Post-sternotomy movement strategies in adults: a scoping review

AIMS

Post-sternotomy movement strategies for adults should be an evidence-informed approach and support a safe, independent return to daily activity. Recent new movement strategies have emerged. The aim of this scoping review was to identify and summarize the available evidence for post-sternotomy movement strategies in adults.

METHODS AND RESULTS

The electronic databases searched included MEDLINE, Embase, Sport Discus, CINAHL, Academic Search Complete, the Cochrane Library, Scopus, and PEDro. The search did not have a date limit. After 2405 duplicates were removed, 2978 records were screened, and 12 were included; an additional 2 studies were identified through reference searching for a total of 14 included studies. A data extraction table was used, and the findings are summarized in a tabular and narrative form. Three post-sternotomy movement strategies were identified in the literature: sternal precautions (SP), modified SP, and Keep Your Move in the Tube (KYMITT™). The authors suggested that the practice of SP was based on expert opinion and not founded in evidence. However, the evidence from the identified articles suggested that new movement strategies are safe and allow patients to choose an increased level of activity that promotes improved functional status and confidence.

CONCLUSION

More prospective cohort studies and multi-centred randomized control trials are needed; however, the current evidence suggests that modified SP and KYMITT™ are as safe as SP and can promote a patient-centred approach.

REGISTRATION

University of Calgary's Digital Repository PRISM http://hdl.handle.net/1880/115439.

An Integrative Review of Patient Education During Inpatient Hematopoietic Stem Cell Transplantation

PROBLEM IDENTIFICATION

Patients undergoing hematopoietic stem cell transplantation (HSCT) have significant learning needs that nurses must provide. The review question was "What teaching methods and strategies have been examined to deliver education to patients undergoing HSCT?"

LITERATURE SEARCH

The review was conducted in November 2022 using the following databases: Scopus®, Embase®, MEDLINE®, CINAHL®, PsycINFO®, and ERIC. The search comprised two main concepts: HSCT and patient education.

DATA EVALUATION

The search yielded 1,458 records after duplicates were removed, and 3 studies were included in this review. The studies were critically appraised using the Mixed Methods Appraisal Tool and deemed to be of moderate quality.

SYNTHESIS

Problem-solving training was the teaching method used in all three studies. Satisfaction was noted among patients and those delivering the intervention. The effect of the training on information retention or application was not measured.

IMPLICATIONS FOR PRACTICE

Additional research is needed to explore how to best educate patients undergoing HSCT while hospitalized. Structured teaching methods may have a sound theoretical basis and warrant additional investigation using more rigorous research methods.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study

Background

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making.

Objective

To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection.

Design

Qualitative descriptive study.

Setting

Five outpatient hemodialysis centers in Calgary, Alberta.

Participants

Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists).

Methods

We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective.

Results

While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers.

Limitations

Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study.

Conclusions

Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Patient and Clinician Perspectives on Shared Decision Making in Vascular Access Selection: A Qualitative Study

RATIONALE & OBJECTIVE

Collaborative approaches to vascular access selection are being increasingly encouraged to elicit patients' preferences and priorities where no unequivocally superior choice exists. We explored how patients, their caregivers, and clinicians integrate principles of shared decision making when engaging in vascular access discussions.

STUDY DESIGN

Qualitative description.

SETTING & PARTICIPANTS

Semistructured interviews with a purposive sample of patients, their caregivers, and clinicians from outpatient hemodialysis programs in Alberta, Canada.

ANALYTICAL APPROACH

We used a thematic analysis approach to inductively code transcripts and generate themes to capture key concepts related to vascular access shared decision making across participant roles.

RESULTS

42 individuals (19 patients, 2 caregivers, 21 clinicians) participated in this study. Participants identified how access-related decisions follow a series of major decisions about kidney replacement therapy and care goals that influence vascular access preferences and choice. Vascular access shared decision making was strengthened through integration of vascular access selection with dialysis-related decisions and timely, tailored, and balanced exchange of information between patients and their care team. Participants described how opportunities to revisit the vascular access decision before and after dialysis initiation helped prepare patients for their access and encouraged ongoing alignment between patients' care priorities and treatment plans. Where shared decision making was undermined, hemodialysis via a catheter ensued as the most readily available vascular access option.

LIMITATIONS

Our study was limited to patients and clinicians from hemodialysis care settings and included few caregiver participants.

CONCLUSIONS

Findings suggest that earlier, or upstream, decisions about kidney replacement therapies influence how and when vascular access decisions are made. Repeated vascular access discussions that are integrated with other higher-level decisions are needed to promote vascular access shared decision making and preparedness.

The availability of support and peritoneal dialysis survival: A cohort study

BACKGROUND

Providing support is important to maintain a patient on peritoneal dialysis (PD), though its impact on outcomes has not been investigated thoroughly. We examined the association between having support and risk of a transfer to hemodialysis.

