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Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
Eve Scarle - Outcomes from a MD CR programme
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Eve Scarle - Outcomes from a MD CR programme

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  • The MI patients had significantly higher perceived consequences about their illness than the other two groups, possibly because of the sudden presentation of their illness. Surgical intervention such as CABG or PTCA tend to be routine planned operations whereas an MI can come on without warning and leave individuals questioning their future
  • Self-efficacy judgements have consistently been shown to predict subsequent performance on a range of health behaviours. The lack of significant difference found between the three groups in terms of confidence to change may indeed suggest that having PTCA surgery could be a potent motivator in itself for making lifestyle changes. The modification of risk factors is critical in the long-term management of CHD. Patients with CHD may be highly motivated to adopt changes immediately following a cardiac event, but as time passes by, this motivation tends to decline as initial shock from the event recedes and people return to their normal daily routines (Burke and Dunbar-Jacob, 1995). Previous work has shown that PTCA patients who did not receive CR could identify specific risk factors affecting their health, but were not compelled to change them (Gulanick and Naito, 1994). Dietary supplementation with omega-3 fish oils has been shown to have important risk reduction benefits in non-fatal MI and mortality (Marckmann and Gronbaek, 1999) and a 15% reduction in the risk of CHD was also observed by increasing both fruit and vegetable consumption (Law and Morris, 1998).
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    • 1. Outcomes from a Multi-disciplinary Cardiac Rehabilitation Programme: Are Angioplasty Patients Addressing Lifestyle Changes? Eve Scarle, Mark Giles, Maggie Gallacher, Julian Bath, Julia Harrison, Alison Anderson Gloucestershire Cardiac Rehabilitation Service Gloucestershire Hospitals NHS Foundation Trust
    • 2. Background <ul><li>Death rates from CHD have fallen by 44% in those under 65 years old (1) </li></ul><ul><li>2.6 million people in the UK living with CHD (1) </li></ul><ul><li>Growth of RACPC and interventional cardiology </li></ul><ul><li>6,000 PTCA in 1982 increased to 54,000 in 2003 (1) </li></ul><ul><li>NSF for CHD (2000) (2) </li></ul><ul><li>“ Once Trusts have an effective system recruiting </li></ul><ul><li>people who have survived an MI or undergone surgery </li></ul><ul><li>to a high quality cardiac rehabilitation, they should </li></ul><ul><li>then extend their rehabilitation services to people </li></ul><ul><li>admitted to hospital with other manifestations of CHD”. (Chapter 7:4) </li></ul>
    • 3. Seen by CR team Seen by CR team Little time for in-hospital education Time for education Physical restrictions e.g. lifting Physical restrictions e.g. lifting Little restriction on activity Activity Restrictions 6-12 weeks 6-12 weeks 1-2 weeks Work 4 weeks off 4-6 weeks off 1 week off Driving Possibly Possibly No History of MI Possible intervention Open-heart surgery Local anaesthetic Intervention Gradual ambulation Post-operative pain and discomfort Immediate relief of symptoms Recovery At least 5 days At least 5 days 1-2 days Length of stay Sudden an unexpected/ can be life-threatening Normally planned Normally planned Intervention MI CABG PTCA  
    • 4. Rationale <ul><li>Limited studies on first time PTCA patients with no history of MI </li></ul><ul><li>May feel cured by the procedure or less sick than other CHD patients-  motivation to change </li></ul><ul><li>Evidence suggests 30-40% of individuals experience recurrent angina or a cardiac event by 2 years (4) (5) </li></ul><ul><li>Less compliance to behaviour changes when compared to CABG patients (3) </li></ul><ul><li>Low levels of CR participation (0-10%) (6) and twice as likely to drop out (7) </li></ul>
    • 5. Method- Comparative Study Initial sample- baseline data n=1387 CR programme Accepted and attended n=590 CABG n=285 MI n=936 PTCA n=166 Completed initial questionnaire and attended 7 weeks rehab Measures- IPQ, SF-12, HADS, Self-efficacy, Risk factor profile Follow-up of patients at 6 months post cardiac event completed second questionnaire Dropped out of CR Programme 13%
    • 6. Cardiac Rehab Programme <ul><li>Seven sessions for two hours </li></ul><ul><li>Multi-disciplinary </li></ul><ul><ul><li>nurse, physiotherapist, psychologist, dietitian </li></ul></ul><ul><li>Exercise and education component </li></ul><ul><li>Based around cognitive behavioural model </li></ul><ul><li>Two follow-ups at six months and one year post cardiac event </li></ul>
