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2.
BMJ Open ; 9(2): e022995, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30826789

RESUMO

INTRODUCTION: Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not. METHODS AND ANALYSES: In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score. ETHICS AND DISSEMINATION: This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals. TRIAL REGISTRATION NUMBER: NCT01842568.

3.
Patient Prefer Adherence ; 12: 1947-1954, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30319244

RESUMO

Purpose: Patients' values are a key component of patient-centered care and shared decision making in health care organizations. There is limited understanding on how patients' values guide their health related decision making or how patients understand the concept of values during these processes. This study investigated patients' understanding of their values in the context of considering the risks/benefits of receiving an implantable cardioverter-defibrillator (ICD). Patients and methods: A qualitative substudy was conducted within a feasibility trial with first-time ICD candidates randomized to receive a patient decision aid or usual care prior to specialist consultation. Semi-structured interviews were conducted with participants post-implantation or post-specialist consultation. Results: Sixteen patients (ten male) aged 47-87 years participated. Of these, ten (62.5%) received the patient decision aid prior to specialist consultation. Findings revealed patients were confused by the word "values" and had difficulty expressing values related to risks/benefits during ICD decision making. When probed, values were conceptualized broadly capturing other factors such as desire to live, good quality of life, family's views, ICD information, control over decision, and medical authority. Conclusion: This study revealed the difficulty patients considering an ICD had with articulating their values in the context of an ICD health decision and highlighted the challenge to effectively elicit patients' values within health decisions overall. It is suggested that there should be a shift away from the use of the word "values" when speaking directly to patients toward language such as "what matters to you the most" or "what is most important to you".

4.
Can J Cardiol ; 34(7): 850-862, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29960614

RESUMO

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.

5.
J Cardiovasc Nurs ; 33(5): 481-491, 2018 Sep/Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29601374

RESUMO

BACKGROUND: Because of battery depletion, an implantable cardioverter-defibrillator (ICD) generator requires surgical replacement every 5 to 7 years. Routine replacement is the norm without discussion with patients about whether or not to proceed. OBJECTIVE: The aim of this study was to develop a patient decision aid (PDA) for patients facing ICD replacement and plan for its implementation. METHODS: An embedded mixed-methods study was conducted using questionnaires and semistructured interviews focused on current ICD replacement practices; PDA acceptability, usability, and content; and PDA implementation. Transcripts were analyzed using constant comparative analysis. RESULTS: Eighteen PDA end users in 16 interviews characterized the current ICD replacement approach as automatic without consideration for patient preferences. The PDA was positively received, and the content was iteratively revised 4 times during the interviews. Changes were related to missing and excess information, language, and wording. The PDA was identified as a means to support a shared decision-making (SDM) process, not to be used as a standalone instrument. To shift current practices to an SDM process, participants identified that an invitation to discuss the option of ICD replacement is required-whether initiated by the patient or the clinician. CONCLUSION: Currently, the option of ICD replacement is rarely offered, and patient preferences are seldom elicited. Participants believed the PDA to be a useful intervention that could help facilitate an SDM process for patients facing ICD replacement. Preparing for implementation during the development phase will allow us to strategize effectively to overcome perceived barriers and capitalize on perceived facilitators during actual implementation.

6.
Curr Opin Cardiol ; 33(1): 42-49, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29216014

RESUMO

PURPOSE OF REVIEW: Strong recommendations exist for implantable cardioverter defibrillators (ICD) in appropriately selected patients. Yet, patient preferences are not often incorporated when decisions about ICD therapy are made. Literature published since 2016 was reviewed aiming to discuss current advances and ongoing challenges with ICD decision-making in adults, discuss shared decision-making (SDM) as a strategy to incorporate preference diagnoses, summarize current evidence on effective interventions to facilitate SDM, and identify opportunities for research and practice. RECENT FINDINGS: Advances in risk stratification can identify patients who will most and least likely benefit from the ICD. Interventions to support SDM are emerging. These interventions present options, the risks, and the benefits of each option, and elicit patients' values and preferences regarding possible outcomes. SUMMARY: Appropriate patient selection for initial or continued ICD therapy is multifactorial. It requires accurate clinical diagnosis using careful risk stratification and accurate preference diagnosis based upon the patient's preferences. SDM aims to unite the elements that constitute these two equally important diagnoses. High-quality decision-making will be difficult to achieve if patients lack or misunderstand information, and if evolving patient preferences are not incorporated when making decisions.


