This study retrospectively evaluated patient records from two cardiac rehabilitation (CR) service centers located in large urban hospitals using a Process Evaluation System (PES) recently developed through a collaborative project of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), Madison, WI, and the Center for Clinical Quality Evaluation (CCQE), Washington, DC. The major aims were to: 1) evaluate the utility of the PES as an audit instrument for assessment of adherence to the 24 quality process criteria that comprised the PES; and 2) determine whether adherence to the PES criteria resulted in different patient outcomes for those cases where intervention need was documented at patient admission. Using the data abstraction manual and audit procedures developed by AACVPR/CCQE, a trained medical technician audited 150 CR records for consecutively treated outpatients who typically received 36 sessions of treatment in either Moses H. Cone Memorial Hospital, N.C. Heart Institute, Greensboro, NC, or Carolinaà ­s Medical Center, Charlotte, NC, covering a calendar period between 1995-97. The data were pooled from both sites for analyses and included patients with one or more of the following diagnoses: MI (37%), angina (14%), coronary revascularization (76%), and other (18%). The cost of utilizing the PES was assessed by evaluating the technician time required to abstract a patient record and this was observed to improve over the course of the review period, i.e., mean abstraction time for initial versus final 20 records = 13.2 min. and 4.6 min., respectively. Experience with the PES suggested areas where instrument revision should be considered, e.g., the operational guidelines for extracting acceptable markers were not always clear enough or sufficiently flexible to allow determination of adherence of a record to the 24 quality process criteria. Adherence to the PES was determined, case by case, for each of the 24 criteria. In 129 cases (86% of the sample), complete adherence was found, i.e. 100% adherence to all 24 criteria that included indicators of key clinical steps for patient intake, treatment planning, and follow-up. The remaining 21 records (14%) showed adherence to at least 21 of the 24 criteria (87.5%). Given the uniformly high levels of adherence to the PES documented by these two program sites, the data could not resolve the question of whether patient outcome effects were different between cases of high versus low adherence to PES. Nonetheless, outcome data were examined to evaluate achievement levels in four different areas widely considered by clinicians as important to treatment success: blood cholesterol, smoking status, exercise tolerance, and body mass index (BMI). Of the study patients diagnosed with dyslipidemia 12 of 27 (44%) had levels < 200 mg/dl by exit. Seven of 14 documented smokers (50%) reported quitting at exit from treatment. Forty-nine patients of 117 (42%) who initially could only maintain treadmill walking for 10 min. at levels below 4 METs, were able to exceed this level by treatment end. Six of 104 (6%) with BMI values > 24.9 kg/m2 had a documented decrease in this indicator of overweight by treatment end. The threshold levels for outcome criteria used here to describe achievement levels in this data set are somewhat arbitrary. However, the criteria are reflective of the standards typically suggested as meaningful for effective secondary risk reduction in CR programs (Franklin et al., 1996). The PES system was developed to audit the quality of CR process in treatment centers, as standardized by a consensus panel to reflect the content of the evidenced-based CR guideline recently published by the US Agency for Health Care Policy and Research (Cardiac Rehabilitation as Secondary Prevention: #17, 1995). The findings of this study suggest that the content markers of quality process in the PES are relevant and the instrument is efficient to administer. When field tested against two urban centers in North Carolina where state statutes require program certification for CR treatment centers, these centers demonstrated uniformly high adherence to the PES and a pattern of good achievement for several patient outcome measures accepted as relevant to evaluation of treatment success for individual patients. / Master of Science

