Cardiac rehabilitation following myocardial infarction. A practical approach

Evaluating the Effectiveness of an Interactive Multimedia Computer-Based Patient Education Program in Cardiac Rehabilitation

The authors have developed a computer-assisted patient education program on exercise and heart health that uses hypermedia-programming techniques. The program design integrated interactive behavioral instructional strategies with attractive multimedia presentations. It also employed user-friendly computer input methods like touch screens to facilitate elderly clients' participation. The learning outcome of patients who were using the computer-assisted educational method was compared to that of patients using the conventional tutorial method. There were 48 cardiac patients (mean age = 58.81) participating in the tutorial-based education, and another 48 (mean age = 56.12) participating in the computer-assisted education program. Results of repeated measures analysis of variance showed that both the computer-assisted instruction (CAI) and tutorial groups had significant improvement in their exercise knowledge (F = 70.68, p, .001) and self-efficacy in applying exercise principles (F = 54.33, p, .002 before and after the training program. A test of between-subjects effects showed that there was a significant main group effect on the exercise knowledge change (F = 29.22, p, .002), but not on the exercise self-efficacy change CF = 1.68, p, .05). In spite of this, the results showed that the CAI group had significantly better exercise knowledge than the tutorial group in both the post-training and follow-up phases. The better learning outcome of the CAI group might be attributed to allowing students to study at their own pace, repeat the difficult parts, and interact with the program contents. Most of the subjects in the computer-assisted group stated they preferred this mode of learning. However, some of them preferred the tutorial method because they could seek help from the tutor when in doubt. From the present results, an interactive multimedia computer-assisted patient education program was demonstrated to be effective for cardiac education. The computer-assisted instructional method is recommended for public health education, such as disease prevention and patients' self-management of chronic diseases.

Reproducibility of ratings of perceived exertion soon after myocardial infarction: responses in the stress-testing clinic and the rehabilitation gymnasium

The purpose of this study was to compare ratings of perceived exertion (RPE; Borg's 6-20 scale) at the same exercise intensity, between a standard exercise electrocardiogram (ECG) treadmill stress test (exECG) and two subsequent bouts of treadmill exercise in a cardiac rehabilitation gymnasium. Eleven patients (mean +/- s) 60.8 +/- 6.1 years performed an exECG within 12.1 +/- 7.5 d after myocardial infarction (MI) and commenced their first exercise-based rehabilitation session (gym-1), which included the use of a motorised treadmill, within 5.0 +/- 1.3 d after the exECG. A second gym session (gym-2) was performed within 4.2 +/- 1.3 d of gym-1. Gym-1 and gym-2 treadmill exercise was performed at an intensity that equated to the penultimate testing stage of exECG, and RPE and heart rate were compared at this level between the three sessions of testing. The mean work rate at the penultimate testing stage of the exECG was 6.0 +/- 1.0 metabolic equivalents; approximately 67% of peak work rate. The RPE at this work rate during exECG, gym-1 and gym-2 were 15.8 +/- 2.7, 13.3 +/- 3.4 and 13.0 +/- 3.6, respectively. A repeated measures ANOVA revealed these RPE responses to be significantly different (F (2, 20) = 9.8; p = 0.001). Post-hoc Bonferroni-corrected pairwise t-tests showed significant differences (p < or = 0.008) between exECG and gym-1 and exECG and gym-2 but not between gym-1 and gym-2. There was no significant difference in heart rate between the three testing sessions (p = 0.076) but it showed signs of a similar trend to RPE. The intra-participant agreement in RPE between gym-1 and gym-2 was substantial; intraclass correlation coefficient (ICC(2,1)) = 0.85 (p < 0.001) and in all but one participant, RPE differed by < or =2 scale points. The RPE responses during standardised exECG treadmill testing, in patients soon after MI, are inflated compared to responses at the same treadmill work rate during subsequent cardiac rehabilitation exercise sessions. Caution is advised in using RPE taken from an initial exECG to guide physical activity in MI patients, but introducing RPE at this point contributes to its subsequent reliable use.

Depression, constructive thinking and patient satisfaction in cardiac treatment adherence

Many patients fail to adhere to prescribed treatment regimens, particularly patients who are depressed. This study examined the link between depression and adherence among 92 patients undergoing post-operative cardiac rehabilitation. Self-reported adherence was measured in terms of both general recommendations and specific health behaviours. Greater depression was associated with general - but not specific - adherence, and this relationship was mediated by lower satisfaction with their doctor - patient interactions. The link between depression and patient satisfaction was itself mediated by less constructive thinking among patients. These results suggest that adherence among cardiac rehabilitation patients may be enhanced by addressing patients' cognitive coping, and by improving the quality of their doctor - patient interactions.

Toward a New Payment System for Inpatient Rehabilitation

BACKGROUND

The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment.

OBJECTIVES

We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855).

RESEARCH DESIGN

We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis.

RESULTS

We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions.