Assuntos
Tomada de Decisão Clínica , Morte Súbita Cardíaca/prevenção & controle , Tomada de Decisões , Desfibriladores Implantáveis , Participação do Paciente , Preferência do Paciente , Humanos , Seleção de Pacientes , Medição de Risco
7.
Artigo em Inglês | MEDLINE | ID: mdl-29201388

RESUMO

Background: Patient decision aids (PtDA) support quality decision-making. The aim of this research was to evaluate the feasibility of conducting a randomized controlled trial delivering an implantable cardioverter defibrillator (ICD)-specific PtDA to new ICD candidates and examining preliminary estimates of differences in outcomes. Methods: Prior to recruitment, ICD candidacy was determined. Consented patients were randomized to (1) usual care or (2) PtDA intervention. Feasibility outcomes included referral and recruitment rates, successful PtDA delivery, and completion of measures. The PtDA intervention was administered prior to specialist consultation and baseline demographics, and measures of decision quality including decisional conflict (DCS), SURE test (Sure of myself, Understand information, Risk-benefit ratio, Encouragement), patient's ICD specific values, ICD knowledge, and health-related quality of life were recorded. Post-consultation, participant's DCS was repeated and decisions to proceed, decline, or defer ICD implantation were collected. Feasibility data was determined using descriptive statistics (continuous and categorical). Preliminary estimates of differences in outcomes were assessed using mean differences. Concordance between values and decision choice was assessed using logistic regression of the intervention group. Results: We identified 135 eligible patients. Eighty-two consented to the trial randomizing patients to usual care (n = 41) or PtDA intervention (n = 41). Feasibility outcome results were (1) referral rate at approximately 20/month, (2) recruitment rate 61%, and (3) successful delivery of PtDA and study management. Pre-consultation, PtDA patients scored lower on the DCS scale (mean, standard deviation [SD] 27.3 (18.4) compared to usual care, 49.4 (18.6); the between-group difference in means [95% confidence interval (CI)] was - 22.1[- 30.23, - 13.97]. A difference remained post-implantation 21.2 (11.7), PtDA intervention 29.9 (13.3), and usual care - 8.7 [- 14.61, - 2.86]. SURE test results supported DCS differences. The PtDA group scored higher on the ICD-related knowledge questions, with 47.50% scoring greater than 3/5 of the knowledge questions correct, compared to 23.09% receiving usual care. The mean [SD] number of correct knowledge responses out of 5 was 3.33(1.19) in the PtDA group and 2.62 (1.16) in usual care pre-implant. Concordance between values and decision choice found a strong association between predicted and actual ICD implant status in the intervention group. Conclusion: Our results suggest that a future definitive trial is feasible. The ICD-specific PtDA shows promise with respect to preliminary estimates of differences in outcomes. Trial registration: NCT01876173.

