Patient Decision Aids for Aortic Stenosis and Chronic Coronary Artery Disease: A Systematic Review and Meta-Analysis.

AIM: Shared decision-making is recommended for patients considering treatment options for severe aortic stenosis (AS) and chronic coronary artery disease (CAD). This review aims to systematically identify and assess patient decision aids (PtDAs) for chronic CAD and AS and evaluate the international evidence on their effectiveness for improving the quality of decision-making. METHODS AND RESULTS: Five databases (Cochrane, CINAHL, Embase, MEDLINE, PsycInfo), clinical trial registers and 30 PtDA repositories/websites were searched from 2006 to March 2023. Screening, data extraction and quality assessments were completed independently by multiple reviewers. Meta-analyses were conducted using Stata statistical software. Eleven AS and 10 CAD PtDAs were identified; seven were less than five years old. Over half the PtDAs were web-based and the remainder paper-based. One AS and two CAD PtDAs fully/partially achieved international PtDA quality criteria. Ten studies were included in the review; four reported on the development/evaluation of AS PtDAs and six on CAD PtDAs. Most studies were conducted in the USA with White, well-educated, English-speaking participants. No studies fulfilled all quality criteria for reporting PtDA development and evaluation. Meta-analyses found that PtDAs significantly increased patient knowledge compared to 'usual care' (mean difference:0.620; 95%CI 0.396, 0.845, p < 0.001) but did not change decisional conflict. CONCLUSION: Patients who use PtDAs when considering treatments for AS or chronic CAD are likely to be better informed than those who do not. Existing PtDAs may not meet the needs of people with low health literacy levels as they are rarely involved in their development.

Becoming partners in rehabilitation with patients in intensive care: physiotherapists' perspectives.

PURPOSE: Person-centred care is widely accepted as being central to high quality care, but little is known about how physiotherapists implement person centred rehabilitation in Intensive Care. This study explores the self-reported experiences and interpretations of physiotherapists delivering person-centred rehabilitation in this setting. METHODS: A qualitative study using Interpretative Phenomenological Analysis explored the lived experiences of physiotherapists and students who have worked in Intensive Care. Three focus groups, with four participants in each, were conducted. Data were fully transcribed, analysed and managed using NVivo software. RESULTS: Participants shared similar interpretations about the principles of person-centred care. Operationalising person-centred rehabilitation during early recovery was not easily achievable. As the person's clinical condition improved, participants moved away from routine physiotherapy and their practice became more person-centred through the development of a partnership. Participants connected as humans to understand the person and respond to their needs within a culture that valued person-centred care. CONCLUSIONS: Physiotherapists aspire to develop a partnership with their patients by connecting on a human level with them and addressing their biopsychosocial needs. Physiotherapists with experience of developing patient partnerships influence the culture of the Intensive Care team and are role-models to facilitate collaborative person-centred activity in others.

Physiotherapists can move from a biomedical approach towards becoming partners with patients in an Intensive Care Unit (ICU) as they become cognitively aware.Physiotherapists become person-centred by connecting as humans to the patient and moving towards a biopsychosocial approach that addresses the physical, psychological and instrumental needs of the patient in ICU.When aiming towards a person-centred approach on ICU, physiotherapists contribute to a culture that nurtures the unique patient and works collaboratively with the family and the health care team.Experience working with patients in ICU, allows physiotherapists to identify opportunities to be person-centred and facilitate other team members in becoming so.

The Core Curriculum for Cardiovascular Nurses and Allied Professionals.

This 2023 update of the Core Curriculum in Cardiovascular Nursing (2015) embraces the formation of the Association of Cardiovascular Nursing and Allied Professionals and reflects the diverse professional backgrounds of our members, including nurses, allied health professionals, and healthcare scientists (in this document referred to collectively as Nurses and Allied Professionals).

Blended Learning in Health Care Education: An Overview and Overarching Meta-analysis of Systematic Reviews.

