Development and testing of innovative patient resources for the management of coronary heart disease (CHD): a descriptive study

Information Needs and Communication Strategies for People with Coronary Heart Disease: A Scoping Review

A critical aspect of coronary heart disease (CHD) care and secondary prevention is ensuring patients have access to evidence-based information. The purpose of this review is to summarise the guiding principles, content, context and timing of information and education that is beneficial for supporting people with CHD and potential communication strategies, including digital interventions. We conducted a scoping review involving a search of four databases (Web of Science, PubMed, CINAHL, Medline) for articles published from January 2000 to August 2022. Literature was identified through title and abstract screening by expert reviewers. Evidence was synthesised according to the review aims. Results demonstrated that information-sharing, decision-making, goal-setting, positivity and practicality are important aspects of secondary prevention and should be patient-centred and evidenced based with consideration of patient need and preference. Initiation and duration of education is highly variable between and within people, hence communication and support should be regular and ongoing. In conclusion, text messaging programs, smartphone applications and wearable devices are examples of digital health strategies that facilitate education and support for patients with heart disease. There is no one size fits all approach that suits all patients at all stages, hence flexibility and a suite of resources and strategies is optimal.

Patient education information material assessment criteria: A scoping review

BACKGROUND

Patient education information material (PEIM) is an essential component of patient education programs in increasing patients' ability to cope with their diseases. Therefore, it is essential to consider the criteria that will be used to prepare and evaluate these resources.

OBJECTIVE

This paper aims to identify these criteria and recognize the tools or methods used to evaluate them.

METHODS

National and international databases and indexing banks, including PubMed, Scopus, Web of Science, ProQuest, the Cochrane Library, Magiran, SID and ISC, were searched for this review. Original or review articles, theses, short surveys, and conference papers published between January 1990 and June 2022 were included.

RESULTS

Overall, 4688 documents were retrieved, of which 298 documents met the inclusion criteria. The criteria were grouped into 24 overarching criteria. The most frequently used criteria were readability, quality, suitability, comprehensibility and understandability.

CONCLUSION

This review has provided empirical evidence to identify criteria, tools, techniques or methods for developing or evaluating a PEIM. The authors suggest that developing a comprehensive tool based on these findings is critical for evaluating the overall efficiency of PEIM using effective criteria.

Use of co-design methodology in the development of cardiovascular disease secondary prevention interventions: A scoping review

INTRODUCTION

There is growing evidence to support the use of co-design in developing interventions across many disciplines. This scoping review aims to examine how co-design methodology has been used in the development of cardiovascular disease (CVD) secondary prevention interventions within health and community settings.

METHODS

We searched four academic databases for studies that used the co-design approach to develop their intervention. Studies were included if consumers (adults with CVD) and key stakeholders (e.g. clinicians, service providers) were involved in the co-design process. The review focused on methodology rather than traditional study outcomes; therefore, co-design processes and activities were extracted and evaluated against a selected co-design framework.

RESULTS

Twenty-two studies were included in this review. Studies were implemented across various settings with consumers and stakeholder groups most frequently consisting of patients and healthcare professionals, respectively. Most studies specifically stated that they used a 'co-design' approach (n = 10); others used terms such as participatory action research (n = 3), user-centred design (n = 3) and community-based participatory research (n = 2). Although there was variability in terminology, co-design processes, and participants, all studies adhered to the key principles of consumer engagement. Predominant co-design activities included semistructured interviews, focus groups, co-design/development workshops and advisory group meetings. Intervention effectiveness was assessed in eight studies showing mixed results.

CONCLUSIONS

This review provides an overview of how the co-design approach has previously been used in the development of CVD secondary prevention interventions. These findings provide methodological considerations that can guide researchers and healthcare services when implementing co-design to develop feasible and acceptable interventions that can improve outcomes for CVD populations.

PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, caregivers, people with lived experience or members of the public were involved in this scoping review. This review article was written by academics who have undertaken a significant amount of co-design work with consumers and stakeholders.