8.
Patient Prefer Adherence ; 11: 1573-1583, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28979105

RESUMO

BACKGROUND: Patient engagement in research is a dominant discourse in clinical research settings as it is seen as a move toward sustainable and equitable health care systems. In Canada, a key driver is the Strategy for Patient-Oriented Research of the Canadian Institutes of Health Research, which asserts that meaningful patient engagement can only be fostered when stakeholders understand its value. This study assessed researchers' perceptions of the meaning and value of patient engagement in research within a Canadian cardiovascular research network. In doing so, the secondary aim was to inform the development of a structured patient engagement initiative by identifying potential challenges and related mitigation strategies. METHODS: We employed a multi-method strategy involving electronic surveys and semi-structured telephone interviews with network research scientists across Canada. Interview data were analyzed using thematic and content analysis. Survey data were analyzed using descriptive statistics. RESULTS: Thirty-eight electronic surveys (response rate =33%) and 16 interviews were completed with network members. Some participants were uncertain about the meaning and value of patient engagement. While voicing guarded support, four challenges relating to patient engagement were identified from the interviews: 1) identification of representative and appropriate patients, 2) uncertainty about the scope of patients' roles given concerns about knowledge discrepancies, 3) a perceived lack of evidence of the impact of patient engagement, and 4) the need for education and culture change as a prerequisite for patient engagement. Research scientists were largely concerned that patients untrained in science and tasked with conveying an authentic patient experience and being a conduit for the voices of others might unsettle a traditional model of conducting research. CONCLUSION: Concerns about patient involvement in research were related to a lack of clarity about the meaning, process, and impact of involvement. This study highlights the need for education on the meaning of patient engagement, evidence of its impact, and guidance on practical aspects of implementation within this research community.

9.
Res Nurs Health ; 40(2): 165-176, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27859452

RESUMO

Caregivers (CGs) contribute important assistance with heart failure (HF) self-care, including daily maintenance, symptom monitoring, and management. Until CGs' contributions to self-care can be quantified, it is impossible to characterize it, account for its impact on patient outcomes, or perform meaningful cost analyses. The purpose of this study was to conduct psychometric testing and item reduction on the recently developed 34-item Caregiver Contribution to Heart Failure Self-care (CACHS) instrument using classical and item response theory methods. Fifty CGs (mean age 63 years ±12.84; 70% female) recruited from a HF clinic completed the CACHS in 2014 and results evaluated using classical test theory and item response theory. Items would be deleted for low (<.05) or high (>.95) endorsement, low (<.3) or high (>.7) corrected item-total correlations, significant pairwise correlation coefficients, floor or ceiling effects, relatively low latent trait and item information function levels (<1.5 and p > .5), and differential item functioning. After analysis, 14 items were excluded, resulting in a 20-item instrument (self-care maintenance eight items; monitoring seven items; and management five items). Most items demonstrated moderate to high discrimination (median 2.13, minimum .77, maximum 5.05), and appropriate item difficulty (-2.7 to 1.4). Internal consistency reliability was excellent (Cronbach α = .94, average inter-item correlation = .41) with no ceiling effects. The newly developed 20-item version of the CACHS is supported by rigorous instrument development and represents a novel instrument to measure CGs' contribution to HF self-care. © 2016 Wiley Periodicals, Inc.


Assuntos
Cuidadores/estatística & dados numéricos , Insuficiência Cardíaca/enfermagem , Psicometria/estatística & dados numéricos , Autocuidado/métodos , Inquéritos e Questionários , Idoso , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
10.
Can J Cardiol ; 32(12): 1396-1401, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27474350

RESUMO

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a complex and clinically heterogeneous arrhythmic condition. Incomplete penetrance and variable expressivity are particularly evident in ARVC, making clinical decision-making challenging. METHODS: Pediatric and adult cardiologists, geneticists, genetic counsellors, ethicists, nurses, and qualitative researchers are collaborating to create the Canadian ARVC registry using a web-based clinical database. Biological samples will be banked and systematic analysis will be performed to examine potentially causative mutations, variants, and biomarkers. Outcomes will include syncope, ventricular arrhythmias, defibrillator therapies, heart failure, and mortality. RESULTS: Preliminary recruitment has enrolled 365 participants (aged 42.7 ± 17.1 years; 50% women), including 129 probands and 236 family members. Previous cardiac arrest occurred in 28 (8%) participants, syncope occurred in 43 (12%) participants, and 46% of probands had a family history of sudden death. Overall yield of genetic testing was 36% for a disease-causing mutation and 20% for a variant of unknown significance. Target enrollment is 1000 affected patients and 500 unaffected family member controls over 7 years. The cross-sectional and longitudinal data collected in this manner will allow a robust assessment of the natural history and clinical course of genetic subtypes. CONCLUSIONS: The Canadian ARVC Registry will create a population-based cohort of patients and their families to inform clinical decisions regarding patients with ARVC.


