Task shifting of cardiovascular risk assessment and communication by nurses for primary and secondary prevention of cardiovascular diseases in a tertiary health care setting of Northern India

The Role of Visualization in Estimating Cardiovascular Disease Risk: Scoping Review

BACKGROUND

Supporting and understanding the health of patients with chronic diseases and cardiovascular disease (CVD) risk is often a major challenge. Health data are often used in providing feedback to patients, and visualization plays an important role in facilitating the interpretation and understanding of data and, thus, influencing patients' behavior. Visual analytics enable efficient analysis and understanding of large datasets in real time. Digital health technologies can promote healthy lifestyle choices and assist in estimating CVD risk.

OBJECTIVE

This review aims to present the most-used visualization techniques to estimate CVD risk.

METHODS

In this scoping review, we followed the Joanna Briggs Institute PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The search strategy involved searching databases, including PubMed, CINAHL Ultimate, MEDLINE, and Web of Science, and gray literature from Google Scholar. This review included English-language articles on digital health, mobile health, mobile apps, images, charts, and decision support systems for estimating CVD risk, as well as empirical studies, excluding irrelevant studies and commentaries, editorials, and systematic reviews.

RESULTS

We found 774 articles and screened them against the inclusion and exclusion criteria. The final scoping review included 17 studies that used different methodologies, including descriptive, quantitative, and population-based studies. Some prognostic models, such as the Framingham Risk Profile, World Health Organization and International Society of Hypertension risk prediction charts, Cardiovascular Risk Score, and a simplified Persian atherosclerotic CVD risk stratification, were simpler and did not require laboratory tests, whereas others, including the Joint British Societies recommendations on the prevention of CVD, Systematic Coronary Risk Evaluation, and Framingham-Registre Gironí del COR, were more complex and required laboratory testing-related results. The most frequently used prognostic risk factors were age, sex, and blood pressure (16/17, 94% of the studies); smoking status (14/17, 82%); diabetes status (11/17, 65%); family history (10/17, 59%); high-density lipoprotein and total cholesterol (9/17, 53%); and triglycerides and low-density lipoprotein cholesterol (6/17, 35%). The most frequently used visualization techniques in the studies were visual cues (10/17, 59%), followed by bar charts (5/17, 29%) and graphs (4/17, 24%).

CONCLUSIONS

On the basis of the scoping review, we found that visualization is very rarely included in the prognostic models themselves even though technology-based interventions improve health care worker performance, knowledge, motivation, and compliance by integrating machine learning and visual analytics into applications to identify and respond to estimation of CVD risk. Visualization aids in understanding risk factors and disease outcomes, improving bioinformatics and biomedicine. However, evidence on mobile health's effectiveness in improving CVD outcomes is limited.

Prevalence, Associated Risk Factors, and Adverse Cardiovascular Outcomes of Statins Discontinuation: A Systematic Review

PURPOSE

Statins are widely prescribed for cardiovascular diseases (CVD) prevention; however, a significant proportion of users discontinue the medication for various reasons. This review aimed to determine the prevalence of statin therapy discontinuation, its associated factors, and adverse cardiovascular outcomes within the first year of discontinuation.

METHODS

The PubMed, EMBASE, ScienceDirect, SCOPUS, and Google Scholar databases were systematically searched from their inception to December 2022. Manual searches were also conducted on the bibliographies of relevant articles. Studies were included for qualitative data synthesis and assessed for methodological quality.

RESULTS

Fifty-two studies, predominantly cohort studies (n = 38), involving 4 277 061 participants were included. The prevalence of statin discontinuation within the first year of statin initiation ranged from 0.8% to 70.5%, which was higher for primary prevention indications. Factors frequently associated with an increased likelihood of statin discontinuation included male sex, nonWhite ethnicity, smoking status, and being uninsured. Conversely, discontinuation was less likely in patients with CVD who received secondary prevention statin therapy and in patients with polypharmacy. Furthermore, age showed diverse and inconsistent relationships with statin discontinuation among various age categories. Five studies that reported the cardiovascular risk of statin discontinuation within the first year of initiation showed significantly increased risk of discontinuation, including all-cause mortality (hazard ratio: 1.36-3.65).