Limited Engaging and Interactive Online Health Information for Adolescents: A Systematic Review of Australian Websites

Adolescents need access to interactive and high-quality online health information about strategies to reduce their risk for non-communicable diseases (NCDs). This study aimed to evaluate the quality, readability and interactivity of webpages with adolescent-specific information on NCD risk factors. Included web pages were: (i) Australian-based; (ii) authored by government bodies or public health organizations; (iii) contained information relevant to NCD risk factors; and (iv) contained adolescent-specific information. In total, 69 web pages were included for evaluation (smoking, n = 6; nutrition, n = 22; alcohol, n = 15; physical activity n = 11; mental health, n = 6; health and obesity, n = 9). Content quality score (modified DISCERN tool) ±standard deviation ranged from fair (49.6 ± 13.6 for nutrition) to good quality (58.4 ± 11.0 for alcohol). Mean readability score (Flesch-Kincaid tool) found most webpages were difficult to read (49.6 ± 14.9, University student level). Adolescent-directed websites were written in plain English (62 ± 7.5, understood by 13-15-year-olds). Mean interactivity score indicated web pages were fairly interactive (13 ± 2.0). The study found very few webpages were written specifically for adolescents and no webpages were of excellent quality, highly interactive and written in plain English. Given the plethora of online health information from non-credible sources, we recommend public health organizations invest in co-designing excellent-quality and interactive online health information with adolescents.

Using a citizens' jury approach to determine a good nutrition resource for pregnant women

OBJECTIVE

The development of user-friendly nutrition resources for pregnant women seldom involves end-users. This qualitative study used a citizens' jury approach to determine if our modification of a longstanding, frequently used dietitian-informed diet and diabetes booklet was deemed to be a good healthy eating resource for pregnant women.

DESIGN

Midwives recruited thirteen first-time pregnant women not requiring specialist obstetric care or specialist dietetic advice for any reason. Participants were sent a copy of the modified healthy eating in pregnancy booklet prior to 'jury day'. Five women were unable to attend the citizens' jury citing reasons such as early labour. At the jury, five experts presented evidence. Participants adjourned, with an independent facilitator, to 'deliberate' as to whether the resource was suitable or not. The verdict was presented, and subsequent discussion was audio-recorded, transcribed and inductively content analysed.

SETTING

Southland, New Zealand.

PARTICIPANTS

Pregnant women aged 19-35 years (n 8), of whom half had a household income <$NZ30 000.

RESULTS

The verdict was 'Yes'; the resource was good. Three themes were derived: communication of health information, resource content and harm reduction in pregnancy. Based on these data, ways to enhance the quality and usability of the booklet were evident.

CONCLUSIONS

Citizens' juries can be used to obtain an independent assessment by end-users of health resources. Our modified diet and diabetes booklet was considered suitable for providing healthy eating advice to pregnant women. Inclusion of end-users' perspectives is critical for end-user relevant content, comprehension and resource credibility.

Understanding Preferences for Osteoporosis Information to Develop an Osteoporosis Patient Education Brochure

CONTEXT

Patient education materials can provide important information related to osteoporosis prevention and treatment. However, available osteoporosis education materials fail to follow best-practice guidelines for patient education.

OBJECTIVE

To develop an educational brochure on bone health for adults aged 50 years and older using mixed-method, semistructured interviews.

DESIGN

This project consisted of 3 phases. In Phase 1, we developed written content that included information about osteoporosis. Additionally, we designed 2 graphic-rich brochures, Brochure A (photographs) and Brochure B (illustrations). In Phase 2, interviewers presented the text-only document and both brochure designs to 53 participants from an academic Medical Center in the Midwest and an outpatient clinic in the Southeastern region of the US. Interviewers used open- and closed-ended questions to elicit opinions regarding the brochures. In Phase 3, using feedback from Phase 2, we revised the brochure and presented it to 11 participants at a third site in the Southeastern US.

MAIN OUTCOME MEASURES

Participants' comprehension of brochure text and acceptability of brochure design.

RESULTS

We enrolled 64 participants. Most were women, white, and college-educated, with an average age of 66.1 years. Participants were able to restate the basic content of the brochure and preferred Brochure A's use of photographs.

CONCLUSIONS

Using feedback from older adults, we developed and refined a brochure for communicating bone health information to older adults at risk of osteoporosis and fragility fractures. The methods outlined in this article may serve to guide others in developing health educational brochures for chronic medical conditions.

Health information needs, sources, and barriers of primary care patients to achieve patient-centered care: A literature review

To synthesize findings from previous studies assessing information needs of primary care patients on the Internet and other information sources in a primary care setting. A systematic review of studies was conducted with a comprehensive search in multiple databases including OVID MEDLINE, CINAHL, and Scopus. The most common information needs among patients were information about an illness or medical condition and treatment methods, while the most common information sources were the Internet and patients' physicians. Overall, patients tend to prefer the Internet for the ease of access to information, while they trust their physicians more for their clinical expertise and experience. Barriers to information access via the Internet include the following: socio-demographic variables such as age, ethnicity, income, education, and occupation; information search skills; and reliability of health information.