Assuntos
Displasia Arritmogênica Ventricular Direita , Morte Súbita Cardíaca , Administração dos Cuidados ao Paciente , Equipe de Assistência ao Paciente/organização & administração , Taquicardia Ventricular , Adulto , Displasia Arritmogênica Ventricular Direita/complicações , Displasia Arritmogênica Ventricular Direita/diagnóstico , Displasia Arritmogênica Ventricular Direita/epidemiologia , Displasia Arritmogênica Ventricular Direita/genética , Canadá/epidemiologia , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desmocolinas/genética , Feminino , Testes Genéticos/estatística & dados numéricos , Testes de Função Cardíaca/métodos , Testes de Função Cardíaca/estatística & dados numéricos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Comunicação Interdisciplinar , Colaboração Intersetorial , Masculino , Proteínas de Membrana/genética , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/organização & administração , Sistema de Registros/estatística & dados numéricos , Medição de Risco/métodos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/mortalidade
11.
Pacing Clin Electrophysiol ; 39(7): 709-22, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26969818

RESUMO

BACKGROUND: Every 4-7 years an implantable cardioverter defibrillator (ICD) pulse generator must be replaced surgically. This procedure is not without risk. In some cases, the risk versus benefit ratio may be against replacement. We aimed to synthesize the evidence on risks, benefits, and costs related to ICD replacement. METHODS: A systematic review was conducted using electronic databases from 2000 onward. Literature screening, quality appraisal, and data extraction were independently conducted by two reviewers. Outcomes included major and minor complications, ICD therapies, and costs, which were synthesized descriptively. RESULTS: Of 1,483 citations, 17 nonrandomized studies met criteria. Median rate of major complications was 4.05% (range 0.55-7.37%) and minor complications was 3.50% (range 0.36-7.37%). Without non-ICD control groups, the true risk reduction provided by the ICD following replacement is unknown. Following ICD replacement, annualized rate of appropriate ICD therapy was 10.52% (range 2.42-75.00%). Of these, patients without therapies during their first generator life and those no longer meeting ICD criteria received appropriate therapies at nontrivial rates. CONCLUSION: Rates of complications associated with ICD replacement are substantial. No study had nonreplacement groups, hence the true risk reduction provided by the ICD following replacement is unknown. Our analysis did not identify a subgroup at low risk of therapies following replacement. Shared discussions should occur with patients about the evidence, healthcare goals, risk tolerances, and feelings about life and death trade-offs to enable high-quality decisions about ICD replacement.


Assuntos
Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/estatística & dados numéricos , Remoção de Dispositivo/mortalidade , Implantação de Prótese/mortalidade , Implantação de Prótese/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Falha de Equipamento/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco/métodos , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
12.
Eur J Cardiovasc Nurs ; 15(7): 486-494, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-26498908

RESUMO

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe symptomatic aortic stenosis at increased surgical risk and likely to derive benefit. Multimodality and multidisciplinary assessment is required for the heart team to determine eligibility for TAVI in a primarily older population. Little is known about patients' motivation and perspectives on making the decision to undergo the complex assessment. AIMS: To explore factors influencing patients' decision making to undergo TAVI eligibility assessment to inform practice, programme development, health policy and future research. METHODS: An exploratory qualitative approach was used. Semistructured interviews were conducted with 15 patients at the time of their referral for assessment to a quaternary cardiac and high volume TAVI centre. RESULTS: Multiple, intersecting factors that included biomedical, functional, social and environmental considerations influenced patients' decision. The six distinct factors were symptom burden, participants' perception as 'experienced' patients, expectations of benefit and risks, healthcare system and informal support, logistical barriers and facilitators, and obligations and responsibilities. CONCLUSIONS: The decision to undergo TAVI eligibility assessment is multifaceted and complex. Programmatic processes of care must be in place to facilitate appropriate and patient-centered decision making and access to TAVI. Strategies are required to mitigate the risks associated with the rapid deterioration of severe aortic stenosis, address patient and referring physicians' education needs, and provide individualised care and equitable access. Future research must focus on patients' experiences throughout the trajectory of TAVI care.


