Cardiac rehabilitation services in Ireland: the impact of a coordinated national development strategy.

BACKGROUND: The national Cardiovascular Health Strategy including specific plans for cardiac rehabilitation was launched in Ireland in 1999. A survey of cardiac rehabilitation services was conducted in 2003 to evaluate progress on service provision. AIM: To establish levels of service provision, service formats and geographic distribution of cardiac rehabilitation services in 2003 and compare them with the status pre-Strategy (1998). METHOD: All hospitals in Ireland (n = 39) admitting cardiac patients to a coronary or intensive care unit were surveyed by postal questionnaire. RESULTS: All hospitals provided information and all reported providing Phase I cardiac rehabilitation. Seventy-seven per cent (30 of 39) provided Phase III rehabilitation in 2003 (i.e. outpatient cardiac rehabilitation services) compared with 29% (12 of 41) in 1998. Of those hospitals currently without programmes, 78% (seven of nine) had plans in place for programme establishment. All programmes had trained cardiac rehabilitation coordinators, multidisciplinary teams and multiple components as recommended in the Strategy. In 82% of hospitals, intervention was provided at Phase II (immediate post-discharge period) while 26% of hospitals provided intervention at Phase IV (long-term maintenance period). CONCLUSIONS: There have been substantial achievements towards the Cardiovascular Health Strategy target of providing cardiac rehabilitation services for all relevant hospitals in Ireland over the past five years. Service provision of cardiac rehabilitation can benefit from collective efforts made across centres to encourage the prioritisation of cardiac rehabilitation in national health policy initiatives.

Good metabolic control is associated with better quality of life in 2,101 adolescents with type 1 diabetes.

OBJECTIVE: It is unclear whether the demands of good metabolic control or the consequences of poor control have a greater influence on quality of life (QOL) for adolescents with diabetes. This study aimed to assess these relations in a large international cohort of adolescents with diabetes and their families. RESEARCH DESIGN AND METHODS: The study involved 2,101 adolescents, aged 10-18 years, from 21 centers in 17 countries in Europe, Japan, and North America. Clinical and demographic data were collected from March through August 1998. HbA(1c) was analyzed centrally (normal range 4.4-6.3%; mean 5.4%). Adolescent QOL was assessed by a previously developed Diabetes Quality of Life (DQOL) questionnaire for adolescents, measuring the impact of diabetes, worries about diabetes, satisfaction with life, and health perception. Parents and health professionals assessed family burden using newly constructed questionnaires. RESULTS: Mean HbA(1c) was 8.7% (range 4.8-17.4). Lower HbA(1c) was associated with lower impact (P < 0.0001), fewer worries (P < 0.05), greater satisfaction (P < 0.0001), and better health perception (P < 0.0001) for adolescents. Girls showed increased worries (P < 0.01), less satisfaction, and poorer health perception (P < 0.01) earlier than boys. Parent and health professional perceptions of burden decreased with age of adolescent (P < 0.0001). Patients from ethnic minorities had poorer scores for impact (P < 0.0001), worries (P < 0.05), and health perception (P < 0.01). There was no correlation between adolescent and parent or between adolescent and professional scores. CONCLUSIONS: In a multiple regression model, lower HbA(1c) was significantly associated with better adolescent-rated QOL on all four subscales and with lower perceived family burden as assessed by parents and health professionals.

Psychosocial issues for cardiac rehabilitation with older individuals.

Psychological management of older people undergoing cardiac rehabilitation should be delivered, in the main, as it is to younger people with the heterogeneity of patient characteristics taken as standard. General considerations in delivering a service to older people include societal definitions of ageing, the profile of older cardiac patient groups, ageism as practised by both health professionals and patients, psychological issues of particular relevance to ageing and evidence from scientific studies with older individuals. These topics are considered in this review. The challenge is to develop a system which includes and is responsive to this growing subgroup of patients who can benefit from cardiac rehabilitation.

Psychosocial outcome assessments for use in cardiac rehabilitation service evaluation: a 10-year systematic review.