INTRODUCTION: Blended learning is an educational approach that integrates face-to-face with online instruction. This overview of existing systematic reviews aims to evaluate the impact of blended learning on educational outcomes in health care professional education, identify gaps in the current evidence, and direction for future reviews. METHODS: Five databases were searched (January 1, 2000 to January 14, 2021) for systematic reviews of blended versus nonblended learning approaches for health care education. "Flipped classroom", unpublished studies, abstracts, and study protocols were excluded. The extracted data included details of included reviews, description of populations, and outcomes according to Kirkpatrick levels. A narrative review is presented, along with an overarching meta-analysis, which evaluates a synthesized estimate of the effect of blended learning based on standardized mean differences. RESULTS: Eleven systematic reviews were included, comprising of 160 primary studies (including 117 randomized controlled trials) from 56 countries with over 18,000 participants. The overall level of evidence was very low quality. An overarching meta-analysis of 93 studies addressing knowledge acquisition favored blended over nonblended learning methods (standardized mean difference 0.768 [95% confidence interval 0.594-0.941]; P < .001). None of the reviews identified an adverse effect on other educational outcomes. DISCUSSION: Blended learning may be superior to traditional teaching approaches in improving knowledge acquisition. We recommend further research to describe the relative benefits of blended learning in each individual context and identify which elements of instructional design are beneficial for each outcome. Finally, we recommend the use of clear and consistent terminology in reported studies.

Development and user-testing of a digital patient decision aid to facilitate shared decision-making for people with stable angina.

BACKGROUND: Research shows that people with stable angina need decision support when considering elective treatments. Initial treatment is with medicines but patients may gain further benefit with invasive percutaneous coronary intervention (PCI). Choosing between these treatments can be challenging for patients because both confer similar benefits but have different risks. Patient decision aids (PtDAs) are evidence-based interventions that support shared decision-making (SDM) when making healthcare decisions. This study aimed to develop and user-test a digital patient decision aid (CONNECT) to facilitate SDM for people with stable angina considering invasive treatment with elective PCI. METHODS: A multi-phase study was conducted to develop and test CONNECT (COroNary aNgioplasty dECision Tool) using approaches recommended by the International Patient Decision Aid Standards Collaboration: (i) Steering Group assembled, (ii) review of clinical guidance, (iii) co-design workshops with patients and cardiology health professionals, (iv) first prototype developed and 'alpha' tested (semi-structured cognitive interviews and 12-item acceptability questionnaire) with patients, cardiologists and cardiac nurses, recruited from two hospitals in Northern England, and (v) final PtDA refined following iterative user-feedback. Quantitative data were analysed descriptively and qualitative data from the interviews analysed using deductive content analysis. RESULTS: CONNECT was developed and user-tested with 34 patients and 29 cardiology health professionals. Findings showed that CONNECT was generally acceptable, usable, comprehensible, and desirable. Participants suggested that CONNECT had the potential to improve care quality by personalising consultations and facilitating SDM and informed consent. Patient safety may be improved as CONNECT includes questions about symptom burden which can identify asymptomatic patients unlikely to benefit from PCI, as well as those who may need to be fast tracked because of worsening symptoms. CONCLUSIONS: CONNECT is the first digital PtDA for people with stable angina considering elective PCI, developed in the UK using recommended processes and fulfilling international quality criteria. CONNECT shows promise as an approach to facilitate SDM and should be evaluated in a clinical trial. Further work is required to standardise the provision of probabilistic risk information for people considering elective PCI and to understand how CONNECT can be accessible to underserved communities.

Poor adherence to lifestyle recommendations in patients with coronary heart disease: results from the EUROASPIRE surveys.