Assuntos
Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Estenose da Valva Aórtica , Cateterismo Cardíaco , Próteses Valvulares Cardíacas , Humanos , Fatores de Risco , Resultado do Tratamento
13.
Curr Opin Support Palliat Care ; 10(1): 18-23, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26716394

RESUMO

PURPOSE OF REVIEW: Transcatheter aortic valve implantation (TAVI) is the recommended treatment for most patients with symptomatic aortic stenosis at high surgical risk. However, TAVI may be clinically futile for patients who have multiple comorbidities and excessive frailty. This group benefits from transition to palliative care to maximize quality of life, improve symptoms, and ensure continuity of health services. We discuss the clinical determination of utility and futility, explore the current evidence guiding the integration of palliative care in procedure-focused cardiac programs, and outline recommendations for TAVI programs. RECENT FINDINGS: The determination of futility of treatment in elderly patients with aortic stenosis is challenging. There is a paucity of research available to guide best practices when TAVI is not an option. Opportunities exist to build on the evidence gained in the management of end of life and heart failure. TAVI programs and primary care providers can facilitate improved communication and processes of care to provide decision support and transition to palliative care. SUMMARY: The increased availability of transcatheter options for the management of valvular heart disease will increase the assessment of people with life-limiting conditions for whom treatment may not be an option. It is pivotal to bridge cardiac innovation and palliation to optimize patient outcomes.


Assuntos
Estenose da Valva Aórtica/psicologia , Cuidados Paliativos/organização & administração , Cuidados Paliativos/psicologia , Qualidade de Vida , Estenose da Valva Aórtica/cirurgia , Comunicação , Humanos , Futilidade Médica , Fatores de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/métodos
14.
Med Decis Making ; 35(8): 959-66, 2015 11.
Artigo em Inglês | MEDLINE | ID: mdl-26246516

RESUMO

BACKGROUND: Patient decision aids (PtDAs) supplement advice from health care professionals by communicating the absolute risk or benefit of treatment options (i.e., X/100). As such, PtDAs have been amenable to binary outcomes only. We aimed to develop and test the validity of the Conversion to Risk Estimates through Application of Normal Theory (CREATE) method for estimating absolute risk based on continuous outcome data. METHODS: CREATE is designed to derive an estimate of the proportion of those who experience a clinically relevant degree of change (CRDoC). We used a 2-stage validation process using real and simulated change score data, respectively. First, using raw data from published intervention trials, we calculated the proportion of patients with a CRDoC and compared that with our CREATE-derived estimate using chi-square tests of association. Second, 200,000 simulated distributions of change scores were generated with widely varying distribution characteristics. Actual and CREATE-derived estimates were compared for each simulated distribution, and relative differences were summarized graphically. RESULTS: The absolute difference between the estimated and actual CRDoC did not exceed 5% for any of the samples based on real data. Applying the CREATE method to 200,000 simulated scenarios demonstrated that the CREATE method should be avoided for outcomes where the underlying distribution can be reasonably assumed to have high levels of skew or kurtosis. CONCLUSION: Our results suggest that standard statistical theory can be used to estimate continuous outcomes in absolute terms with reasonable accuracy for use in PtDAs; caution is advised if outcome summary statistics are assumed to have been derived from highly skewed distributions.


