European Journal of Cardiovascular Nursing http://cnu.sagepub.com/

Effects of community based cardiac rehabilitation: Comparison with a hospital-based programme Sultan M Mosleh, Christine M Bond, Amanda J Lee, Alice Kiger and Neil C Campbell Eur J Cardiovasc Nurs published online 8 January 2014 DOI: 10.1177/1474515113519362 The online version of this article can be found at: http://cnu.sagepub.com/content/early/2014/01/08/1474515113519362

Published by: http://www.sagepublications.com

On behalf of:

European Society of Cardiology

Additional services and information for European Journal of Cardiovascular Nursing can be found at: Email Alerts: http://cnu.sagepub.com/cgi/alerts Subscriptions: http://cnu.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> OnlineFirst Version of Record - Jan 8, 2014 What is This?

Downloaded from cnu.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on January 15, 2014

519362 research-article2014

CNU0010.1177/1474515113519362European Journal of Cardiovascular NursingMosleh et al.

EUROPEAN SOCIETY OF CARDIOLOGY ®

Original Article

Effects of community based cardiac rehabilitation: Comparison with a hospital-based programme

European Journal of Cardiovascular Nursing 201X, Vol. XX(X) 1­–9 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515113519362 cnu.sagepub.com

Sultan M Mosleh1, Christine M Bond2, Amanda J Lee2, Alice Kiger3 and Neil C Campbell3

Abstract Background: With typically fewer than 35% of eligible patients attending outpatient cardiac rehabilitation (CR), more accessible provision is required. Community-based cardiac rehabilitation is one option but its effects need to be compared with those of hospital-based CR. Aims: The purpose of this study was to compare changes in health-related quality of life (HRQOL), anxiety and depression, and exercise and smoking rates, between attendees at community-based and hospital-based CR programmes. Method: A prospective comparative cohort design was used. Consecutive patients admitted to Aberdeen Royal Infirmary and eligible for CR were recruited and followed up by self-report questionnaire. Outcomes were health status (RAND-36), Hospital Anxiety and Depression Scale (HADS), Godin Leisure-Time Exercise and smoking status. Results: There were 136 of 179 (75%) attenders at community-based CR, compared to 169 of 209 (80%) at hospitalbased CR (p=0.242). In univariate analysis, there were no significant differences between the two groups in health status, HADS, and frequency or intensity of exercise immediately after the CR programme or six months later. Adjusting for other significant factors, patients who attended community CR reported higher RAND-36 energy scores at six months compared with attenders at hospital CR (p=0.020), but were less likely to undertake frequent exercise (p=0.041). Conclusions: Community-based CR appears to achieve similar attendance rates and effects on health status and health behaviour as hospital-based CR. This option might help overcome the poor attendance of patients with long travelling times to hospital-based CR. Keywords Community-based cardiac rehabilitation, hospital-based cardiac rehabilitation, health status, health behaviour Date received: 10 October 2013; revised 12 December 2013; accepted 15 December 2013

Introduction Despite accumulating evidence for the benefits of cardiac rehabilitation (CR), the attendance rate worldwide and in the UK is poor with less than 35% of eligible patients participating.1–3 Many barriers to CR attendance are reported.4 Organisational barriers include work conflicts, transport difficulties and long distances to a rehabilitation centre. In a quantitative review of 32 studies, patients were found to be more likely to attend CR when the programmes were easily accessible.5 Bittner et al. found that referral to CR was more likely if the patient lived in area in which the rehabilitation facility was located.6

Community and home-based programmes are ways to provide CR locally. A Cochrane review found that homebased CR had similar effects and costs to hospital-based 1Department

of Fundamentals and Adult Nursing, University of Mutah, Jordan 2Centre of Academic Primary Care, University of Aberdeen, Scotland 3Medical Statistics Team, University of Aberdeen, Scotland Corresponding Author: Sultan Mosleh, Department of Fundamentals and Adult Nursing, Faculty of Nursing, University of Mutah, PO Box 7, Karak 61710, Jordan. Email: [email protected]

