Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Digitization and health inequality and equity in nursing

Background: The use of information and communication technologies (ICT) in health care is increasing attention. To describe health inequalities and equity with regard to the use of digital health technologies in a care context and to understand interrelationships, it is of particular importance for the field of care research to use models and theories that explain health inequalities and equity in the use of digital technologies. Aims: This article aims to identify models and theories from the field of nursing and health research that explain the phenomenon of health inequalities and the influence of digital health technologies on the emergence of inequalities. Methods: Relevant articles were searched in electronic databases (MEDLINE, CINAHL & SocINDEX) between July and August 2019 in German and English, within the methodological framework of a scoping review. The systematic literature search and data extraction were performed by 2 reviewers. The description of data refers to standard criteria by 8-1Christiansen and Baum (1997). Results: From a total of 25 relevant articles, 2 were identified for inclusion in the current overview. One model is focusing on ICT for health and the other model focuses on eHealth. No nursing theory could be identified in the context of describing the phenomenon of digital inequality. Conclusions: In both models, there is a lack of discussion about the impact of nursing aspects on the use and acceptance of eHealth technologies. One point should also be the development of models and theories that consider the user perspective of vulnerable groups.

Behavior change techniques for increasing physical activity in cancer survivors: a systematic review and meta-analysis of randomized controlled trials

Purpose

The purpose of this systematic review and meta-analysis is to investigate how physical activity (PA) can be effectively promoted in cancer survivors. The effect of PA-promoting interventions in general, behavior change techniques (BCTs), and further variables as moderators in particular are evaluated.

Methods

This study included randomized controlled trials of lifestyle interventions aiming at an increase in PA that can be carried out independently at home, published by December 2016, for adults diagnosed with cancer after completion of the main treatment. Primary outcomes were subjective and objective measures of PA prior to and immediately after the intervention. Meta-analysis and meta-regression were used to estimate effect sizes (ES) in terms of standardized mean differences, variation between ES in terms of heterogeneity indices (I²), and moderator effects in terms of regression coefficients.

Results

This study included 30 studies containing 45 ES with an overall significant small positive effect size of 0.28 (95% confidence interval=0.18–0.37) on PA, and I²=54.29%. The BCTs Prompts, Reduce prompts, Graded tasks, Non-specific reward, and Social reward were significantly related to larger effects, while Information about health consequences and Information about emotional consequences, as well as Social comparison were related to smaller ES. The number of BCTs per intervention did not predict PA effects. Interventions based on the Theory of Planned Behavior were associated with smaller ES, and interventions with a home-based setting component were associated with larger ES. Neither the duration of the intervention nor the methodological quality explained differences in ES.

Conclusion

Certain BCTs were associated with an increase of PA in cancer survivors. Interventions relying on BCTs congruent with (social) learning theory such as using prompts and rewards could be especially successful in this target group. However, large parts of between-study heterogeneity in ES remained unexplained. Further primary studies should directly compare specific BCTs and their combinations.

Longitudinal randomised controlled trials in rehabilitation post-stroke: a systematic review on the quality of reporting and use of baseline outcome values

Background

The World Health Organisation stresses the need to collect high quality longitudinal data on rehabilitation and to improve the comparability between studies. This implies using all the information available and transparent reporting. We therefore investigated the quality of reported or planned randomised controlled trials on rehabilitation post-stroke with a repeated measure of physical functioning, provided recommendations on the presentation of results using regression parameters, and focused on the difficulties of adjustment for baseline outcome measures.

Methods

We performed a systematic review of the literature from 2011 to 2013 and collected information on the way data was analysed. Moreover we described various approaches to analyse the data using mixed models illustrated with real data.

Results

Eighty-four eligible studies were identified of which 61 % (51/84) failed to analyse the data longitudinally. Moreover, for 30 % (25/83) the method for adjustment for baseline is not known or not existent. Using real data we were able to show how much difference in results an adjustment for baseline data can make. We showed how to provide interpretable intervention effects using regression coefficients while making use of all the information available in the data.

Conclusions

Our review showed that improvements were needed in the analysis of longitudinal trials in rehabilitation post-stroke in order to maximise the use of collected data and improve comparability between studies. Reporting fully the method used (including baseline adjustment) and using methods like mixed models could easily achieve this.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0344-y) contains supplementary material, which is available to authorized users.

[Data protection in rehabilitation research]

Data protection is regulated by legislation and has to be adhered to by scientists, too. This overview shows where aspects of data protection have to be considered in rehabilitation research. Important legal sources are the code of social law X, the German Federal Data Protection Act and the data protection acts of the German states. Specific recommendations about patient information sheet and written informed consent are given for research based on interviews with study participants. Furthermore, operations such as collecting, processing, using, storing, publishing and archiving of personal data are explained, taking into account the requirements of data protection. A practical example (URL: www.thieme-connect.de/ejournals/toc/rehabilitation) shows how to separate personal data and research data using the services of an external data custodian.