Use of health services and perceived need for information and follow-up after percutaneous coronary intervention.

OBJECTIVE: Few patients achieve full control of their coronary artery disease (CAD) risk factors. Follow-up, such as cardiac rehabilitation, is important to increase adherence to lifestyle changes and treatment, to improve the patient's risk profile, and to treat established complications of CAD clinical events. However, the type of follow-up patients receive varies. Therefore, the aim of this research note was to describe and compare patients' self-reported use of health services, the type of follow-up patients reported to prefer, and the type of information patients reported to be important, in two countries with different follow-up practices after PCI. RESULTS: We included 3417 patients in Norway and Denmark, countries with different follow-up strategies after PCI. The results showed large differences between the countries regarding health services used. In Denmark the most frequently used health services were consultations at outpatient clinics followed by visits to the general practitioner and visits to the fitness centre, whereas in Norway visits to the general practitioner were most common, followed by rehospitalisation and no follow-up used. However, patients found the same type of follow-up and information important in both countries. Patients' perceived need for follow-up and information decreased over time, suggesting a need for early follow-up when the patients are motivated. TRIAL REGISTRATION: NCT03810612 (18/01/2019).

Screening for - and prevalence of - anxiety and depression in cardiac rehabilitation in the post-COVID era. An observational study.

BACKGROUND: Approximately 20-30% of patients with a cardiac disease suffer from anxiety and/or depression, leading to poor health outcomes. To identify this subgroup, clinical guidelines recommend screening for anxiety and depression in cardiac rehabilitation (CR). It is unknown how screening practice is delivered post-COVID. METHODS: This observational study used data from the National Audit of Cardiac Rehabilitation from April 2018-March 2022. Descriptive statistics were used to assess screening rates and prevalence, while a multivariate logistic regression model was performed to analyse determinants for screening for anxiety and depression among patients participating in cardiac rehabilitation. RESULTS: The population consisted of 245,705 patients, where 128,643 (52.4%) were screened and 117,062 (47.6%) were not. Patients attending CR during first year of COVID-19 were less likely to be screened. Patients with female gender, living alone, non-white ethnicity, living in the most deprived areas, current smoking, and physical inactivity were less likely to be screened, while patients who were revascularized, having an objective physical fitness test, and attending a certified CR center were more likely to be screened. For patients attending CR during COVID-19, the prevalence of anxiety and depression decreased significantly. For anxiety the prevalence dropped from 34.4% to 15.8%, for depression the prevalence dropped from 33.5% to 16.5%. CONCLUSION: CR service provision was negatively impacted during COVID-19, leading to much lower screening for anxiety and depression in the CR setting. Prevalence of anxiety and depression decreased during COVID-19 for this population, possibly because psychologically affected patients refrained from attending CR.

Screening for anxiety and depression in clinical practice: translating scores from World Health Organization-5/Anxiety Symptom Scale-2/Major Depression Inventory-2 to Hospital Anxiety and Depression Scale.

AIMS: The aim of this study was to evaluate if a combination of World Health Organization-5 (WHO-5), Anxiety Symptom Scale-2 (ASS-2), and Major Depression Inventory-2 (MDI-2) can replace the Hospital Anxiety and Depression Scale (HADS) as screening tool for anxiety and depression in cardiac patients across diagnoses and whether it is feasible to generate crosswalks (translation tables) for use in clinical practice. METHODS AND RESULTS: We used data from the Danish 'Life with a heart disease' survey, in which 10 000 patients with a hospital contact and discharge diagnosis of ischaemic heart disease, heart failure, heart valve disease, or atrial fibrillation in 2018 were invited. Potential participants received an electronic questionnaire including 51 questions on health, well-being, and evaluation of the health care system. Crosswalks between WHO-5/ASS-2 and HADS anxiety dimension (HADS-A) and between WHO-5/MDI-2 and HADS depression dimension (HADS-D) were generated and tested using item response theory (IRT). A total of 4346 patients responded to HADS, WHO-5, ASS-2, and MDI-2. Model fit of the bi-factor IRT models illustrated appropriateness of a bi-factor structure and thus of essential uni-dimensionality [root mean square error of approximation (RMSEA) (P value) range 0.000-0.053 (0.0099-0.7529) for anxiety and 0.033-0.061 (0.0168-0.2233) for depression]. A combination of WHO-5 and ASS-2 measured the same trait as HADS-A, and a combination of WHO-5 and MDI-2 measured the same trait as HADS-D. Consequently, crosswalks (translation tables) were generated. CONCLUSIONS: Our study shows that it is feasible to use crosswalks between HADS-A and WHO-5/ASS-2 and HADS-D and WHO-5/MDI-2 for screening cardiac patients across diagnoses for anxiety and depression in clinical practice.