Downloaded from cnu.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on January 15, 2014

2

European Journal of Cardiovascular Nursing XX(X)

programmes.7 Some patients, however, value the opportunity for peer support and this may improve their uptake and adherence.8 Community-based group programmes offer this opportunity and early evaluations have reported improvements in exercise levels and reductions in angina similar to those reported by hospital-based programmes.9 Since then, however, there have been changes in both CR programme content and participant demography. Early programmes consisted of exercise training, whereas now a comprehensive approach is recommended, including assessment of risk factors, psychological and educational interventions, risk factor correction, stress management and relaxation training, and delivered by a multidisciplinary group according to national standards.4,10,11 Patients now enrolled in cardiac rehabilitation are older and more likely to have co-morbidities such as diabetes.12 As community-based programmes may have less access to specialist staff and resources compared to their hospital counterparts, it is important to investigate whether, in practice, they have similar benefits or not. The aim of this study was to compare changes in health related quality of life (HRQOL), anxiety, depression, exercise and smoking rates, between attendees at community-based versus hospital-based CR programmes.

Methods

physician are available if needed. The community-based programmes are delivered from sports centres in Aberdeenshire at Banchory, Banff, Peterhead and Inverurie by a nurse and a physiotherapist

Participants All patients enrolled in CR were eligible to take part in the study. Patients eligible for the programme were those admitted to the University Hospital with acute myocardial infarction or undergoing coronary artery bypass surgery or coronary angioplasty and referred to either the hospitalbased CR in Aberdeen city or one of the four communitybased CR programmes in Aberdeenshire based upon where they lived. Patients were excluded from the CR programme and this study if they had terminal illness, arrhythmia, alcohol or drug abuse, or mental or physical disability.

Outcome measures Five health outcome measures were used. The first three are suggested in both the National Service Framework (NSF) for coronary heart disease and the national guidelines for CR as valid, reliable instruments for audit of CR programmes.13

HRQOL

Design This was a prospective comparative cohort study.

Setting The study was set in northeast Scotland. The locations included one hospital-based programme and four community programmes. Recruitment and baseline data collection (time zero: T0) were between January–December 2007. First follow-up (T1) commenced in June 2007 and ceased in June 2008. Second follow-up (T2) commenced in February 2008 and ceased in November 2008.

Cardiac rehabilitation The eight-week outpatient CR programme in all five locations was developed by the same team to comply with the British Association of Cardiovascular Prevention and Rehabilitation (BACPR) and Scottish Intercollegiate Guideline Network (SIGN) guidelines which are evidencebased.10,11 They normally commence six weeks after hospital discharge, although in some cases they begin later depending on the waiting list. There are two sessions of exercise training and relaxation, and one session of education per week over eight weeks. The hospital-based programme is provided at the University Hospital, a teaching hospital. It is run by a multidisciplinary team (a CR nurse, a physiotherapist and a dietician) and a psychologist and

The RAND-36 (RAND: Research and Development, http://www.rand.org/) was used to evaluate patients’ HRQOL. The 36 items on the questionnaire are divided into eight scales: physical functioning (10 items), social functioning (two items), role limitation due to physical problem (five items), role limitation due to emotional problem (three items), mental health (five items), energy/ fatigue (four items), bodily pain (two items), and general health (five items).14 The RAND-36 includes the same items as the SF-36 (SF: Short-Form Health Survey), as developed in the Medical Outcomes Study. The SF-36 has been found to be a sensitive, reliable generic HRQOL instrument for cardiac patients.15

Anxiety and depression The Hospital Anxiety and Depression Scale (HADS) is a well-validated screening tool that was included to describe the patient’s mental health status. It has a sensitivity and specificity greater than 80% in cardiac patients and good internal consistency with a mean Cronbach’s alpha 0.83 for anxiety and 0.82 for depression.16