Social support plays a key role in the rehabilitation of acute and chronically ill people. Generally, if one receives some type of social support then he or she is more likely to improve their physical, emotional, and/or psychological well-being during the rehabilitative phase. The type and amount of social support the cardiac patient perceives may affect participation in cardiac rehabilitation. The purpose of this study was to 1) determine if there was a difference between the amount of social support perceived by men and women entering a phase II cardiac rehabilitation exercise program 2) to examine the relationship between social support and the first four weeks of rehabilitation compliance. A sample (n = 29) of twenty two men (63.1 y.o. ± 10.1) and seven women (70.4 y.o. ± 11.4) voluntarily completed the Medical Outcomes Study (MOS) Social Support Survey as they entered into the phase II programs. The sample population consisted of patients with one or more of the following characteristics: MI (76%), CABG (59%), PVD (21%), PTCA (28 %), diabetes (21 %), hypertension (48 %), and angina (41 %). Two sites were used in the study; one urban and one rural. Each program session consisted of 60 minutes of exercise which consisted of flexibility, cardiovascular, and strength conditioning routines. All sessions were monitored by exercise specialists and registered nurses. Classes met three times per week on Monday, Wednesday, and Friday. As patients entered the programs, they were administered the MOS Survey which consists of 19 questions that address four types of social support -- <i>tangible, affection, positive interaction, and emotional.</i> Each patient's attendance was recorded from initial entry to the end of four weeks. Data collection began in February 1995 and ended in May 1995. The results of the study demonstrated that there were no significant differences between men and women and their perception of social support at entry into the program. The mean total social support scores for men and women were 314.1 ± 85.2 and 307.1 ± 47.0 (p = 0.84), respectively out of a possible 400. There was no significant relationship between men and women and their compliance to the program (X² = 3.15, df 2; P = 0.21). In addition, there was no significant relationship between low, medium, and high compliers and their overall social support scores (p = 0.41). Results from these analyses should be viewed with caution as sample sizes were small. In conclusion, this study did not find that social support was associated with cardiac rehabilitation compliance. However, low entry rates into both programs and the extended length of the study resulted in very low sample sizes. Hence, the analyses may not have had sufficient statistical power to identity differences and make valid comparisons. / Master of Science

Despite known associations between fitness and recurrent cardiovascular events, changes in cardiorespiratory fitness (CRF) and muscle strength with long-term cardiac rehabilitation (CR) have not been extensively examined in men, and data in women is absent in the literature. The purpose of this thesis was to estimate changes in CRF and muscle strength associated with long-term CR program enrollment in men and women, and to examine the influence of baseline fitness and age on these fitness trajectories in men. Our methods and interpretations of the findings are discussed in the thesis, but in brief, using mixed model analyses we observed important fitness benefits over long-term CR enrollment in men and women and influences of baseline fitness and age on the trajectories in men. Our data provide new evidence of improved fitness trajectories in men and women after long-term CR enrollment and highlight the importance of long-term exercise-based CR after the completion of short-term programs. Larger prospective cohort studies are warranted to confirm the observations, and to identify potential mechanisms underlying these findings. / Dissertation / Doctor of Philosophy (PhD)

In the UK angina affects 2 million people (BHF, 2010b) and unfortunately secondary prevention interventions such as Cardiac Rehabilitation (CR) are not widely available for this population (NACR, 2011). This doctoral research project examined the effectiveness and feasibility of an alternative intervention for this population; CR delivered via the internet. The programme was interactive and comprised personalised goal setting orientated around exercise, diet, emotions, and smoking with support available through an online email link or synchronised chat room. A randomised controlled trial (RCT) and semi-structured interviews were used to evaluate the intervention. Primary care patients with angina were randomised to either an intervention group (n=48) or to a control group that did not receive any intervention other than treatment as usual (n=47). Outcome measures were taken at baseline, 6 week and 6 month follow ups. The primary outcome measure was daily steps (measured objectively using Sensewear Pro 3® accelerometer technology). Secondary outcome measures included daily energy expenditure (EE), daily duration of sedentary activity (DDSA), daily duration of moderate activity (DDMA), daily duration of vigorous activity (DDVA), weight, diastolic blood pressure (DBP), systolic blood pressure (SBP), body fat %, fat intake, fibre intake, anxiety, depression, self-efficacy, and health related quality of life (HRQOL). At the 6 week follow up the intervention group had greater improvements than the control group in daily steps, daily EE, DDSA, DDMA, weight, self-efficacy, emotional quality of life and frequency of angina symptoms. In addition, at the 6 month follow up there were significantly greater improvements in anxiety, and frequency of angina symptoms among the intervention group compared to the control group. Semi-structured interviews were also conducted with a subsample of intervention group participants at the 6 week follow up (n=16). Themes resulting from these interviews indicated a high level of programme acceptability and feasibility; ‘self reported improvements’ and ‘programme facilitators’. However, the theme labelled ‘programme barriers’ illustrated intervention related challenges which should be taken into account when delivering the programme. Overall the study demonstrated that a new web based CR programme was effective at improving lifestyle related cardiac risk factors for a primary care angina population in both the short-term (significantly improved daily steps, DDSA, DDMA, weight, self-efficacy, emotional QOL and frequency of angina) and medium-term (significantly improved anxiety, and frequency of angina). These findings on the whole suggest that the programme could be offered to a primary care angina population who are not routinely included within conventional CR. However, there is a need to consider the factors described to affect engagement of the programme; family and work commitments, bad weather, older age, receiving the programme late in angina diagnosis and levels of self-motivation.