METHODS

In this retrospective observational cohort study, we used data captured in the Dialysis Measurement Analysis and Reporting system about patients who started PD in Alberta, Canada, between 1 January 2013 and 30 September 2018. Support was defined as the availability of a support person in the home who was able, willing and available to provide support for PD in the patient's residence. The outcome of interest was a transfer to hemodialysis for at least 90 days. We estimated the cumulative incidence of a transfer over time accounting for competing risks and hazard ratios to summarise the association between support and a transfer. We split follow-up time as hazard ratios varied over time.

RESULTS

Six hundred and eighty-three incident PD patients, median age 58 years (IQR: 47-68) and 35% female, were followed for a median of 15 months. The cumulative incidence of a transfer to hemodialysis at 24 months was 26%. Having support was associated with a reduced risk of a transfer between 3 and 12 months after the start of dialysis (HR_3-12mo: 0.44; 95% CI: 0.25-0.78), but not earlier (hazard ratio (HR)_<3mo: 0.96; 95% confidence interval (CI): 0.55-1.69) or later (HR_>12mo: 1.19; 95% CI: 0.65-2.17).

CONCLUSIONS

A transfer to hemodialysis is common. Having a support person at home is associated with a short-term protective effect after the initiation of PD.

A systematic review of yoga interventions for helping health professionals and students

Helping Health Professionals (HHP) and HHP students are among the highest risk occupational groups for compromised mental and physical health. There is a paucity of information regarding preventive interventions for mental and physical health in this group of healthcare providers.

OBJECTIVE

The objective of this review was to examine the effectiveness of yoga interventions for the prevention and reduction of mental and physical disorders among HHPs and HHP students.

DESIGN

An exhaustive systematic search was conducted in May 2020. Databases searched in the OVID interface included: MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Embase, and PsycINFO. EbscoHost databases searched included: CINAHL Plus with Full Text, SPORTDiscus with Full Text, Alt HealthWatch, Education Research Complete, SocINDEX with Full Text, ERIC, and Academic Search Complete. Scopus was also searched.

RESULTS

The search yielded 4,973 records, and after removal of duplicates 3197 records remained. Using inclusion and exclusion criteria, titles and abstracts were screened and full text articles (n = 82) were retrieved and screened. Twenty-five studies were identified for inclusion in this review. Most frequently reported findings of yoga interventions in this population included a reduction in stress, anxiety, depression, and musculoskeletal pain.

CONCLUSION

It is our conclusion that mental and physical benefits can be obtained through implementation of yoga interventions for HHPs and HHP students across a variety of settings and backgrounds. However, researchers would benefit from following recommended guidelines for the design and reporting of yoga interventions to improve study quality and rigour.

The implementation of correctional nursing practice-Caring behind bars: A grounded theory study

AIM

To understand how registered nurses implement their nursing practice in correctional institutions with healthcare governance by a health authority (e.g. Ministry of Health).

DESIGN

Straussian grounded theory.

METHODS

Simultaneous data collection and analysis were undertaken using theoretical sampling, constant comparison and memo writing. Thirteen registered nurses engaged in semi-structured telephone interviews about implementing their correctional nursing practice including, providing direct care to adult offenders. Data were collected (December 2018 to October 2019) until saturation occurred. Analytic coding (open, axial and final theoretical integration) was performed to identify the core category and subcategories around which the substantive theory was developed.

RESULTS

The theory of Caring Behind Bars refers to the process of how registered nurses implemented their correctional nursing practice to care for offenders. The core category of Caring Behind Bars is comprised of five subcategories: tension between custody and caring, adaptability and advocacy, offender population, provision of care, and challenging and positive elements.

CONCLUSION

Caring Behind Bars required registered nurses to address tension between custody and caring by adapting and advocating to access offenders. The provision of care required registered nurses to use assessment skills and numerous resources to provide a variety of patient focused care to offenders. The consequences of Caring Behind Bars had challenging and positive elements.

IMPACT

The tension provides purposeful space to continue improving teamwork among correctional officers and registered nurses. More research is required about the impact of correctional healthcare governance models on professional practice and health outcomes. Frontline registered nurses can use the theory to make informed choices when providing care. Registered nurses practising in other domains of correctional nursing (i.e. administration, education and research) can also use this theory to advance and inform practice with the goal of promoting offender health.

Social Support in the Peritoneal Dialysis Experience: A Qualitative Descriptive Study

Background:

People with end-stage kidney disease can either pursue conservative (palliative) management or kidney replacement therapy. Although transplant is preferred, there is a limited number of organs available rendering the majority of patients treated with some form of dialysis. Hemodialysis and peritoneal dialysis are equivalent regarding clinical outcomes, but peritoneal dialysis is much less costly to provide. Peritoneal dialysis is most often done in the home by the patient or a support person and carries a self-care burden on patients and families. Social support is important for patients receiving peritoneal dialysis and in sustaining peritoneal dialysis therapy. Few studies have comprehensively explored social support in the context of peritoneal dialysis.