CONCLUSION

Our findings indicate a high prevalence of statin discontinuation and an increased likelihood of adverse cardiovascular outcomes within the first year of discontinuation, despite wide variability across published studies. This review highlights the importance of addressing the modifiable risk factors associated with statin discontinuation, such as smoking and lack of insurance coverage.

Cardiovascular disease risk assessment in patients with rheumatoid arthritis: A scoping review

Patients with rheumatoid arthritis (RA) have an increased risk of developing cardiovascular disease (CVD). Identification of at-risk patients is paramount to initiate preventive care and tailor treatments accordingly. Despite international guidelines recommending all patients with RA undergo CVD risk assessment, rates remain suboptimal. The objectives of this review were to map the strategies used to conduct CVD risk assessments in patients with RA in routine care, determine who delivers CVD risk assessments, and identify what composite measures are used. The Joanna Briggs Institute methodological guidelines were used. A literature search was conducted in electronic and grey literature databases, trial registries, medical clearing houses, and professional rheumatology organisations. Findings were synthesised narratively. A total of 12 studies were included. Strategies reported in this review used various system-based interventions to support delivery of CVD risk assessments in patients with RA, operationalised in different ways, adopting two approaches: (a) multidisciplinary collaboration, and (b) education. Various composite measures were cited in use, with and without adjustment for RA. Results from this review demonstrate that although several strategies to support CVD risk assessments in patients with RA are cited in the literature, there is limited evidence to suggest a standardised model has been applied to routine care. Furthermore, extensive evidence to map how health care professionals conduct CVD risk assessments in practice is lacking. Research needs to be undertaken to establish the extent to which healthcare professionals are CVD risk assessing their patients with RA in routine care. Key Points • A limited number of system-based interventions are in use to support the delivery of CVD risk assessments in patients with RA. • Multidisciplinary team collaboration, and education are used to operationalise interventions to support Health Care Professionals in conducting CVD risk assessments in practice. • The extent to which Health Care Professionals are CVD risk assessing their patients with RA needs to be established.

Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

Task-shifting in asthma and chronic obstructive pulmonary disease management: A review of the obstructive lung disease program

Objective

Task shifting, an approach to address physician shortage through redistribution of clinical tasks, may help address the high burden of chronic respiratory diseases like asthma and COPD. We aimed to measure its utility and impact in the Obstructive Lung Disease program (OLD).

Methods

A retrospective, cross-sectional study was conducted at five integrated outpatient departments of Primary Care Program within Indus Hospital & Health Network, Pakistan, from January 2018 to March 2023. After a formative evaluation, registered nurses were trained as Lung Health Nurses (LHNs) to perform spirometry, collect Patient Reported Outcome Measures (PROMs) including Asthma Control Test (ACT), modified Medical Research Council (mMRC) dyspnea score and COPD Assessment Test (CAT), counsel on inhaler use and tobacco cessation, and refer to pulmonary rehabilitation (PR). Data was collected online contemporaneously on REDCap and later analyzed using Excel and STATA 14.

Results

Pre-implementation, a monthly average of 126 asthmatics and 33 COPD patients visited primary care centers. Medical records of 147 OLD patients showed 8% received inhaler education, 3% completed ACT and 2% had mMRC documented. Implementation included capacity building of nine LHNs. Of 7427 referrals to the program, 86% underwent nurse-led assessments. LHNs performed spirometry (92%), PROMs assessments [ACT (89%), CAT (91%), mMRC (85%)], inhaler education (97%), tobacco cessation advice (85%) and made PR referrals (94%).

Conclusion

Trained nurses can play a role in providing holistic and timely care for patients with CRDs and strengthen existing healthcare systems. Future directions may include expanding nurse clinical counselling roles through telehealth monitoring and home management.

