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Evaluation of an early discharge service for cardiac rehabilitation at home Dal-Santo, Mary Gail 1987

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EVALUATION OF AN EARLY DISCHARGE SERVICE FOR CARDIAC REHABILITATION AT HOME By MARY GAIL DAL-SANTO B.N., M c G i l l U n i v e r s i t y , 1969 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (Department o f H e a l t h S e r v i c e s P l a n n i n g and A d m i n i s t r a t i o n ) We accept t h i s t h e s i s as conforming t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA September 1987 © Mary G a i l Dai-Santo, 1987 .A 6 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of V ^ M - T l * C f t P , g ftuD faPfceriNOlOfcy The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date O c < \< ( ^ l  D E - 6 ( 3 / 8 1 ) ABSTRACT This study evaluates the outcomes of a hospital-based cardiac r e h a b i l i t a t i o n program designed to d e l i v e r the f i r s t phase of cardiac r e h a b i l i t a t i o n services at home. The program was established i n a community hospital i n 1985, operating under the a d m i n i s t r a t i o n of the h o s p i t a l ' s Medical Day Centre. Patients s u f f e r i n g from acute myocardial i n f a r c t i o n (MI) are referred to the program by t h e i r physician and receive services from a cardiac nurse s p e c i a l i s t immediately upon discharge. The services continue for a period of 6 weeks. The outcomes of importance i n the study are the e f f e c t s of the program on hosp i t a l services i n the i n i t i a l 10 month period and on patient's health r e l a t e d behaviour 3 months post i n f a r c t i o n . Results of the study indicate that program goals were achieved during the i n i t i a l 10 months of the study. Physicians referred 92% of the e l i g i b l e p a t i e n t s and the average length of stay (ALOS) i n h o s p i t a l was s a t i s f a c t o r i l y reduced. For p a t i e n t s with uncomplicated MI the ALOS was 8.6 days by the tenth month. At 3 month follow up, patients reported s i g n i f i c a n t improvements over t h e i r pre i n f a r c t i o n h e a l t h r e l a t e d behaviour. There were s i g n i f i c a n t i n c r e a s e s i n the frequency of l i g h t e x e r c i s e (p<-0005), i n the regular use of low fat dairy products (p=.0003) and i n the p r a c t i c e of r e s t r i c t i n g c a l o r i e s (p=.003) while s i g n i f i c a n t decreases were reported i n the frequency of consuming f r i e d foods (p<.0005), salted foods (p<.0005) and r i c h foods i i i (p<.005) and i n t h e r e g u l a r use o f t a b l e s a l t (p=.00003). Smoking c e s s a t i o n was r e p o r t e d by 50% of the smokers at f o l l o w up. P a t i e n t s r e p o r t e d a h i g h l e v e l o f s a t i s f a c t i o n w i t h the program, d e s c r i b i n g the s e r v i c e as w e l l timed, i n f o r m a t i v e , p r a c t i c a l and v a l u a b l e i n r e s t o r i n g t h e i r s e l f c o n f i d e n c e . While t h e s e r e s u l t s were s a t i s f a c t o r y w i t h r e g a r d s t o the program g o a l s , the e v a l u a t i o n was based on a s i n g l e group d e s i g n and f u r t h e r i n v e s t i g a t i o n i s d e s i r a b l e w i t h comparisons between h o s p i t a l s and between p a t i e n t s w i t h and without exposure t o the program. i v TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES ix ACKNOWLEDGEMENTS x INTRODUCTION 1 CHAPTER 1: OVERVIEW 5 A. Cardiovascular Disease 5 1. Mortality 5 2. Health Care Costs 7 3. Morbidity 9 a) Antecedent Morbidity 13 b) C l i n i c a l Manifestations 23 c) Consequential Morbidity 26 B. Cardiac Reha b i l i t a t i o n 31 C. Current Concepts i n Health Promotion 40 CHAPTER I I : CONCEPTUAL FRAMEWORK 43 A. A Systems Approach 43 B. Planning/Evaluation Model 45 C. Health Behaviour Change Model 49 CHAPTER I I I : PROGRAM DESCRIPTION 54 A. H i s t o r i c a l and P o l i t i c a l Context 54 B. A r t i c u l a t i o n of the Program 56 C. Implications for Evaluation 61 V TABLE OF CONTENTS CONTINUED Page CHAPTER IV: DESIGN AND METHODOLOGY 64 A. Evaluation of the E f f e c t s on Hospital Services 64 B. Evaluation of C l i n i c a l E f f e c t s 66 CHAPTER V: RESULTS AND ANALYSIS 70 A- E f f e c t of CEDS on Hospital Services 71 1. Physician Referrals 71 2. Length of Stay i n Hospital 74 B. Patient C h a r a c t e r i s t i c s 77 1. Demographics 77 2. Antecedent Risks for MI 79 C. C l i n i c a l E f f e c t s of CEDS 80 1. E f f e c t s on Exercise and A c t i v i t y Levels 81 2. E f f e c t s on Dietary Practices 87 3. E f f e c t s on Smoking 94 4. Compliance with Medication Regimes 94 5. S a t i s f a c t i o n with Program 96 D. Intervening Factors 97 1. Perceived Predisposition to MI 98 2. Perceived Health Status 98 3. B e l i e f s and Plans 99 4. Alternate Personal Strategies 102 E. Use of Health Hazard Appraisal 103 CHAPTER VI: CONCLUSIONS AND RECOMMENDATIONS 106 BIBLIOGRAPHY 112 v i TABLE OF CONTENTS CONTINUED Page APPENDIX A: INTRODUCTORY LETTER 119 APPENDIX B: QUESTIONNAIRE AT 1 WEEK POST INFARCTION 121 APPENDIX C: QUESTIONNAIRE AT 14 WEEKS POST INFARCTION .... 126 APPENDIX D: FOLLOW UP INTERVIEW AT 14 WEEKS POST INFARCTION 131 v i i LIST OF TABLES Page TABLE 5.1 Average Number of Days Length of Stay for MI Patients Within CEDS During the I n i t i a l 10 Month Period 75 TABLE 5.2 Average Number of Days Length of Stay for MI Patients Hospitalized Within the I n i t i a l 10 Month Period of CEDS but Residing Out of the Area 76 3. TABLE 5.3 Frequency of Light Exercise Before MI by Type of Change Reported at Follow Up 82 4. TABLE 5.4 Frequency of Light Exercise Before MI and at Follow Up 83 5. TABLE 5.5 Levels of Daily A c t i v i t y Before MI and at Follow Up 84 6. TABLE 5.6 Frequency of Using Table Salt Before MI and at Follow Up 88 7. TABLE 5.7 Frequency of Consuming 1 or More Servings of Salty Foods Before MI and at Follow Up 89 8. TABLE 5.8 Frequency of Using Low Fat Dairy Products Before MI and at Follow Up 90 9. TABLE 5.9 Frequency of Consuming 1 or More Servings of Fried Foods Before MI and at Follow Up 91 10. TABLE 5.10 Frequency of Reducing Calories to Reduce Weight Before MI and at Follow Up 92 11. TABLE 5.11 Frequency of Consuming 1 or More Servings of Rich/Sweet Foods Before MI and at Follow Up 93 v i i i LIST OF TABLES CONTINUED Page 12. TABLE 5.12 B e l i e f i n the Need for S p e c i f i c Behavioural Changes 1 Week and 14 Weeks Post Infarction , 101 13. TABLE 5.13 Plans to Make S p e c i f i c Behavioural Changes 1 Week and 14 Weeks Post Infarction , 102 14. TABLE 5.14 Health Hazard Appraisal: Differences i n the Average Appraised Age and Average Achievable Age as a Result of Behavioural Changes Made i n the 14 Week Period Post I n f a r c t i o n . 105 i x LIST OF FIGURES Page 1. FIGURE 1.1 M o r b i d i t y and m o r t a l i t y o f Ischemic Heart Disease 12 2. FIGURE 2.2 P l a n n i n g and E v a l u a t i o n Model 48 3. FIGURE 2.3 H e a l t h Behaviour Change Model 50 X ACKNOWLEDGEMENT S Several i n d i v i d u a l s have contributed t h e i r advice and t h e i r energy during the preparation of t h i s t h e s i s . I am grateful to each for t h e i r support and would l i k e to express my appreciation to John Milsum for his thoughtful and kind guidance as my thesis advisor, to Carol Herbert, Nancy Waxier-Morrison and Mai Weinstein for t h e i r willingness to provide advice and alternate points of view as members of my thesis committee, to Dr. O.K. L i t h e r l a n d and Val Young f o r providing the op p o r t u n i t y , as program a d m i n i s t r a t o r s , to do the evaluation, to A l l i s o n Rose, the cardiac nurse s p e c i a l i s t , f or her good humour and support throughout the evaluation, t o S h e r r y Miyamoto f o r her e x p e r t i s e i n t y p i n g and organizing the f i n a l format of the document, and to Orest Dai-Santo, i n p a r t i c u l a r , f or his patience and support. 1 INTRODUCTION C a r d i a c r e h a b i l i t a t i o n i s d e s i g n e d t o reduce the consequences of established cardiac disease and restore patients to an optimal l e v e l of functioning at work and at l e i s u r e . Current c a r d i a c r e h a b i l i t a t i o n programs began with a trend toward early mobilization of myocardial i n f a r c t i o n (MI) patients i n h o s p i t a l i n the e a r l y 1950's (Wenger, 1984a). This was supported by continued evidence of i t s benefits, and by the developments of t r e a d m i l l e x e r c i s e t e s t i n g and ambulatory electr o c a r d i o g r a p h y (ECG). Programs have now extended, i n general, to include three phases of r e h a b i l i t a t i o n : Phase I, beginning i n hospital with low l e v e l a c t i v i t y , and progressing to ambulation and s t a i r climbing; Phase II, a hospital-based exercise program; and Phase III , a community-based exercise maintenance program. With the advent of the Framingham Study (Dawber, 1980) i n 1950 the ground work was l a i d for addressing the reduction of primary r i s k factors, and hopefully for i d e n t i f y i n g new opportunities to i n t e r r u p t the natural h i s t o r y of cardiac disease. Although s t u d i e s i n secondary prevention have l a r g e l y focussed on pharmacological and s u r g i c a l interventions, there has also been rapid growth i n the area of psychological research since the early 1970's. Cardiac r e h a b i l i t a t i o n programs have adopted much work and r e s e a r c h from t h i s l a t t e r area i n managing the b e h a v i o u r a l aspects of r i s k f a c t o r s , e s p e c i a l l y smoking 2 cessation and weight control, and by the early 1980's one review ( F r o e l i c h e r & P o l l o c k , 1983) r e p o r t e d t h a t 40% of the r e h a b i l i t a t i o n programs included behavioural change strategies i n r i s k factor reduction. Although associations between r i s k factor reduction and recurrent cardiac events are s t i l l being established, i n i t i a l studies on m u l t i - f a c t o r a l r e h a b i l i t a t i o n programs (Friedman, Thoreson, et a l , 1984; Frasure-Smith & P r i n c e , 1985; K a l l i o , Hamalainen, Hakkila & L u u r i l a , 1979; Oldenburg & Perkins, 1985; Rahe, Ward & Hayes, 1979; Roviaro, Holmes & Holmsten, 1984) show p o s i t i v e trends and support the e f f o r t s of those addressing r i s k f a c t o r reduction i n t h e i r programs on the simple basis that i t i s wise and prudent. Few stress management strategies were reported i n t h i s 1983 review, perhaps because the concept of stress was not i d e n t i f i e d amongst the o r i g i n a l r i s k f a c t o r s . However, the recent m u l t i f a c t o r a l s t u d i e s r e f e r to i t more f r e q u e n t l y . This coincides with the formal recognition of the importance of Type A, or coronary prone behaviour i n 1980 by the National Heart Lung and Blood I n s t i t u t e (NHLB) (Weiss, 1981), and i s supported most strongly by reports of the Recurrent Coronary Prevention Project (Freidman, Thoreson, et a l , 1984) which succeeded i n reducing r e c u r r e n t i n f a r c t i o n s by reducing coronary prone behaviour with psychological strategies. The v a r i o u s a s p e c t s of c a r d i a c r e h a b i l i t a t i o n j u s t mentioned involve a r e l a t i v e l y complex but loosely woven network of services that are dependent on both i n t e r d i s c i p l i n a r y , and 3 i n t e r a g e n c y , c o o p e r a t i o n and r e f e r r a l to be most e f f e c t i v e . The program e v a l u a t e d i n t h i s study i s newly e s t a b l i s h e d i n a 400 bed community h o s p i t a l and focusses on the p r o v i s i o n of Phase I s e r v i c e s . I t has the unique f e a t u r e of employing a c a r d i a c nurse s p e c i a l i s t t o d e l i v e r the s e r v i c e to p a t i e n t s at home, while s i m u l t a n e o u s l y p r o v i d i n g an o p p o r t u n i t y f o r p h y s i c i a n s to d i s c h a r g e p