Assuntos
Técnicas de Apoio para a Decisão , Medição de Risco/métodos , Resultado do Tratamento , Doenças Cardiovasculares/terapia , Comportamento de Escolha , Simulação por Computador , Humanos , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
Eur J Cardiovasc Nurs ; 14(1): 79-89, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24399843

RESUMO

AIMS: The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients' self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care? METHODS: MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords 'careers', 'family members' and 'lay persons' for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients-either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted. RESULTS: Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients' self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs' activities on patients' self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: To our knowledge, this is the first systematic review to examine CGs' contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs' contributions on patient self-care outcomes.


Assuntos
Cuidadores/organização & administração , Insuficiência Cardíaca/enfermagem , Autocuidado/métodos , Doença Crônica , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Assistência de Longa Duração/organização & administração , Masculino , Prognóstico , Controle de Qualidade , Índice de Gravidade de Doença , Resultado do Tratamento
17.
Res Theory Nurs Pract ; 28(1): 71-86, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24772608

RESUMO

Over the last two decades, the number of patients receiving implantable cardiac defibrillators (ICDs) for the prevention of sudden cardiac death has grown significantly. This growth is largely the result of broadened indication for ICD use because of the success of trials demonstrating efficacy. Early ICD indication centered on secondary prevention, which then advanced to primary prevention in high-risk patients. Nurses delivering care to these patients not only manage this complex technology but also patients' uncertainty about their survival and related psychosocial adjustment to receiving an ICD. To inform practice, theoretical models such as Mishel's (1988) uncertainty in illness model provide insight into such acute phases of illness. This article proposes expansion of the uncertainty in illness model to advance knowledge in this field for nurses caring for patients with ICD.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Incerteza , Humanos
18.
BMC Cardiovasc Disord ; 14: 14, 2014 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-24483947

RESUMO

BACKGROUND: Chronic stable angina (CSA) has a major negative impact on health-related quality of life (HRQL) including poor general health status, psychological distress, and inability to self-manage. METHODS: We used meta-analysis to assess the effectiveness of self-management interventions for improving stable angina symptoms, HRQL and psychological well-being. Nine trials, involving 1,282 participants in total, were included. We used standard inverse-variance random-effects meta-analysis to combine the trials. Heterogeneity between trials was evaluated using chi-square tests for the tau-squared statistic and quantified using the I2 statistic. RESULTS: There was significant improvement in the frequency of angina symptoms (Seattle Angina Questionnaire [SAQ], symptom diary) across trials, standardized mean difference (SMD): 0.30 (95% Confidence interval [CI] 0.14, 0.47), as well as reduction in the use of sublingual (SL) nitrates, SMD: -0.49 (95% CI -0.77, -0.20). Significant improvements for physical limitation (SAQ), SMD: 0.38 (95% CI 0.20, 0.55) and depression scores (Hospital Anxiety and Depression Scale), SMD: -1.38 (95% CI -2.46, -0.30) were also found. The impact of SM on anxiety was uncertain due to statistical heterogeneity across trials for this outcome, I2 = 98%. SM did not improve other HRQL dimensions including angina stability, disease perception, and treatment satisfaction. CONCLUSIONS: SM interventions significantly improve angina frequency and physical limitation; they also decrease the use of SL nitrates and improve depression in some cases. Further work is needed to make definitive conclusions about the impact of SM on cardiac-specific anxiety.


Assuntos
Angina Estável/terapia , Qualidade de Vida , Autocuidado , Angina Estável/complicações , Angina Estável/diagnóstico , Angina Estável/psicologia , Ansiedade/etiologia , Ansiedade/prevenção & controle , Distribuição de Qui-Quadrado , Depressão/etiologia , Depressão/prevenção & controle , Humanos , Saúde Mental , Inquéritos e Questionários , Resultado do Tratamento
19.
Trials ; 14: 346, 2013 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-24148851