Physical exercise The Godin Leisure-Time Exercise questionnaire was used to measure the time spent performing exercise during leisure.17 It is a self-administration seven-day recall questionnaire and

Downloaded from cnu.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on January 15, 2014

3

Mosleh et al. has three levels of exercise, strenuous; moderate; and mild exercise. The participants were asked how often per week they engaged in these three levels exercise for 15 min or more during their free time. It also enquires into the weekly frequency of sweat-inducing activity. Both the NSF for coronary heart disease and the national guidelines for CR have selected the Godin Leisure-Time Exercise questionnaire as a valid, reliable instrument to evaluate patients who attend a CR programme and to develop a dataset for audit of the benefit of CR.13 The internal reliability for questions is satisfactory, with the mean of Cronbach’s α ranging from 0.62–0.81.18

Exercise intention The Exercise Intention and Planning questionnaire was used to provide information on patients’ intention to change their behaviour and practice physical exercise in future. The questionnaire was developed by Luszczynska and Schwarzer19 and it is composed of three subscales: intention to maintain exercise (six items); action planning (five items), which is about when, where, and how exercise is taken; and coping planning (five items), which assesses respondents’ plans to maintain physical exercise in difficult situations (e.g. having little time or experiencing a setback). Reported Cronbach’s alpha values are 0.82–0.88 for intentions, 0.92–0.95 for action planning and 0.90–0.91 for coping planning.19

Smoking status Smoking status was measured with items developed from previous studies.20,21 Participants selected the statement that best described their smoking status from the following options: ‘I smoke daily’; ‘I smoke occasionally, but not every day’; ‘I used to smoke daily, but do not smoke at all now’; ‘I used to smoke occasionally, but do not smoke at all now’ and ‘I have never smoked’. Patients who used to smoke were then asked to indicate the date they stopped or the number of years since they had stopped smoking.

Additional variables collected All of the above measures were combined into a simple questionnaire with additional items on demography (age, sex, co-habitation, employment status). Patient’s deprivation level was described using Carstairs scores for Scottish postcode sectors from the 2001 Census. Carstairs decile scores were assigned to each participant based on their address postcode of residence.22 These scores, were collapsed into three categories. The first category representing the least deprived 30% of the Scottish population (1=least deprived), the third category representing the most deprived 30% (3=most deprived) and the second

level representing the remaining 40% of Scottish population (2= moderate deprivation). Data were also collected on key medical co-morbidities: diabetes, stroke, cancer, myocardial infarction, cardiac surgery, percutaneous transluminal coronary angioplasty, hypertension, respiratory diseases (including asthma, emphysema, chronic bronchitis), and joint diseases (including rheumatism, arthritis, chronic back pain).

Data collection and method of follow-up Smoking status, HADS and Godin Leisure-Time Exercise exercise were measured pre-hospital discharge (T0) by self-completion questionnaire. All measures except smoking status were applied at T1 (immediately after the eightweek course of CR had been completed) by postal questionnaire and all measures were then repeated at T2 (six months later) again by postal questionnaire. Two reminder questionnaires were sent to non-responders at two-weekly intervals. Participants who did not respond to the first follow-up (T1) were still eligible for second follow-up (T2) questionnaire unless they had withdrawn or died.

Sample size calculation With a sample of 212 participants at baseline, the study had 80% power at the two-sided 5% significance level to detect a 10-point (moderate) difference in the mean RAND-36 scores between those patients who had attended hospital versus those who had attended community based CR.23,24

Statistical methods Statistical analyses were conducted using SPSS 18. Missing data were treated as missing at random and excluded from statistical analysis. The two-sample t-test was used to compare continuous health outcomes (exercise intention score, HADS) between attenders at the hospital and community based programmes. Scores in the RAND-36 and the Godin Leisure-Time Exercise questionnaire were not normally distributed, so the Mann-Whitney rank test was used. Between groups differences in smoking status was investigated using the Chi-square test. In order to identify potential confounders, appropriate univariate tests were used to identify associations between outcome variables and the additional demographic, socio-economic and morbidity variables collected at baseline. The Pearson correlation coefficient was used to investigate the strength of the linear association between age, which was normally distributed, and the T2 scores of the RAND-36, the Godin Leisure-Time Exercise questionnaire and the HADS. The Spearman’s