AIMS: Despite the high use of cardioprotective medications, the risk factor control in patients with coronary heart disease (CHD) is still inadequate. Guidelines identify healthy lifestyles as equally important in secondary prevention as pharmacotherapy. Here, we describe reasons for poor lifestyle adherence from the patient's perspective. METHODS AND RESULTS: In the EUROASPIRE IV and V surveys, 16 259 CHD patients were examined and interviewed during a study visit ≥6 months after hospital discharge. Data gathering was fully standardized. The Brief Illness Perception questionnaire was completed by a subsample of 2379 patients. Half of those who were smoking prior to hospital admission, were still smoking; 37% of current smokers had not attempted to quit and 51% was not considering to do so. The prevalence of obesity was 38%. Half of obese patients tried to lose weight in the past month and 61% considered weight loss in the following month. In relation to physical activity, 40% was on target with half of patients trying to do more everyday activities. Less than half had the intention to engage in planned exercise. Only 29% of all patients was at goal for all three lifestyle factors. The number of adverse lifestyles was strongly related to the way patients perceive their illness as threatening. Lifestyle modifications were more successful in those having participated in a cardiac rehabilitation and prevention programme. Patients indicated lack of self-confidence as the main barrier to change their unhealthy behaviour. CONCLUSION: Modern secondary prevention programmes should target behavioural change in all patients with adverse lifestyles.

The Role of Acceptance and Commitment Therapy in Cardiovascular and Diabetes Healthcare: A Scoping Review.

Acceptance and commitment therapy (ACT) is an adapted form of cognitive behavioural therapy. ACT focuses on how thinking affects behaviour and promotes psychological flexibility. The prevalence of psychological distress among people living with cardiovascular disease (CVD) and/or type 2 diabetes mellitus (T2DM) is high, and ACT may offer an alternative treatment approach. This scoping review explored the use of ACT as an intervention to support adults living with CVD and/or T2DM. A systematic search of the literature resulted in the inclusion of 15 studies. Studies were reviewed using the Joanna Briggs Institute approach to conducting scoping reviews. Most studies (n = 13) related to people living with T2DM, and most (n = 10) used a pre-post design, four studies were randomised controlled trials, and one was a qualitative study. Eight studies reported an improvement in the outcome(s) assessed post-intervention, suggesting that ACT was an acceptable and valid intervention to support people living with CVD or T2DM. However, studies were underpowered and only limited studies involved people living with CVD. ACT was assessed as a valuable approach to improve a range of patient-reported outcomes for those living with CVD or T2DM, and further research involving robust study designs and larger cohorts are warranted.

Coronary risk reduction intervention for siblings and offspring of patients with premature coronary heart disease: the CRISO study protocol for a randomised controlled pilot study.

BACKGROUND: Research has consistently demonstrated that preventive cardiology programs have limited success, and healthy practices among high-risk individuals remain suboptimal. Furthermore, there are no current programmes in Malta that offer support to first-degree relatives of patients with premature coronary heart disease. This internal pilot study will determine the feasibility, acceptability, and potential effectiveness of a preventative intervention. METHODS/DESIGN: We are conducting a 12-month single-centre, two-armed group randomised controlled trial (RCT), recruiting a sample of 100 asymptomatic first-degree relatives of patients with premature coronary heart disease (CHD). The study seeks to test an evidence-based intervention to reduce modifiable risk and determine its feasibility and acceptability. The Intervention will be delivered at an outpatient office based in a large acute academic hospital. It will comprise risk communication using an online risk calculator, a counselling style adapted from motivational interviewing, and 12 weekly telephone goal reinforcement calls (3 months). Control subjects will receive verbal lifestyle advice only. Feasibility will be assessed through recruitment and retention. Qualitative evaluation interviews will be conducted with a subsample of 24 purposefully selected participants at 12 months. Assessment for risk factor changes will be measured at pre-intervention and 6 and 12 months. Associations between variables will also be assessed descriptively. DISCUSSION: Preventive cardiology guidelines highlighted the importance of lifestyle interventions, and lifestyle intervention adherence was proven to reduce atherosclerotic cardiovascular disease (ASCVD) risk, regardless of the individual's genetic risk. Preventive cardiology programmes may fail to adequately support persons in modifying risky behaviours, and research demonstrates that healthy practices among high-risk individuals can remain suboptimal. Siblings and offspring of patients with premature CHD are at increased risk of ASCVD. Despite this, there is no process in place for routine screening and support to modify risk. It is hypothesised that participants assigned to the intervention arm will show more cardio-protective lifestyle-related improvement from the baseline than those in the control group. To date, this is the first trial being conducted amongst Maltese first-degree relatives. This study addresses the needed research, and the results will inform a definitive trial. The funding institution is the University of Malta. TRIAL REGISTRATION: ISRCTN, ISRCTN21559170 ; Registered 06/08/2020.