A variety of measures are currently used to assess psychosocial outcome (quality of life) in cardiac rehabilitation programmes. However, there is no consensus on the most appropriate instruments to use. Instruments that are not sufficiently responsive to change in cardiac populations are unsuitable as audit tools as they underrepresent the benefits of programme attendance. To identify the most responsive instruments in cardiac rehabilitation populations a systematic overview of studies for the 10-year period 1986-1995 was conducted. The following databases were searched: Medline, Psychlit, Cinahl and Sociofile and 32 relevant studies were identified. The effect size statistic (a comparison of the magnitude of change to the variability in baseline scores) was used to determine those instruments most responsive to change. The following instruments were identified as being responsive in more than one study: Beck Depression Inventory, Global Mood Scale, Health Complaints Checklist, Heart Patients Psychological Questionnaire and Speilberger State Anxiety Inventory. There is little consensus on psychosocial evaluation instrument use in the cardiac rehabilitation literature. A number of measures show significant potential for routine outcome assessment. Formal assessment of these instruments is recommended to inform final recommendations about instrument selection for audit and evaluation purposes in cardiac rehabilitation.

Assessing adherence to dietary recommendations for hemodialysis patients: the Renal Adherence Attitudes Questionnaire (RAAQ) and the Renal Adherence Behaviour Questionnaire (RABQ).

This article describes preliminary investigations into the psychometric properties of two scales for hemodialysis patients (N=35): the Renal Adherence Attitudes Questionnaire (RAAQ), a 26-item scale measuring attitudes toward adherence: and the Renal Adherence Behaviour Questionnaire (RABQ), a 25-item scale measuring self-reported dietary (diet and fluid) adherence. Factor analysis of the RAAQ yielded a four-factor structure. These factors were attitudes to social restrictions, well-being, self-care/support, and acceptance. The scale demonstrated high internal and test-retest reliability. Factor analysis of the RABQ gave a five-factor structure: adherence to fluid restrictions; adherence regarding potassium and phosphate restrictions, adherence regarding self-care; adherence regarding sodium intake; and adherence in times of particular difficulty. This scale had moderately high internal reliability and high test-retest reliability. Validity for the RABQ was tested with independent measures of adherence; biochemical (serum potassium, serum phosphate, and interdialytic weight gain) and dietician-rated (potassium and fluid). There was little association among the differing measures of adherence. These scales facilitate empirical evaluation of dietary adherence for hemodialysis patients.

Imaging of intramedullary tumour spread in osteosarcoma. A comparison of techniques.

The level of bone resection for osteosarcoma depends on the pre-operative evaluation of the extent of intramedullary tumour. We compared the accuracy of magnetic resonance imaging (MRI), computerised tomography (CT), and isotope bone scanning with the actual extent of the tumour in the resected specimens from 34 patients with primary osteosarcoma of a long bone. The extent of medullary tumour was defined accurately in 23 of 24 MRI scans (96%) and 24 of 32 CT scans (75%). A flexion contracture of a joint close to the tumour was an important cause for inaccurate measurements from both MRI and CT scans. Isotope bone scanning was inaccurate: its role is now confined to detecting skeletal metastases and skip lesions.

The effect size statistic: useful in health outcomes research ?

An increasing array of health status instruments provides challenges to the researcher in selecting the most appropriate measure in health outcomes studies. The responsiveness of a measure is its ability to identify small but important changes over time or following interventions. For health outcomes studies, responsiveness is an important psychometric requirement to guide instrument selection and it can be evaluated using the effect size statistic. The calculation and meaning of effect sizes are described here. Effect size considerations can also contribute to other topics of importance to health researchers. Issues of power and statistical and clinical significance are discussed.

Patients' experiences of dialysis services: are national health strategy targets being met?