a t i e n t s e a r l i e r . Inherent i n the process i s an o p p o r t u n i t y f o r the p a t i e n t t o r e c e i v e c o n s i s t e n t , e a s i l y a v a i l a b l e care i n the e a r l i e s t stages of r e h a b i l i t a t i o n , and to become i n t e g r a t e d with other aspects and phases of the c a r d i a c r e h a b i l i t a t i o n network. E v a l u a t i o n of the program focusses on two areas of outcome - impact of the program on o t h e r h o s p i t a l s e r v i c e s and c l i n i c a l outcomes o f the s e r v i c e , as w e l l as d i s c u s s i n g the r e l e v a n t l i t e r a t u r e and h i s t o r i c a l context of the program. The study i s developed w i t h i n a conceptual framework t h a t u t i l i z e s a b a s i c understanding of systems theory and r e f e r s t o two s e p a r a t e models, one f o r each area o f outcome i n the e v a l u a t i o n . T h i s p e r s p e c t i v e p r o v i d e s r e c o g n i t i o n o f the ongoing n a t u r e of p l a n n i n g / e v a l u a t i o n and b e h a v i o u r a l change p r o c e s s e s , and p r o v i d e s an o p p o r t u n i t y t o acknowledge the r e l e v a n c e of c u r r e n t p r i n c i p l e s i n h e a l t h promotion. A l s o , the models are f l e x i b l e and can be adapted to p a r t i c u l a r f e a t u r e s of the program. Chapter I reviews i n f o r m a t i o n on c a r d i o v a s c u l a r d i s e a s e i n g e n e r a l and the use of c u r r e n t h e a l t h i n d i c a t o r s i n d e s c r i b i n g 4 and evaluating the r e h a b i l i t a t i o n of myocardial i n f a r c t i o n p a t i e n t s . The relevance of current p r i n c i p l e s i n he a l t h promotion i s a l s o c o n s i d e r e d . Chapter II de s c r i b e s the conceptual framework and i t s r e l a t i o n s h i p to the design and process of the evaluation. Chapter III provides a description of the program being evaluated, i n c l u d i n g h i s t o r i c a l and p o l i t i c a l factors i n i t s development, and Chapter IV explains the design and methodology involved i n the evaluation. The r e s u l t s and t h e i r a n a l y s i s are contained i n Chapter V, and Chapter VI concludes with discussion and recommendations. 5 CHAPTER I: OVERVIEW A. Cardiovascular Disease C a r d i o v a s c u l a r disease (CVD) i s a broad term covering several diseases of the c i r c u l a t o r y system. The most common forms of CVD are ischemic or coronary heart disease (IHD/CHD), and i n p a r t i c u l a c u t e m y o c a r d i a l i n f a r c t i o n (MI) and c e r e b r o v a s c u l a r d i s e a s e . B o t h forms are l i n k e d t o a r t e r i o s c l e r o s i s . Other forms of CVD include hypertension, rheumatic heart disease and various other r e l a t e d cardiovascular problems. 1. M o r t a l i t y CVD i s presently the leading cause of death i n Canada and has accounted for more than half of a l l deaths for the past three decades. In 1982 60% of these CVD deaths were due to ischemic heart disease (IHD) and 20% from cerebrovascular disease (Nicholls, Nair, MacWilliam, Moen & Mao, 1986). Cancer follows CVD i n second place, accounting for almost one quarter of a l l deaths, while deaths from accidents, poisoning and violence are i n t h i r d place. The data indicates a v a r i e t y of patterns by age, sex and geography, as well as changing trends i n the mortality rates among these leading causes of death. Changes relevant to CVD w i l l p r i m arily be discussed i n terms of IHD since t h i s form of CVD accounts for the greatest number of 6 CVD deaths as well as showing the greatest decline i n mortality recently. In 1985 IHD on i t s own was the leading cause of death i n Canada accounting for 40% of a l l deaths (Causes of Death, 1986). The gap between cancer and IHD has been narrowing over the l a s t s e v e r a l years, however, as m o r t a l i t y r a t e s from IHD have decreased s u b s t a n t i a l l y and those from cancer have increased s l i g h t l y . At a p r o v i n c i a l l e v e l cancer has surpassed IHD as the leading cause of death i n B.C., Alberta and Quebec. Vari a t i o n by sex i s e v i d e n t . Using age standardized death ra t e s , mortality from cancer exceeded that from IHD i n females at a national l e v e l as of 1983 while for males the change was li m i t e d to the three provinces of B.C., Alberta and Quebec. Cancer, therefore, i s seen to be replacing IHD as the leading cause of death much more ra p i d l y for women than men although i t has not surpassed IHD as the o v e r a l l leading cause of death at a national l e v e l (Causes of Death, 1986). As mentioned the g r e a t e s t i n f l u e n c e on t h i s trend i s reported to be the declining mortality rates for IHD. These declines began i n both Canada and the U.S. i n the mid 1960's and were f i r s t noticeable i n the western regions where the rates were already lower. Both countries have experienced a decline that has progressed more rapidl y i n recent years and has been greatest i n eastern regions. Over the l a s t decade A u s t r a l i a , Belgium and F i n l a n d have a l s o shown pronounced d e c l i n e s ; however, i n France and some Eastern European countries there 7 have been s i g n i f i c a n t increases. In many countries there has been l i t t l e or no change reported (Nicholls, Nair, MacWilliam, Moen, Mao, 1986). Although there i s general agreement that these declines represent a genuine change, rather than s t a t i s t i c a l a r t i f a c t , there i s no consensus on whether i t i s due to a decrease i n the incidence or severity of the disease, to improved su r v i v a l or to a combination of the two. U n t i l t h i s i s r e s o l v e d i t i s uncertain whether the trend i s due to l i f e s t y l e changes amongst Canadians that could reduce the incidence and severity of IHD, to more widespread use of advanced medical and s u r g i c a l technology that could increase s u r v i v a l , or to some combination of the two. When more i n f o r m a t i o n i s a v a i l a b l e b e t t e r evaluation of desirable resource a l l o c a t i o n w i l l be possible on a population basis. 2. H e a l t h Care Costs Current health care costs for CVD remain large, however, despite declining mortality and are expected to remain that way i n the foreseeable future. In Canada the d i r e c t h ospital costs alone have been estimated at $2 b i l l i o n a year (Nicholls, Nair, MacWilliam, Moen & Mao, 1986). Such estimates are based on the ongoing body of data from the national hospital insurance plans and incorporate data on the number of days i n hos p i t a l , the number of hospital discharges per year and the medical reasons for h o s p i t a l i z a t i o n along with other factors. A recent federal 8 study on CVD i n Canada (Nicholls, Nair, MacWilliam, Moen & Mao, 1986) reviews h o s p i t a l i z a t i o n patterns and reports that IHD and cerebrovascular disease are second only to mental i l l n e s s as the leading cause of h o s p i t a l i z a t i o n i n Canada. Between 1971 and 1981 there was l i t t l e change i n the number of days spent i n hospital by people with IHD but a substantial increase i n the number o f h o s p i t a l days consumed by p a t i e n t s w i t h cerebrovascular disease. Among men, IHD and cerebrovascular disease combined were the leading reason for h o s p i t a l i z a t i o n , accounting for more than 3,400,000 h o s p i t a l days spent i n 1981. This compared with approximately 1,600,000 days spent i n hospital for men with cancer and almost 1,700,000 days for mental diseases. IHD and cerebrovascular disease were the leading cause of h o s p i t a l i z a t i o n f o r women, acc o u n t i n g f o r approximately 4,000,000 hospital days. This compared with 2,330,000 days for d e l i v e r i e s and 2,272,000 days for mental diseases. The h o s p i t a l discharge r a t e s f o r both men and women increased i n the early 1970's. For men, the rate peaked i n 1974 before declining, while for women the peak year was 1973. The decline has been more consistent for women than for men i n the l a t t e r years. Although the h o s p i t a l discharge rates have declined, the 1980 rate remains higher than the rate at the end of the 1960's for men, and only s l i g h t l y lower for women. 9 3. Morbidity Other repercussions of CVD are the extensive personal, s o c i a l and economic costs that arise i n addition to those costs incurred by the health care system. A d e s c r i p t i o n of these other repercussions follows, within the broad framework of m o r b i d i t y p r e s e n t e d i n the r e c e n t f e d e r a l p u b l i c a t i o n , Demographic and Health Indicators (Peron & Strohmenger, 1985). Using t h i s framework these repercussions can be included within d i f f e r e n t classes of morbidity that are described i n 2 ways, one by the method of observation and one by t h e i r r e l a t i o n s h i p to the onset of disease. Differences are recognized between the use of the terms precursor, r i s k marker and r i s k factor i n t h i s model and i n the WHO Dictionary of Epidemiology (1983). Three types of morbidity ari s e depending on the method of observation: perceived morbidity, or the experience of altered f u n c t i o n and behaviour as reported i n p o p u l a t i o n surveys; diagnosed morbidity, or that i d e n t i f i e d by medical diagnosis and best known from hospital morbidity s t a t i s t i c s , and occasionally from disease r e g i s t e r s ; and objective morbidity, or that which c o u l d i d e a l l y be i d e n t i f i e d by s y s t e m a t i c a l l y examining representative groups i n the population. To date the hospital or diagnosed m o r b i d i t y has been the f a m i l i a r measure of morbidity and i t has matched quite c l o s e l y with other d i s a b i l i t y and mortality data for the p r i n c i p a l causes of h o s p i t a l i z a t i o n ( e x c l u d i n g c h i l d b i r t h ) . However, i n t e r e s t i n perceived 10 m o r b i d i t y has r e c e n t l y a t t r a c t e d i n c r e a s i n g i n t e r e s t , i n p a r t because of i t s r o l e i n determining demand f o r c a r e . P o t e n t i a l m o r b i d i t y and b e h a v i o u r a l m o r b i d i t y are the two types o f m o r b i d i t y r e l a t e d t o the onset o f d i s e a s e . P o t e n t i a l o r a n t e c e d e n t m o r b i d i t y r e l a t e s t o those f a c t o r s t h a t are i d e n t i f i a b l e as a n t e c e d e n t s o f d i s e a s e and which may be c l a s s i f i e d as p r e c u r s o r s , o r b i o l o g i c a l a b n o r m a l i t i e s , t h a t are d e t e c t a b l e b e f o r e t h e appearance o f the f i r s t symptoms or c l i n i c a l problems; r i s k f a c t o r s , o r o t h e r c h a r a c t e r i s t i c s t h a t are o f t e n b e h a v i o u r a l and/or are amenable t o i n t e r v e n t i o n ; and r i s k m a r k e r s , o r c h a r a c t e r i s t i c s o f i n d i v i d u a l s o r t h e i r environment which are u n c o n t r o l l a b l e o r can o n l y be c o n t r o l l e d w i t h d i f f i c u l t y . The c o n c e p t o f b e h a v i o u r a l o r c o n s e q u e n t i a l m o r b i d i t y r e l a t e s t o the consequences of d i s e a s e and i s developed from a number o f d i s e a s e - i n d u c e d behaviours t h a t r e f l e c t the s o c i a l and economic r e p e r c u s s i o n s o f d i s e a s e . These e f f e c t s are d e s c r i b e d as d e v i a t i o n s from the norm and are fundamentally c h a r a c t e r i z e d as impairments, or bi o m e d i c a l d e v i a t i o n s t h a t determine any l o s s or a b n o r m a l i t y o r p s y c h o l o g i c a l o r p h y s i o l o g i c a l f u n c t i o n i n g ; and/or d i s a b i l i t i e s , o r d e f i c i e n c i e s t h a t r e s t r i c t the a b i l i t y t o perform an a c t i v i t y i n the manner o r range c o n s i d e r e d t o be n o r m a l . Thus any p e r s o n who, b e c a u s e o f i m p a i r m e n t o r d i s a b i l i t y , i s a t a disadvantage w i t h l i f e i n s o c i e t y compared t o peers may be c o n s i d e r e d as having a handicap. 