Educational theory and its application to advanced life support courses: a narrative review.

The knowledge, skills and attitudes taught on Advanced Life Support (ALS) courses are an important learning requirement for healthcare professionals who are involved with the care of acutely unwell patients. It is essential that the course design and delivery is appropriately planned to ensure that it optimises the learning opportunities for all learners. This paper offers a narrative review of how the application of educational theory has positively influenced the evolution of ALS courses since their inception in the late twentieth century. By embracing and understanding the relevant educational theories, the ALS course design has transformed from a predominantly lecture-based and behaviourist approach, to a more participative and social constructivist approach to learning. In addition, the advent of smarter technology and the challenges posed by the COVID-19 pandemic have facilitated a more connectivist approach to learning. It can therefore be demonstrated that the ALS course is influenced by a combination of theoretical approaches and provides a diverse framework of teaching and learning strategies that cater for many individual learning styles. Any further evolution and development of the course should be based upon contemporary educational theory to ensure that it remains fit for purpose.

Grounded theory: what makes a grounded theory study?

Grounded theory (GT) is both a research method and a research methodology. There are several different ways of doing GT which reflect the different viewpoints of the originators. For those who are new to this approach to conducting qualitative research, this can be confusing. In this article, we outline the key characteristics of GT and describe the role of the literature review in three common GT approaches, illustrated using exemplar studies.

Physical Activity and Cardiac Self-Efficacy Levels During Early Recovery After Acute Myocardial Infarction: A Jordanian Study.

BACKGROUND: Regular physical activity is important for patients with established coronary heart disease as it favorably influences their coronary risk profile. General self-efficacy is a powerful predictor of health behavior change that involves increases in physical activity levels. Few studies have simultaneously measured physical activity and self-efficacy during early recovery after a first acute myocardial infarction (AMI). PURPOSE: The aims of this study were to assess changes in objectively measured physical activity levels at 2 weeks (T2) and 6 weeks (T3) and self-reported cardiac self-efficacy at hospital discharge (T1) and at T2 and T3 in patients recovering from AMI. METHODS: A repeated-measures design was used to recruit a purposive sample of patients from a single center in Jordan who were diagnosed with first AMI and who did not have access to cardiac rehabilitation. A body-worn activity monitor (activPAL) was used to objectively measure free-living physical activity levels for 7 consecutive days at two time points (T2 and T3). An Arabic version of the cardiac self-efficacy scale was administered at T1, T2, and T3. Paired t tests and analysis of variance were used to examine differences in physical activity levels and cardiac self-efficacy scores, respectively. RESULTS: A sample of 100 participants was recruited, of which 62% were male. The mean age of the sample was 54.5 ± 9.9 years. No statistically significant difference in physical activity levels was measured at 2 weeks (T2) and 6 weeks (T3). Cardiac self-efficacy scores improved significantly between T1, T2, and T3 across subscales and global cardiac self-efficacy. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Participants recovering from AMI in Jordan did not increase their physical activity levels during the early recovery phase, although cardiac self-efficacy scores improved. This may be because the increase in cardiac self-efficacy was not matched by the practical skills and knowledge required to translate this positive psychological construct into behavioral change. This study provides a first step toward understanding the complex relationship between cardiac self-efficacy and physical activity in this population. The authors hope that these findings support the design of culturally appropriate interventions to increase physical activity levels in this population.

Motivational interviewing to support modifiable risk factor change in individuals at increased risk of cardiovascular disease: A systematic review and meta-analysis.