RESUMO

BACKGROUND: Patients, identified to be at risk for but who have never experienced a potentially lethal cardiac arrhythmia, have the option of receiving an implantable cardioverter defibrillator (ICD) as prophylaxis against sudden cardiac death - a primary prevention indication. In Canada, there is no clear framework to support patients' decision-making for these devices. Decision support, using a decision aid, could moderate treatment-related uncertainty and prepare patients to make well-informed decisions. Patient decision aids provide information on treatment options, risks, and benefits, to help patients clarify their values for outcomes of treatment options. The objectives of this research are: 1) develop a decision aid, 2) evaluate the decision aid, and 3) determine the feasibility of conducting a trial. METHODS/DESIGN: A development panel comprised of the core investigative team, health service researchers, decision science experts, cardiovascular healthcare practitioners, and ICD patient representatives will collaborate to provide input on the content and format of the aid. To generate probabilities to include in the aid, we will synthesize primary prevention ICD evidence. To obtain anonymous input about the facts and content, we will employ a modified Delphi process. To evaluate the draft decision aid will invite ICD patients and their families (n = 30) to rate its acceptability. After we evaluate the aid, to determine the feasibility, we will conduct a feasibility pilot randomized controlled trial (RCT) in new ICD candidates (n = 80). Participants will be randomized to receive a decision aid prior to specialist consultation versus usual care. Results from the pilot RCT will determine the feasibility of research processes; inform sample size calculation, measure decision quality (knowledge, values, decision conflict) and the influence of health related quality of life on decision-making. DISCUSSION: Our study seeks to develop a decision aid, for patients offered their first ICD for prophylaxis against sudden cardiac death. This paper outlines the background and methods of a pilot randomized trial which will inform a larger multicenter trial. Ultimately, decision support prior to specialist consultation could enhance the decision-making process between patients, physicians, and families, associated with life-prolonging medical devices like the ICD. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01876173.


Assuntos
Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/prevenção & controle , Técnicas de Apoio para a Decisão , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Seleção de Pacientes , Prevenção Primária/instrumentação , Projetos de Pesquisa , Arritmias Cardíacas/complicações , Arritmias Cardíacas/diagnóstico , Protocolos Clínicos , Morte Súbita Cardíaca/etiologia , Técnica Delfos , Estudos de Viabilidade , Humanos , Ontário , Participação do Paciente , Relações Médico-Paciente , Projetos Piloto , Valor Preditivo dos Testes , Relações Profissional-Família , Medição de Risco , Fatores de Risco
20.
Health Expect ; 16(1): 69-79, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21645190

RESUMO

BACKGROUND: Patients are offered implantable defibrillators (ICDs) for the prevention of sudden cardiac death (SCD). However, patients' decision-making process (DMP) of whether or not to accept an ICD has not been explored. We asked patients about their decision making when offered an ICD. DESIGN/SETTING: A grounded theory methodology was employed. Patients were recruited from three ICD centres. Those who received an ICD underwent interviews the first month after implant. Declining patients had interviews at their convenience. In-depth analysis of transcripts was completed. Identified themes were placed along process pathways in a DMP model and tested. FINDINGS: Forty-four patients consented to participate (25% women). Thirty-four accepted an ICD and 10 (23%) declined. Ages ranged from 26 to 87 (mean = 65; SD = 12.5). Participants were retired (65%), had ischaemic heart disease (64%) and some post-secondary education (52%). The DMP was triggered when patient's risk for SCD was communicated. The physician's recommendation and a new awareness SCD risk were motivators to accept the ICD. Patient's decision-making approaches fell along a continuum, from active and engaged to passive and indifferent. Patient's approaches were influenced most by the following: (i) trust; (ii) social influences and (iii) health state. CONCLUSIONS: Health-care providers need to recognize the DMP pathways in which ICD candidacy and SCD risk are understood. The factors that influence a patient's decision warrant discussion pre-implant. It is imperative that patients comprehend the meaning of ICD candidacy to make an informed decision. Participants did not recall alternatives to receiving ICD therapy.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Tomada de Decisões , Desfibriladores Implantáveis/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Preferência do Paciente/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Desfibriladores Implantáveis/estatística & dados numéricos , Feminino , Nível de Saúde , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Confiança
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