11 There are several advantages for describing and estimating IHD and MI m o r b i d i t y i n t h i s context: i t i n v o l v e s an u n d e r s t a n d i n g of c u r r e n t work on h e a l t h i n d i c a t o r s , i t strengthens the l i n k between t r a d i t i o n a l epidemiology and c l i n i c a l practice and i t relates e a s i l y to the systems models i n the next chapter. Reference w i l l be made to a model (see Figure 1.1) adapted from the r e p o r t on Demographic and Health Indicators i n the discussion. Although at f i r s t glance only one aspect of the model, consequential morbidity, may appear to have relevance for cardiac r e h a b i l i t a t i o n i t becomes c l e a r on further c o n s i d e r a t i o n that the antecedent f a c t o r s are necessary to understand the context i n which patients have had an MI as well as f o r planning v a r i o u s aspects of r e h a b i l i t a t i o n . Thus information on both types of morbidity w i l l be presented. ANTECEDENT MORBIDITY CLINICAL MANIFESTATIONS CONSEQUENTIAL MORBIDITY PRECURSORS Hypertension Hypercholesterolemia Diabetes Abnormal EGG RISK FACTORS Smoking Obesity Sedentary lifestyle Coronary prone behaviour 4 > Angina Myocardial Infarction BEHAVIOURAL MORBIDITY Denial Depression and/or anxiety Disturbed sleep Role conflicts IMPAIRMENT-^  DISABILITY-^ HANDICAP RISK MARKERS Age Sex Family History FIGURE 1.1 MORBIDITY AND MORTALITY OF ISCHEMIC HEART DISEASE 13 a) Antecedent Morbidity Antecedent or potential morbidity w i l l be described f i r s t . Before the Framingham Study i t was generally accepted that at h e r o s c l e r o t i c disease, e s p e c i a l l y ischemic heart disease, was an i n e v i t a b l e r e s u l t of the aging process. However, as a r e s u l t o f t h e s t u d y i t was e s t a b l i s h e d t h a t h y p e r t e n s i o n , hypercholesterolemia and smoking were major factors increasing the r i s k of IHD and MI as well as i n a c t i v i t y , obesity and diabetes (Dawber, 1980). Since then Type A behaviour and r e l a t e d p e r s o n a l i t y f a c t o r s have also been associated with increased r i s k of IHD and MI (Weiss, 1980). I t i s important to remember, however, that research has also indicated that the c l a s s i c a l factors o r i g i n a l l y established i n the Framingham Study account for only about one-half of the IHD incidence i n middle-aged American men (Keys, Aravanis, et a l , 1972). Also while the presence of more factors indicate greater l i k e l i h o o d of IHD, i t has been shown that the best combination of these factors s t i l l f a i l to i d e n t i f y most new cases of the disease (Jenkins, 1971). In any case, the benefits of primary intervention with these f a c t o r s has proven to be greater than those of secondary prevention post i n f a r c t i o n (Kannel, 1984). In the following section each established factor, including psychological factors w i l l be mentioned separately as either a precursor, r i s k factor or r i s k marker. 14 i ) Precursors H y p e r t e n s i o n : As w i t h s e v e r a l o t h e r f a c t o r s , i n c r e a s i n g values of blood pressure beyond an optimal l e v e l produces increasingly higher r e l a t i v e r i s k s . Assuming a normal blood pressure as being 120/80, then a blood pressure of 160/95 roughly doubles the r i s k of IHD. S i m i l a r l y those with a d i a s t o l i c pressure of 95 to 105 have twice the heart attack r i s k of persons of 75 to 85 (Simborg, 1970). In a review of coronary r i s k factors Milsum (1984) reports a range of r e l a t i v e r i s k l e v e l s of 1.5 for 140/90 to 2.5 for 160/95 to a maximum r e l a t i v e r i s k of 6. In a review of data from the National Centre for Health S t a t i s t i c s , Smith (1987) r e p o r t s no change i n the prevalence of hypertension between surveys completed i n 1962 and 1974, but a decrease by the late 1970's that coincides with p u b l i c and p r o f e s s i o n a l campaigns addressing the hazards of hypertension. The e f f e c t s of c o n t r o l l i n g hypertension are demonstrated i n terms of decreased mortality and morbidity i n the Hypertension Detection and Follow up Program (1979). The Recommendations of the S c i e n t i f i c Councils of the International Society and Federation of Cardiology on Risk Reduction aft e r myocardial I n f a r c t i o n (Koenig, 1986) at T i t i s e e i n the late 1983, known as the T i t i s e e Report, acknowledge that higher m o r t a l i t y and r e i n f a r c t i o n r a t e s are a s s o c i a t e d w i t h hypertension a f t e r an MI, and that c o n t r o l of the r i s k i s important. 15 Hypercholesterolemia: Progressively higher r e l a t i v e r i s k s are associated with higher serum cholesterol concentrations, as ju s t desribed for high blood pressure. Levels of 175 mg/dl have less than 1/2 the r i s k of MI of those with l e v e l s between 250 and 275 mg/dl. and less than 1/3 the r i s k of those with lev e l s above 300 mg/dl. (Smith, 1987). Milsum (1984) reports s i m i l a r figures with a maximum reported r e l a t i v e r i s k of 5.5. Recently the Coronary Primary Prevention T r i a l has demonstrated a s i g n i f i c a n t r e d u c t i o n i n m o r t a l i t y from d i e t a r y and drug interventions. However Kannel (1984) reports that high serum c h o l e s t e r o l l e v e l s have not been c o n s i s t e n t l y r e l a t e d to r e i n f a r c t i o n and death and t h a t now the low d e n s i t y lipoprotein/high density l i p o p r o t e i n (LDL/HDL) cholesterol r a t i o should be considered as well. The T i t i s e e Report (Koenig, 1986) re c o g n i z e s the i n h e r e n t c o n t r o v e r s i e s and concludes that hypercholesterolemid due to elevated l e v e l s of low density l i p o p r o t e i n should be treated even though i t presents less r i s k a f t e r an MI than before the f i r s t attack. Diabetes: The Framingham data show that of those men, aged 30-59, i n i t i a l l y free of IHD, diabetics have 1.4 times greater incidence of IHD than nondiabetics. The incidence i n diabetic women i s 2.5 times greater. The r i s k of death from IHD i s 2.3 times higher i n diabetic men and 5.7 times higher i n diabetic women. Approximately 2% of the American population i s diagnosed as having diabetes (Simborg, 1970). Control of diabetes with 16 o r a l or i n j e c t a b l e i n s u l i n has not been convincingly shown to reduce the sequence of IHD although treatment should, for other reasons, follow the usual guidelines (Kannel, 1984). Abnorma1 ECG: As a precursor, an abnormal ECG ref e r s to any of a v a r i e t y of deviations from the normal i n an i n d i v i d u a l who i s eit h e r at rest, or under con t r o l l e d exercise conditions and c l i n i c a l l y free of IHD. Simborg's report (1970) indicates that a wide v a r i e t y of re s t i n g abnormalities were established by the Tecumseh and Framingham Studies and an increased r i s k of IHD i s demonstrated i n the l a t t e r study. In an 8-year follow-up of the Framingham study, the r i s k of developing CHD i s 3 times higher i f the i n i t i a l EKG showed T-wave inversion, twice as high for codable Q waves, and 1.25 times higher with i n i t i a l f l a t T-waves. There i s no r i s k associated with ST-segment depression. After 12 years, the r i s k of death from CHD i s 8.9 times higher i n those who have ever had l e f t v e n t r i c u l a r hypertrophy by EKG c r i t e r i a compared with those who have not. The r i s k i s 6.7 times higher f o r complete i n t r a - v e n t r i c u l a r block. However l i t t l e information i s available on whether abnormalities can be altered toward normal and none on whether i t would a f f e c t the incidence of IHD. ECG exercise t e s t i n g began with the Master's two-step test i n the 1920's and now involves b i c y c l e ergometry and treadmill t e s t i n g . Many tests and evaluation c r i t e r i a have been developed and many studies indicate that s i g n i f i c a n t ischemic depression 17 on an exercise ECG i s one of the strongest r i s k s for IHD known. Simborg found no reports of f a i l u r e to associate a posi t i v e exercise t e s t r e s u l t with increased r i s k of IHD. i i ) Risk Factors Smoking: Smokers have mortality r a t i o s greater than those of nonsmokers and these r a t i o s increase with the amount smoked. Morta l i t y r a t i o s are 1.4 for smoking less than 10 cigarettes d a i l y , 1.7 for 10 to 19 cigarettes d a i l y , 1.9 for 20 to 39 c i g a r e t t e s d a i l y and 2.2 for more than 40 cigarettes d a i l y . Overall, smokers r e l a t i v e r i s k of death i s 1.7 times greater than nonsmokers (Passamani, Frommer & Levy, 1984). Milsum (1984) reports the range of r e l a t i v e r i s k s from 1.5 to 6.5. The prevalence of smoking i n the U.S. has decreased, between 1965 and 1980, from 52% to 38% i n men and 34% to 30% i n women. Relative r i s k s decline following cessation of smoking u n t i l a r i s k l e v e l comparable to nonsmokers i s reached (Smith, 1987). The T i t i s e e Report (Koenig, 1986) concludes that smoking i s undoubtedly a major primary r i s k factor for IHD and i d e n t i f i e s at l e a s t s i x nonrandomized studies i n secondary prevention that have shown s i g n i f i c a n t reduction of both f a t a l and nonfatal MI i n patients who stopped smoking compared to those who did not. Smoking cessation i s suggested to be the most e f f e c t i v e single intervention i n the management of IHD and MI. 18 P h y s i c a l I n a c t i v i t y : Although i n c r e a s i n g p h y s i c a l a c t i v i t y has been a major g o a l i n both primary and secondary p r e v e n t i o n programs, the e f f e c t s o f p h y s i c a l t r a i n i n g alone have proven to be c o n t r o v e r s i a l i n terms of r e d u c i n g both f a t a l and n o n f a t a l o c c u r r e n c e s of MI (Kannel, 1984) . In p a r t i c u l a r Kannel mentions the f a i l u r e o f the most c a r e f u l l y c o n t r o l l e d t r i a l s t o show any s i g n i f i c a n t b e n e f i t i n p r e v e n t i n g r e i n f a r c t i o n o r p r o l o n g i n g l i f e . However the importance of p h y s i c a l a c t i v i t y i s g e n e r a l l y a c c e p t e d . A c c o r d i n g t o t h e T i t i s e e Report (Koenig, 1986) dynamic e x e r c i s e can be recommended as secondary p r e v e n t i o n f o r s e v e r a l e s t a b l i s h e d reasons: 1) To c o m b a t t h e d e l e t e r i o u s e f f e c t s o f i m m o b i l i z a t i o n . 2) To improve p h y s i c a l working c a p a c i t y and c a r d i o v a s c u l a r performance. 3) To i n c r e a s e s e l f c o n f i d e n c e , emotional s t a b i l i t y , and t o decrease d e p r e s s i o n and f e a r . 4) To f a c i l i t a t e r e t u r n t o normal l i f e ( i n c l u d i n g work i f a p p r o p r i a t e ) . 5) To improve weight c o n t r o l , j o i n t m o b i l i t y and s t a b i l i t y and neuromuscular c o o r d i n a t i o n . I t may a l s o encourage p a t i e n t s t o modify o t h e r more powerful r i s k f a c t o r s . 