Objective:

To explore how patients, family members, and nurses view social support.

Design:

Qualitative, descriptive study.

Setting:

An outpatient peritoneal dialysis clinic in Western Canada.

Participants:

Patients, family members, and nurses.

Methods:

Patients (n = 15), family members (n = 6), and nurses (n = 11) were interviewed between January and May 2018. Content analysis was undertaken using 4 attributes of social support (ie, emotional support, instrumental support, informational support, and appraisal support) as an analytic framework.

Results:

Themes related to the 4 attributes of social support were identified: addressing emotional needs and managing emotion (emotional support); peritoneal dialysis tasks and life tasks (instrumental support); accessing information, receiving information, and learning (informational support); and affirmation/external reassurance and self-confidence (appraisal support). The social support needs of both patients and family members varied and were dependent on their existing support networks and individual perspectives of support.

Limitations:

It is possible that some of the study findings were gender-bound as well as context-specific. The study findings could be different if the patient and caregiver sample were more balanced based on sex. There are also unique attributes of each peritoneal dialysis program that may impact the transferability of these findings to other practice settings.

Conclusion:

Home-based peritoneal dialysis has potential benefit to patients and health care systems. However, receiving peritoneal dialysis requires support. If health care providers wish to promote this treatment, they must also understand how to best support patients and their family members.

Trial Registration:

Not applicable.

"In the tube" following sternotomy: A quasi-experimental study

BACKGROUND

Traditionally, physical movement has been limited for cardiac surgery patients, up to 12-weeks post-operatively. Patients are asked to use "standard sternal precautions," restricting their arm movement, and thereby limiting stress on the healing sternum.

AIM

To compare return to function, pain/discomfort, wound healing, use of pain medication and antibiotics, and post-operative length of hospital stay in cardiac surgery patients having median sternotomy who used standard sternal precautions or Keep Your Move in the Tube movement protocols post-operatively.

METHODS

A quasi-experimental design was used (100 standard sternal precautions and 100 Keep Your Move in the Tube patients). Patients were followed in person or by telephone over a period of 12-weeks postoperatively. Outcomes were measured at day 7, as well as weeks 4, 8, and 12 weeks.

RESULTS

The majority of participants (77% in each group) were male and had coronary artery bypass graft surgery (66% standard sternal precautions and 72% Keep Your Move in the Tube). Univariate analysis revealed the standard sternal precautions group had lesser ability to return to functional activities than the Keep Your Move in the Tube group (p<0.0001) over time. This difference was minimized however, by week 12. Multivariate analysis revealed that increasing age, body mass index, and female sex were associated with greater functional impairment over time, but no difference between standard sternal precautions and Keep Your Move in the Tube groups.

CONCLUSIONS

Keep Your Move in the Tube, a novel patient-oriented movement protocol, has potential for cardiac surgery patients to be more confident and comfortable in their recovery.

Development of a Culturally Tailored Motivational Interviewing-Based Intervention to Improve Medication Adherence in South Asian Patients

BACKGROUND

South Asians (SAs) are among the fastest growing ethnic population in Western countries and have a higher risk of cardiovascular diseases relative to the general population. SAs living in Canada also have poorer adherence to medical regimens for treating cardiovascular disease, relative to other ethnic groups. Motivational interviewing (MI) maybe effective in improving health-related behaviour change in patients; however, the research is nascent on the effectiveness of MI in SAs and may also require cultural adaptation.

AIM

To develop a culturally tailored MI-based intervention to improve medication adherence in hypertensive SA patients living in Canada.

METHODS

Previous literature about medication adherence in SAs was reviewed, along with transcripts and responses to open-ended survey questions from our previous studies with SAs, to draft an MI intervention manual. The manual received extensive feedback from the study team, SA community members and health-care providers who work with SA patients. The feedback was used to refine the manual and make it culturally tailored and relevant to SA hypertensive patients living in Canada.

RESULTS

A culturally tailored MI-based manual which we called a "motivational communication manual" was developed to support a study focused on improving medication adherence in SA hypertensive patients. The development process, components (eg, being culturally sensitive, family involvement, providing education about medications, reminders, etc.) and cultural nuances included in the manual are described in this paper.

CONCLUSION

This is the first culturally tailored MI-based intervention manual that has been developed with the aim of improving medication adherence in hypertensive SA patients and that includes direct feedback from SA community members. Use of this manual may improve the accessibility and adoption of MI-based practices in improving health behaviours in SAs living in Canada as well as encourage further research studies and clinical trials with SA patients.

