Home-based versus centre-based cardiac rehabilitation

BACKGROUND

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

OBJECTIVES

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Barriers and facilitators to virtual education in cardiac rehabilitation: a systematic review of qualitative studies

Background

Due to restrictions imposed by the severe acute respiratory syndrome coronavirus 2 pandemic much attention has been given to virtual education in cardiac rehabilitation (CR). Despite growing evidence that virtual education is effective in teaching patients how to better self-manage their conditions, there is very limited evidence on barriers and facilitators of CR patients in the virtual world.

Aims

To identify barriers and facilitators to virtual education participation and learning in CR.

Methods

A systematic review of peer-reviewed literature was conducted. Medline, Embase, Emcare, CINAHL, PubMed, and APA PsycInfo were searched from inception through April 2021. Following the PRISMA checklist, only qualitative studies were considered. Theoretical domains framework (TDF) was used to guide thematic analysis. The Critical Appraisal Skills Program was used to assess the quality of the studies.

Results

Out of 6662 initial citations, 12 qualitative studies were included (58% ‘high’ quality). A total of five major barriers and facilitators were identified under the determinants of TDF. The most common facilitator was accessibility, followed by empowerment, technology, and social support. Format of the delivered material was the most common barrier. Technology and social support also emerged as barriers.

Conclusion

This is the first systematic review, to our knowledge, to provide a synthesis of qualitative studies that identify barriers and facilitators to virtual education in CR. Cardiac rehabilitation patients face multiple barriers to virtual education participation and learning. While 12 qualitative studies were found, future research should aim to identify these aspects in low-income countries, as well as during the pandemic, and methods of overcoming the barriers described.

Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite strong evidence supporting the benefits of cardiac rehabilitation (CR), over 80% of eligible patients do not participate in CR. Digital health technologies (ie, the delivery of care using the internet, wearable devices, and mobile apps) have the potential to address the challenges associated with traditional facility-based CR programs, but little is known about the comprehensiveness of these interventions to serve as digital approaches to CR. Overall, there is a lack of a systematic evaluation of the current literature on digital interventions for CR.

Objective

The objective of this systematic literature review is to provide an in-depth analysis of the potential of digital health technologies to address the challenges associated with traditional CR. Through this review, we aim to summarize the current literature on digital interventions for CR, identify the key components of CR that have been successfully addressed through digital interventions, and describe the gaps in research that need to be addressed for sustainable and scalable digital CR interventions.

Methods

Our strategy for identifying the primary literature pertaining to CR with digital solutions (defined as technology employed to deliver remote care beyond the use of the telephone) included a consultation with an expert in the field of digital CR and searches of the PubMed (MEDLINE), Embase, CINAHL, and Cochrane databases for original studies published from January 1990 to October 2018.

Results

Our search returned 31 eligible studies, of which 22 were randomized controlled trials. The reviewed CR interventions primarily targeted physical activity counseling (31/31, 100%), baseline assessment (30/31, 97%), and exercise training (27/31, 87%). The most commonly used modalities were smartphones or mobile devices (20/31, 65%), web-based portals (18/31, 58%), and email-SMS (11/31, 35%). Approximately one-third of the studies addressed the CR core components of nutrition counseling, psychological management, and weight management. In contrast, less than a third of the studies addressed other CR core components, including the management of lipids, diabetes, smoking cessation, and blood pressure.

Conclusions

Digital technologies have the potential to increase access and participation in CR by mitigating the challenges associated with traditional, facility-based CR. However, previously evaluated interventions primarily focused on physical activity counseling and exercise training. Thus, further research is required with more comprehensive CR interventions and long-term follow-up to understand the clinical impact of digital interventions.

Interactive patient education via an audience response system in cardiac rehabilitation

Objectives:

Patient education and compliance play an important role in the success of rehabilitation in cardiovascular diseases. The aim of this study is to analyze whether interactive learning methods, in this study, the audience response system with a “clicker,” can improve the learning success of patients during and after their rehabilitation process.

Methods:

In a randomized, prospective cohort study, a total of 260 patients were randomized to either an interactive training group using Athens audience response system or to a control group without the use of audience response system during the educational sessions. Patients were taught and tested on four different topics concerning their primary disease: heart failure, arterial hypertension, prevention of cardiovascular diseases, and coronary heart disease. After each session, the patients had to answer questions on the previously taught topics via questionnaires. These questions were asked again at the day of discharge, as well as 3 and 12 months after discharge. Additional information on the patients’ health, plus their mental status, was gathered with the help of further questionnaires (HADS and SF-12).