Task Sharing for Managing Common Noncommunicable Disease in a Nurse Led Noncommunicable Diseases Clinic in Peri-Urban Community of Chandigarh

Background

Nurse led noncommunicable diseases (NCD) clinic may address the significant shortage of human resource for health for managing common NCDs. The objective of this study is to assess the feasibility and effectiveness of nurse-led NCD clinic for identification, prevention, and management of common NCDs.

Materials and Methods

A quasi experimental study was conducted at a Public Health Dispensary in periurban community of Northern India. Situational analysis and stakeholders' interview were done based on which the clinic was setup and run over a period of 2 months by registered nurses and nursing students to offer screening, health education and appropriate referral. The primary outcome of study was proportion of population screened, prevalence of common NCDs, risk factors modification, medication adherence, and patient satisfaction.

Results

It was feasible to run a nurse led clinic in terms of availability of space, equipment to run the clinic and human resource. A total of 455 individuals aged ≥30 years were enrolled using the total enumeration sampling technique. There was a significant increase in screening rates from 0.29% to 3.7% in nurse-led NCD clinic. There was significant mean change in systolic blood pressure (18.75 ± 6.92 mm Hg), diastolic blood pressure (4.4 ± 3.71 mm Hg), random blood sugar (33.36 ± 38.49 mg/dl) Body Mass Index, and waist circumference (P < 0.01) among the population screened. Medication adherence significantly increased from 7.8% to 76.4% (P < 0.01) after 2 months of nurse-led NCD clinic.

Conclusion

Task sharing for managing common NCDs in nurse-led NCD clinic was feasible and effective in increasing screening rates, medication adherence, and risk factors modification among studied population.

Nurse-led cardiovascular diseases risk assessment and communication using WHO/ISH risk prediction chart in a tertiary care hospital of North India

Cardiovascular diseases (CVDs) contribute to most of the potentially preventable burden through early risk assessment. Nurse-led CVD risk assessment is an effective strategy to address the human resource crisis for CVD prevention. An interventional study was conducted in medicine wards of a tertiary care hospital in North India to train nurses in CVD risk assessment and its communication. All bedside nurses (n = 30) of selected wards were enrolled and trained in CVD risk assessment and communication using WHO/ISH risk prediction charts. Once fully trained, each nurse enrolled patients (>40 years of age) from their respective wards to assess and communicate CVD risk. To calculate the reliability of risk assessment, investigator simultaneously assessed CVD risk with nurses. The mean age of nurses was 32.07 ± 6.31 years. The results revealed that training significantly increased the knowledge of nursing personnel (P < 0.001). There was perfect inter-rater reliability agreement (Cohen's k = 0.929) between nurses and investigators while assessing CVD risk. Nurses demonstrated good communication skills. The study concluded that nurses can be trained successfully in CVD risk assessment and communication. The study recommends the task shifting of CVD risk assessment to nurses after providing proper training.

Estimating the gap between demand and supply of medical appointments by physicians for hypertension care: a pooled analysis in 191 countries

INTRODUCTION

With a growing number of people with hypertension, the limited number of physicians could not provide treatment to all patients. We quantified the gap between medical appointments available and needed for hypertension care, overall and in relation to hypertension treatment cascade metrics.

METHODS

Ecological descriptive analysis. We combined country-year-specific data on hypertension prevalence, awareness, treatment and control (from Non-Communicable Disease Risk Factor Collaboration) and number of physicians (from WHO). We estimated from 1 to 12 medical appointments per year for patients with hypertension. We assumed that physicians could see 25 patients per day, work 200 days/year and dedicate 10% of their time to hypertension care.