6) To induce f a v o u r a b l e m e t a b o l i c changes such as i n c r e a s e o f HDL r e l a t i v e t o LDL c h o l e s t e r o l , d e c r e a s e o f t r i g l y c e r i d e l e v e l s and i n c r e a s e i n the s e n s i t i v i t y t o i n s u l i n . Body Weight/Obesity: The r e l e v a n c e of o b e s i t y t o IHD i s w e l l summarized i n the T i t i s e e Report (Koenig, 1986) which r e p o r t s t h a t f o r many y e a r s l i f e i n s u r a n c e d a t a and some p r o s p e c t i v e s t u d i e s i n d i c a t e d t h a t o b e s i t y was a major r i s k 19 factor for mortality due to coronary heart disease. Later, the rol e of obesity was questioned, as no strong c o r r e l a t i o n between overweight and atherosclerosis or i t s complications was found. In secondary prevention, there i s no evidence that weight r e d u c t i o n of patients with p r i o r myocardial i n f a r c t i o n was followed by a re d u c t i o n i n m o r t a l i t y r a t e or i n nonfatal r e i n f a r c t i o n . Nevertheless, the following statement appears j u s t i f i e d : Overweight alone i s not a s i g n i f i c a n t r i s k factor, but the correction of obesity i s desirable because of i t s close r e l a t i o n to hypertension, hyperlipidemia, diabetes. Kannel (1984) i d e n t i f i e s an additional benefit of weight control - that of reducing dependence on drugs i n the reduction of other coronary r i s k factors. P s y c h o l o g i c a l Factors: Simborg (1970) reviews e a r l y developments a s s o c i a t i n g psychological f a c t o r s with IHD and mentions i n p a r t i c u l a r O s i e r ' s statement t h a t i n some in d i v i d u a l s " a r t e r i o s c l e r o s i s seems to come as a d i r e c t r e s u l t of high pressure l i f e " (Osier & McCrae, 1920) and Dunbar's development of personality p r o f i l e s i n disease i n the 1940's that i n c l u d e d the coronary p r o f i l e or p e r s o n a l i t y (Dunbar, 1943). Then he reviews the major study of personality and IHD done by the Western Collaborative Group (Rosenman, Friedman, Straus et a l , 1966) that established Type A as a r i s k factor i n the development of IHD and reports that the t o t a l incidence of CHD was 3.4 times higher i n those with personality Type A than 20 with p e r s o n a l i t y Type B. In the younger aged group the incidence i n Type A subjects was 6.4 times higher. Afte r 4 1/2 years, the o v e r a l l incidence i s 2.4 times higher i n Type A, and 2.8 times higher i n the younger ages with Type A. These r e l a t i o n s h i p s hold true independent of blood pressure, serum l i p i d s , ponderal index or smoking. After 5 1/2 years, the cumulative death rate from CHD was approximately 6 times higher i n Type A persons than Type B. The pioneering e f f o r t s of Rosenman, Friedman and others were recognized i n 1977 when the National Heart, Lung and Blood I n s t i t u t e (NHLBI) (Weiss, 1981) began a two phase comprehensive review and concluded with the statement that "the review panel a c c e p t s the a v a i l a b l e body of s c i e n t i f i c e v i d e n c e as demonstrating that Type A behaviour as defined by the structured interview used i n the Western Collaborative Group Study, the Jenkins A c t i v i t y Survey and the Framingham Type A behaviour scale - i s associated with an increased r i s k of c l i n i c a l l y apparent coronary heart disease i n employed, middle-aged U.S. c i t i z e n s . This r i s k i s greater than that imposed by age, e l e v a t e d v a l u e s of s y s t o l i c b l o o d p r e s s u r e and serum choles t e r o l , and smoking, and appears to be of the same order of magnitude as the r e l a t i v e r i s k associated with the l a t t e r three of these other factors". This was q u a l i f i e d by three future concerns that: 1) More o b j e c t i v e l y q u a n t i f i a b l e and r e p l i c a b l e measurement techniques are needed. 21 2) The s i m i l a r i t i e s and d i f f e r e n c e s between Type A behaviour and coronary prone behaviour i n terms of both s p e c i f i c i t y and p h y s i o l o g i c mechanism must be established. 3) Further s t u d i e s are needed to provide an adequate population base i n terms of race, age, socio economic s t a t u s , c u l t u r a l and sex v a r i a b l e s t o a l l o w generalization of findings concerning Type A behaviour to the population as a whole. Since then much additional research has been reported i n terms of assessment (Crisp, Queenan & D'Souza, 1984; Ruberman, W e i n b l a t t , Goldberg & Chaudhary, 1984) and i n t e r v e n t i o n (Mumford, Schlesinger & Glass, 1982; Friedman, Thoreson et a l , 1984; Frasure-Smith & Price, 1985; Oldenburg & Perkins, 1985) at the l e v e l of secondary prevention. The most d e f i n i t i v e study of secondary prevention to date has been that of Friedman et a l i n 1984. In t h e i r Recurrent Coronary Prevention Project they succeeded i n reducing Type A behaviour by 44% i n the treated group compared to 25% i n the controls, and t h i s was associated with a reduction i n cardiac recurrency rate to 7% compared with 13% for the controls (p<0.005). i i i ) Risk Markers Age and Sex: IHD i s the most common cause of death among Canadian men over the age of 45. In 1982 i t accounted for almost 1/4 of deaths among men i n t h e i r early 40's and more than 1/3 i n t h e i r early 60's. For women cerebrovascular disease causes proportionally more deaths from CVD u n t i l age 40 and then IHD becomes the major form of CVD and, by age 65 i t i s the most 22 common cause of death. Men and women have very s i m i l a r m o r t a l i t y r a t e s f o r cerebrovascular disease. With MI the mortality rates are up to 8 times higher for men than for women i n t h e i r early 40's, and remain 3 to 4 times higher u n t i l age 70 when men and women experience s i m i l a r mortality rates. The greatest number of potential years of l i f e l o s t before age 70 (PYLL) f o r men and women together, i s from cancer and t h i s i s followed by CVD (Nicholls, Nair, MacWilliam, Moen & Mao, 1986). Mor t a l i t y rates i n the f i r s t year following an i n i t i a l MI reverse and are 20% for men and 45% for women, although much of the female mortality occurs early within the f i r s t month. The annual mortality rate for both sexes i n t h i s regard i s 3 to 4 times that of the general population, and tends to decline with time a f t e r the MI. Sudden death accounts for more than half of the mortality (Kannel, 1984). R e i n f a r c t i o n r a t e s are al s o unevenly d i s t r i b u t e d with second MI occurring i n 13% of the men and 40% of the women within 5 years. About half of these r e i n f a r c t i o n s are f a t a l (Kannel, 1984). Thus men experience greater incidence and mortality rates from IHD u n t i l t h e i r mid s i x t i e s a f t e r which there i s l i t t l e difference between the sexes. However, af t e r an i n i t i a l MI women are more prone to r e i n f a r c t i o n and death. F a m i l y H i s t o r y : The f a c t t h a t IHD shows f a m i l i a l c l u s t e r i n g i s w e l l documented i n Simborg's review (1970) although the question as to whether the influence i s genetic or 23 environmental could not be answered from the available evidence. In his summary he reports that f a m i l i a l c l u s t e r i n g i s es p e c i a l l y true i n the younger aged persons with CHD. Slack and Evans showed that male r e l a t i v e s of male coronary patients under age 55 had a 5.2 f o l d increase i n death from CHD compared to male r e l a t i v e s of a control group of the same age. Si m i l a r l y , the female r e l a t i v e s had a 2.8 f o l d increase. The male r e l a t i v e s of female coronary patients under age 65 had 6.4 times the death rate from CHD experienced by the female r e l a t i v e s of controls. The female r e l a t i v e s of female coronary patients had a 6.9 f o l d increase. In a study of parents of medical students, Thomas showed that the prevalence of CHD among s i b l i n g s of ind i v i d u a l s with CHD was 4 times higher than among s i b l i n g s of individ u a l s without CHD. In the Western Collaborative Study, r i s k of CHD was 2.4 times higher i n those subjects with a p o s i t i v e family h i s t o r y of CHD compared to those with a negative family history. b) C l i n i c a l Manifestations In Figure 1.1 c l i n i c a l manifestations and consequential morbidity are presented separately to d i f f e r e n t i a t e 2 l e v e l s of intervention: the f i r s t , acute intensive care i n the hospital and the second, early r e h a b i l i t a t i o n i n the home. Cl e a r l y there are many complications that can maintain a patient i n an acute stage of the disease or return them to i t during the process of r e h a b i l i t a t i o n , e s p e c i a l l y i n phase I. For the purpose of 24 discussion, however, movement from one stage to another w i l l be considered as a di r e c t progression. The manifestations of IHD are sudden death, myocardial i n f a r c t i o n (MI) or angina. Amongst asymptomatic men age 30 to 62 years, the f i r s t overt manifestations occur at approximately 1% per year and of these 13% present as sudden death, 7% as unstable angina, 38% as stable angina and 42% as MI (Oberman, 1980). Sudden death, i n general, accounts for 50% of a l l coronary deaths, occurs within an hour of onset of symptoms and takes place outside the h o s p i t a l . Prompt community resusci t a t i o n measures have been reported to produce 66% r e s u s c i t a t i o n rates for v e n t r i c u l a r f i b r i l l a t i o n , with 14 to 25% survival rates after h o s p i t a l i z a t i o n (Oberman, 1980). The r i s k of sudden death can be assessed more accurately f o r i n d i v i d u a l s with known cardiac disease and t h i s w i l l be discussed under r e h a b i l i t a t i o n . Also of current inter e s t i s the fact that sudden death has been reported to occur without evidence of recent i n f a r c t i o n or occlusion (Davies, 1977; Reichenbach, Moss & Meyer, 1977; Cobb, Baum, Alvarez & Shaffer, 1975), and may re s u l t from ventricular f i b r i l l a t i o n related to a combination of ischemia and stress related sympathetic stimulation (Olsson, Rehnquist, 1982; Lown & Verrier, 1976). In the f i r s t year, mortality rates are large l y related to the degree of myocardial damage and coronary occlusion, and after that depend on a combination of these factors plus varying 25 eff e c t s from the r i s k s i d e n t i f i e d i n the section on antecedent morbidity. With regard to MI several studies have reported 30% mortality rates with l e f t main coronary artery disease, 13 to 15% for three-vessel disease, 10% for two-vessel disease and 4 to 8% f o r s i n g l e - v e s s e l disease w i t h i n one year without i n t e r v e n t i o n . Risks are f u r t h e r escalated by evidence of increasing l e f t v e n t r i c u l a r dysfunction. C l e a r l y such r i s k assessment i s dependent on medical diagnosis, including invasive techniques. By using such assessment information i n combination with i n f o r m a t i o n on antecedent r i s k s , m u l t i - v a r i a t e r i s k p r o f i l e s are evolving for the post i n f a r c t i o n period (Kannel, 1984). Myocardial i n f a r c t i o n i s c l i n i c a l l y recognizable 75% of the time and i s confirmed by ECG and enzyme changes. THe remaining cases are s i l e n t or atypical and would be unrecognized except for ECG changes and possible enzyme changes. The majority of MI patients are s t a b i l i z e d after two or three days i n coronary care and proceed to the e a r l y stages of r e h a b i l i t a t i o n . Case f a t a l i t y rates during the acute phase vary greatly with the degree of myocardial damage and coronary occlusion but, with current monitoring systems, f a t a l i t i e s are now reported to average 15% (Kannel, 1984). Unstable angina (also known as acute coronary i n s u f f i c i e n c y and p r e i n f a r c t i o n angina) i s a term used to describe patients o s c i l l a t i n g between stable angina and MI. E a r l i e r studies suggested a 5 to 32% mortality rate within one year but more 26 recent studies report a 6% mortality rate, a 7 - 12% incidence r a t e f o r MI and 44% e i t h e r f r e e of angina or s u f f e r i n g infrequent attacks. However such information varies widely depending on the study population and d e f i n i t i o n s (Oberman, 1980). Stable angina (angina pectoris) either can become disabling and require medical and/or s u r g i c a l intervention or i t may also disappear e i t h e r t e m p o r a r i l y or permanently even without treatment. P r i o r to coronary artery bypass surgery (CABG) the prognosis for stable angina d i f f e r e d l i t t l e from that for MI with the exception that women were reported to have a better prognosis than men (Oberman, 1980). c) Consequential Morbidity The i n i t i a l event of MI c a r r i e s with i t an increased r i s k of f o r other cardiac related events. Assessment of these r i s k s has become increasingly accurate with greater use of invasive and noninvasive techniques that help anticipate events ranging from sudden death to q u a l i t y of l i f e concerns. Assessment strategies w i l l be mentioned r e l a t i v e to the major physiological and psychological events that commonly follow an MI. Greater emphasis w i l l be placed on noninvasive techniques since there i s increasing reference to them i n the r e h a b i l i t a t i o n l i t e r a t u r e . 