Results:

A total of 260 patients (201 men and 59 women) were recruited. The patients were on average 61.1 ± 11 years old. A significant short-term effect on the patients’ knowledge about their disease was found immediately after the educational sessions in the intervention group. However, there was no long-term effect in either the intervention or control group. Although there was no statistical significance found in any of the observations, a positive short-term effect on learning capacity as well as positive trends in mental and physical health after discharge could be found in patients after the use of audience response system during their rehabilitation.

Conclusion:

This study provides interesting and new data on the use of an interactive learning method for patients to gain knowledge about their primary disease and eventually improve their physical and mental health status in a long-term perspective. By implementing different and new ways of teaching and interaction during the hospitalization, not only patients, but also medical staff and caregivers could benefit.

Can causal explanations about endothelial pathophysiology benefit patient education? A cluster randomized controlled trial in cardiac rehabilitation

OBJECTIVE

To examine whether explaining causal links among endothelial pathophysiology, cardiac risk factors, symptoms and health behaviors (termed causal information) enhances patients' depth of knowledge about cardiovascular disease self-management and their perceptions of the cardiac rehabilitation and secondary prevention (CRSP) program.

METHODS

Newly referred CRSP patients (N = 94) were cluster randomized to usual care (control; UC) or usual care with causal information (intervention; UC + CI). Depth of knowledge (factual vs. deep) was measured with an adapted cognitive-reasoning task. Patients' cardiovascular knowledge and beliefs about the efficacy of a CRSP program were assessed.

RESULTS

After controlling for education level, patients in UC + CI demonstrated deeper knowledge about cardiovascular management than did those in UC. The UC + CI group showed higher factual knowledge than their counterparts after covarying education, occupation status and BMI. The UC + CI group also rated the CRSP program as more credible than those in UC, after controlling for age. Deep knowledge mediated the relationship between group conditions and perceived credibility of CRSP.

CONCLUSION

Causal information can enhance the depth of patients' understanding of cardiovascular disease management and perceived treatment credibility of the CRSP program.

PRACTICE IMPLICATIONS

Explaining causal links may help improve patient education delivery and enhance patient engagement in CRSP.

Patient education in the management of coronary heart disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Patient education in the management of coronary heart disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

A systematic review of the literature reporting on studies that examined the impact of interactive, computer-based patient education programs

OBJECTIVE

To evaluate studies that examined the impact of interactive, computer-based education (ICBE) programs on patient education.

METHODS

The Medline and CINAHL databases were searched to identify randomized controlled studies that evaluated the impact of ICBE programs.

RESULTS

The 25 studies that met the selection criteria generally supported the ability of ICBE programs to promote knowledge gains. Results related to economic or clinical outcomes were less consistent. Significant variations were noted across studies in program features, implementation and integration strategies, and in comparison program attributes and quality. It is likely that these differences contributed to the disparity in findings across studies.

CONCLUSION

Although significant inconsistencies in results were noted, the research provided collective evidence that ICBE programs had the potential to add great value to the patient education process. Programs must be properly designed and implementation and integration processes effectively planned in order to achieve consistently positive outcomes.

PRACTICE IMPLICATIONS

Consideration of the "best practices" derived from the research and noted in this report will assist healthcare providers in designing, selecting, and implementing effective ICBE programs.

Assessing patient attitudes to computerized screening in primary care: psychometric properties of the computerized lifestyle assessment scale

BACKGROUND

Computer-based health-risk assessments are electronic surveys which can be completed by patients privately, for example during their waiting time in a clinic, generating a risk report for the clinician and a recommendation sheet for the patient at the point of care. Despite increasing popularity of such computer-based health-risk assessments, patient attitudes toward such tools are rarely evaluated by reliable and valid scales. The lack of psychometric appraisal of appropriate scales is an obstacle to advancing the field.

OBJECTIVE

This study evaluated the psychometric properties of a 14-item Computerized Lifestyle Assessment Scale (CLAS).

METHODS

Out of 212 female patients receiving the study information at a family practice clinic, 202 completed a paper questionnaire, for a response rate of 97.6%. After 2 weeks, 52 patients completed the scale a second time.

RESULTS

Principal component analysis revealed that CLAS is a multidimensional scale consisting of four subscales (factors): (1) BENEFITS: patient-perceived benefits toward the quality of medical consultation and means of achieving them, (2) Privacy-Barrier: concerns about information privacy, (3) Interaction-Barrier: concerns about potential interference in their interaction with the physician, and (4) Interest: patient interest in computer-assisted health assessments. Each subscale had good internal consistency reliability ranging from .50 (2-item scale) to .85 (6-item scale). The study also provided evidence of scale stability over time with intraclass correlation coefficients of .91, .82, .86, and .67 for the four subscales, respectively. Construct validity was supported by concurrent hypotheses testing.

CONCLUSIONS

The CLAS is a promising approach for evaluating patients' attitudes toward computer-based health-risk assessments.