    • 7. Results <ul><li>Attendance </li></ul><ul><li>Quality of Life (SF-12)- physical and mental </li></ul><ul><li>Anxiety and Depression (HADS) </li></ul><ul><li>Illness Perceptions (IPQ) </li></ul><ul><li>Risk behaviours </li></ul><ul><li>Self-efficacy </li></ul>
    • 8. Results <ul><li>SF-12 </li></ul><ul><ul><li>Mental health improved in all 3 groups </li></ul></ul><ul><ul><li>Physical health better for PTCA at baseline </li></ul></ul><ul><ul><li>Improvements in physical health in MI and CABG group </li></ul></ul><ul><li>HADS </li></ul><ul><ul><li>Reductions in anxiety and depression scores </li></ul></ul><ul><ul><li>Greater improvement in those who had clinically meaningful scores </li></ul></ul>
    • 9. Results <ul><li>Illness Perception (IPQ) </li></ul><ul><ul><li>Increased timeline scores </li></ul></ul><ul><ul><ul><li>Patients who accepted their condition to be long-term (timeline) had better diet and exercise self-efficacy scores (8). </li></ul></ul></ul><ul><ul><ul><li>Perceiving CHD as chronic may be instrumental in engaging individuals in making long-term changes. </li></ul></ul></ul><ul><ul><li>MI thought consequences of illness were more serious </li></ul></ul><ul><ul><li>Following rehab PTCA patients had increased consequences scores </li></ul></ul><ul><ul><ul><li>CR may facilitate a raising of awareness of the consequences of CHD and enhance motivation to make behavioural changes </li></ul></ul></ul>
    • 10. Results <ul><li>Self-efficacy </li></ul><ul><ul><li>No group differences </li></ul></ul><ul><ul><ul><li>Increased SE for stress reduction and dietary changes </li></ul></ul></ul><ul><ul><ul><li>High SE scores for stopping smoking and increasing fitness </li></ul></ul></ul><ul><li>Risk Factor Modification </li></ul><ul><ul><li>No group differences </li></ul></ul><ul><ul><ul><li>80.4% abstinence from smoking at 6 months </li></ul></ul></ul><ul><ul><ul><li>Significant increases in fruit and vegetable and oily consumption, and frequency of exercise </li></ul></ul></ul><ul><ul><ul><li>No significant improvements in BMI </li></ul></ul></ul>
    • 11. Study Limitations <ul><li>Lack of control group </li></ul><ul><ul><li>No assessment on individuals who refuse CR </li></ul></ul><ul><ul><li>Threats to internal validity </li></ul></ul><ul><li>Data collection difficult with lengthy questionnaire </li></ul><ul><ul><li>Need all answers for each measure at each time point </li></ul></ul><ul><li>Data only available up to six months post event </li></ul>
    • 12. Conclusion <ul><li>No significant differences between three groups in success at CR </li></ul><ul><li>CR a worthwhile venture for PTCA patients </li></ul><ul><li>PTCA motivated to attend CR and make favourable lifestyle changes </li></ul><ul><li>Evidence suggests only 5-10% of PTCA patients are offered the chance to attend CR (6) </li></ul>
    • 13. Future Directions <ul><li>Long-term follow-up period beyond one year </li></ul><ul><li>Investigate individuals that refuse CR </li></ul><ul><li>Investigate patient activity levels outside CR </li></ul><ul><li>Explore alternative tools for CR </li></ul><ul><ul><li>Home programme </li></ul></ul><ul><ul><li>Videos/dvds </li></ul></ul><ul><ul><li>Evening classes </li></ul></ul>
    • 14. Any Questions?
    • 15. References <ul><li>1. Heart Stats Website </li></ul><ul><li>http://www.heartstats.org/ (2005) accessed on the 25th July 2005. </li></ul><ul><li>2. Department of Health (2000) The National Service Framework for Coronary Heart Disease, London: HMSO. </li></ul><ul><li>3. Crouse, J. and Hagaman, A. (1991) Smoking Cessation in relation to Cardiac Procedures, Amercian Journal of Epidemiology, 134 (7), pp. 699-703. </li></ul><ul><li>4. Hlatky, M. Charles, E. Norbrega, F. Gelmen, K. Johnstome, I. & Melvin, J. (1995) Comparison of Coronary Bypass Surgery with Angioplasty in Patients with Multi-Vessel Disease (BARI) , New England Medical Journal, 335, pp. 217-25. </li></ul><ul><li>5. Tuniz, D. Bernardi, G. Molinis, G. Valente, M. D’Odorico, N. Mirolo, R. Morocuttl, G. Spedicato, L. & Fioretti, P. (2004) Ambulatory Cardiac Rehabilitation with Individualised Care after Elective Coronary Angioplasty: One Year Outcome, European Heart Journal Supplements, 6 (A), A1-10. </li></ul><ul><li>6. Bethell, H. Turner, S. Evans, M. & Rose, L. (2001) Cardiac Rehabilitation in the United Kingdom. How Complete is the Provision?, Cardiopulmonary Rehabilitation, 21 (2), pp. 111-15. </li></ul><ul><li>7. Turner, S. Bethell, H. Evans, J. Goddard, J. & Mullee, M. (2002) Patient Characteristics and Outcomes of Cardiac Rehabilitation, Journal of Cardiopulmonary Rehabilitation, 22, pp. 253-260. </li></ul><ul><li>8. Lau-Walker, M. (2004) Relationship between Illness Representation and Self-Efficacy, Journal of Advanced Nursing , 48 (3), pp. 216-225. </li></ul>Contact details for further information: [email_address] [email_address]

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