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Clifford C, Girdauskas E, Klotz SGR, Kurz S, Löwe B, Kohlmann S. Patient-centered evaluation of an expectation-focused intervention for patients undergoing heart valve surgery: a qualitative study. Front Cardiovasc Med 2024; 11:1338964. [PMID: 38426119 PMCID: PMC10902160 DOI: 10.3389/fcvm.2024.1338964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Objective Randomized controlled trials demonstrate the effectiveness of expectation-focused interventions in improving recovery outcomes following cardiac surgery. For dissemination in routine health care, it is important to capture the perspective of affected individuals. This qualitative study explores the perceived benefits and intervention-specific needs of patients who received expectation-focused intervention in the context of heart valve surgery. In addition, it explores potential barriers and adverse effects. Methods As part of an Enhanced Recovery After Surgery (ERAS) program within a multicentered randomized controlled trial, patients undergoing minimally invasive heart valve surgery received an intervention focused on their expectations. Six weeks after the intervention, semi-structured interviews were conducted with 18 patients to assess its feasibility, acceptance, barriers, benefits, and side effects. The transcribed interviews were analyzed using qualitative content analysis. Results The results indicate that both the intervention and the role of the patient and psychologist are key aspects in evaluating the expectation-focused intervention. Five key themes emerged from the patients' perspective: personal needs, expectations and emotions, relationship, communication, and individuality. Patients valued the preparation for surgery and recovery and the space for emotions. Establishing a trustful relationship and addressing stigmatization were identified as primary challenges within the intervention. Conclusion Overall, patients experienced the expectation-focused intervention as helpful and no adverse effects were reported. Perceived benefits included enhanced personal control throughout the surgery and recovery, while the potential barrier of stigmatization towards a psychologist may complicate establishing a trustful relationship. Addressing personal needs, as a relevant topic to the patients, could be achieved through additional research to identify the specific needs of different patient subgroups. Enhancing the expectation-focused intervention could involve the implementation of a modular concept to address individual needs better.
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Affiliation(s)
- Caroline Clifford
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Medical Center Augsburg, Augsburg, Germany
| | - Susanne G. R. Klotz
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Saskia Kurz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Kohlmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Horn N, Gärtner L, Rastan AJ, Andrási TB, Lenz J, Böning A, Salzmann-Djufri M, Puvogel U, Genovese M, Kus S, Rief W, Salzmann S. Preoperative optimization of cardiac valve patients' expectations: Study protocol of the randomized controlled ValvEx-trial. Front Cardiovasc Med 2023; 10:1105507. [PMID: 36937912 PMCID: PMC10018216 DOI: 10.3389/fcvm.2023.1105507] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction Complete recovery after surgery depends on psychological factors such as preoperative information, expectations, and surgery-associated anxiety. Prior studies have shown that even a short preoperative psychological intervention aiming at optimized expectations (EXPECT) can improve postoperative outcomes in coronary artery bypass patients. However, this intervention may benefit only a small subgroup of heart surgery patients since implementing preoperative psychological interventions into the daily clinical routine is difficult due to the additional time and appointments. It is unclear whether the EXPECT intervention can be shortened and whether heart valve patients would also benefit from interventions that optimize patients' expectations. The multicenter ValvEx trial aims (i) to adapt an effective preoperative psychological intervention (EXPECT) to make it brief enough to be easily integrated into the preoperative routine of heart valve patients and (ii) to examine if the adapted preoperative psychological intervention improves the subjectively perceived illness-related disability (PDI) up to 3 months after surgery. Materials and analysis In two German university hospitals, N = 88 heart valve patients who undergo heart surgery are randomized into two groups [standard of care (SOC) vs. standard of care plus interventional expectation manipulation (SOC and EXPECT)] after baseline assessment. Patients in the EXPECT group additionally to standard of care participate in the preoperative psychological intervention (30-40 min), focusing on optimizing expectations and have two booster-telephone calls (4 and 8 weeks after the surgery, approx. 15 min). Both groups have assessments again on the evening before the surgery, 4 to 6 days, and 3 months after the surgery. Discussion The trial demonstrates excellent feasibility in the clinical routine and a high interest by the patients. Ethics and dissemination The Ethics Committees of the Department of Medicine of the Philipps University of Marburg and the Department of Medicine of the University of Giessen approved the study protocol. Study results will be published in peer-reviewed journals and presented at congresses. Clinical trial registration ClinicalTrials.gov, identifier NCT04502121.
