Perceived work performance of patients who experienced an acute coronary syndrome event

The Positive Emotions after Acute Coronary Events behavioral health intervention: Design, rationale, and preliminary feasibility of a factorial design study

BACKGROUND

Positive psychological constructs, such as optimism, are associated with greater participation in cardiac health behaviors and improved cardiac outcomes. Positive psychology interventions, which target psychological well-being, may represent a promising approach to improving health behaviors in high-risk cardiac patients. However, no study has assessed whether a positive psychology intervention can promote physical activity following an acute coronary syndrome.

OBJECTIVE

In this article we will describe the methods of a novel factorial design study to aid the development of a positive psychology-based intervention for acute coronary syndrome patients and aim to provide preliminary feasibility data on study implementation.

METHODS

The Positive Emotions after Acute Coronary Events III study is an optimization study (planned N = 128), subsumed within a larger multiphase optimization strategy iterative treatment development project. The goal of Positive Emotions after Acute Coronary Events III is to identify the ideal components of a positive psychology-based intervention to improve post-acute coronary syndrome physical activity. Using a 2 × 2 × 2 factorial design, Positive Emotions after Acute Coronary Events III aims to: (1) evaluate the relative merits of using positive psychology exercises alone or combined with motivational interviewing, (2) assess whether weekly or daily positive psychology exercise completion is optimal, and (3) determine the utility of booster sessions. The study's primary outcome measure is moderate-to-vigorous physical activity at 16 weeks, measured via accelerometer. Secondary outcome measures include psychological, functional, and adherence-related behavioral outcomes, along with metrics of feasibility and acceptability. For the primary study outcome, we will use a mixed-effects model with a random intercept (to account for repeated measures) to assess the main effects of each component (inclusion of motivational interviewing in the exercises, duration of the intervention, and inclusion of booster sessions) from a full factorial model controlling for baseline activity. Similar analyses will be performed on self-report measures and objectively-measured medication adherence over 16 weeks. We hypothesize that the combined positive psychology and motivational interviewing intervention, weekly exercises, and booster sessions will be associated with superior physical activity.

RESULTS

Thus far, 78 participants have enrolled, with 72% of all possible exercises fully completed by participants.

CONCLUSION

The Positive Emotions after Acute Coronary Events III study will help to determine the optimal content, intensity, and duration of a positive psychology intervention in post-acute coronary syndrome patients prior to testing in a randomized trial. This study is novel in its use of a factorial design within the multiphase optimization strategy framework to optimize a behavioral intervention and the use of a positive psychology intervention to promote physical activity in high-risk cardiac patients.

Value of robotically assisted surgery for mitral valve disease

IMPORTANCE

The value of robotically assisted surgery for mitral valve disease is questioned because the high cost of care associated with robotic technology may outweigh its clinical benefits.

OBJECTIVE

To investigate conditions under which benefits of robotically assisted surgery mitigate high technology costs.

DESIGN, SETTING, AND PARTICIPANTS

Clinical cohort study at a large multispecialty academic medical center comparing costs of robotically assisted surgery with 3 contemporaneous conventional surgical approaches for degenerative mitral valve disease. From January 1, 2006, through December 31, 2010, a total of 1290 patients with a mean (SD) age of 57 (11) years underwent mitral valve repair for regurgitation from posterior leaflet prolapse. Robotically assisted surgery was performed in 473 patients, complete sternotomy in 227, partial sternotomy in 349, and anterolateral thoracotomy in 241. Comparisons were based on intent to treat, with 3 propensity-matched groups formed based on demographics, symptoms, cardiac and noncardiac comorbidities, valve pathophysiologic disorders, and echocardiographic measurements: robotic vs sternotomy (198 pairs) vs partial sternotomy (293 pairs) vs thoracotomy (224 pairs).

INTERVENTIONS

Mitral valve repair.

MAIN OUTCOMES AND MEASURES

Cost of care (expressed as robotic capital investment, maintenance of equipment, and direct technical hospital costs) and benefit of care (based on differences in recovery time).