RESULTS

We studied 191 countries. Forty-one countries would not have enough physicians to provide at least one medical appointment per year to all the population with hypertension; these countries were low/lower middle income and in sub-Saharan Africa or East Asia and Pacific. Regardless of the world region, ≥50% of countries would not have enough physicians to provide ≥8 medical appointments to their population with hypertension. Countries where the demand exceeded the offer of medical appointments for hypertension care had worse hypertension diagnosis, treatment and control rates than countries where the demand did not exceed the offer. There were positive correlations between the physician density and hypertension diagnosis (r=0.70, p<0.001), treatment (r=0.70, p<0.001) and control (r=0.59, p<0.001).

CONCLUSIONS

Where physicians are the only healthcare professionals allowed to prescribe antihypertensive medications, particularly in low and middle-income countries, the healthcare system may struggle to deliver antihypertensive treatment to patients with hypertension.

Career Development and Occupational Disease in Chinese Nurses: A Cross-Sectional Study

BACKGROUND

A high tendency of intention to leave has been noted for nurses in China. The nursing profession is currently unstable.

METHODS

A sample of 51406 nurses from 311 hospitals in China who completed the self-administered questionnaire online was recruited via the China Nursing Association by email and phone using a simple random sampling method. The recruitment occurred between July 2016 and July 2017.

RESULTS

The majority of the nurses had working experience ≤20 years and had to work on night shifts. A high percentage of nurses (71.8%) had insomnia, followed by 37.0% who developed varicose veins and 40.9% who experienced musculoskeletal-related disorders. The proportions of the nurses who developed gastrointestinal and urinary system diseases were 56.0% and 18.2%, respectively. Nearly half of the nurses did not have a clear goal for their future career development and intended to leave. Nurses with long working hours each week were positively associated with the development of occupational diseases. The prevalence of occupational diseases was independently associated with career development.

CONCLUSIONS

A high prevalence of occupational diseases was noted among nurses in China. The data indicated that 50% of the nurses were vague regarding their career planning. The data suggest that managers need to pay more attention and to prevent this problem. Appropriate interventions should also be provided.

Medication Adherence Interventions for Cardiovascular Disease in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

The burden of cardiovascular diseases (CVD) is high in low- and middle-income countries (LMICs). Medications are integral to the management and control of CVD; however, suboptimal adherence impacts health outcomes. This systematic review aims to critically examine interventions targeted at improving medication adherence among persons with CVD in LMICs.

METHODS

In this systematic review, we searched online databases PubMed, Embase, and CINAHL for studies that evaluated a medication adherence intervention for CVD, reported adherence as an outcome measure, were conducted in LMICs and reported the strategy or tool used to measure adherence. We included articles published in English, available in full text, peer-reviewed, and published between 2010 and 2020.

RESULTS

We included 45 articles in this review. The majority of the studies implemented counseling and educational interventions led by nurses, pharmacists, or community health workers. Many of the studies delivered medication-taking reminders in the form of phone calls, text messages, short message services (SMS), and in-phone calendars. Multi-component interventions were more effective than unifocal interventions. Interventions involving technology, such as mobile phone calls, electronic pillboxes, and interactive phone SMS reminders, were more effective than generic reminders. The outcomes reported in the studies varied based on the complexity and combination of strategies. When interventions were implemented at both the patient level, such as reminders, and at the provider level, such as team-based care, the effect on medication adherence was larger.

CONCLUSION

In LMICs, medication adherence interventions among persons with CVD included a combination of patient education, reminders, fixed-dose combination therapy and team-based care approach were generally more effective than singular interventions. Among patients who had CVD, the medication adherence interventions were found to be moderately effective. Future studies focusing on improving medication adherence in LMICs should consider non-physician-led interventions and appropriately adapt the interventions to the local context.