Multimedia educational aids for improving consumer knowledge about illness management and treatment decisions: a review of randomized controlled trials

Psychiatric practice is becoming increasingly more complex in terms of the available treatment options, use of new technologies for assessments, and a need for psychiatric patients and their caregivers to be familiar with general medical procedures. This trend will only intensify in the years to come. Routine methods of providing information relevant to clinical decision making about healthcare evaluations or management are often suboptimal. Relatively little research has been done on enhancing the capacity of psychiatric patients and the caregivers to make truly informed decisions about management. In this paper, we review studies that compared the effects of multimedia (video- or computer-based) educational aids with those of routine procedures to inform healthcare consumers about medical evaluations or management. Although most of these investigations were conducted in non-psychiatric patients, the results should be relevant for psychiatric practice of tomorrow. We searched MEDLINE, PsycINFO, and CINAHL bibliographic databases. Randomized controlled trials that used objective measures of knowledge or understanding of the information provided were selected. Studies were rated as positive if the multimedia educational aid resulted in a greater improvement in knowledge or understanding than the control condition. The quality of each study was also rated using a newly developed Scale for Assessing Scientific Quality of Investigations (SASQI). A total of 37 randomized controlled trials were identified. Nearly two-thirds of the studies (23/37) in diverse patient populations and for varied medical assessments and treatments reported that multimedia educational aids produced better understanding of information compared to routine methods. SASQI scores for the positive and negative studies were comparable, suggesting that lower quality was not related to positive findings. In conclusion, multimedia educational aids hold promise for improving the provision of complex medical information to patients and caregivers. It is likely that as psychiatric patients and their treating clinicians face increasingly complex choices regarding mental health treatment, multimedia decisional aids could become an effective supplement to the clinician patient interaction in near future.

A systematic review of computer-based softwares for educating patients with coronary heart disease

OBJECTIVE

To evaluate the use of computer-based softwares for educating patients with coronary heart disease.

METHODS

A systematic electronic search for randomised controlled trials and comparison studies published from 1999 to the end of 2005 using the MEDLINE (1999-2005), EMBASE (1999-2005) and CINAHL (1999-2005) was carried out. Articles including the reference lists in the following journals were hand-searched: Patient Education and Counselling and Patient Counselling and Health Education.

RESULTS

A total of 487 articles were identified. Based on a review of abstracts, five studies fulfilled the inclusion criteria of the review. A scoring sheet was used to assess the papers' quality. All studies reported significantly increased knowledge in patients using the educational software when compared to standard education. The difference in knowledge between the intervention and control groups remained high even at 6 months follow up. Furthermore, patients reported high satisfaction with the educational programs.

CONCLUSION

Despite there only being five studies that met the inclusion criteria, this review supports the successful use of computer software to increase knowledge in patients with coronary heart disease. The reviewed articles reveal that computer-based education has an important role in increasing patients' knowledge about their condition.

PRACTICAL IMPLICATIONS

It is commonly reported that patients want more information about their illness. This study shows that computer-based education can be a useful, acceptable to patients and effective way to deliver education about coronary heart disease.

The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes

Background

A primary focus of self-care interventions for chronic illness is the encouragement of an individual's behavior change necessitating knowledge sharing, education, and understanding of the condition. The use of the Internet to deliver Web-based interventions to patients is increasing rapidly. In a 7-year period (1996 to 2003), there was a 12-fold increase in MEDLINE citations for “Web-based therapies.” The use and effectiveness of Web-based interventions to encourage an individual's change in behavior compared to non-Web-based interventions have not been substantially reviewed.

Objective

This meta-analysis was undertaken to provide further information on patient/client knowledge and behavioral change outcomes after Web-based interventions as compared to outcomes seen after implementation of non-Web-based interventions.

Methods

The MEDLINE, CINAHL, Cochrane Library, EMBASE, ERIC, and PSYCHInfo databases were searched for relevant citations between the years 1996 and 2003. Identified articles were retrieved, reviewed, and assessed according to established criteria for quality and inclusion/exclusion in the study. Twenty-two articles were deemed appropriate for the study and selected for analysis. Effect sizes were calculated to ascertain a standardized difference between the intervention (Web-based) and control (non-Web-based) groups by applying the appropriate meta-analytic technique. Homogeneity analysis, forest plot review, and sensitivity analyses were performed to ascertain the comparability of the studies.