The Burden of Atherosclerotic Cardiovascular Disease in South Asians Residing in Canada: A Reflection From the South Asian Heart Alliance

South Asians (SAs), originating from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan), represent one quarter of the global population and are the largest visible minority in Canada. SAs experience the highest rates of coronary artery disease in Canada. Although conventional cardiovascular risk factors remain predictive in SA, the excess risk is not fully explained by these risk factors alone. Abdominal obesity, metabolic syndrome, and insulin resistance likely contribute a greater risk in SAs than in other populations. The South Asian Heart Alliance has been recently formed to investigate and recommend the best strategies for the prevention of cardiometabolic disease in SAs in Canada. This topic review represents a comprehensive overview of the magnitude of cardiovascular disease in SAs in Canada, with a review of conventional and novel risk markers in the SA population. Both primary and secondary prevention strategies are suggested and when possible, adapted specifically for the SA population. The need for SAs and their healthcare professionals to be more aware of the problem and potential solutions, along with the need for population-specific research, is highlighted.

South Asians' experience of managing hypertension: a grounded theory study

OBJECTIVE

We examined the process that South Asians undergo when managing their hypertension (HTN).

METHOD

Using grounded theory methods, 27 community-dwelling English-, Punjabi-, or Hindi-speaking South Asian participants (12 men and 15 women), who self-identified as having HTN were interviewed. Transcripts were analyzed using constant comparison.

RESULTS

The core category was "fitting it in". First, the participants assessed their diagnosis and treatment primarily in the context of their current family/social environment. Participants who paid attention to their diagnosis either fully or partly embraced activities and attitudes associated with successful management of hypertension. However, those who did not attend to their diagnosis, identified other familial/social factors, stress of immigration, and not having symptoms of their disease as barriers. The longer the time since diagnosis of HTN, the more participants came to appropriately manage their HTN.

CONCLUSION

Healthcare providers may use this information to enhance their cultural understanding of how and why South Asians manage their HTN.

The evaluation of a brief motivational intervention to promote intention to participate in cardiac rehabilitation: A randomized controlled trial

OBJECTIVES

Cardiac rehabilitation (CR) is an effective treatment for cardiovascular disease, yet many referred patients do not participate. Motivational interviewing could be beneficial in this context, but efficacy with prospective CR patients has not been examined. This study investigated the impact of motivational interviewing on intention to participate in CR.

METHODS

Individuals recovering from acute coronary syndrome (n = 96) were randomized to motivational interviewing or usual care, following CR referral but before CR enrollment. The primary outcome was intention to attend CR. Secondary outcomes included CR beliefs, barriers, self-efficacy, illness perception, social support, intervention acceptability, and CR participation.

RESULTS

Compared to those in usual care, patients who received the motivational intervention reported higher intention to attend CR (p = .001), viewed CR as more necessary (p = .036), had fewer concerns about exercise (p = .011), and attended more exercise sessions (p = .008). There was an indirect effect of the intervention on CR enrollment (b = 0.45, 95% CI 0.04-1.18) and CR adherence (b = 2.59, 95% CI 0.95-5.03) via higher levels of intention. Overall, patients reported high intention to attend CR (M = 6.20/7.00, SD = 1.67), most (85%) enrolled, and they attended an average of 65% of scheduled CR sessions.

CONCLUSION

A single collaborative conversation about CR can increase both intention to attend CR and actual program adherence.

PRACTICE IMPLICATIONS

The findings will inform future efforts to optimize behavioral interventions to enhance CR participation.

Exploring structural barriers to diabetes self-management in Alberta First Nations communities

BACKGROUND

Type 2 diabetes is highly prevalent in Canadian First Nations (FN) communities. FN individuals with diabetes are less likely to receive guideline recommended care and access specialist care. They are also less likely to be able to engage in optimal self-management behaviours. While the systemic and racial contributors to this problem have been well described, individuals' experiences with structural barriers to care and self-management remain under-characterized.

METHODS

We utilized qualitative methods to gain insight into the structural barriers to self-management experienced by FN individuals with diabetes. We conducted a qualitative descriptive analysis of a subcohort of patients with diabetes from FN communities (n = 5) from a larger qualitative study. Using detailed semi-structured telephone interviews, we inquired about participants' diabetes and barriers to diabetes self-management. Inductive thematic analysis was performed in duplicate using NVivo 10.

RESULTS

The structural barriers faced by this population were substantial yet distinct from those described by non-FN individuals with diabetes. For example, medication costs, which are usually cited as a barrier to care, are covered for FN persons with status. The barriers to diabetes self-management that were commonly experienced in this cohort included transportation-related difficulties, financial barriers to uninsured health services, and lack of accessible diabetes education and resultant knowledge gaps.