This large, national survey of cardiac patients study shows that the psychometric scales, World Health Organization-5 (WHO-5), Anxiety Symptom Scale-2 (ASS-2), and Major Depression Inventory-2 (MDI-2), can be used instead of the Hospital Anxiety and Depression Scale (HADS) in follow-up care when screening for anxiety and depression in cardiac patients: The combination of the questionnaires, WHO-5, ASS-2, and MDI-2, can replace the HADS questionnaire.Translation tables (crosswalks) are presented for use in clinical practice.

A web-based intervention for patients with an implantable cardioverter defibrillator - A qualitative study of nurses' experiences (Data from the ACQUIRE-ICD study).

Objective: The aim of this study was to explore cardiac nurses' experiences with a comprehensive web-based intervention for patients with an implantable cardioverter defibrillator. Methods: We conducted an explorative qualitative study based on individual semi-structured interviews with 9 cardiac nurses from 5 Danish university hospitals. Results: We found one overall theme: "Between traditional nursing and modern eHealth". This theme was derived from the following six categories: (1) comprehensive content in the intervention, (2) patient-related differences in engagement, (3) following the protocol is a balancing act, (4) online communication challenges patient contact, (5) professional collaboration varies, and (6) an intervention with potential. Cardiac nurses were positive towards the web-based intervention and believe it holds a large potential. However, they felt challenged by not having in-person and face-to-face contact with patients, which they found valuable for assessing patients' wellbeing and psychological distress. Conclusion: Specific training in eHealth communication seems necessary as web-based care entails a shift in the nursing role and requires a different way of communication.InnovationFocusing on the user experience in web-based care from the perspective of cardiac nurses is innovative, and by applying implementation science this leads to new knowledge to consider when developing and implementing web-based care.

Return to work: does cardiac rehabilitation make a difference? Danish nationwide register-based study.

AIM: to assess whether participation in cardiac rehabilitation affects the probability of returning to work after ischaemic heart disease. METHODS: the study population consisted of 24,509 patients (18-70 years of age) discharged from an inpatient admission at a Danish hospital during 2014-2018 and who were working before their admission. Only patients with a percutaneous coronary intervention or coronary artery bypass grafting surgery procedure and ICD-10 codes I20-I25 as their main diagnosis or ICD-10 codes I21, I240, I248 or I249 as secondary diagnosis during an emergency admission were included. Exposure was defined as participation in cardiac rehabilitation (N = 15,742), and binary indicator of being at work in the last week of a given month were used as primary outcomes. Coarsened exact matching (CEM) of exposed and unexposed patients was used to reduce selection bias. Logistic regression models were applied on the matched population (N = 15,762). RESULTS: Less deprived and less comorbid patients were more likely to receive cardiac rehabilitation. CEM succeeded in arriving at a population where this selection was reduced and in this population we found that patients who received cardiac rehabilitation had a lower probability of returning to work after 3 months (OR 0.81, 95%CI: 0.77-0.84), a higher but insignificant probability after 6 (OR 1.02, 95%CI: 0.97-1.08), and a higher probability after 9 (OR 1.08, 95%CI: 1.02-1.15) and 12 months (OR 1.20, 95%CI: 1.13-1.28). CONCLUSIONS: Deprived and comorbid patients have lower use of cardiac rehabilitation. In a matched population where this bias is reduced, cardiac rehabilitation will increase the probability of returning to work.

Effects of screening for anxiety and depression in patients with ischaemic heart disease - a nationwide Danish register study.

AIM: To investigate the effect of screening for anxiety and depression (AD) in patients with ischaemic heart disease (IHD) on the likelihood of receiving treatment for AD. METHODS: We used a nationwide dataset of all Danish patients with an incident IHD diagnosis in the period 2015-2018 (N = 80,701) of which 20,461 (25%) were exposed to screening for AD as part of cardiac rehabilitation. A binary composite indicator for the use of any AD treatment (prescriptions of AD drugs, general practitioner (GP) counselling or referral to a psychologist), was modelled as the dependent variable. The probability of receiving AD treatment was estimated using linear probability and instrumental variable regression models. RESULTS: Exposure to AD screening was lower for patients with low income (change in probability -0.67, 95% CI -0.76; -0.59), low education (change in probability -0.16, 95% CI -0.20; -0.13), and a high comorbidity burden (change in probability -0.09, 95% CI -0.10; -0.07). Screened patients had a lower conditional probability of AD treatment (change in probability -0.0061, p < 0.001) than non-screened patients. The patient's GP also had an impact on the probability of being referred for AD treatment. Using an instrumental variable approach did not affect the results. CONCLUSIONS: Screening for AD was subject to selection at the patient level; patients at lower risk of AD had a higher probability of being screened. Hence, extending systematic screening to cover a larger population may not achieve a noticeable increase in the uptake of AD treatment if it is not supported by appropriate measures to reduce reverse selection into screening.