BACKGROUND: Programmes using motivational interviewing show potential in facilitating lifestyle change, however this has not been well established and explored in individuals at risk of, yet without symptomatic pre-existent cardiovascular disease. The objective of this systematic review and meta-analysis was to determine the effectiveness of motivational interviewing in supporting modifiable risk factor change in individuals at an increased risk of cardiovascular disease. METHODS: Systematic review and meta-analysis with results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-related databases were searched for randomised controlled trials from 1980 to March 2020. Criteria for inclusion included; preventive programmes, motivational interviewing principles, modification of cardiovascular risk factors in adults of both genders, different ethnicities and employment status, and having at least 1 or more modifiable cardiovascular risk factor/s. Two reviewers independently extracted data and conducted a quality appraisal of eligible studies using an adapted Cochrane framework. The Cochrane framework supports to systematically identify, appraise and synthesize all the empirical evidence that meets the pre-specified eligibility criteria to answer a specific question. FINDINGS: A total of 12 studies met the inclusion criteria. While completeness of intervention reporting was found to be adequate, the application of motivational interviewing was found to be insufficiently reported across all studies (mean overall reporting rate; 68%, 26% respectively). No statistical difference between groups in smoking status and physical activity was reported. A random effects analysis from 4 studies was conducted, this determined a synthesized estimate for standardised mean difference in weight of -2.00kg (95% CI -3.31 to -0.69 kg; p = 0.003), with high statistical heterogeneity. Pooled results from 4 studies determined a mean difference in LDL-c of -0.14mmol/l (5.414mg/dl), which was non-significant. The characteristics of interventions more likely to be effective were identified as: use of a blended approach delivered by a nurse expert in motivational interviewing from an outpatient-clinic. The application of affirmation, compassion and evocation, use of open questions, summarising, listening, supporting and raising ambivalence, combining education and barrier change identification with goal setting are also important intervention characteristics. CONCLUSIONS: While motivational interviewing may support individuals to modify their cardiovascular risk through lifestyle change, the effectiveness of this approach remains uncertain. The strengths and limitations of motivational interviewing need to be further explored through robust studies.

Self-management support activities in primary care: A qualitative study to compare provision across common health problems.

OBJECTIVE: To explore the views of primary care teams about the provision of self-management support to patients with common health problems. METHODS: Semi-structured interviews were conducted with twenty-one members of the primary care team from thirteen general practices. Interviews were transcribed verbatim, and analysed using the 'Framework' approach. RESULTS: Three categories and six sub-categories illustrating different self-management support activities across common health problems were identified from the analysis of interviews, and contributed to one major theme and one cross-cutting theme. Referral and signposting were frequently used to facilitate patient engagement with external services and resources. Practitioners faced some challenges in balancing medical management and psychosocial support and motivating patients to engage with self-management. CONCLUSIONS: Primary care teams described providing a wide range of self-management support activities, but the pattern of use varied for different types of health problem. These patterns may have been influenced, in part, by general practices focusing upon achieving financially incentivised quality improvement goals. PRACTICE IMPLICATIONS: To improve self-management support, practitioners need a digital repository of services/resources, motivational interviewing skills, an understanding of the optimum duration and pattern of consultations, and incentivised targets that match a biopsychosocial model of care.

Frequency of anxiety after stroke: An updated systematic review and meta-analysis of observational studies.

BACKGROUND: Anxiety is a common and distressing problem after stroke. AIMS: To undertake an updated systematic review and meta-analysis of observational studies of anxiety after stroke and integrate the findings with those reported previously. SUMMARY OF REVIEW: Multiple databases were searched in May 2018 and 53 new studies were included following dual independent sifting and data extraction. These were combined with 44 previous studies to form a combined data set of 97 studies, comprising 22,262 participants. Studies using interview methods were of higher quality. Rates of anxiety by interview were 18.7% (95% confidence interval 12.5, 24.9%) and 24.2% (95% confidence interval 21.5, 26.9%) by rating scale. Rates of anxiety did not lower meaningfully up to 24 months after stroke. Eight different anxiety subtypes were also reported. CONCLUSIONS: This review confirms that anxiety occurs in around one in four patients (by rating scale) and one in five patients (by interview). More research on anxiety subtypes is needed for an informed understanding of its effects and the development of interventions.

A systematic review and thematic synthesis exploring how a previous experience of physical activity influences engagement with cardiac rehabilitation.