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Affiliation(s)
- Nicole Horn
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
- *Correspondence: Nicole Horn,
| | - Laura Gärtner
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Ardawan J. Rastan
- Department of Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Térezia B. Andrási
- Department of Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Juliane Lenz
- Department of Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, Justus Liebig University, Giessen, Germany
| | | | - Ulrike Puvogel
- Department of Cardiovascular Surgery, Justus Liebig University, Giessen, Germany
| | - Maria Genovese
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Sibel Kus
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Winfried Rief
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Stefan Salzmann
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
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Salzmann S, Laferton JAC, Shedden-Mora MC, Horn N, Gärtner L, Schröder L, Rau J, Schade-Brittinger C, Murmann K, Rastan A, Andrási TB, Böning A, Salzmann-Djufri M, Löwe B, Brickwedel J, Albus C, Wahlers T, Hamm A, Hilker L, Albert W, Falk V, Zimmermann T, Ismail I, Strauß B, Doenst T, Schedlowski M, Moosdorf R, Rief W. Pre-surgery optimization of patients' expectations to improve outcome in heart surgery: Study protocol of the randomized controlled multi-center PSY-HEART-II trial. Am Heart J 2022; 254:1-11. [PMID: 35940247 DOI: 10.1016/j.ahj.2022.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
The PSY-HEART-I trial indicated that a brief expectation-focused intervention prior to heart surgery improves disability and quality of life 6 months after coronary artery bypass graft surgery (CABG). However, to investigate the clinical utility of such an intervention, a large multi-center trial is needed to generalize the results and their implications for the health care system. The PSY-HEART-II study aims to examine whether a preoperative psychological intervention targeting patients' expectations (EXPECT) can improve outcomes 6 months after CABG (with or without heart valve replacement). EXPECT will be compared to Standard of Care (SOC) and an intervention providing emotional support without targeting expectations (SUPPORT). In a 3-arm multi-center randomized, controlled, prospective trial (RCT), N = 567 patients scheduled for CABG surgery will be randomized to either SOC alone or SOC and EXPECT or SOC and SUPPORT. Patients will be randomized with a fixed unbalanced ratio of 3:3:1 (EXPECT: SUPPORT: SOC) to compare EXPECT to SOC and EXPECT to SUPPORT. Both psychological interventions consist of 2 in-person sessions (à 50 minute), 2 phone consultations (à 20 minute) during the week prior to surgery, and 1 booster phone consultation post-surgery 6 weeks later. Assessment will occur at baseline approx. 3-10 days before surgery, preoperatively the day before surgery, 4-6 days later, and 6 months after surgery. The study's primary end point will be patients' illness-related disability 6 months after surgery. Secondary outcomes will be patients' expectations, subjective illness beliefs, quality of life, length of hospital stay and blood sample parameters (eg, inflammatory parameters such as IL-6, IL-8, CRP). This large multi-center trial has the potential to corroborate and generalize the promising results of the PSY-HEART-I trial for routine care of cardiac surgery patients, and to stimulate revisions of treatment guidelines in heart surgery.
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Affiliation(s)
- Stefan Salzmann
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany.
| | | | - Meike C Shedden-Mora
- Department of Psychology, Medical School Hamburg, Hamburg, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicole Horn
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Laura Gärtner
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Lara Schröder
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Jörn Rau
- Coordination Center for Clinical Trials (KKS), University of Marburg, Marburg, Germany
| | | | - Kirsten Murmann
- Coordination Center for Clinical Trials (KKS), University of Marburg, Marburg, Germany
| | - Ardawan Rastan
- Department for Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Térezia B Andrási
- Department for Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Christian Albus
- Department of Psychosomatics and Psychotherapy, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Alfons Hamm
- Department of Physiological and Clinical Psychology/ Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Lutz Hilker
- Department of Cardiovascular Surgery, Clinic Karlsburg, Heart and Diabetes Center Mecklenburg-Western Pommerania, Karlsburg, Germany
| | | | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Tanja Zimmermann
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Bernhard Strauß
- Institute of Psychosocial Medicine, Psychotherapy, and Psychooncology, University Hospital Jena, Germany
| | - Torsten Doenst
- Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Clinic Essen, Essen, Germany, and Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institute, Stockholm, Sweden
| | - Rainer Moosdorf
- Department for Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Winfried Rief
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
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Horn N, Laferton JAC, Shedden-Mora MC, Moosdorf R, Rief W, Salzmann S. Baseline depressive symptoms, personal control, and concern moderate the effects of preoperative psychological interventions: the randomized controlled PSY-HEART trial. J Behav Med 2022; 45:350-365. [PMID: 35522399 PMCID: PMC9160109 DOI: 10.1007/s10865-022-00319-0] [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: 03/01/2021] [Accepted: 04/03/2022] [Indexed: 11/06/2022]
Abstract
This study examined whether baseline (3–14 days pre-surgery) levels of (i) depressive or (ii) anxiety symptoms and (iii) illness beliefs moderate the effects of additional preoperative interventions before coronary artery bypass graft surgery on (i) depressive or (ii) anxiety symptoms and (iii) illness beliefs 1 day before surgery, 1 week and 6 months after surgery. In the PSY-HEART trial, 115 patients were assessed. They were randomized into one of three groups: 1. receiving standard medical care only (SMC), additional psychological interventions: 2. aiming to optimize patients’ expectations (EXPECT), or 3. focusing on emotional support. Patients with a higher baseline level of depressive symptoms receiving a preoperative psychological intervention indicated lower depressive symptoms 6 months after surgery compared to SMC. EXPECT increased personal control and concern levels in patients with low baseline personal control/concern 1 day before surgery. Brief preoperative psychological interventions can improve psychological outcomes in heart surgery patients. Baseline status may moderate these effects. The study has been approved by the medical ethics committee of the Philipps University of Marburg and has been pre-registered at www.clinicaltrials.gov (NCT01407055) on August 1, 2011.