Implementation of systematic screening for anxiety and depression in cardiac rehabilitation: Real world lessons from a longitudinal study.

AIMS: Systematic screening for anxiety and depression is widely recommended as a core component of cardiac rehabilitation in ischemic heart disease, however, recommendation-practice gaps are common and limited knowledge exists about factors hindering and supporting implementation. The study aimed to assess adherence to national clinical guideline recommendations and to gain a greater understanding of the implementation of screening in real-world practice. METHODS: An observational, longitudinal mixed-methods design including hospitals and municipalities in Denmark. We retrieved nationwide survey data from 2013, 2015, 2018 and 2021 to assess adherence to screening on programme level, and clinical quality registry data from 2016 to 2020 to assess proportion of patients screened. Data were analysed descriptively. Semi-structured interviews with healthcare professionals were conducted in 2015 (n = 11) and 2020 (n = 11) to explore how screening was conducted and factors supporting implementation. Normalization Process Theory guided interviews and content analysis. RESULTS: Screening on programme level increased from 61% to 88% in hospitals and 20% to 89% in municipalities. The individual proportion of patients screened remained relatively stable in both hospitals and municipalities overall, however with considerable inter-site differences. Screening practices became more aligned to guidelines, pushed by formal recommendations and monitoring, and pulled by activities strengthening the knowledge and motivation among staff. CONCLUSION: Screening for anxiety and depression improved considerably over the seven-year period, from a scattered practice driven by individuals to a movement where healthcare professionals had a feeling of going with the flow. Nationwide implementation of screening requires national and local supporting activities and a continuous effort.

Systematic screening for anxiety and depression in cardiac rehabilitation - are we there yet?

BACKGROUND: Anxiety and depression are prevalent in 20% of patients with acute coronary syndrome (ACS) and associated with poor outcomes. Guidelines recommend screening for these conditions in cardiac rehabilitation (CR) however, clinical practice is inconsistent. Sparse knowledge exists on determinants for screening. METHODS: This observational study used data from the National Audit of Cardiac Rehabilitation from January 2016-December 2019. A multivariate logistic regression model was performed to analyze patient- and provider level determinants for screening for anxiety and depression among patients with ACS. RESULTS: The population consisted of 138,018 patients, where 82,507 (59.8%) were screened and 55,511 (40.2%) were not. Younger age, non-white ethnicity, living in areas of social deprivation, current smoking, body mass index>30, and physical activity<150 min per week were negatively correlated with patients being screened. Compared to patients having a percutaneous coronary intervention, patients undergoing coronary artery bypass grafting or medical treatment were less likely to be screened. History of anxiety, depression, osteoporosis, chronic back problems, and asthma were positively correlated with screening, while chronic obstructive pulmonary disease, diabetes, hypertension, and stroke were negatively correlated with screening. Regarding provider level, certification of CR centers was positively associated with screening, while looking over time data showed an incremental negative trend in screening from 2016 to 2019. CONCLUSION: We found both patient and provider level determinants of screening for anxiety and depression. Clinical practice is still inconsistent especially for high-risk groups. We recommend systematic screening to enable tailored interventions which in turn may mitigate inequity in health outcomes.

Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol.

BACKGROUND: One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care. METHODS: eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness. DISCUSSION: To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Internet-based treatment of anxiety and depression in patients with ischaemic heart disease attending cardiac rehabilitation: a feasibility study (eMindYourHeart).