Results

Aggregation of participant data revealed a total of 11,754 participants (5,841 women and 5,729 men). The average age of participants was 41.5 years. In those studies reporting attrition rates, the average drop out rate was 21% for both the intervention and control groups. For the five Web-based studies that reported usage statistics, time spent/session/person ranged from 4.5 to 45 minutes. Session logons/person/week ranged from 2.6 logons/person over 32 weeks to 1008 logons/person over 36 weeks. The intervention designs included one-time Web-participant health outcome studies compared to non-Web participant health outcomes, self-paced interventions, and longitudinal, repeated measure intervention studies. Longitudinal studies ranged from 3 weeks to 78 weeks in duration. The effect sizes for the studied outcomes ranged from -.01 to .75. Broad variability in the focus of the studied outcomes precluded the calculation of an overall effect size for the compared outcome variables in the Web-based compared to the non-Web-based interventions. Homogeneity statistic estimation also revealed widely differing study parameters (Q_w16 = 49.993, P ≤ .001). There was no significant difference between study length and effect size. Sixteen of the 17 studied effect outcomes revealed improved knowledge and/or improved behavioral outcomes for participants using the Web-based interventions. Five studies provided group information to compare the validity of Web-based vs. non-Web-based instruments using one-time cross-sectional studies. These studies revealed effect sizes ranging from -.25 to +.29. Homogeneity statistic estimation again revealed widely differing study parameters (Q_w4 = 18.238, P ≤ .001).

Conclusions

The effect size comparisons in the use of Web-based interventions compared to non-Web-based interventions showed an improvement in outcomes for individuals using Web-based interventions to achieve the specified knowledge and/or behavior change for the studied outcome variables. These outcomes included increased exercise time, increased knowledge of nutritional status, increased knowledge of asthma treatment, increased participation in healthcare, slower health decline, improved body shape perception, and 18-month weight loss maintenance.

Evaluating the efficacy of tele-cognitive rehabilitation for functional performance in three case studies

Traumatic brain injury (TBI) is one of the main causes of long-term disability, and its rehabilitation is a challenge to the healthcare team. Tele-rehabilitation, through using advancements in networking and tailor-made software, has been developed and applied to the cognitive rehabilitation of persons with brain injury in the present study. Tele-cognitive rehabilitation uses customized online computer software as a treatment mode. The online treatment software is operated on an interactive tele-communication platform--for example, video conferencing with screen sharing. Through implementing the tele-cognitive rehabilitation activities, therapists can help clients to practise and thus improve their cognitive skills through using the treatment software successfully. Moreover, hypermedia programming techniques allow the therapist to adjust the software to meet the client's treatment needs, so that the treatment is appropriate to his/her functional levels and living environment. Also the software can customize immediate visual, auditory and personalized feedback to motivate the client and training can be set at the right pace for the client's needs. The present study aimed to evaluate the effectiveness and perceived efficacy of the newly developed customized tele-cognitive rehabilitation programme for three subjects with traumatic brain injury through using single-case and qualitative research design. The cognitive factors investigated in this pilot study were, respectively, Chinese word recognition, prospective memory and semantic memory. The subjects had undergone a recruitment process with stipulated screening criteria. A single case experimental design (ABA reversal/withdrawal design) consisted of a no-intervention baseline phase (A), an intervention phase (B) and a no-intervention withdrawal phase (A). There were six sessions in each phase, making a total of 18 sessions. Tele-cognitive rehabilitation software was tailor-made according to each subject's cognitive functional needs. To monitor the change in cognitive functions, variables were tapped by tailor-made assessment and qualitative questionnaires through interviews, and they were then used to explore subjects' opinions of the programme and to test the treatment efficacy of the tele-cognitive rehabilitation programme. Finally, the relationships among the three phases were analysed through visual analysis and trend line analysis by means of the split-middle method. The three persons with brain injury showed improving trends and levels of specific cognitive performance during the treatment phase. Qualitative findings were analysed and confirmed the efficacy of the treatment module. The tele-cognitive rehabilitation approach was well received by subjects. The authors suggest that further replication studies of this kind should be conducted in the future and that more subjects should be recruited to improve the generalizability of the results.

Process and Outcome in Cardiac Rehabilitation: An Examination of Cross-Lagged Effects

Cardiac rehabilitation patients improve cardiorespiratory fitness and quality of life, yet therapeutic processes that produce these changes remain unknown. A cross-lagged panel design was used to determine whether early-treatment enhancement of self-efficacy regarding abilities to change diet and exercise habits and the quality of the patient-staff working alliance predicted late-treatment changes in a wide range of outcomes, but not vice versa. Eighty cardiac patients participating in a 12-week program completed measures at early, mid- and late treatment. Early-treatment changes in exercise self-efficacy predicted late-treatment changes in activity level, depression, and working alliance, but not vice versa. Diet self-efficacy changes correlated with concurrent changes in fat intake and body weight. Early-treatment changes in cardiorespiratory fitness and activity level predicted late-treatment changes in working alliance, but not vice versa. Findings suggest that increased exercise self-efficacy represents an important therapeutic mechanism by which rehabilitation gains are realized. ((c) 2004 APA, all rights reserved)