CONCLUSIONS

FN Albertans with diabetes face a myriad of barriers to self-management, which are distinct from the Non-FN population. In addition to the barriers introduced by colonialism and historical injustices, finances, geographic isolation, and lack of diabetes education each impede optimal management of diabetes. Programs targeted at addressing FN-specific barriers may improve aspects of diabetes self-management in this population.

Financial barriers and adverse clinical outcomes among patients with cardiovascular-related chronic diseases: a cohort study

BACKGROUND

Some patients with cardiovascular-related chronic diseases such as diabetes and heart disease report financial barriers to achieving optimal health. Previous surveys report that the perception of having a financial barrier is associated with self-reported adverse clinical outcomes. We sought to confirm these findings using linked survey and administrative data to determine, among patients with cardiovascular-related chronic diseases, if there is an association between perceived financial barriers and the outcomes of: (1) disease-related hospitalizations, (2) all-cause mortality and (3) inpatient healthcare costs.

METHODS

We used ten cycles of the nationally representative Canadian Community Health Survey (administered between 2000 and 2011) to identify a cohort of adults aged 45 and older with hypertension, diabetes, heart disease or stroke. Perceived financial barriers to various aspects of chronic disease care and self-management were identified (including medications, healthful food and home care) from the survey questions, using similar questions to those used in previous studies. The cohort was linked to administrative data sources for outcome ascertainment (Discharge Abstract Database, Canadian Mortality Database, Patient Cost Estimator). We utilized Poisson regression techniques, adjusting for potential confounding variables (age, sex, education, multimorbidity, smoking status), to assess for associations between perceived financial barriers and disease-related hospitalization and all-cause mortality. We used gross costing methodology and a variety of modelling approaches to assess the impact of financial barriers on hospital costs.

RESULTS

We identified a cohort of 120,752 individuals over the age of 45 years with one or more of the following: hypertension, diabetes, heart disease or stroke. One in ten experienced financial barriers to at least one aspect of their care, with the two most common being financial barriers to accessing medications and healthful food. Even after adjustment, those with at least one financial barrier had an increased rate of disease-related hospitalization and mortality compared to those without financial barriers with adjusted incidence rate ratios of 1.36 (95% CI: 1.29-1.44) and 1.24 (1.16-1.32), respectively. Furthermore, having a financial barrier to care was associated with 30% higher inpatient costs compared to those without financial barriers.

DISCUSSION

This study, using novel linked national survey and administrative data, demonstrates that chronic disease patients with perceived financial barriers have worse outcomes and higher resource utilization, corroborating the findings from prior self-report studies. The overall exposure remained associated with the primary outcome even in spite of adjustment for income. This suggests that a patient's perception of a financial barrier might be used in clinical and research settings as an additional measure along with standard measures of socioeconomic status (ie. income, education, social status).

CONCLUSIONS

After adjusting for relevant covariates, perceiving a financial barrier was associated with increased rates of hospitalization and mortality and higher hospital costs compared to those without financial barriers. The demonstrable association with adverse outcomes and increased costs seen in this study may provide an impetus for policymakers to seek to invest in interventions which minimize the impact of financial barriers.

Prevalence of Barriers and Facilitators to Enhancing Conservative Kidney Management for Older Adults in the Primary Care Setting

BACKGROUND AND OBJECTIVES

Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m2) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method.

RESULTS

Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively).

CONCLUSIONS

We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.

Development of a conceptual framework for understanding financial barriers to care among patients with cardiovascular-related chronic disease: a protocol for a qualitative (grounded theory) study

BACKGROUND

Patients with cardiovascular-related chronic diseases may face financial barriers to accessing health care, even in Canada, where universal health care insurance is in place. No current theory or framework is adequate for understanding the impact of financial barriers to care on these patients or how they experience financial barriers. The overall objective of this study is to develop a framework for understanding the role of financial barriers to care in the lives of patients with cardiovascular-related chronic diseases and the impact of such barriers on their health.

METHODS

We will perform an inductive qualitative grounded theory study to develop a framework to understand the effect of financial barriers to care on patients with cardiovascular-related chronic diseases. We will use semistructured interviews (face-to-face and telephone) with a purposive sample of adult patients from Alberta with at least 1 of hypertension, diabetes, heart disease or stroke. We will analyze interview transcripts in triplicate using grounded theory coding techniques, including open, focused and axial coding, following the principle of constant comparison. Interviews and analysis will be done iteratively to theoretical saturation. Member checking will be used to enhance rigour.

INTERPRETATION

A comprehensive framework for understanding financial barriers to accessing health care is instrumental for both researchers and clinicians who care for patients with chronic diseases. Such a framework would enable a better understanding of patient behaviour and nonadherence to recommended medical therapies and lifestyle modifications.

Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with type 2 diabetes mellitus: a population-based cohort study

AIM

To determine the prescribing of and adherence to oral hypoglycaemic agents, insulin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statin therapy among South-Asian, Chinese and white people with newly diagnosed diabetes.