Aims: Anxiety and depression are prevalent in 20% of patients with ischaemic heart disease (IHD); however, treatment of psychological conditions is not commonly integrated in cardiac rehabilitation (CR). Internet-based psychological treatment holds the potential to bridge this gap. To examine the feasibility of an eHealth intervention targeting anxiety and depression in patients with IHD attending CR. Methods and results: We used a mixed-methods design, including quantitative methods to examine drop-out and change in anxiety and depression scores, and qualitative methods (thematic analysis) to evaluate patients' and nurses' experiences with the intervention. The therapist-guided intervention consisted of 12 modules provided via a web-based platform. The primary outcome was drop-out, with a drop-out rate <25% considered acceptable. Patients were considered as non-drop-out if they completed ≥5 modules. Out of 60 patients screened positive for anxiety and/or depression, 29 patients were included. The drop-out rate was 24% (7/29). Patients had a mean improvement in anxiety and depression scores of 5.5 and 4.6, respectively. On average, patients had 8.0 phone calls with their therapist and 19.7 written messages. The qualitative analysis of patients' experiences identified four themes: treatment platform, intervention, communication with therapist, and personal experience. Patients were positive towards the intervention, although some found the assignments burdensome. From the nurses, we identified three themes: intervention, inclusion procedure, and collaboration with study team. The nurses were positive, however, due to limited time some struggled with the inclusion procedure. Conclusion: Integrating an eHealth intervention in CR is feasible and the drop-out rate acceptable.

Facilitators for using data from a quality registry in local quality improvement work: a cross-sectional survey of the Danish Cardiac Rehabilitation Database.

OBJECTIVES: To investigate use of data from a clinical quality registry for cardiac rehabilitation in Denmark, considering the extent to which data are used for local quality improvement and what facilitates the use of these data, with a particular focus on whether there are differences between frontline staff and managers. DESIGN: Cross-sectional nationwide survey study. SETTING, METHODS AND PARTICIPANTS: A previously validated, Swedish questionnaire regarding use of data from clinical quality registries was translated and emailed to frontline staff, mid-level managers and heads of departments (n=175) in all 30 hospital departments participating in the Danish Cardiac Rehabilitation Database. Data were analysed descriptively and through multiple linear regression. RESULTS: Survey response rate was 58% (101/175). Reports of registry use at department level (measured through an index comprising seven items; score min 0, max 7, where a low score indicates less use of data) varied significantly between groups of respondents: frontline staff mean score 1.3 (SD=2.0), mid-level management mean 2.4 (SD=2.3) and heads of departments mean 3.0 (SD=2.5), p=0.006. Overall, department level use of data was positively associated with higher perceived data quality and usefulness (regression coefficient=0.22, p=0.019), management request for data (regression coefficient=0.40, p=0.008) and personal motivation of the respondent (regression coefficient=1.63, p<0.001). Among managers, use of registry data was associated with data quality and usefulness (regression coefficient=0.43, p=0.027), and among frontline staff, reported data use was associated with management involvement in quality improvement work (regression coefficient=0.90, p=0.017) and personal motivation (regression coefficient=1.66, p<0.001). CONCLUSIONS: The findings suggest relatively sparse use of data in local quality improvement work. A complex interplay of factors seem to be associated with data use with varying aspects being of importance for frontline staff and managers.

"Struggling with practices" - a qualitative study of factors influencing the implementation of clinical quality registries for cardiac rehabilitation in England and Denmark.

BACKGROUND: The use of clinical quality registries as means for data driven improvement in healthcare seem promising. However, their use has been shown to be challenged by a number of aspects, and we suggest some may be related to poor implementation. There is a paucity of literature regarding barriers and facilitators for registry implementation, in particular aspects related to data collection and entry. We aimed to illuminate this by exploring how staff perceive the implementation process related to the registries within the field of cardiac rehabilitation in England and Denmark. METHODS: A qualitative, interview-based study with staff involved in collecting and/or entering data into the two case registries (England N = 12, Denmark N = 12). Interviews were analysed using content analysis. The Consolidated Framework for Implementation Research was used to guide interviews and the interpretation of results. RESULTS: The analysis identified both similarities and differences within and between the studied registries, and resulted in clarification of staffs´ experiences in an overarching theme: ´Struggling with practices´ and five categories; the data entry process, registry quality, resources and management support, quality improvement and the wider healthcare context. Overall, implementation received little focused attention. There was a lack of active support from management, and staff may experience a struggle of fitting use of a registry into a busy and complex everyday practice. CONCLUSION: The study highlights factors that may be important to consider when planning and implementing a new clinical quality registry within the field of cardiac rehabilitation, and is possibly transferrable to other fields. The results may thus be useful for policy makers, administrators and managers within the field and beyond. Targeting barriers and utilizing knowledge of facilitating factors is vital in order to improve the process of registry implementation, hence helping to achieve the intended improvement of care processes and outcomes.