27 i ) Impairments and D i s a b i l i t i e s As i m p a i r m e n t s form t h e b a s i s f o r d i s a b i l i t y i n t h i s framework o f m o r b i d i t y i t i s important t o e s t a b l i s h the degree of impairment p r e s e n t . The most common symptoms r e p o r t e d post i n f a r c t i o n are p a i n , s h o r t n e s s o f b r e a t h and f a t i g u e as w e l l as f e e l i n g s o f a n x i e t y and d e p r e s s i o n t h a t m a n i f e s t i n many forms and are w e l l d e s c r i b e d by Hackett and Cassem (1984) and Cay (1982,a). U n d e r l y i n g c o n d i t i o n s , i n p a r t i c u l a r c o n g e s t i v e h e a r t f a i l u r e , angina and arrhythmias, are assessed w i t h a v a r i e t y of medical t e c h n i q u e s and subsequently managed l a r g e l y w i t h medical and s u r g i c a l i n t e r v e n t i o n s . P s y c h o l o g i c a l m a n i f e s t a t i o n s are assessed through o b s e r v a t i o n and i n t e r v i e w as w e l l as v a r i o u s t e s t s . I t i s commonly r e p o r t e d , however, t h a t p h y s i o l o g i c a l and p s y c h o l o g i c a l assessments s t a n d i n d e p e n d e n t l y o f each o t h e r b ecause t h e way i n d i v i d u a l s r e s pond i s independent o f the p h y s i c a l s e v e r i t y of t h e i r s i t u a t i o n (Cay, 1982,a; Hackett & Cassem, 1982). T h i s has been o f p a r t i c u l a r c o n c e r n i n r e h a b i l i t a t i o n w i t h r e g a r d t o such i s s u e s s u r r o u n d i n g r e t u r n t o work, d i s a b i l i t y p e n s i o n s , e a r l y r e t i r e m e n t , a l t e r n a t e placements, reduced e f f i c i e n c y and employer d i s c r i m i n a t i o n , as w e l l as the l e g a l and e t h i c a l i m p l i c a t i o n s f o r p r o f e s s i o n a l s p a r t i c i p a t i n g i n the decision-making process (de V e l a s c o , J.A., 1986; Naughton, 1984; S e g a l l , 1984). Many o t h e r examples of the e f f e c t o f such a d i s c r e p a n c y occur i n the r e h a b i l i t a t i o n process and w i l l be d i s c u s s e d i n the context of b e h a v i o u r a l m o r b i d i t y . 28 i i ) Behavioural Morbidity Behavioural morbidity i s assessed i n terms of disease-induced behaviours that can be evaluated q u a n t i t a t i v e l y and q u a l i t a t i v e l y . As mentioned the discrepancy between diagnosed physical impairment (diagnosed morbidity) and patient reactions (perceived morbidity) i s often most obvious i n r e l a t i o n to d i f f i c u l t i e s regarding employment situ a t i o n s but i t also has other e f f e c t s . Hackett and Cassem (1982) note that the f i r s t response of most North Americans to chest pain from MI i s to act such that the average delay i s 4 to 5 hours before seeking medical help. This pattern of behaviour seems to bear no r e l a t i o n s h i p to education l e v e l , socio-economic status, sex, hi s t o r y of previous MI, acquaintance with i n d i v i d u a l s who have had angina and cardiovascular disease or those who have been exposed to an educational program i n which these p r i n c i p l e s are outlined. They suggest much of the delay i s rooted i n denial and the need to minimize fear. Understandably the same mechanism i s used by a s u b s t a n t i a l proportion of patients i n the post i n f a r c t i o n stage. Subsequent to an MI the extent of a patient' s reaction to the event continues to remain independent of the severity of t h e i r physical condition (Cay, 1982a). Various suggestions have been made as to why such a discrepancy e x i s t s . Fear and anxiety have been mentioned as a basis for denial. Some suggest i t c h i e f l y r e f l e c t s t h e i r usual s t y l e of coping (Cassem & Hackett, 29 1982). Others suggest i t i s the r e s u l t of personality factors and/or continuing stress from p r i o r psychosocial stressors such as occupational experiences and/or more than an average number of l i f e events i n the previous 2 years, p a r t i c u l a r l y the f i n a l 3 months (Konig, 1986; Falger & Appels, 1982; Theorell, 1982). Although the various theories are not conclusive as to the cause of the discrepancy, i t remains i n i t s e l f an important factor i n understanding lack of compliance and other reactions i n the r e h a b i l i t a t i o n process. Other manifestations of behavioural morbidity are well described by Cay (1982a) and Cassem and Hackett (1984). They describe a natural cycle of emotional upset following an MI that i s characterized by decreasing anxiety at the time of hospital discharge, and increasing depression on return home. Although t h i s c y c l e can be s e l f - l i m i t i n g , evidence shows that the emotional upset i s severe i n one t h i r d of the patients and, i f not a l l e v i a t e d , can s t i l l be s i g n i f i c a n t l y disturbing for 25% of the patients more than one year l a t e r . Stern (1984) repo r t s that the f i r s t month at home i s frequently the most c r i t i c a l i n recovery. Expectations of physical recovery and rapid return to premorbid functioning are often contradicted by a r e a l i t y marked by easy f a t i g u a b i l i t y and weakness, and by dietary, sexual and recreational l i m i t a t i o n s . Complaints frequently include nervousness, disturbed sleep, diminished appetite, tearfulness, s o c i a l withdrawal, a sense of uselessness and pessimism about the future. This i s confounded 30 by recommendations to make l i f e s t y l e changes, any c o n f l i c t i n g medical advice, side e f f e c t s of medication and the reactions of family and friends that are frequently overprotective. Short term medical and psychological treatment i s reported to be b e n e f i c i a l , w i t h o c c a s i o n a l p s y c h i a t r i c r e f e r r a l s f o r exceptionally acute short term reactions or for extended periods of severe reaction that could then q u a l i f y as impairments and/or d i s a b i l i t i e s . Interpretation and education i n conjunction with e a r l y e x e r c i s e t e s t i n g and e a r l y p a r t i c i p a t i o n i n exercise classes i s also reported to counteract t h i s reaction which has been described as homecoming depression. In summary i t i s evident that consequential morbidity requires a multifaceted assessment and that diagnosed morbidity w i l l f r e q u e n t l y not e x p l a i n the p a t i e n t s ' perceptions and re a c t i o n to t h e i r experience of MI. E a r l y assessments are important to c a r d i a c r e h a b i l i t a t i o n e s p e c i a l l y f o r e a r l y ambulation and decreased length of stay i n ho s p i t a l , when the p r o c e s s s t a r t s much s o o n e r . Both p s y c h o l o g i c a l and p h y s i o l o g i c a l e f f e c t s of MI have been described since the 1960's, but only r e c e n t l y has the impact of psychological factors been so frequently addressed both i n terms of assessment and intervention and from the time of admission throughout the l a t e r phases of r e h a b i l i t a t i o n . 31 B. C a r d i a c R e h a b i l i t a t i o n The evolution of medical attitudes towards the recovery of MI patients has been dramatic i n the l a s t 30 years. Denolin (1986) and Wenger (1984) both r e c a l l that physical a c t i v i t y was not s i g n i f i c a n t l y l i m i t e d for coronary patients i n the 1700's and 1800's. However a f t e r MI was recognized as a c l i n i c a l e n t i t y by H e r r i c k i n 1912 a p e r i o d of marked r e s t r i c t i o n followed from the 1920's through the 1940's. Protracted bed r e s t of s i x to eight weeks i n hospital was the mainstay of treatment, a c t i v i t y as strenuous as s t a i r climbing was deferred for a year and return to productive work and normal l i v i n g was unusual. This was supported by studies of the pathological process by Mallory (1939) and others that indicated a period of at l e a s t 6 weeks was necessary f o r healing of the scarred myocardium and development of c o l l a t e r a l c i r c u l a t i o n . Denolin records a statement made by White i n 1945 that advises "Acute coronary thrombosis must be regarded more ser i o u s l y than most cardiac conditions, and rest i n bed for weeks or months (a minimum of four weeks) should be prescribed i n order to assure as sound a healing of the myocardial i n f a r c t as possible, with a very gradual and careful convalescence (a minimum of one month aft e r beginning to s i t up out of bed)...". Other s i m i l a r quotes are provided. A challenge to these r e s t r i c t i o n s came i n 1944 when Levine drew a t t e n t i o n to the f a c t t h a t p r o l o n g e d b e d r e s t had unfavourable e f f e c t s . In 1952 Levine and Lown demonstrated that 32 s i t t i n g i n a chair 7 days a f t e r the onset of an MI was safe for the patient and had c e r t a i n advantages. Thus, with the onset of the " c h a i r treatment" the c u r r e n t emphasis i n c a r d i a c r e h a b i l i t a t i o n was borne although not widely accepted. Not u n t i l the e a r l y 1960's was there widespread use of e a r l y m o b i l i z a t i o n and since then the period of bedrest has been progressively reduced as well as the length of h o s p i t a l i z a t i o n . In contrast to 1960, when the average length of stay was 42 days, and i n 1970 when i t was 18 to 21 days, the average h o s p i t a l i z a t i o n now ranges from as few as 7 to as many as 14 days i n the U.S. (Wenger, H e l l e r s t e i n , Blackburn & Castranova, 1982). As mentioned e a r l i e r a s i m i l a r trend has occurred i n Canada. Thus, although r e h a b i l i t a t i o n began s t a r t i n g much e a r l i e r , there was less time i n hospital to progress to desired l e v e l s of a c t i v i t y and consequently, i n the early 1970's, cardiac exercise programs were begun for patients a f t e r discharge. Phase II programs, designed for up to 4 months a f t e r discharge, were u s u a l l y h e l d i n the h o s p i t a l and Phase III or maintenance programs were held i n the community. The e a r l i e s t program i n Canada began i n 1967 at the Toronto Re h a b i l i t a t i o n Centre under Kavanagh (Kavanagh, 1976). The expanded use of ECG's and the addition of radionuclide angiography has enhanced such programs greatly. E a r l i e r prognostic s t r a t i f i c a t i o n and more s p e c i f i c a c t i v i t y p r e s c r i p t i o n s are p o s s i b l e with e a r l y submaximal exercise t e s t i n g at around the tenth day post i n f a r c t i o n , with 33 ambulatory monitoring using the Holter monitor as well as with repeat exercise t e s t i n g . In t h e i r review Denolin and Wenger also report on the emphasis that has been placed on physical r e h a b i l i t a t i o n for many years and the present greater recognition of psychosocial factors. In the broadest sense psychosocial factors include issues surrounding compliance with medical regimes, r i s k factor reduction, family r e l a t i o n s h i p s and employment, and involve interventions that are l a r g e l y psychological such as education and