RESULTS

Cost of care (median [15th and 85th percentiles]) for robotically assisted surgery exceeded that of alternative approaches by 26.8% (-5.3% and 67.9%), 32.1% (-6.1% and 69.6%), and 20.7% (-2.4% and 48.4%) for complete sternotomy, partial sternotomy, and anterolateral thoracotomy, respectively. Higher operative costs were partially offset by lower postoperative costs and earlier return to work: a median (15th and 85th percentiles) of 35 (19 and 63) days for robotically assisted surgery, 49 (21 and 109) days for complete sternotomy, 56 (30 and 119) days for partial sternotomy, and 42 (18 and 90) days for anterolateral thoracotomy. Resulting net differences (median [15th and 85th percentiles]) in the cost of robotic surgery vs the 3 alternatives were 15.6% (-14.7% and 55.1%), 15.7% (-19.4% and 51.2%), and 14.8% (-7.4% and 43.6%), respectively. Beyond a volume threshold of 55 to 100 robotically assisted operations per year, distribution of the cost of this technology broadly overlapped those of conventional approaches.

CONCLUSIONS AND RELEVANCE

In exchange for higher procedural costs, robotically assisted surgery for mitral valve repair offers the clinical benefit of least-invasive surgery, lowest postoperative cost, and fastest return to work. The value of robotically assisted surgery that is similar to that of conventional approaches can be realized only in high-volume centers.

Lessons learned conducting breastfeeding intervention research in two northern plains tribal communities

AIM

The overall purpose of this article was to describe the challenges and benefits of conducting breastfeeding intervention research with two Native American Tribal communities.

METHODS

A focus group with an interpretive approach was used to collect data within this qualitative study as a means of incorporating a complex, holistic, subjective interpretation of the case managers' perceptions and experiences. In addition, researchers' field notes were used. Findings are discussed in relation to Rogers' Diffusion of Innovation Framework.

RESULTS

Themes that emerged during the focus group discussions were related to innovation, relative advantage, complexity, compatibility, trialability, and observability.

CONCLUSIONS

Conducting research in Native American Tribal communities was both enriching and challenging. The research protocol needs to be culturally appropriate, and complex components need to be videotaped for review on an ongoing basis. Time constraints of case managers need to be examined prior to development of the research protocol.

Evaluating health-related quality of life, work ability, and disability in pulmonary arterial hypertension: an unmet need

To our knowledge, there are no specific and validated measures of quality of life (QoL) or degree of disability for pulmonary arterial hypertension (PAH). A review of the literature shows that, with the exception of one recently designed specifically for pulmonary hypertension, QoL questionnaires used in PAH studies are generic measures. These are selected because of shared symptoms that do not necessarily correlate well with functional or physiologic measures and have not been validated for applicability in PAH. In this review, we present the available QoL tools for pulmonary artery hypertension and describe the need for more specific instruments that consider the physical and emotional implications of the diseases associated with PAH and the impact of various treatment options. We also discuss the impact of PAH on work ability and the need for provisions to address medical disability status and Social Security benefit status.

Two aspects of the clinical and humanistic burden of systemic lupus erythematosus: mortality risk and quality of life early in the course of disease

OBJECTIVE

To evaluate mortality risk and predictors among recently diagnosed systemic lupus erythematosus (SLE) patients.

METHODS

The vital status of 265 SLE patients and 355 controls enrolled in the Carolina Lupus Study (median time since diagnosis 13 months) was determined approximately 5 years after enrollment. We also assessed the utility of an 8-item quality of life instrument, derived from the standard 36-item Medical Outcomes Study Short Form 36, as an additional measure of disease impact.

RESULTS

Five years after diagnosis, 9.7% of patients compared with 0.3% of controls had died (P < 0.0001). Increased mortality risk was seen among older patients (adjusted hazard ratio [HR] 1.03, 95% confidence interval [95% CI] 1.01-1.06 per 1-year increment in age) and among men, African Americans, patients with lupus nephritis, and patients with anti-double-stranded DNA antibodies (adjusted HR approximately 2.0 for each of these factors). In addition, patients who did not provide a blood sample at study enrollment experienced increased mortality risk (age-, sex-, and race-adjusted HR 3.7, 95% CI 1.5-9.1). Similar results were seen in analyses limited to time from study enrollment. Physical component scores of the quality of life measure were 7.7 points lower (P < 0.0001) and mental component scores were 1.8 points lower (P = 0.07) in patients compared with controls.

CONCLUSION

The mortality risk among SLE patients is significant, particularly among African Americans, even early in the disease process and even with currently available treatments. Differences between cases and controls in health-related quality of life using the Short Form 8 also demonstrate the multidimensional burden of SLE.