BACKGROUND: Exercise-based cardiac rehabilitation is recognised internationally as an effective therapy to improve quality of life and reduce the risk of hospital readmission for individuals diagnosed with acute coronary syndrome. Despite this, half of eligible individuals choose not to engage and the main reason is lack of interest. Furthermore, prior to attending, 40% of eligible individuals report meeting physical activity guidelines. It is unclear whether this influences decisions about engagement. AIMS: The aim of this review is to examine systematically qualitative evidence describing patients' perceptions and experiences, and synthesise what is known about how a previous experience of physical activity in adults diagnosed with acute coronary syndrome influences engagement with physical activity during cardiac rehabilitation. METHODS: A systematic review and thematic synthesis was conducted of primary qualitative studies to examine peer-reviewed literature published between1990 and 2017, accessed from database searches of MEDLINE, CINHAL, PsycINFO and Embase. RESULTS: The initial search produced 486 studies, and of these 12 relevant studies were included in this review. Studies included 388 participants from six countries. For previously active individuals, communication factors, self-perceptions of an exercise identity and experience of cardiac rehabilitation influence engagement in physical activity during cardiac rehabilitation. CONCLUSION: In adults diagnosed with acute coronary syndrome, communication post event and during cardiac rehabilitation is a source of self-appraisal and creates expectations of cardiac rehabilitation. In addition, perceptions of an exercise identity and experience of exercise-based cardiac rehabilitation influence decisions about engagement. To improve uptake and adherence, health professionals should consider previous physical activity levels and tailor information to optimise physical activity post event.

Cardiologists' and patients' views about the informed consent process and their understanding of the anticipated treatment benefits of coronary angioplasty: A survey study.

BACKGROUND: Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments. AIM: To assess cardiologists' and patients' views about the informed consent process and anticipated treatment benefits. METHODS: Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres. RESULTS: A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients' and cardiologists' views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative. CONCLUSIONS: The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as 'teach back' and decision support which improve patient comprehension.

Patients' Experiences of Cardiovascular Health Education and Risk Communication: A Qualitative Synthesis.

Coronary heart disease (CHD) has no cure, and patients with myocardial infarction are at high risk for further cardiac events. Health education is a key driver for patients' understanding and motivation for lifestyle change, but little is known about patients' experience of such education. In this review, we aimed to explore how patients with CHD experience health education and in particular risk communication. A total of 2,221 articles were identified through a systematic search in five databases. 40 articles were included and synthesized using thematic analysis. Findings show that both "what" was communicated, and "the way" it was communicated, had the potential to influence patients' engagement with lifestyle changes. Communication about the potential of lifestyle change to reduce future risk was largely missing causing uncertainty, anxiety, and, for some, disengagement with lifestyle change. Recommendations for ways to improve health education and risk communication are discussed to inform international practice.

Environmental noise levels in hospital settings: A rapid review of measurement techniques and implementation in hospital settings.

BACKGROUND: Hospitals provide treatment to improve patient health and well-being but the characteristics of the care environment receive little attention. Excessive noise at night has a negative impact on in-patient health through disturbed sleep. To address this hospital staff must measure night-time environmental noise levels. Therefore, an understanding of environmental noise measurement techniques is required. In this review, we aim to 1) provide a technical overview of factors to consider when measuring environmental noise in hospital settings; 2) conduct a rapid review on the equipment and approaches used to objectively measured noise in hospitals and identify methodological limitations. DESIGN: : A rapid review of original research articles, from three databases, published since 2008. Studies were included if noise levels were objectively measured in a hospital setting where patients were receiving treatment. RESULTS: 1429 articles were identified with 76 included in the review. There was significant variability in the approaches used to measure environmental noise in hospitals. Only 14.5% of studies contained sufficient information to support replication of the measurement process. Most studies measured noise levels using a sound level meter positioned closed to a patient's bed area in an intensive care unit. CONCLUSION: : Unwanted environmental noise in hospital setting impacts negatively on patient and staff health and well-being. However, this literature review found that the approaches used to objectively measure noise level in hospital settings have been inconsistent and poorly reported. Recommendations on best-practice methods to measure noise levels in hospital environments are provided.