CONCLUSION

Further research is warranted to assess how to create accurate and reliable health information sources for both Internet and non-Internet users.

Understanding communication of health information: a lesson in health literacy for junior medical and physiotherapy students

Best practice communication between healthcare professionals and patients involves using quality patient information leaflets (PILs). We assessed medical and physiotherapy students' (N = 337) ability to appraise the readability, psychology theory content and quality of nine international smoking PILs. Flesch scores ranged from 52.8-79.7% (fairly difficult to fairly easy). Students identified components of the Health Belief Model (84-98%), Theory of Planned Behaviour (65-88%) and Transtheoretical Model (37-86%). Importantly, student-proposed additional theory-based content had no detrimental effect on readability scores. Overall quality scores indicated low-moderate quality. This assignment helped students critically evaluate the utility of PILs for communication.

Validation of the Society for Vascular Surgery's objective performance goals for critical limb ischemia in everyday vascular surgery practice

BACKGROUND

To develop standardized metrics for expected outcomes in lower extremity revascularization for critical limb ischemia (CLI), the Society for Vascular Surgery (SVS) has developed objective performance goals (OPGs) based on aggregate data from randomized trials of lower extremity bypass (LEB). It remains unknown, however, if these targets can be achieved in everyday vascular surgery practice.

METHODS

We applied SVS OPG criteria to 1039 patients undergoing 1039 LEB operations for CLI with autogenous vein (excluding patients on dialysis) within the Vascular Study Group of New England (VSGNE). Each of the individual OPGs was calculated within the VSGNE dataset, along with its surrounding 95% confidence intervals (CIs) and compared to published SVS OPGs using χ(2) comparisons and survival analysis.

RESULTS

Across most risk strata, patients in the VSGNE and SVS OPG cohorts were similar (clinical high-risk [age >80 years and tissue loss]: 15.3% VSGNE; 16.2% SVS OPG; P = .58; anatomic high risk [infrapopliteal target artery]: 57.8% VSGNE; 60.2% SVS OPG; P = .32). However, the proportion of VSGNE patients designated as conduit high-risk (lack of single-segment great saphenous vein) was lower (10.2% VSGNE; 26.9% SVS OPG;P < .001). The primary safety endpoint, major adverse limb events (MALE) at 30 days, was lower in the VSGNE cohort (3.2%; 95% CI, 2.3-4.6) than the SVS OPG cohort (6.2%; 95% CI, 4.2-8.1; P = .05). The primary efficacy OPG endpoint, freedom from any MALE or postoperative death within the first year (MALE + postoperative death [POD]), was similar between VSGNE and SVS OPG cohorts (77%; 95% CI, 74%-80%) SVS OPG, 74% (95% CI, 71%-77%) VSGNE, P = .58). In the remaining safety and efficacy OPGs, the VSGNE cohort met or exceeded the benchmarks established by the SVS OPG cohort.

CONCLUSION

Community and academic centers in everyday vascular surgery practice can meet OPGs derived from centers of excellence in LEB. Quality improvement initiatives, as well as clinical trials, should incorporate OPGs in their outcome measures to facilitate communication and comparison of risk-adjusted outcomes in the treatment of CLI.

Impact of medical consultation frequency on modifiable risk factors and medications at 12 months after acute coronary syndrome in the CHOICE randomised controlled trial

BACKGROUND

We aimed to determine whether the frequency of General Practitioner and Cardiologist consultations impacted on improvements in risk factors in Choice of Health Options in Reducing Cardiovascular Events (CHOICE) randomised controlled trial.

METHODS

Retrospective subgroup analysis of single-blind randomised controlled trial. We included acute coronary syndrome survivors not accessing cardiac rehabilitation in the CHOICE trial whose General Practitioner or Cardiologist returned a visit frequency survey. The CHOICE group participated in tailored risk factor reduction packaged as clinic visit plus 3 months telephone support. Controls participated in physician-directed usual medical care. We compared total cholesterol, systolic blood pressure, smoking status, physical activity, number of modifiable risk factors and medications with frequency of medical consultations at baseline and 12 months.

RESULTS

Most control and CHOICE patients saw their General Practitioner≥5 times (85% vs 90%) and Cardiologist at least once (65% vs 57%). CHOICE patients had a significantly better modifiable risk profile (factor levels and multiples) and more patients were on evidence-based medications at 12 months compared to controls. In CHOICE, the significant reduction in total cholesterol was unrelated to medical visits but lower systolic blood pressure was significant in patients who saw their General Practitioner≥5 compared with ≤4 times. In controls, frequency of medical visits was not associated with any changes in risk profile.