Leveraging role of non-physician health workers in prevention and control of non-communicable diseases in India: Enablers and challenges

Due to upsurge of non-communicable disease (NCD) burden, there is accentuated emphasis on task sharing and shifting NCDs-related health care delivery to non-physician healthcare workers especially nursing personnel and grass root level health professionals. This narrative review summates role of non-physician health workers, highlights various enablers and challenges while engaging them in delivery of NCD services so as to prevent and control various NCDs in India. Pubmed, Google scholar databases were searched using various keywords and Mesh terminologies. In addition, reference lists of selected articles were also screened. It is concluded that with regular update of knowledge, training, and supervision, these workers can efficiently deliver promotive, preventive, curative, and rehabilitative NCD-related healthcare services to needy. While engagement of this workforce in NCDs mitigation is a transforming concept, it also has its own challenges and issues which need to be explored and addressed in order to utilize this human resource to their maximum potential.

Work activities of primary health care nurses in Poland: National Survey Results

BACKGROUND

In some countries, including Poland, nurses have acquired autonomy from being a designated "ancillary staff" to "professional staff" only in recent decades. No prior published studies have examined, however, whether the actual nursing practice in primary health care (PHC) has evolved with the advancement of education and professional autonomy. The aim of this study is to assess the scope of practice of a PHC nurses and their actual work activities.

METHODS

A cross-sectional study design using an investigator-developed survey was conducted in Poland, in 2018. The survey was sent to professionally active PHC nurses in Poland. Of the 225 questionnaires distributed, 202 (89.8%) were returned.

RESULTS

Out of 44 work activities examined, the most often performed activity was administering medications. Less frequent activities included recognizing patients' nursing needs and health problems and monitoring, assessing, and interpreting basic vital signs. A correlation was found between the length of work experience and the following three activities: performing nursing care, issuing referrals for specific diagnostic tests, and ordering of specific treatments, medications, and nutritional supplements. The longer was the work experience, the more often the nurses performed nursing care (r = 0.15; p = 0.035) but less often issued referrals for diagnostic tests (r = - 0.24; p = 0.001) or orders within their scope of practice (r = - 0.23; p = 0.002).

CONCLUSION

While nurses in general are most likely to carry out physician orders, junior nurses tend to be more likely to work toward professional autonomy and pursuing new challenges. PHC nurses in Poland perform work associated more with carrying out physicians' orders and less with what they were prepared to do. Engaging nursing students in interprofessional education, dissemination of nursing research, and advocacy of nursing professional organizations on behalf of the profession may be an effective strategy to overcome the current barriers for PHC nurses to work the top of their license.

Cardiovascular risk using WHO-ISH chart among Diabetes and Hypertensive patients in a remote rural area of South India

INTRODUCTION

Cardiovascular diseases (CVDs) are major problems in India and many other developing and developed countries. As India is committed to provide universal health care for the population, there is a need to find out the prevalence and determinants of CVD risk among high-risk individuals (Diabetes and Hypertensive patients) in the remote rural area of India to deliver appropriate services, as they are considered as neglected population.

METHODS

We screened high-risk individuals (Hypertension and Diabetes patients) for CVD risk using WHO/ISH chart, in a remote rural area of south India, covering ten villages surrounding the Rural Health Training Centre (RHTC), in August-September 2017. After line-listing the participants from the electronic database of RHTC, screening with questionnaire and biochemical tests was done at village level as the first step. Thereafter, the participants were invited to the hospital on a particular day where electrocardiography (ECG) and echocardiography (ECHO) were done with special consultation.

RESULTS

Among the total of 303 individuals screened at the village level, 64 [21%(CI 17-25)] had a higher risk for CVD. 235 people attended the special consultation; among them, 212 underwent ECG and 88 underwent ECHO. Among those screened with ECHO, 18 had some cardiac pathologies. The relationship between CVD risk and other factors is shown in. After final adjustment, illiteracy [adjusted prevalence ratio (aPR) 1.8 (0.1-3.1)], anemia [aPR 1.8 (1-3.6)], and chronic renal diseases [aPR 1.8 (1.0-3.4)] were found to be associated with high risk for CVD among hypertension and diabetes groups.

CONCLUSION

Cardiovascular disease risk assessment using WHO/ISH chart showed an association with poor education, anemia, and chronic kidney disease.