counselling regarding additional interventions, for example CABG, b e h a v i o u r a l change techniques and s e l f management. Recently a national survey (Sikes & Rodenhauser, 1987) was made of a l l U.S.hospitals with coronary care units to determine the prevalence of p s y c h o s o c i a l r e h a b i l i t a t i o n programs f o r MI p a t i e n t s . The r e s u l t s indicate widespread use of inpatient programs i n v o l v i n g p a t i e n t s and f a m i l i e s i n a one-to-one a p p r o a c h . O n l y h a l f as many h o s p i t a l s o f f e r e d an e d u c a t i o n a l / c o u n s e l l i n g program a f t e r d i s c h a r g e or made r e f e r r a l s to such a s e r v i c e . Three quarters of the post discharge services were provided on a one-to-one basis. Nursing was predominantly responsible for inpatient counselling. Both i n and o u t p a t i e n t programs a l s o i n v o l v e d s o c i a l workers, d i e t i c i a n s , physical and occupational therapists, psychologists, p s y c h i a t r i s t s , chaplains and technicians and these professionals formed i n t e r d i s c i p l i n a r y teams up to h a l f the time. Mention i s 34 made that none of the programs r e f l e c t s involvement of the work place i n r e h a b i l i t a t i o n to date. Lamm (1986) reports that CVD gained slowly i n the int e r e s t and concern of WHO but that by 1958 a cardiovascular disease unit was established. Subsequently, the f i r s t WHO Seminar on Cardiac R e h a b i l i t a t i o n was held i n 1967 and soon a f t e r that a d e f i n i t i o n of cardiac r e h a b i l i t a t i o n (WHO, 1969) was written that continues to be a v a l i d and complete d e f i n i t i o n . I t states that 'the r e h a b i l i t a t i o n of cardiac patients can be defined as the sum of a c t i v i t i e s required to ensure them the best possible p h y s i c a l , mental and s o c i a l conditions so that they may, by t h e i r own e f f o r t s , resume as normal a place as possible i n the l i f e of the community. Rehabilitation should take place at an early stage and be continuous. The physician must bear i t i n mind from h i s very f i r s t contact with the patient and not lose sight of i t i n any phases of treatment or supervision. Every a s p e c t of the p a t i e n t must be t a k e n i n t o a c count i n r e h a b i l i t a t i o n , i n c l u d i n g h i s p h y s i o l o g i c a l , c l i n i c a l p s y c h o l o g i c a l and s o c i a l problems. L a s t l y , r e h a b i l i t a t i o n cannot be regarded as an i s o l a t e d form of therapy, but must be integrated with the whole treatment of which i t constitutes only one facet'. I f c r i t i c i s m were to be made i t would address a lack of recognition for the increasingly responsible roles of other d i s c i p l i n e s i n both research and c l i n i c a l areas. However, from the point of view of patient care, the d e f i n i t i o n i s 35 comprehensive i n terms of the current research and work i n r e h a b i l i t a t i o n . S i n c e much of the work i n r e h a b i l i t a t i o n has been established on an empirical basis there has been considerable emphasis i n recent years on the evaluation of current programs as well as the i n i t i a t i o n of randomized c o n t r o l l e d studies of various interventions. Outcome variables i n the early research were often l i m i t e d to mortality and to morbidity i n terms of r e i n f a r c t i o n rates. Cay (1982,b) comments that the r e s u l t s of three m u l t i c e n t r e s t u d i e s f o c u s s i n g on e x e r c i s e (American National Exercise and Heart Disease Project, Ontario Multicentre Exercise Heart T r i a l and WHO European Multicentre Study) would be a f a i l u r e i n these terms. However, indicators of decreased p s y c h o l o g i c a l problems and b e t t e r s o c i a l f u n c t i o n i n g were p o s i t i v e . If comprehensive r e h a b i l i t a t i o n i s to be evaluated a v a r i e t y of indicators are necessary, including mortality and morbidity. Some r e c e n t s t u d i e s t h a t i n c l u d e p s y c h o l o g i c a l i n t e r v e n t i o n s have had e f f e c t s on a v a r i e t y of v a r i a b l e s . E a r l i e r reference was made to the reduction i n Type A behaviour and r e i n f a r c t i o n rates i n the Recurrent Coronary Prevention Project (Friedman et a l , 1984). A Canadian study, the Ischemic Heart Disease L i f e Stress Monitoring Program, (Frasure-Smith & Prince, 1985) reports a s i g n i f i c a n t reduction i n m o r t a l i t y although no reduction i n r e h o s p i t a l i z a t i o n rates. This involved monthly post i n f a r c t i o n telephone monitoring of psychological 36 symptoms of stress using Goldberg's General Health Questionnaire and, whenever a patient's score rose above a c r i t i c a l l e v e l , a v i s i t to the patient's home by a project nurse. An Australian study (Oldenburg & Perkins, 1985) reported that educational and counselling interventions were s i g n i f i c a n t l y more e f f e c t i v e than routine medical and nursing care on psychological and l i f e s t y l e functioning, and as well reported decreased symptoms of heart disease and increased l e v e l s of s e l f management. An American study (DeBusk, Haskell, M i l l e r , Berra & Taylor, 1985) evaluated the difference between medically-directed at-home r e h a b i l i t a t i o n and medically supervised group r e h a b i l i t a t i o n s t a r t i n g 3 weeks p o s t i n f a r c t i o n and found no d i f f e r e n c e i n m o r t a l i t y , r e i n f a r c t i o n or compliance rates. The authors suggest there are p o t e n t i a l advantages i n terms of increased convenience for the patients and improved communication with the nurse and physician regarding d a i l y concerns. These p a r t i c u l a r studies i l l u s t r a t e the use of a v a r i e t y of i n d i c a t o r s i n evaluating the outcomes of cardiac r e h a b i l i t a t i o n . Some authors ( P h i l i p , A.E., 1982) stress the need to develop robust measures that can incorporate physical and psychological factors i n a common framework while others (Cay, 1982, b) stress the need to develop new indicators that are more se n s i t i v e to the "softer but equally r e a l " issues of q u a l i t y of l i f e . Marmot & T h e o r e l l (1982) conclude well when they state that "the profound changes i n human environment and the u t i l i z a t i o n of a modern l i f e s t y l e , where speed and constant competition are 37 dominating, have made coronary disease the s o c i a l disease of our times and the plague of c i v i l i z a t i o n . Psychological stresses cannot be d i f f e r e n t i a t e d from the general environment and cannot be i s o l a t e d from diet, physical i n a c t i v i t y , high blood pressure, carbohydrate intolerance, high LDL le v e l s and heredity factors. A l l these may influence the natural course of the disease... Further research on psychological factors should be based on a c l o s e c o o p e r a t i o n between c a r d i o l o g i s t s , p s y c h o l o g i s t s , s o c i o l o g i s t s and e p i d e m i o l o g i s t s . . . A l l s i d e s should be reminded that i n our world, l i k e i n our body, there i s no action without reaction, no l i f e without stress, no gain without r i s k . The future w i l l show whether a s c i e n t i f i c a l l y based s o l u t i o n can be found." At the end of the chapter recent ideas from the area of h e a l t h promotion w i l l be mentioned and t h e i r p o t e n t i a l relevance to these r e h a b i l i t a t i o n concerns. In concluding t h i s s e c t i o n , f a c t o r s important to the planning of r e h a b i l i t a t i o n programs w i l l be mentioned. The type of i n s t i t u t i o n or agency w i l l determine which phase of r e h a b i l i t a t i o n i s developed. Hospitals include Phase I and f r e q u e n t l y Phase II i n t h e i r s e r v i c e s and these w i l l be discussed f i r s t . Given the shortened length of stay, the end of Phase I may need to be provided on an ambulatory basis and c e r t a i n l y t h i s i s true for Phase I I . For that reason, a guide i n the American H o s p i t a l A s s o c i a t i o n e n t i t l e d " H o s p i t a l Ambulatory Care: Making It Work" (Wacker & Tseng, 1983) i s useful i n i d e n t i f y i n g important planning p r i n c i p l e s for Phase I 38 and II r e h a b i l i t a t i o n programs. Planning i s divided into two stages, strategy formulation and strategy implementation. The p a r t i c i p a t i o n of key i n d i v i d u a l s i n c l u d i n g administration, medical s t a f f and the governing board i s important i n the i n i t i a l planning stage as well as good timing and the right p o l i t i c a l c l i m a t e . In the second stage of p l a n n i n g , p a r t i c i p a t i o n of department heads, chiefs of s t a f f and other mid l e v e l managers i s important. F i n a l approval must be given by top management regarding resource a l l o c a t i o n , evaluation of o b j e c t i v e s and d e l e g a t i o n of management a u t h o r i t y and r e s p o n s i b i l i t y . Although marketing s t r a t e g i e s have not t r a d i t i o n a l l y been considered i n the Canadian Health Care system, ambulatory care s e r v i c e s are dependent on physician r e f e r r a l and, i n that sense, they must be marketed to physicians as useful, asccessible and accountable. Operational planning and budgeting w i l l vary i n d e t a i l but must include organization, management, manpower, costs and revenues. The manner i n which a l l these matters are handled i s important to the development of ambulatory care programs such as cardiac r e h a b i l i t a t i o n . The community provides a base for Phase III programs and s i m i l a r planning and implementation strategies can be adaptated f o r the o r g a n i z a t i o n s i n v o l v e d . Government and voluntary organizations are most frequently responsible for these programs as w e l l as o t h e r community a g e n c i e s , depending on the circumstances. Schlesinger et a l ( 1 9 8 6 ) present an i n t e r e s t i n g overview of government programs i n Germany and Finland, and of 39 business and i n d u s t r i a l programs i n the U.S. Goodwin (1986) describes the ro l e of voluntary organizations and the active r o l e of the N a t i o n a l Heart Foundation of A u s t r a l i a i n p a r t i c u l a r . Guzman et a l (1986) summarize a survey of 50 centres i n 33 countries that provides i n t e r e s t i n g information w h i l e r e c o g n i z i n g l i m i t a t i o n s of the study i n terms of g e n e r a l i z a b i l i t y and s u b j e c t i v i t y . The study concludes that the present s t a t e of the art i n cardiac r e h a b i l i t a t i o n can be s i m p l i f i e d as being predominantly oriented toward ph y s i c a l t r a i n i n g , b e i n g i n s t i t u t i o n a l l y based ( e i t h e r as i n or o u t p a t i e n t treatment) and being championed by motivated patients. Trends suggest that cardiac r e h a b i l i t a t i o n , i n the future, should become more oriented toward q u a l i t y of l i f e considerations, be increasingly community based and championed by motivated and knowledgeable physicians. In summary then, cardiac r e h a b i l i t a t i o n has developed as an independent but integrated aspect of cardiac care i n the l a s t 30 years. Approaches to r e h a b i l i t a t i o n have changed dramatically and the f i e l d i s broadening with the i n c l u s i o n of more p s y c h o s o c i a l i n t e r v e n t i o n s . R e h a b i l i t a t i o n s e r v i c e s are provided by a va r i e t y of organizations, although no discussion of interorganizational planning and cooperation has been noted i n the l i t e r a t u r e so f a r . 