Hjärtrehabilitering är ett program som ger bästa möjliga medicinska, fysiska och psykiska förutsättningar för patienter som har drabbats av kranskärlssjukdom, Den förbättrar livskvaliteten hos dessa patienter till en optimal individuell funktionsnivå. Syftet med denna studie var att belysa upplevelser av hjärtrehabilitering hos patienter med kranskärlssjukdom. En litteraturöversikt baserad på elva artiklar, tio av kvalitativ och en kvantitativ design hämtade från tre databaser Cinahl Complete, PubMed och PsycINFO. Artiklarna granskades enligt Friberg (2017) och därefter sammanställdes resultat i form av fyra tema. Vid analysen av de valda artiklarna har fyra huvudteman inklusive några underteman identifierats: Psykologiska upplevelser av hjärtrehabiliteringen. Upplevelser av stöd och motivation. Upplevelser av sjuksköterskans roll. Upplevelser av förhinder att delta i hjärtrehabilitering. Resultatet från denna litteraturöversikt har diskuterats utifrån Dorothea Orems egenvårdsteori. Patienterna hade en positiv inställning till hjärtrehabilitering men de flesta upplevde förhinder i någon form. Brist på information kan förbättras genom att vårdpersonalen har rätt kunskap och ger stöd. För att underlätta svårigheter av livsstilsförändringar kan sjuksköterskan använda motiverande samtal utifrån patientens individuella behov för att utveckla egenvårdskapaciteten hos patienten. / Cardio rehabilitation is a programme which provides best possible medical, physical and mental conditions for patients who have suffered from cardiovascular disease. It improves quality of life for these patients to an optimal individual functioning level. The aim of this study was to highlight experiences from cardiac rehabilitation of patients with coronary artery disease. This study was carried out by a literature review method. Eleven articles, ten of qualitatative and of quantitative design identified in three databases: Cinahl Complete, PubMed och PsycINFO. Articles were reviewed according to Friberg (2017) and then the result was compiled in the form of four themes. In the analysis of the selected articles, four main themes, including some sub-themes, have been identified: Phsycological experiences of cardiac rehabilitation, Experiences of support and motivation, Experiences of nurses’ role and Experiences facing difficulties attending cardic rehabilitation program. Results from this literature review have been discussed related to Dorothea Orem's self-care theory. The patients had a positive attitude towards cardiac rehabilitation but most experienced some form of obstruction. Lack of information can be improved by the health care professions having the right knowledge and providing support. In order to facilitate difficulties in lifestyle changes, the nurse can use motivational talks based on the patient's individual need to develop self-care capacity in the patient.

Background: Despite national guidance and empirical support for its clinical and cost-effectiveness, cardiac rehabilitation (CR) is underused. Only 44% of patients go to CR, with angioplasty (Percutaneous Coronary Intervention; PCI) patients being least likely to attend (31% of 87,000). Aim: To investigate the relationship between ‘continuity of care’ and patients’ motivation towards CR, through the lens of self-determination theory, and develop a model to inform service design to increase CR uptake and adherence. Methods: A mixed methods approach was used. In Study 1, a theoretical model of continuity of care and motivational antecedents was tested with a cross-sectional sample of 107 PCI patients. To further explore interactions between continuity of care and motivation towards cardiac rehabilitation, a Critical Interpretive Synthesis of the extant literature was used in Study 2, and focus groups were carried out with patients and service providers in Study 3. Results: In Study 1, continuity of care positively predicted patients’ autonomous motivation towards CR, and this was partially mediated by autonomy support. Autonomy support was associated with CR attendance. In Studies 2 and 3, aspects of continuity of care with positive effects on attendance were identified. These included timely, appropriate information provision, relationships bridging CR phases and settings, and continuing management strategies incorporating trusting, warm staff-patient relationships, and positive encouragement and feedback about progress. The SDT constructs of autonomy support, need satisfaction, internalisation and quality of motivation helped to explain positive and negative influences of continuity on attendance. Conclusion: Continuity of care has a positive effect on patients’ motivation towards CR. The most enduring motivation comes from delivering continuity of care in an autonomy-supportive and competence-supportive way. Longitudinal research is needed to compare how need-supportive and need-thwarting aspects of continuity of care affect CR attendance and adherence, and whether these relationships are influenced by need satisfaction and need frustration.