Downloaded from cnu.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on January 15, 2014

4

European Journal of Cardiovascular Nursing XX(X)

Invited to take part in the study (n=551)

Before hospital discharge (T0) Questionnaire (Godin Leisure Time Exercise, HADS and Smoking)

Completion of CR programme (T1) Questionnaire (RAND-36, the Godin Leisure Time Exercise, Exercise Intention and Planning and HADS)

Six months after T1 (T2) Questionnaire (RAND-36, the Godin Leisure Time Exercise, Exercise Intention and Planning, HADS and Smoking)

115 declined 49 excluded: 29 medical reasons 4 died 16 not referred to CR

Agreed to participate n=387

Invited to hospital CR n=208

Invited to community CR n=179

Attended hospital CR n=169

Attended community CR n=134

T1 142 (84%) respondents

T1 115 (86%) respondents

T2 128 (76%) respondents

T2 109 (81%) respondents

Figure 1.  Patient recruitment and follow-up process. HADS: Hospital Anxiety and Depression Scale.

rank correlation coefficient was used to investigate the strength of the linear association between the scores of the RAND-36 and the Godin Leisure-Time Exercise questionnaire and HADS. Factors that emerged from univariate analysis with a significance level of ≤0.05 were included in multivariate models as potential confounders. Forward stepwise linear regression modelling was used to identify whether community or hospital-based CR was independently associated with the continuous health outcomes (HRQOL, HADS and physical exercise) at T2 after adjustment for baseline factors. Forward stepwise logistic regression was similarly used to identify whether site of CR was independently associated with smoking status at T2 after adjustment for baseline confounders.

Ethical approval Full ethical approval was sought from the Grampian Research Ethics Committee and was granted on 17 November 2006 (ref. no.: 06/S0802/119).

Results Of the 551 patients eligible to take part in the study, 115 (21%) declined and 49 (9%) became ineligible for CR (29 became unwell, 16 were not referred as the referral sheets were lost, and four died prior to data collection). The remaining 387 (68%) patients agreed to take part in the study and completed the baseline questionnaire (Figure 1).

Downloaded from cnu.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on January 15, 2014

5

Mosleh et al. Table 1.  Baseline comparison between attenders and non-attenders at cardiac rehabilitation (CR).

Age Gender (male) Married or living as married Living alone Medical history High blood pressure Diabetes Respiratory disease Joint disease Cancer Stroke Myocardial infarction Cardiac surgery Angioplasty Working status Employed Unemployed Sick Retired Smoking status Current smoker Ex-smoker Never smoked Anxiety level at admission Not anxious (score 10) Depression level at admission Not depressed (score 10) Deprivation level Level 1 (low deprivation) Level 2 Level 3(high deprivation)

Attenders (n=303)

Non-attenders (n=80)a

pvalue

61 (11) 219 (72) 230 (76) 54 (18)

67 (10) 47 (59) 53 (66) 20 (25)

116 (38) 44 (14) 38 (13) 46 (15) 8 (3) 6 (2) 215 (71) 121 (40) 93 (30)

42 (52) 14 (17) 9 (11) 18 (22) 1 (1) 4 (5) 61 (76) 27 (34) 27 (34)

131 (44) 15 (5) 15 (5) 134 (46)

21 (26) 3 (4) 8 (10) 48 (60)

46 (15) 166 (55) 90 (30)

16 (20) 41 (51) 23 (29)

170 (60) 65 (23) 50 (17)

43 (58) 20 (27) 11 (15)

230 (81) 41 (14) 14 (5)

57 (77) 13 (18) 4(5)

194 (65) 77 (26) 28 (9)

55 (71) 12 (16) 10 (13)