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Affiliation(s)
- Nicole Horn
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany.
| | - Johannes A C Laferton
- Division of Medical Psychology, Department of Medicine, Health and Medical University Potsdam, Potsdam, Germany
| | - Meike C Shedden-Mora
- Department of Psychology, Medical School Hamburg, Hamburg, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Moosdorf
- Department for Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Stefan Salzmann
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
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Salzmann S, Euteneuer F, Laferton JAC, Shedden-Mora MC, Schedlowski M, Moosdorf R, Rief W. IL-8 and CRP moderate the effects of preoperative psychological interventions on postoperative long-term outcomes 6 months after CABG surgery - The randomized controlled PSY-HEART trial. Brain Behav Immun 2021; 91:202-211. [PMID: 33002633 DOI: 10.1016/j.bbi.2020.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/24/2020] [Accepted: 09/23/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Inflammation has been related to several somatic and psychological disorders and may moderate effects of psychological interventions. In the PSY-HEART trial patients benefitted from preoperative psychological interventions before undergoing coronary artery bypass graft surgery (CABG) and, if necessary, concomitant valvular surgery, compared to standard medical care. In this study we examined whether patients' baseline inflammatory status moderated the intervention effects. MATERIAL AND METHODS In a prospective three-arm randomized clinical trial with 6-months follow-up, 124 patients scheduled for CABG surgery alone or concomitant with valvular surgery were randomized to (i) standard medical care only (SMC) or two preoperative psychological interventions: (ii) CBT-based optimizing expectations (EXPECT) and an (iii) an active control group focusing on emotional support (SUPPORT). Available baseline CRP- (n = 79), IL-6- (n = 78), IL-8- (n = 78) and TNF-alpha-(n = 80) parameters were considered as potential moderators (CRP as a categorical and continuous moderator). Linear mixed model analyses were calculated to test whether baseline inflammatory levels moderated intervention effects on disability, mental and physical quality of life at 6 months after surgery. RESULTS IL-8 moderated intervention effects on patients' disability and categorical CRP moderated intervention effects on mental quality of life. Follow-up tests indicated that EXPECT (and in part SUPPORT) led to lower postoperative disability and higher mental quality of life compared to SMC in patients with low baseline inflammatory markers. EXPECT indicated higher mental quality of life compared to SUPPORT in the high CRP subgroup. Patients in the SMC group had higher mental quality of life in the high CRP subgroup compared to the low CRP subgroup. CONCLUSION Especially for patients with a lower inflammatory baseline status preoperative psychological interventions might be helpful to optimize long-term CABG surgery outcomes.
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Affiliation(s)
- Stefan Salzmann
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany.
| | - Frank Euteneuer
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany; Clinical Psychology and Psychotherapy, Medical School Berlin, Berlin, Germany
| | - Johannes A C Laferton
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany; Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin, Germany
| | - Meike C Shedden-Mora
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Clinic Essen, Essen, Germany; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institute, 17177 Stockholm, Sweden
| | - Rainer Moosdorf
- Department for Cardiovascular Surgery, Heart Center, Philipps University of Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
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Abstract
PURPOSE OF REVIEW To review the current state of preoperative psychological preparation to improve outcomes after cardiac surgery. RECENT FINDINGS Preoperative psychosocial factors are associated with short- and long-term outcomes after cardiac surgery. There are several approaches to optimize patients' preoperative psychological status with promising effects on postoperative outcomes (e.g., less complications, improved quality of life). Preoperative psychological preparation often aims to improve patients' knowledge or social support and to modify and optimize expectations and illness beliefs. Preoperative psychological preparation is gaining importance for cardiac surgery. However, patients' psychological status still does not get as much attention as it deserves. Preoperative psychological preparation seems to have positive effects on postoperative outcomes. Since overall evidence is still weak, further studies are warranted to understand which intervention works best for whom and why.
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Affiliation(s)
- Stefan Salzmann
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
| | | | - Marcel Wilhelm
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
| | - Frank Euteneuer
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
- Department of Psychology, Clinical Psychology and Psychotherapy, Medical School Berlin, Berlin, Germany
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