METHODS

The present study was a population-based cohort study using administrative and pharmacy databases to include all South-Asian, Chinese and white people aged ≥ 35 years with diabetes living in British Columbia, Canada (1997-2006). Adherence to each class of medication was measured using proportion of days covered over 1 year with optimum adherence defined as ≥ 80%.

RESULTS

The study population included 9529 South-Asian, 14 084 Chinese and 143 630 white people with diabetes. The proportion of people who were prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statin or oral hypoglycaemic agents was ≤ 50% for all groups. South-Asian and Chinese people had significantly lower adherence for all medications than white people, with the lowest adherence to angiotensin-converting enzyme inhibitor treatment (South-Asian people: adjusted odds ratio 0.37, 95% CI 0.34-0.39; P<0.0001; Chinese people: adjusted odds ratio 0.50, 95% CI 0.47-0.54; P<0.0001) and statin therapy (South-Asian people: adjusted odds ratio 0.47, 95% CI 0.41 - 0.53, P < 0.0001; Chinese people: adjusted odds ratio 0.72, 95% CI 0.67 - 0.77; P<0.0001) compared with white people.

CONCLUSION

Adherence to evidence-based pharmacotherapy was substantially worse among the South-Asian and Chinese populations. Care providers need to be alerted to the high levels of non-adherence in these groups and the underlying causes need to be investigated.

Comparison of sampling methods for hard-to-reach francophone populations: yield and adequacy of advertisement and respondent-driven sampling

BACKGROUND

Francophones who live outside the primarily French-speaking province of Quebec, Canada, risk being excluded from research by lack of a sampling frame. We examined the adequacy of random sampling, advertising, and respondent-driven sampling for recruitment of francophones for survey research.

METHODS

We recruited francophones residing in the city of Calgary, Alberta, through advertising and respondentdriven sampling. These 2 samples were then compared with a random subsample of Calgary francophones derived from the 2006 Canadian Community Health Survey (CCHS). We assessed the effectiveness of advertising and respondent-driven sampling in relation to the CCHS sample by comparing demographic characteristics and selected items from the CCHS (specifically self-reported general health status, perceived weight, and having a family doctor).

RESULTS

We recruited 120 francophones through advertising and 145 through respondent-driven sampling; the random sample from the CCHS consisted of 259 records. The samples derived from advertising and respondentdriven sampling differed from the CCHS in terms of age (mean ages 41.0, 37.6, and 42.5 years, respectively), sex (proportion of males 26.1%, 40.6%, and 56.6%, respectively), education (college or higher 86.7% , 77.9% , and 59.1%, respectively), place of birth (immigrants accounting for 45.8%, 55.2%, and 3.7%, respectively), and not having a regular medical doctor (16.7%, 34.5%, and 16.6%, respectively). Differences were not tested statistically because of limitations on the analysis of CCHS data imposed by Statistics Canada.

INTERPRETATION

The samples generated exclusively through advertising and respondent-driven sampling were not representative of the gold standard sample from the CCHS. Use of such biased samples for research studies could generate misleading results.

The influence of ethnicity and gender on navigating an acute coronary syndrome event

BACKGROUND

Ethnicity and gender may influence acute coronary syndrome patients recognizing symptoms and making the decision to seek care.

OBJECTIVE

To examine these potential differences in European (Caucasian), Chinese and South Asian acute coronary syndrome patients.

METHODS

In-depth interviews were conducted with 20 European (Caucasian: 10 men/10 women), 18 Chinese (10 men/eight women) and 19 South Asian (10 men/nine women) participants who were purposively sampled from those participating in a large cohort study focused on acute coronary syndrome. Analysis of transcribed interviews was undertaken using constant comparative methods.

RESULTS

Participants followed the process of: having symptoms; waiting/denying; justifying; disclosing/ discovering; acquiescing; taking action. The core category was 'navigating the experience'. Certain elements of this process were in the forefront, depending on participants' ethnicity and/or gender. For example, concerns regarding language barriers and being a burden to others varied by ethnicity. Women's tendency to feel responsibility to their home and family negatively impacted the timeliness in their decisions to seek care. Men tended to disclose their symptoms to receive help, whereas women often waited for their symptoms to be discovered by others. Finally, the thinking that symptoms were 'not-urgent' or something over which they had no control and concern regarding potential costs to others were more prominent for Chinese and South Asian participants.

CONCLUSION

Ethnic- and gender-based differences suggest that education and support, regarding navigation of acute coronary syndrome and access to care, be specifically targeted to ethnic communities.