BACKGROUND: The National Health Strategy envisages a health system incorporating patient views; and providing accessible, consultant-led dialysis services with patient choice of dialysis modality, in all regions. AIMS: To describe patients' experiences of renal services against National Health Strategy objectives. METHODS: Telephone interviews with 192 dialysis patients from three hospitals in the Eastern region. RESULTS: One-quarter of participants (16% of haemodialysis [HD] and 46% of peritoneal dialysis patients) lived outside the Eastern region, and travelled there because dialysis was not available locally. Two-thirds (65%) had a choice of dialysis modality. High satisfaction with interpersonal care was observed (83-98% satisfaction). Dissatisfaction with physical environment included parking (39-56%), waiting areas (62-69%), HD unit space (74%). Regarding support services, dietary services were satisfactory (92-95%), with lower satisfaction ratings for social and financial support services (62%). CONCLUSIONS: Structural and management issues must be addressed to advance a quality agenda for renal care in Ireland.

Cardiac rehabilitation service provision in Ireland: the Irish Association of Cardiac Rehabilitation survey.

BACKGROUND: The first national survey of cardiac rehabilitation services was conducted. AIMS: To establish levels of service provision, service formats, and geographic distribution of cardiac rehabilitation services in 1998. METHODS: Public hospitals in the Republic (n=41) and Northern Ireland (n=12) which provide services to cardiac patients were surveyed. RESULTSl Response rate was 81%. Twelve centres (29%) in the Republic and nine (75%) in Northern Ireland provided cardiac rehabilitation. There was wide geographic variability in service provision. Most centres were unable to identify the proportion of eligible patient participation. Most programmes were established for less than five years. All programmes had multidisciplinary teams, multicomponent courses and co-ordinators. Additionally, 44% of hospitals without programmes had plans regarding programme establishment. CONCLUSIONS: The findings highlight the underdeveloped but rapidly expanding nature of cardiac rehabilitation services in Ireland. They provide a baseline from which to address rehabilitation needs and to judge the success of the National Cardiovascular Health Strategy in addressing these needs.

Ethical approval for national studies in Ireland: an illustration of current challenges.

BACKGROUND: Ethical approval of research projects is, appropriately, an essential prerequisite in health settings. AIMS: This paper outlines difficulties encountered with procedures for gaining ethical approval for two multicentre surveys in Ireland. METHODS: The experiences of two national surveys were documented. RESULTS: Delays in processing ethics applications led to substantial delays in both surveys. Research ethics committees (RECs) assessed applications in an idiosyncratic manner. CONCLUSION: In Ireland, there is currently no accepted mechanism for single location ethical approval for multicentre studies. Instead, they require separate approval from all participating centres. The challenges of this system of application to multiple committees are outlined in this paper, and possible solutions presented.

General practitioner and public health nurse views of nutritional risk factors in the elderly.

A number of risk factors for malnutrition in the elderly have been identified, but their relative importance has yet to be established. General practitioners and public health nurses were interviewed to elicit the relative weights placed on 6 major risk factors when assessing nutritional risk in the elderly (living alone, recent bereavement, denture problems, mobility problems, psychiatric morbidity and multiple medication use). Participants rated risk for 35 hypothetical cases, described by their status on the 6 risk factors. Multiple regression models of these judgments revealed a consistently high weight for psychiatric morbidity compared to the other factors. Little group variation in diagnostic policies was observed between general practitioners and public health nurses or by case gender. These policies may reflect the perception that psychiatric problems pervade many areas of life functioning related to nutritional intake and are therefore more likely to cause malnutrition than other, more specific risk factors.

Study skills instruction in medical school.

Effective study skills are an essential component of medical education. Following analysis of current study habits of students attending the Royal College of Surgeons in Ireland (RCSI) a brief study skills course was developed for premedical students. Course evaluation indicated that instructed students reported more positive study habits one year later than did those without such instruction: a greater number of instructed students reported taking detailed notes during lectures (56 vs 32%) and starting to revise early in term (28% vs 11%) while fewer of these students routinely used the notes of other students after lectures (2 vs 10%) or as study material (0 vs 6%). A study skills course is now routinely provided in conjunction with individual student counselling, where necessary, to facilitate student success in this Medical School.

Communication skills training in undergraduate medicine: attitudes and attitude change.

The importance of communication skills training in undergraduate medical education is now widely accepted. However little is known about student attitudes towards their own communication skills and whether their attitudes changes as a result of participating in communication skills courses. The aim of the present study was to identify these attitudes prior to commencing such a course and to further evaluate changes in these attitudes on completion of the course. Results demonstrated an improvement in perceived confidence regarding a number of specific communication skills. The study provides further evidence of the value of such courses in undergraduate medical training.