40 C. Current Concepts i n Health Promotion When WHO d e f i n e d h e a l t h as more than the absence o f d i s e a s e or i n f i r m i t y i n 1948, formal r e c o g n i t i o n was g i v e n t o p h y s i c a l , mental and s o c i a l w e l l b e i n g as the f u r t h e r dimensions of h e a l t h . O p e r a t i o n a l i z i n g and subsequently measuring these aspects o f w e l l b e i n g has o c c u r r e d s l o w l y . R e c e n t l y WHO f o r m a l i z e d f u r t h e r d i s c u s s i o n s on the concept of h e a l t h w i t h the e s t a b l i s h m e n t o f a new program i n H e a l t h Promotion i n the WHO Regional O f f i c e f o r E u r o p e i n 1984. I n d i s c u s s i o n s o f t h e w o r k i n g g r o u p s ( D i s c u s s i o n document, 1986) H e a l t h has been d e s c r i b e d as the exte n t t o which an i n d i v i d u a l o r group i s abl e , on the one hand, t o r e a l i z e a s p i r a t i o n s and s a t i s f y needs, and, on the oth e r hand, t o change or cope wi t h the environment. Health, then, i s c o n s i d e r e d t o be a re s o u r c e f o r d a i l y l i v i n g r a t h e r than an endpoint o f achievement and c o n s i s t s o f an ongoing process o f a d a p t a t i o n and a d j u s t m e n t . C a r d i a c r e h a b i l i t a t i o n c l e a r l y enables t h i s p rocess by l i m i t i n g adverse consequences o f acute i l l n e s s , a m e l i o r a t i n g symptoms and enhancing r e s i d u a l f u n c t i o n . As p a t i e n t s a c q u i r e knowledge, c o n f i d e n c e and s k i l l s they become i n c r e a s i n g l y competent i n s e l f management and, at some p o i n t , b a r r i n g f u r t h e r c o m p l i c a t i o n s , c o m p l e t e t h e p r o c e s s o f r e h a b i l i t a t i o n and independently e s t a b l i s h t h e i r own l e v e l of commitment t o m a i n t a i n i n g and promoting t h e i r g e n e r a l good h e a l t h . H e a l t h promotion, however, i s r o o t e d h i s t o r i c a l l y i n h e a l t h e d u c a t i o n and has u s u a l l y f u n c t i o n e d o u t s i d e c l i n i c a l boundaries 41 i n h e a l t h c a r e . The c u r r e n t concept d e s c r i b e s h e a l t h promotion as the p r o c e s s of e n a b l i n g people t o i n c r e a s e c o n t r o l over, and t o improve, t h e i r h e a l t h . I t i s based on f i v e u n d e r l y i n g p r i n c i p l e s s t a t i n g t h a t : 1. H e a l t h promotion i n v o l v e s the p o p u l a t i o n as a whole i n  t h e c o n t e x t o f t h e i r e v e r y d a y l i f e , r a t h e r t han  f o c u s i n g on people at r i s k f o r s p e c i f i c d i s e a s e s . I t enables people t o take c o n t r o l over, and r e s p o n s i b i l i t y f o r , t h e i r h e a l t h as an important component o f everyday l i f e - both as spontaneous and o r g a n i z e d a c t i o n f o r h e a l t h . T h i s r e q u i r e s f u l l and c o n t i n u i n g access to i n f o r m a t i o n about h e a l t h and how i t might be sought f o r by a l l t h e p o p u l a t i o n , u s i n g , t h e r e f o r e , a l l d i s s e m i n a t i o n methods a v a i l a b l e . 2. H e a l t h promotion i s d i r e c t e d towards a c t i o n on the  determinants or causes of h e a l t h . H e a l t h promotion, t h e r e f o r e , r e q u i r e s a c l o s e c o o p e r a t i o n o f s e c t o r s beyond h e a l t h s e r v i c e s , r e f l e c t i n g the d i v e r s i t y of c o n d i t i o n s which i n f l u e n c e h e a l t h . Government, at both l o c a l and n a t i o n a l l e v e l s , has a unique r e s p o n s i b i l i t y t o a c t a p p r o p r i a t e l y and i n a t i m e l y way t o ensure t h a t the ' t o t a l ' environment, which i s beyond the c o n t r o l of i n d i v i d u a l s and groups, i s conducive t o h e a l t h . 3. H e a l t h promotion combines d i v e r s e , but complementary  methods o r a p p r o a c h e s , i n c l u d i n g c o m m u n i c a t i o n , educati o n , l e g i s l a t i o n , f i s c a l measures, o r g a n i z a t i o n a l change, community development and spontaneous l o c a l a c t i v i t i e s a g a i n s t h e a l t h hazards. 4. H e a l t h promotion aims p a r t i c u l a r l y a t e f f e c t i v e and  c o n c r e t e p u b l i c p a r t i c i p a t i o n . T h i s focus r e q u i r e s the f u r t h e r development o f p r o b l e m - d e f i n i n g and d e c i s i o n -making l i f e s k i l l s both i n d i v i d u a l l y and c o l l e c t i v e l y . 5. While h e a l t h promotion i s b a s i c a l l y an a c t i v i t y i n the h e a l t h and s o c i a l f i e l d s , and not a medical s e r v i c e , h e a l t h p r o f e s s i o n a l s - p a r t i c u l a r l y i n primary h e a l t h  care - have an important r o l e i n n u r t u r i n g and e n a b l i n g  h e a l t h promotion. H e a l t h p r o f e s s i o n a l s should work to w a r d s d e v e l o p i n g t h e i r s p e c i a l c o n t r i b u t i o n s i n e d u c a t i o n and h e a l t h advocacy. H e a l t h promotion a c t i v i t i e s can be c l u s t e r e d by t h e i r focus on access t o h e a l t h , development of an environment conducive to 42 h e a l t h , s t r e n g t h e n i n g s o c i a l s u p p o r t n e t w o r k s , p r o m o t i n g p o s i t i v e h e a l t h b e h a v i o u r , and/or i n c r e a s i n g knowledge and d i s s e m i n a t i n g i n f o r m a t i o n . In t h i s broader sense, h e a l t h promotion has r e l e v a n c e to i s s u e s i n c a r d i a c r e h a b i l i t a t i o n t h a t i n v o l v e a l t e r n a t e systems o f d e l i v e r y , i n t e r o r g a n i z a t i o n a l c o o p e r a t i o n and consumer p a r t i c i p a t i o n . Both t h e s e i s s u e s and the need f o r b e t t e r i n d i c a t o r s o f w e l l being are p a r t of l a t e r d i s c u s s i o n s on the c o n c e p t u a l framework and methodology. 43 CHAPTER I I : CONCEPTUAL FRAMEWORK A. A Systems Approach E v a l u a t i o n i s the f i n a l s t a g e i n the p l a n n i n g -i m p l e m e n t i o n - e v a l u a t i o n p r o c e s s , i n the same way t h a t r e h a b i l i t a t i o n i s i n the dia g n o s t i c - t r e a t m e n t - r e h a b i l i t a t i o n sequence. Clearly none of the stages i n either process occurs independently of the others, nor do events progress i n an e n t i r e l y l i n e a r f a s h i o n . In o r d e r to i n t e g r a t e these i n t e r r e l a t i o n s h i p s two models based on the systems approach w i l l be used as the conceptual framework f o r d i s c u s s i n g the evaluation. Before discussing the two models, however, b r i e f r e f e r e n c e w i l l be made to the systems approach and i t s ch a r a c t e r i s t i c s . The systems approach conceives of a l i v i n g system as com p r i s i n g a s e t of in t e r d e p e n d e n t u n i t s t h a t i n t e r a c t continually i n order to maintain as nearly as possibly a steady state. Feedback i s an essential part of the s e l f regulatory process. When the e f f e c t of an external force i s f e l t within the boundaries of a system i t works to maintain a steady state by eliminating or counteracting deviations from the normal, or, i t w i l l at times permit increased deviation from the normal and allow subsequent change i n the system. Thus a system i s maintained i n a state of dynamic equilibrium by a flow of information that i s evaluated and interpreted into a un i f i e d response of some sort. M i l l e r (1978) has recently developed the 44 approach i n d e t a i l from general systems theory and others have u t i l i z e d the approach as a framework for discussing planning and evaluation (Blum, 1981) as well as conceptualizing health and i l l n e s s (Feuerstein, Labbe & Kuczmierczyk, 1986; Milsum, 1984) and c l i n i c a l practice (Sundberg, Taplin & Tyler, 1983). The systems approach i s helpful i n developing compact informational flow diagrams that can incorporate current data and insight and stimulate further useful questions. For the purposes of t h i s study, i t provides a basis for describing the developmental process of the program and helping to gain insight into the behavioural change processes of patients during r e h a b i l i t a t i o n . Although the approach does not lend i t s e l f to immediate mathematical treatment, i t provides the opportunity to develop underlying methodological equations that can be the basis for further research and evaluation after an i n i t i a l descriptive study such as t h i s one. This study addresses two areas of i n t e r e s t regarding outcome fo r the cardiac r e h a b i l i t a t i o n program. F i r s t , the e f f e c t s on the hospital i n terms of decreased length of stay, and secondly, c l i n i c a l e f f e c t s i n terms of the program's goals and objectives. The results regarding length of stay are of immediate concern to the administration i n a l l o c a t i n g future r e s o u r c e s , w h i l e an independent f o l l o w up of p a t i e n t s ' perceptions and r e l a t e d behaviour can provide information p o t e n t i a l l y useful i n confirming or changing current program a c t i v i t i e s and/or planning for the future. As mentioned, two 45 models are presented as a framework for the discussion: the f i r s t i s a simple planning-evaluation model and the second a more complex model of health behaviour change. The f i r s t model serves to describe the whole evaluation process although greater emphasis i s placed on the process of evaluating length of stay information since t h i s i s of immediate concern to a l l involved. The second model provides a t h e o r e t i c a l framework from which to consider the various aspects of assessment that are included i n following-up patients a f t e r r e h a b i l i t a t i o n . B. Planning/Evaluation Model A simple planning-evaluation model has been devised to i n d i c a t e the r o l e e v a l u a t i o n p l a y e d when the c a r d i a c r e h a b i l i t a t i o n program was f i r s t established and to discuss the experience as i t occurred. Factors that were h i s t o r i c a l l y important i n securing support for the program w i l l be discussed i n a de s c r i p t i o n of the program i n the next chapter. B r i e f l y , however, the program began at Lions Gate Hospital i n December 1984 with temporary funding and administrative support from within the ho s p i t a l . It was known as the Cardiac E a r l y Discharge Service (CEDS) and was e s t a b l i s h e d as an ambulatory program i n the Medical Day Centre (MDC). Achievement of permanent program status was c h i e f l y dependent on acceptance and r e f e r r a l s from the medical s t a f f , close cooperation between the Cardiac Care Unit (CCU) and Medical Day Centre and a reduction i n the average length of stay. Implementation of the 46 program was a shared r e s p o n s i b i l i t y between the Medical Day Centre's coordinator and the program's c l i n i c a l d i r e c t o r . In t u r n program s t a f f worked w i t h i n a m a t r i x system of r e s p o n s i b i l i t y and were accountable to the program di r e c t o r on c l i n c i a l matters and to the MDC coordinator for administrative reports. F i n a l decisions regarding further resource a l l o c a t i o n rested with the hospital administration. When the Medical Day Centre opened i n February, 1980, there were 10 programs, and evaluation was the established function of a research a s s i s t a n t . However funds were not available to continue the evaluation component afte r 1981. When CEDS was established the need for evaluation was anticipated and plans were i n i t i a t e d by the coordinator of the MDC to involve a student from the Health Care Planning and Administrative Program i n the process. Subsequently approval for student p a r t i c i p a t i o n was granted by the h o s p i t a l administrator and the medical committee at Lions Gate, and by the Ethics Review Committee at U.B.C. Although i n i t i a l arrangements were made for the evaluation i n November 1984, the actual process began i n August 