Gender, socioeconomic and ethnic/racial disparities in cardiovascular disease: a time for change

Cardiovascular disease (CVD) mortality rates have declined steadily over the past few decades but gender, socioeconomic and ethnic/racial disparities have not. These disparities impede cardiovascular health care reaching all those in need. The origins of disparities in CVD are numerous and wide-ranging, having largely evolved from inequalities in society. Similarly, disparities in CVD, interventions and outcomes will also vary depending on the minority or disadvantaged group. For this reason, strategies aimed at reducing such disparities must be stratified according to the target group, while keeping in mind that these groups are not mutually exclusive. There is a pressing need to move beyond what can be inferred from traditional cardiovascular risk factor profiling toward implementation of interventions designed to address the needs of these populations that will eventuate in a reduction of disparities in morbidity and mortality from CVD. This will require targeted and sustainable actions. Only by ensuring timely and equitable access to care for all through increased awareness and active participation can we start to close the gap and deliver appropriate, acceptable and just care to all, regardless of gender, socioeconomic status or ethnicity/race.

Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review

BACKGROUND

Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood.

DESIGN

We performed a systematic review using qualitative meta-synthesis.

METHODS

A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995.

RESULTS

A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging.

CONCLUSIONS

The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.

South Asians' cardiac medication adherence

AIM

This paper is a report of a narrative review examining the current state of knowledge regarding adherence with cardiac medication among South Asian cardiac patients.

BACKGROUND

South Asians experience higher rates of cardiovascular disease than any other ethnic group. South Asians may be less adherent with a cardiac medication regimen than Caucasians. The factors contributing to adherence are important to discover to assist South Asians to optimize their cardiac health.

DATA SOURCES

CINAHL, Medline (Ovid), PsychINFO, EMB Reviews-(Cochrane), and EMBASE were accessed using the key words: 'South Asian', 'Asia', 'East India', 'India', 'Pakistan', 'Bangladesh', 'Sri Lanka', 'medication compliance', 'medication noncompliance' and 'medication adherence'. English language papers published from January 1980 to January 2013 were eligible for inclusion.

REVIEW METHODS

Abstracts were reviewed for redundancy and eligibility by the primary author. Manuscripts were then retrieved and reviewed for eligibility and validity by the first and last authors. Content analysis strategies were used for the synthesis.

RESULTS

Thirteen papers were in the final data set; most were conducted in India and Pakistan. Medication side-effects, cost, forgetfulness and higher frequency of dosing contributed to non-adherence. South Asian immigrants also faced language barriers, which contributed to non-adherence. Knowledge regarding the medications prescribed was a factor that increased adherence.

CONCLUSION

South Asians' non-adherence to cardiac medications is multifaceted. How South Asians who newly immigrate to Western countries make decisions regarding their cardiac medication adherence ought to be explored in greater detail.

Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis

Background:

Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients’ decisions to participate.

Methods:

To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms.

Results:

Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients’ participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women’s experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation.

Conclusions:

Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a ‘consumer behaviour’ and interventions should mobilize family support, promote ‘patient friendly’ scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

Understanding the influence of urban- or rural-living on cardiac patients' decisions about diet and physical activity: descriptive decision modeling

BACKGROUND

It is challenging to assist people to attend to risk factors for coronary artery disease (CAD). There is potential for cultural elements associated with place of residence (i.e., urban- or rural-living) to have an effect on peoples' decision-making about managing CAD risk.

AIM

To better understand patient's decision-making processes regarding having a heart-healthy diet and engaging in regular physical activity (major CAD risk factors), and the potential influence of urban- or rural-living.

METHODS

Based on a previous series of qualitative interviews with 42 cardiac patients (21 urban-living, 21 rural-living), hierarchical decision-models regarding eating a heart-healthy diet and engaging in regular physical activity were developed, and a survey based on the decision-models generated. The models were then tested for 'fit' with another group of 42 cardiac patients, and were revised to make them more parsimonious. The final models were tested with a novel group of 647 CAD patients from Alberta, Canada (327 urban-living, 320 rural-living). The primary analysis was focused on determining the extent to which patients completing the survey fell in the correct behavioral group. Thereafter individual nodes were examined to determine decision-making constructs that were different between urban- and rural-living patients.

RESULTS

When tested, the models had overall accuracy of 93.5% for diet and 97.5% for physical activity. The most salient model nodes that led to differing behavioral outcomes reflected these constructs: perception of control over health; time, effort, or competing priorities; receipt of appropriate information; and appeal of the activity.

CONCLUSIONS

This information is potentially useful to assist healthcare providers to: (1) understand patients' decisions regarding their cardiac risk factor modification behavior, and (2) better direct conversations about risk factor modification and educational activities.

Language barriers: use of regular medical doctors by Canada's official language minorities

OBJECTIVE

To assess use of regular medical doctors (RMDs), as well as awareness and use of telephone health lines or telehealth services, by official language minorities (OLMs) in Canada.

DESIGN

Analysis of data from the 2006 postcensal survey on the vitality of OLMs.