Factors associated with delay to treatment for acute myocardial infarction in Ireland.

Irish data from the ISIS-2 multi-centre study of thrombolytic therapy has indicated longer delays to treatment for acute myocardial infarction (AMI) than in other countries (7.9 vs 6.9 hours, p < 0.001). Further examination of this database (n = 831 patients) found no influence of age and sex of patient on delay times. Distance from hospital was not associated with delay while previous experience of MI was marginally associated with decreased delay (previous MI: 7.1 vs no previous MI: 8 hours, p = 0.06). These relatively lengthy Irish delays require further investigation to inform management strategies aimed at reducing delay.

Should children with minor medical problems be sent to hospital? A study of infant care practices within families.

The admission of children to hospital for minor medical problems is frequently influenced by family and social circumstances. This study compared the infant care practices of families of children admitted to hospital for gastroenteritis (n = 76) and families caring for children with gastroenteritis at home (n = 76). Mothers of children who were admitted to hospital were more likely to use medical sources of advice on parenting and less likely to use other non-family sources than home care mothers. They also received less support in the education/entertainment of their children from fathers. There were many similarities between the two groups, including the high level of behaviour problems of the children and the relatively low level of involvement of fathers in child care tasks. Both of these factors serve to increase stress on mothers to the point where they may be unable to cope with a sick child at home.

What predicts depression in cardiac patients: sociodemographic factors, disease severity or theoretical vulnerabilities?

Depression is associated with increased cardiovascular risk in acute coronary syndrome (ACS) patients, but some argue that elevated depression is actually a marker of cardiovascular disease severity. Therefore, disease indices should better predict depression than established theoretical causes of depression (interpersonal life events, reinforcing events, cognitive distortions, type D personality). However, little theory-based research has been conducted in this area. In a cross-sectional design, ACS patients (n = 336) completed questionnaires assessing depression and psychosocial vulnerabilities. Nested logistic regression assessed the relative contribution of demographic or vulnerability factors, or disease indices or vulnerabilities to depression. In multivariate analysis, all vulnerabilities were independent significant predictors of depression (scoring above threshold on any scale, 48%). Demographic variables accounted for <1% of the variance of depression status, with vulnerabilities accounting for significantly more (pseudo R² = 0.16, χ²(change) = 150.9, df = 4, p < 0.001). Disease indices accounted for 7% of the variance in depression (pseudo R² = 0.07, χ² = 137.9, p < 0.001). However, adding the vulnerabilities increased the overall variance explained to 22% (pseudo R² = 0.22, χ² = 58.6, df = 4, p < 0.001). Theoretical vulnerabilities predicted depression status better than did either demographic or disease indices. The presence of these proximal causes of depression suggests that depression in ACS patients is not simply a result of cardiovascular disease severity.

Cardiac rehabilitation staff views about discussing sexual issues with coronary heart disease patients: a national survey in Ireland.

BACKGROUND: While a healthy sexual life is regarded as an important aspect of quality of life, sexual counselling from healthcare providers for cardiac patients has received little attention in the literature. AIM: To document current practice and assess the needs of cardiac rehabilitation service providers in Ireland with regard to sexual assessment and management for patients. METHODS: Cardiac rehabilitation staff in all relevant centres in Ireland responded to a postal questionnaire. Sexual health management was assessed by a series of questions on current practice, staff attitudes, beliefs and perceived barriers to discussing sexual problems. RESULTS: Staff (N=60; 61% response rate) reported a lack of assessment and counselling protocols for addressing sexual health problems, with little or no onward referral system available. Results also suggest staff believe that patients do not expect them to ask about their sexual concerns. Barriers reported included an overall lack of confidence (45%), knowledge (58%) and training (85%). CONCLUSION: Development of guidelines, assessment protocols and training for cardiac rehabilitation staff are essential in the area of sexual health problems in order to improve the quality of services for patients with coronary heart disease.