JM. Moving the Dial on Heart Failure Patient Adherence Rates. Patient Prefer Adherence 2020; 14:2407-2418. [PMID: 33324042 PMCID: PMC7733338 DOI: 10.2147/ppa.s283277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Heart failure remains a substantive contributor to patient morbidity and mortality rates worldwide and represents a significant burden on the healthcare ecosystem. Faced with persistent physical symptoms and debilitating social consequences, patients follow complex treatment regimens and often have difficulty adhering to them. PURPOSE In this manuscript, we review factors which contribute to low adherence rates and advance potential single- and multi-factor-based interventions. It is hoped that these observations can lead to improvements in managed care of this vulnerable population of patients. METHODS A narrative review of the primary literature was performed on contributing factors with primary focus on the period 2015-2020 using available databases and search engines. Adherence pain points identified were mapped against a series of potential solutions which are presented. RESULTS Enhancement of treatment adherence relies on two approaches viz. single-factor and multi-factor solutions. Single factors identified include electronic reminders, enhanced health education, financial incentives, gamification strategies, community drivers, persona-based modeling, and burden relief of poly pharmacy. Multi-factor solutions combine two or more of the seven approaches offering the potential for flexible interventions tailored to the individual. DISCUSSION AND CONCLUSION Heart failure patients with poor adherence have increased mortality, hospitalization needs, and healthcare costs. This review highlights current single-factor and multi-factor adherence methods. Against a backdrop of diversity of approaches, multi-factor solutions cast the widest net for positively influencing adherent behaviors. A key enabler lies in the development and leveraging of patient personas in the synthesis of successful intervention methods. Deployable solutions can also be envisioned in clinical trials where adherence tracking represents an essential component.
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Affiliation(s)
- Eleanna Makris
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
| | - Lucy Hu
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
| | - Graham B Jones
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
- Clinical and Translational Science Institute, Tufts University Medical Center, Boston, MA02111, USA
| | - Justin M Wright
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
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Campbell DJT, Lee-Krueger RCW, McBrien K, Anderson T, Quan H, Leung AA, Chen G, Lu M, Naugler C, Butalia S. Strategies for enhancing the initiation of cholesterol lowering medication among patients at high cardiovascular disease risk: a qualitative descriptive exploration of patient and general practitioners' perspectives on a facilitated relay intervention in Alberta, Canada. BMJ Open 2020; 10:e038469. [PMID: 33234627 PMCID: PMC7689086 DOI: 10.1136/bmjopen-2020-038469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/17/2020] [Accepted: 10/28/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The objective of our study was to explore the perspectives of patients and general practitioners (GPs) regarding interventions to increase initiation of cholesterol lowering medication (or statins), including a proposed laboratory-based facilitated relay intervention. DESIGN Qualitative descriptive study using interviews and focus groups for data collection, and thematic analysis for data analysis. SETTING Primary care providers and patients in Calgary, Alberta, Canada. PARTICIPANTS 17 GPs with primarily community-based, non-academic practices with at least 1 year of practice experience participated in semistructured interviews. 14 patients at high risk of cardiovascular disease participated in focus groups. MAIN OUTCOME MEASURES Exploration of strategies that might be used to enhance the prescription of, and adherence to statin therapy for patients with statin-indicated conditions. RESULTS GPs proposed a variety of interventions to improve statin prescription, including electronic record audit solutions, GP directed education, and patient-oriented campaigns. Patients expressed that they may benefit from being provided access to their laboratory test results, as well as targeted education. Both parties provided positive feedback on the proposed laboratory-based facilitated relay intervention, while pointing out areas for improvement. Notably, GPs were concerned that the patient-directed component of the intervention might jeopardise therapeutic relationships, and patients were concerned about accidental disclosure of personal health information. Important considerations for the design of facilitated relay messaging should include brevity, simplicity and the provision of contact information for inquiries. CONCLUSIONS GPs and patients described several suggestions for increasing statin initiation and welcomed the proposal of a laboratory-based facilitated relay strategy. These findings support further testing of this intervention which may enhance GPs' ability to successfully engage patients in cardiovascular risk reduction through statin therapy.
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Affiliation(s)
- David J T Campbell
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Kerry McBrien
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd Anderson
- Department of Cardiac Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mingshan Lu
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonia Butalia
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Desveaux L, Saragosa M, Russell K, McCleary N, Presseau J, Witteman HO, Schwalm JD, Ivers NM. How and why a multifaceted intervention to improve adherence post-MI worked for some (and could work better for others): an outcome-driven qualitative process evaluation. BMJ Open 2020; 10:e036750. [PMID: 32883724 PMCID: PMC7473621 DOI: 10.1136/bmjopen-2019-036750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To explore (1) the extent to which a multicomponent intervention addressed determinants of the desired behaviours (ie, adherence to cardiac rehabilitation (CR) and cardiovascular medications), (2) the associated mechanism(s) of action and (3) how future interventions might be better designed to meet the needs of this patient population. DESIGN A qualitative evaluation embedded within a multicentre randomised trial, involving purposive semistructured interviews. SETTING Nine cardiac centres in Ontario, Canada. PARTICIPANTS Potential participants were stratified according to the trial's primary outcomes of engagement and adherence, resulting in three groups: (1) engaged, adherence outcome positive, (2) engaged, adherence outcome negative and (3) did not engage, adherence outcome negative. Participants who did not engage but had positive adherence outcomes were excluded. Individual domains of the Theoretical Domains Framework were applied as deductive codes and findings were analysed using a framework approach. RESULTS Thirty-one participants were interviewed. Participants who were engaged with positive adherence outcomes attributed their success to the intervention's ability to activate determinants including behavioural regulation and knowledge, which encouraged an increase in self-monitoring behaviour and awareness of available supports, as well as reinforcement and social influences. The behaviour of those with negative adherence outcomes was driven by beliefs about consequences, emotions and identity. As currently designed, the intervention failed to target these determinants for this subset of participants, resulting in partial engagement and poor adherence outcomes. CONCLUSION The intervention facilitated CR adherence through reinforcement, behavioural regulation, the provision of knowledge and social influence. To reach a broader and more diverse population, future iterations of the intervention should target aberrant beliefs about consequences, memory and decision-making and emotion. TRIAL REGISTRATION NUMBER ClinicalTrials.gov registry; NCT02382731.
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Affiliation(s)
- Laura Desveaux
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marianne Saragosa
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Kirstie Russell
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Nicola McCleary
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Université Laval, Quebec City, Quebec, Canada
| | - J-D Schwalm
- Translation and Health Systems Research Program, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Noah Michael Ivers
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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