CONCLUSION

For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

The case for early statin therapy in acute coronary syndromes

Three large secondary prevention studies have shown that, in patients with a history of cardiovascular disease, statin treatment reduces the risk of further events and lowers overall mortality. In these studies, total mortality was reduced by as much as 30% in high-risk groups and 22% in average-risk groups. However, these studies did not include patients immediately after the coronary event. There are many benefits to early intervention with statin therapy in patients with acute coronary syndromes, including reduction of the risk of a subsequent event, which is highest immediately after the index event. Early treatment may reduce this likelihood in the first months after a coronary event by stabilizing atherosclerotic plaques and improving endothelial function in addition to lowering low-density lipoprotein cholesterol levels. This article reviews the case for early statin therapy in patients with a history of coronary heart disease. Results of clinical studies have now shown early statin therapy to be safe and cost-effective in reducing in-hospital and 6-month mortality.

Evidence for the benefit of early intervention with pravastatin for secondary prevention of cardiovascular events

Treatment with HMG-CoA reductase inhibitors (or statins) lowers total and LDL cholesterol and decreases the risk of cardiovascular events. The absolute benefits are greater in patients with a higher baseline cardiovascular risk, so statins are particularly suited to secondary prevention. Although three large studies have shown convincingly that, in patients with a history of cardiovascular disease, simvastatin or pravastatin treatment reduces the risk of further events and lowers overall mortality, those studies have not included patients in the period immediately after an acute coronary event. They are, therefore, of limited value in answering the question of when to start statin treatment. However, there are practical reasons for starting statin treatment as early as possible, and results of clinical studies have now shown this to be a safe option for pravastatin. Early treatment with pravastatin can stabilize coronary atherosclerosis and improve endothelial function. More importantly, there is also evidence that early treatment with pravastatin can produce a clinical benefit a few months after the initial coronary event.

Factors associated with work resumption: a 5 year follow-up with cardiac patients

Physiological and psychological parameters of 41 cardiac patients who retired after an inpatient rehabilitation treatment in Germany were compared with those of 41 patients (matched exactly according to sex, age, and diagnosis) who worked after a 5 year follow-up. Both samples were selected from a large pool of 733 consecutive cardiac patients participating in the rehabilitation program with follow-ups at 1, 3 and 5 years. The following physiological parameters were assessed: clinical characteristics such as biochemical variables and functional parameters of the left ventricle, performance and electrocardiogram during ergometric exercise, and medication. Psychological parameters assessed with questionnaires comprised: life satisfaction, physical complaints, and illness behavior, socioeconomic and anamnestic data. No substantial differences were observed for medical data, but psychological parameters showed striking differences. Retired patients were characterized by lower work satisfaction, complaints of being more handicapped by the disease, higher 'propensity for pension', more frequent complaints concerning their general state of health, and lower education level.

Cardiac rehabilitation programs and the problem of patient dropout

As one of the leading causes of death in the United States, coronary atherosclerotic heart disease (CAHD) has been shown to have a reduced incidence if the principles of primary prevention are instituted to reduce cardiac risk factors. In people who already suffer from CAHD, employing secondary prevention such as controlling hypertension, reducing serum lipid levels, eliminating nicotine intake, reducing stress, losing weight, and increasing exercise habits can decrease recurrence of problems related to CAHD. Cardiac rehabilitation programs are a way to help CAHD patients restore optimal medical, physiological, psychological, social, and vocational performance following an acute cardiac event. A major problem in cardiac rehabilitation programs is patient dropout. For any cardiac rehabilitation program to be a success, the CAHD patient must become invested in the maintenance of health and, therefore, committed to participation in the program. The author reviews the current literature, including discussions of the history of cardiac rehabilitation, current trends in cardiac rehabilitation programs, factors that influence patients' investment in these programs, and ways in which the cardiac rehabilitation nurse might intervene to make an impact on patients' participation.

Evaluation of a home-based rehabilitation programme for patients recovering from acute myocardial infarction

There is substantial evidence of the importance of rehabilitation for patients recovering from acute myocardial infarction in reducing mortality, morbidity, and psychological distress. The aim of this study was to compare a recently established home-based coronary rehabilitation programme in a coronary care unit (CCU) with the provision of a selection of information leaflets commonly provided for patients after their myocardial infarction. A comparative study was carried out between two randomly allocated groups of patients receiving either the Heart Manual rehabilitation programme (n = 17) or general advice and information booklets (n = 17), with follow-up at 1, 3 and 6 weeks after discharge for both groups. Questionnaire measurements included anxiety and depression (HAD score), general practitioner (GP) visits, and patients' perception of their confidence of recovery and progress. The findings show that patients receiving the Heart Manual had significantly higher scores in their confidence of recovery and perception of their progress than the group receiving booklets. The Heart Manual group showed improved levels of anxiety with unchanged scores in depression, while patients receiving the booklets experienced increased depression with little change in their anxiety levels. These results help to provide guidance for health care professionals on a form of rehabilitation which is effective for patients and their families in hospital and within the community.