<p>Syftet med studien var att jämföra skattad livskvalitet hos patienter med kranskärlssjukdom före och efter genomgången 12 månaders hjärtrehabilitering samt att jämföra skattad livskvalitet hos kvinnor och män. Urvalet bestod av 117 patienter (35 kvinnor och 82 män) som deltog i hjärtrehabiliteringen vid Hälsoinvest Högbo AB under åren 1996-2001. För skattning av livskvalitet användes formuläret QLQ-AP (Quality of Life Questionnaire - Angina Pectoris). QLQ-AP är ett sjukdomsspecifikt formulär och de 22 frågorna är indelade i fyra olika skalor: fysisk aktivitet, somatiska symtom, emotionellt och tillfredsställelse med livet. Huvudresultatet i studien visade att deltagarna (n=117) efter genomgången rehabilitering skattade en signifikant förbättrad livskvalitet för totalskalan samt för samtliga delskalor avseende QLQ-AP. Det fanns inga signifikanta skillnader mellan kvinnor och män i skattad livskvalitet, varken före eller efter genomgången rehabilitering. Kvinnorna skattade dock endast en signifikant förbättring inom skalan ”emotionellt” medan männen skattade signifikant förbättrad livskvalitet för totalskalan samt för samtliga delskalor. Slutsats: I denna studie var skattad livskvalitet förbättrad efter hjärtrehabilitering. För männen ökade den dock inom fler aspekter än för kvinnorna.</p> / <p>The aim of the study was to compare how patients with coronary artery disease rated their quality of life before and after participating in a 12 month cardiac rehabilitation program and to compare how women and men rated their quality of life. The sample consisted of 117 patients (35 women and 82 men) who participated in a cardiac rehabilitations program at Hälsoinvest Högbo AB between the years 1996-2001. Quality of life was measured using the QLQ-AP questionnaire (Quality of Life Questionnaire - Angina Pectoris). QLQ-AP is a disease-specific instrument and the 22 questions are grouped into a global score and four different subscales: physical activity, somatic symptoms, emotional distress and life satisfaction. The study showed a significant improvement of quality of life among the participants (n=117) for the global score and the four subscales of the QLQ-AP following cardiac rehabilitation. No significant differences in rated quality of life were seen between women and men, neither before nor after attending the rehabilitation program. The women, however, only showed a significant improvement of quality of life for the subscale emotional distress while the men showed a significant improvement of quality of life for the global score as well as for the four subscales. Conclusion: In this study, the rated quality of life improved after attending a cardiac rehabilitation program. However, the men improved in more aspects than the women did.</p>

Syftet med studien var att jämföra skattad livskvalitet hos patienter med kranskärlssjukdom före och efter genomgången 12 månaders hjärtrehabilitering samt att jämföra skattad livskvalitet hos kvinnor och män. Urvalet bestod av 117 patienter (35 kvinnor och 82 män) som deltog i hjärtrehabiliteringen vid Hälsoinvest Högbo AB under åren 1996-2001. För skattning av livskvalitet användes formuläret QLQ-AP (Quality of Life Questionnaire - Angina Pectoris). QLQ-AP är ett sjukdomsspecifikt formulär och de 22 frågorna är indelade i fyra olika skalor: fysisk aktivitet, somatiska symtom, emotionellt och tillfredsställelse med livet. Huvudresultatet i studien visade att deltagarna (n=117) efter genomgången rehabilitering skattade en signifikant förbättrad livskvalitet för totalskalan samt för samtliga delskalor avseende QLQ-AP. Det fanns inga signifikanta skillnader mellan kvinnor och män i skattad livskvalitet, varken före eller efter genomgången rehabilitering. Kvinnorna skattade dock endast en signifikant förbättring inom skalan ”emotionellt” medan männen skattade signifikant förbättrad livskvalitet för totalskalan samt för samtliga delskalor. Slutsats: I denna studie var skattad livskvalitet förbättrad efter hjärtrehabilitering. För männen ökade den dock inom fler aspekter än för kvinnorna. / The aim of the study was to compare how patients with coronary artery disease rated their quality of life before and after participating in a 12 month cardiac rehabilitation program and to compare how women and men rated their quality of life. The sample consisted of 117 patients (35 women and 82 men) who participated in a cardiac rehabilitations program at Hälsoinvest Högbo AB between the years 1996-2001. Quality of life was measured using the QLQ-AP questionnaire (Quality of Life Questionnaire - Angina Pectoris). QLQ-AP is a disease-specific instrument and the 22 questions are grouped into a global score and four different subscales: physical activity, somatic symptoms, emotional distress and life satisfaction. The study showed a significant improvement of quality of life among the participants (n=117) for the global score and the four subscales of the QLQ-AP following cardiac rehabilitation. No significant differences in rated quality of life were seen between women and men, neither before nor after attending the rehabilitation program. The women, however, only showed a significant improvement of quality of life for the subscale emotional distress while the men showed a significant improvement of quality of life for the global score as well as for the four subscales. Conclusion: In this study, the rated quality of life improved after attending a cardiac rehabilitation program. However, the men improved in more aspects than the women did.