SETTING

Canada.

PARTICIPANTS

In total, 7691 English speakers in Quebec and 12 376 French speakers outside Quebec, grouped into those who experienced language barriers and those with no language barriers.

MAIN OUTCOME MEASURES

Health services utilization (HSU) by the presence of language barriers; HSU measures included having an RMD, use of an RMD's services, and awareness of and use of telephone health lines or telehealth services. Multivariable models examined the associations between HSU and language barriers.

RESULTS

After adjusting for age and sex, English speakers residing in Quebec with limited proficiency in French were less likely to have RMDs (adjusted odds ratio [AOR] 0.66, 95% CI 0.50 to 0.87) and to use the services of their RMDs (AOR 0.65, 95% CI 0.50 to 0.86), but were more likely to be aware of the existence of (AOR 1.50, 95% CI 1.16 to 1.93) and to use (AOR 1.43, 95% CI 0.97 to 2.11) telephone health lines or telehealth services. This pattern of having and using RMDs and telehealth services was not observed for French speakers residing outside of Quebec.

CONCLUSION

Overall we found variation in HSU among the language barrier populations, with lower use observed in Quebec. Age older than 45 years, male sex, being married or in common-law relationships, and higher income were associated with having RMDs for OLMs.

Experiences of French speaking immigrants and non-immigrants accessing health care services in a large Canadian city

French speakers residing in predominantly English-speaking communities have been linked to difficulties accessing health care. This study examined health care access experiences of immigrants and non-immigrants who self-identify as Francophone or French speakers in a mainly English speaking province of Canada. We used semi-structured interviews to gather opinions of recent users of physician and hospital services (N = 26). Language barriers and difficulties finding family doctors were experienced by both French speaking immigrants and non-immigrants alike. This was exacerbated by a general preference for health services in French and less interest in using language interpreters during a medical consultation. Some participants experienced emotional distress, were discontent with care received, often delayed seeking care due to language barriers. Recent immigrants identified lack of insurance coverage for drugs, transportation difficulties and limited knowledge of the healthcare system as major detractors to achieving health. This study provided the groundwork for future research on health issues of official language minorities in Canada.

Weight and patients' decision to undergo cardiac surgery

Obese patients are less likely to have cardiac surgery than normal weight patients. This could be due to physician or patient decision-making. We undertook a qualitative descriptive study to explore the influence of obesity on patients' decision-making to have cardiac surgery. Forty-seven people referred for coronary artery bypass graft (CABG) surgery were theoretically sampled. Twelve people had declined cardiac surgery. Participants underwent in-depth interviews aimed at exploring their decision-making process. Data were analyzed using conventional content analysis. Though patients' weight did not play a role in their decision, their relationship with their cardiologist/surgeon, the rapidity and orchestration of the diagnosis and treatment, appraisal of risks and benefits, previous experience with other illness or others who had cardiac surgery, and openness to other alternatives had an impact. It is possible that there is a lack of comfort or acknowledgment by all parties in discussing the influence of weight on CABG surgery risks.

Understanding coronary artery disease patients' decisions regarding the use of chelation therapy for coronary artery disease: descriptive decision modeling

BACKGROUND

A considerable number of patients receive chelation therapy to treat their coronary artery disease. However, there is no current empirical evidence to support its use.

AIM

To better understand patient's decision-making processes regarding the use of chelation therapy as a treatment for coronary artery disease.

METHODS

Based on qualitative interviews with 32 coronary artery disease patients, a taxonomy of decision-related issues, hierarchical decision-model, and survey based on the model were developed. The model was then pilot tested with another group of 30 patients and revised accordingly. The final model was tested with another group of 167 patients (27 current users, 72 previous users, and 68 never users of chelation therapy). The primary examination of the model was to determine the degree to which it successfully identified people who fell within each behavioral group. This was done by dividing the total number of successes by the total number of cases on all paths (or questions in the questionnaire).

RESULTS

The most important elements in the decision to use or not use chelation therapy were: previous experience with or learning about chelation therapy, openness to alternative treatments, satisfaction with current level of (traditional) care, physician opinion regarding chelation therapy, costs associated with chelation therapy, perceived access to chelation therapy provider, current state of health (good or bad), and wanting to do 'all one can' for heart health. When tested, the ability of the model to predict the appropriate outcome was nearly 93%. The most salient junctures in the model that led participants to different behavioral outcomes were: considering using non-traditional treatments; perceptions regarding potential risks and benefits; cost; and believing that using chelation therapy was 'doing all that they can' to help their heart health.

CONCLUSIONS

Descriptive decision-modeling is a useful method to depict cardiac patients' decision-making concerning the use of chelation therapy. It can also assist healthcare providers and policy makers in directing interventions and policy aimed at enhancing the use of evidence-based therapies for cardiac patients.