CONCLUSIONS

Acute coronary syndrome survivors receiving frequent medical follow-up without packaged secondary prevention had no improvement in multiple risk factors over 12 months. CHOICE patients who saw their doctors frequently were more likely to have significantly reduced systolic blood pressure and be on evidence-based medications.

Chronic illness and smoking cessation

INTRODUCTION

Smoking is among the leading causes of premature mortality and preventable death in the United States. Although smoking contributes to the probability of developing chronic illness, little is known about the relationship between quitting smoking and the presence of chronic illness. The present study investigated the association between diagnoses of one or more chronic diseases (diabetes, hypertension, or high cholesterol) and smoking status (former or current smoker).

METHODS

The data analyzed were a subset of questions from a 155-item telephone-administered community survey that assessed smoking status, demographic characteristics, and presence of chronic disease. The study sample consisted of 3,802 randomly selected participants.

RESULTS

Participants with diabetes were more likely to report being former smokers, after adjusting for sociodemographic characteristics, whereas having hypertension or high cholesterol was not associated significantly with smoking status. The likelihood of being a former smoker did not increase as number of diagnosed chronic diseases increased. Participants who were women, older (aged 65+), or single were significantly less likely to be former smokers. Participants with at least a college degree, those with incomes of 50,000+ US dollars, and those who were underweight or obese were more likely to be former smokers.

DISCUSSION

These findings were inconsistent with research that has suggested that having a chronic illness or experiencing a serious medical event increases the odds of smoking cessation. Supporting prior research, we found that being male, having a higher income, and being obese were associated with greater likelihood of being a former smoker.

The CHOICE (Choice of Health Options In prevention of Cardiovascular Events) replication trial: study protocol

Background

Although morbidity and mortality from coronary heart disease (CHD) are high, only a minority of acute coronary syndrome (ACS) survivors accesses an effective secondary prevention program. We aim to determine whether the previously proven CHOICE program can be replicated at multiple sites and whether ongoing reinforcement further improves risk factor modification.

Methods/design

Participants eligible for but not accessing standard cardiac rehabilitation will be randomly allocated to either a previously tested 3-month CHOICE program or a 30-month CHOICE program (CHOICE-plus). Both groups will participate in individualised risk factor modules of differing duration that involve choice, goal setting and telephone follow-up for three months. CHOICE-plus will also receive additional face-to-face and telephone reinforcement between three and 30 months. At one site we will recruit a randomised control group, receiving conventional care. Primary outcomes are lipid levels, blood pressure, physical activity levels and smoking rates. Secondary outcomes include readmission rates, death, the number of risk factors, other modifiable risk factors, quality of life and process evaluation measures over three years.

Discussion

We present the rationale and design of a multi-centre, replication study testing a modular approach for the secondary prevention of CHD following an ACS.

Trial Registration

[Clinical Trial Registration Number, ACTRN12608000182392]

Physicians' shared decision-making behaviors in depression care

BACKGROUND

Although shared decision making (SDM) has been reported to facilitate quality care, few studies have explored the extent to which SDM is implemented in primary care and factors that influence its application. This study assesses the extent to which physicians enact SDM behaviors and describes factors associated with physicians' SDM behaviors within the context of depression care.

METHODS

In a secondary analysis of data from a randomized experiment, we coded 287 audiorecorded interactions between physicians and standardized patients (SPs) using the Observing Patient Involvement (OPTION) system to assess physician SDM behaviors. We performed a series of generalized linear mixed model analyses to examine physician and patient characteristics associated with SDM behavior.

RESULTS

The mean (SD) OPTION score was 11.4 (3.3) of 48 possible points. Older physicians (partial correlation coefficient = -0.29; beta = -0.09; P < .01) and physicians who practiced in a health maintenance organization setting (beta = -1.60; P < .01) performed fewer SDM behaviors. Longer visit duration was associated with more SDM behaviors (partial correlation coefficient = 0.31; beta = 0.08; P < .01). In addition, physicians enacted more SDM behaviors with SPs who made general (beta = 2.46; P < .01) and brand-specific (beta = 2.21; P < .01) medication requests compared with those who made no request.

CONCLUSIONS

In the context of new visits for depressive symptoms, primary care physicians performed few SDM behaviors. However, physician SDM behaviors are influenced by practice setting and patient-initiated requests for medication. Additional research is needed to identify interventions that encourage SDM when indicated.