This preliminary investigation utilized both a top-down theory (Banduras Self-Efficacy Theory: SET, 1997) and a bottom-up theory (Leventhals Common Sense Model: CSM, 1980) to examine the cognitions and exercise behavior of novice cardiac rehabilitation (CR) participants engaged in 3 months of standard CR treatment. The primary purpose of this study was to investigate if the Illness Perception Questionnaire (IPQ,) as a reflection of the CSM, could classify CR novices relative to the strength of their illness perceptions. A further objective was to detect differences at baseline between the illness perception groups when evaluating SET variables and health-related outcomes that have been identified as important correlates of CR adherence. Additionally, the study proposed to determine differences between illness perception groups on adherence to recommended exercise therapy in CR. Lastly, differences between the groups on the assessed variables over the 3 month-rehabilitation period was examined. Forty-nine CR initiates were recruited. Participants were measured at 4 different time points over the 3-month initiation phase of CR. The IPQ, SF-36 (assessing health-related quality of life; HRQL,) and other social cognitive measures, including self-regulatory efficacy and positive and negative outcome expectations, were used to examine individuals. Participants completed measures at initiation of CR, after 2 weeks in CR, 6 weeks in CR and at the end of the 3-month initiate phase of CR. At onset of the program, cluster analysis successfully classified participants to weaker and stronger symptom-identity groups (i.e., illness perception groups). These groups were shown to be significantly different on the illness perceptions of identity, consequences and emotion. Upon initiation of CR, the classified groups were also significantly different on likelihood and value of negative outcome expectations, as well as physical and mental HRQL. At baseline, the group with stronger identity, consequences and emotion had higher negative outcome expectations and lower HRQL. In regards to adherence at the end of 3-months of CR, significant differences were found between the groups such that the group with stronger identity, consequences and emotion were less adherent to CR. This study was an initial exploration of the effectiveness of using the CSM along with SET. The findings offer insight into complementary use of top-down and bottom-up theoretical constructs to study psychological beliefs and adherence to exercise therapy in this rehabilitation setting.

Cardiovascular disease (CVD) is the leading cause of death among Canadian women, and accounts for up to 30% of deaths among women worldwide. Women with CVD are typically older than their male counterparts, experience worse functional status, are more likely to experience non-CVD health conditions such as diabetes or arthritis, and will live with these health conditions for more years than men. Physical activity (PA) and cardiac rehabilitation (CR) participation is lower among women compared to men, but little is known about the PA and health promotion experiences, priorities and practices of older women living with CVD. Guided by a socioenvironmental approach to health promotion, a mixed method design involving a mail survey (N=127) and qualitative interviews (N=15) was employed to describe and explore the PA and health promotion practices, preferences and priorities of older women (≥65 years) living with CVD in the Champlain health region of Ontario. Nearly 60% of survey respondents were referred to CR. Logistic regression analysis revealed urban residence as a predictor of CR referral (p<0.01, OR=3.24; 95% CI: 1.44-7.30). Nearly 55% of respondents attended CR, which was predicted by CR referral (p<0.01, OR=32.26; 95% CI: 9.26-111.11), availability of transportation (p<0.05, OR=9.96; 95% CI: 1.22-81.41), and a history of structured PA (p<0.05, OR=3.64; 95% CI: 1.16-11.36). Respondents were more active than their peers, but received little support from their physician for PA. Older women’s incidental PA (walking six or more hours/week for transportation) was predicted by their sense of community belonging (p<0.05, OR=2.6; 95% CI: 1.05-6.29) and having energy for PA (p<0.05, OR=5.8; 95% CI: 1.21-27.92). Interview participants (including four who had attended CR) described health as a resource that enables them to lead busy, active lives. Most participants attributed CVD to genetics or stress, but still engaged in health-promoting activities, including structured and incidental PA. Participants engaged in ‘incidental’ activities such as walking, gardening, and housekeeping tasks purposefully, with the intention of maintaining or improving their health. This research can inform public health initiatives and health care services (including CR) to better meet the needs and preferences of the growing population of older women with CVD.