1985 after the program had been functioning for 8 months. Length of stay data was assessed immediately and the f i r s t p a t i e n t s were i n v i t e d to p a r t i c i p a t e i n the follow up process i n September 1985. Patient p a r t i c i p a t i o n was considered more appropriate at t h i s point than e a r l i e r i n the program since by then the service process had had time to become es t a b l i s h e d . Consequently 47 patient follow up continued beyond the f i r s t year of the program i n o r d e r to o b t a i n s u f f i c i e n t numbers. Throughout the evaluation there was close cooperation with the program s t a f f and MDC coordinator. Length of stay data was analyzed, the re s u l t s were reviewed by the c l i n i c a l d i r e c t o r of the program and the MDC coordinator, and then included i n a year end report of the program to the h o s p i t a l administrator. Subsequently further interim funding was arranged u n t i l the program became permanently established i n the summer of 1986. The p l a n n i n g - e v a l u a t i o n model (See Figure 2.2) shows e v a l u a t i o n as c l o s i n g a feedback loop i n the p l a n n i n g -implementation-evaluation process and indicates that outcomes rather than process variables are of primary concern. The flow of evaluation information on established programs would normally follow the broken l i n e to MDC administration. However, as the program was i n a demonstration phase, information from the evaluation was also d i r e c t e d to the h o s p i t a l administrator. Thus the program was dependent on hospital administration at that point. Depending on administrative i n t e r p r e t a t i o n of the outcomes, the feedback could be a d e c i s i o n to maintain the steady state and continue the program, or, conversely to deviate and make changes that could range from eliminating the program to making substantial a l t e r a t i o n s to i t . Whichever decision was made, reaction within the MDC would t h e o r e t i c a l l y be to return to a new steady s t a t e as r a p i d l y as po s s i b l e to maintain continued equilibrium i n a l l programs. 48 HOSPITAL <-ADMINISTRATION MEDICAL DAY ^ ~ CENTRE V PLANNING > EVALUATION IMPLEMENTATION OUTCOMES FIGURE 2.2: Planning and Evaluation Model The diagram therefore provides a simple v i s u a l presentation of the MDC as a system of in d i v i d u a l s i n t e r a c t i n g through t h e i r work i n various programs. Equilibrium i s re-established a f t e r i n i t i a l adjustment to the new cardiac r e h a b i l i t a t i o n program. Informal evaluation i s anticipated as a regular function of program management, and in t e r n a l adjustments between and within programs are expected as part of maintaining a dynamic but steady state i n the MDC. However, decisions made i n the context of the larger system of the hospital provide the opportunity for the MDC to be externally influenced i n an unknown manner. Given the c a p a c i t y of i n d i v i d u a l s to a n t i c i p a t e such events, considerable mental and emotional adjustment and readjustment occurred throughout the l a s t three months of the program which maintained an element of excitement throughout the evaluation process. Subsequently a d e c i s i o n was made to continue the program. Other ramifications could be i d e n t i f i e d by expanding 49 the diagram to integrate other systems, such as the CCU, into a model of interactions for the larger hospital system, including e x t e r n a l f a c t o r s such as p o l i t i c a l i n f l u e n c e s w i t h i n the community and from the p r o v i n c i a l government. However, for the purposes of evaluating CEDS, the system under study i s the MDC and i t i s adequately represented by the simpler model. C. H e a l t h Behaviour Change Model A systems model was developed by K e r s e l l and Milsum (1985) t o i n t e g r a t e the i n f l u e n c e of s o c i a l , e n v i r o n m e n t a l , psycho l o g i c a l and p h y s i o l o g i c a l f a c t o r s on health behaviour change. Although i t was developed around issues of primary prevention the model i s adaptable to any stage of prevention and/or treatment t h a t i n v o l v e s p a t i e n t p a r t i c i p a t i o n i n behaviour change. The model focuses at the l e v e l of i n d i v i d u a l change and develops around four successive but i n t e r r e l a t e d sets of conditions (see Figure 2.3). The f i r s t set of conditions or e x t e r n a l antecedents serve primarily as inputs to the second l e v e l or p e r s o n a l antecedent conditions. These r e l a t e d i r e c t l y to the i n d i v i d u a l and i n p a r t i c u l a r to t h e i r health status. The t h i r d set of conditions include s o c i o - p s y c h o l o g i c a l f a c t o r s which combine input from the f i r s t two conditions with feedback from the l a s t set, the b e h a v i o u r a l conditions. The focus of the model i s on the t h i r d l e v e l , the point at which many factors synthesize to determine whether or not change w i l l be i n i t i a t e d . Health behaviour changes anticipated i n the process of cardiac I II III IV EXTERNAL ANTECEDENT CONDITION PERSONAL ANTECEDENT CONDITION SOCIO-PSYCHOLOGICAL CONDITION BEHAVIOURAL CONDITION R i r t . h r i a t B . Sex Parental and Hereditary/ Genetic Process F a m i l y Structitff So< io-Culti ral Influi nces Basic IPhysiplnaicaJ, Socio-Cultura Environmental Mi leu Makeup Personal Demographic Dynami cs Personal Tpmnpraphy Personal Socialization Process Personal Health Dynami cs Health Fnvi rnnmental Factors 3iaracteri sties Social Influences Health Status Pe rception of Self Perception of Social Influence Perception of Health Status Ski lis/Behaviours Motivation to Comply with Social Influence H p a l t h R p l J P f s Behavioural Repertoire Intention Formation Process Percepti on of Envi ronmental Factors Beliefs about Incentives/ Rarriprc fnr H o ; . 1 t h Ski Beha Hpfllth Intention v I Is/ ours Behaviour Change/ Maintenance Behaviours Behaviour Health Behaviours Figure 2.3 Health Behaviour Change Model 51 r e h a b i l i t a t i o n f i t e a s i l y within t h i s model as well as the various types of morbidity discussed i n Chapter One (Figure 1.1). Both of these w i l l be described i n r e l a t i o n to the variables of i n t e r e s t i n the evaluation. Evaluation of c l i n i c a l aspects of the program was based on the program's goals and objectives, and on current information i n the l i t e r a t u r e . Not a l l outcome variables were s p e c i f i e d i n the objectives although they were i m p l i c i t i n the experience of program s t a f f . Some v a r i a b l e s favoured pre-MI and post-MI assessment of behaviour change while others could only be assessed a f t e r the MI. If the study were developed with a comparison group of post-MI patients any of the variables could be p o t e n t i a l indicators of the d i f f e r e n t i a l e f f e c t s of having a cardiac r e h a b i l i t a t i o n program. The m a j o r i t y of v a r i a b l e s assessed i n the e v a l u a t i o n c l u s t e r around health dynamics within personal antecedents of change and perception of s e l f , health status and environmental factors i n socio-psychological conditions. Behavioural changes were assessed i n r e l a t i o n to antecedent behaviours described i n personal health dynamics. The major variables w i l l be described i n the sequence of the diagram (Figure 2.3). Family h i s t o r y of IHD and diabetes are assessed from within external antecedent conditions. Personal antecedents include occupation, employment status, age, sex, marital status and l i v i n g s i t u a t i o n , as well as i n d i c a t o r s of personal health status that include the d i f f e r e n t aspects of morbidity. Risk 52 markers, those c h a r a c t e r i s t i c s of an i n d i v i d u a l that are hard to change or control, emerge d i r e c t l y from the family hi s t o r y i n terms of IHD and diabetes. Precursors, b i o l o g i c a l abnormalities preceding c l i n i c a l symptoms, are affected by family h i s t o r y and include hypertension, hypercholesteremia, and diabetes. Risk f a c t o r s , behavioural and/or other c h a r a c t e r i s t i c s that are amenable to change, are also influenced by family and s o c i a l h i s t o r y , and i n c l u d e smoking, p h y s i c a l i n a c t i v i t y , overweight/obesity and other coronary prone behaviours. In a d d i t i o n to r i s k markers, precursors and r i s k f a c t o r s as i n d i c a t o r s of antecendent morbidity, p a t i e n t s also d i s p l a y c h a r a c t e r i s t i c s of consequential morbidity that are a r e s u l t of previous medical events and/or subsequent to t h e i r present MI. Previous h i s t o r y of MI or r e l a t e d events are assessed, and symptoms such as pain, shortness of breath and fatigue are included as impairments i f substantiated with medical evidence; otherwise they are a r b i t r a r i l y i n c l u d e d with behavioural morbidity. Behavioural morbidity then includes reports of f e e l i n g unwell ph y s i c a l l y , f e e l i n g anxious and/or depressed and experiencing disturbed patterns of work, recreation and rest. Return to work, adequate sleep patterns, favourite a c t i v i t i e s and d r i v i n g are included to complete the assessment of personal health dynamics. The t h i r d set of conditions includes information about p a t i e n t s ' perceptions regarding t h e i r p r e d i s p o s i t i o n to MI, t h e i r plans and confidence i n changing s p e c i f i c behaviours such 53 a smoking, dietary habits and exercise, and t h e i r perceptions of the e f f e c t of the r e h a b i l i t a t i o n p r o c e s s . Evidence of discrepancies between patients' overt reaction to MI and the severity of t h e i r condition i s also included. In the f i n a l set of conditions behavioural changes are s p e c i f i c a l l y related to compliance with current treatment recommendations, prevention of fut u r e recurrences ( f o r example, smoking cessation) and an increased sense of well being (for example, improved q u a l i t y of re s t or r e l a x a t i o n ) . Thus the model provides an opportunity to consider, within one framework, both assessment and outcome factors that are important i n evaluating the c l i n i c a l e f f e c t s of the program. Clearly, each patient i s influenced by a multitude of factors and must consider more than one change i n most cases. However, while each i n d i v i d u a l process i s complex, simpler group measures of s p e c i f i c behavioural outcomes are valuable i n assessing the e f f e c t s of the program. 54 CHAPTER I I I : PROGRAM DESCRIPTION A. H i s t o r i c a l and P o l i t i c a l Context Establishment of the MDC at Lions Gate Hospital was an important chapter i n the h i s t o r y of the hospital's development as well as an e s s e n t i a l factor i n planning for the Cardiac Early Discharge Service (CEDS). Highlights of the hospital's growth and development follow to provide further i n s i g h t i n t o the o r i g i n s of CEDS which i s a unique service, as judged from the l i t e r a t u r e reviews. Carswell (1980) r e c a l l s the early o r i g i n s of the f i r s t Hospital Society for North Vancouver i n 1920 and t h e i r negotiations with the C i t y of North Vancouver and the d i s t r i c t s of North and West Vancouver to b u i l d a hospital on the North Shore. Many events followed culminating i n the North Vancouver General Hospital as a small acute care h o s p i t a l . Subsequent population increases pressed hospital services beyond t h e i r capacity and the present seven storey structure was b u i l t , opening i n 1961 as Lions Gate Hospital. Next door, at the old h o s p i t a l , renovations enabled the b u i l d i n g to serve as an A c t i v a t i o n Unit with 25 r e h a b i l i t a t i o n beds as well as a separate p s y c h i a t r i c ward. From t h i s location ambulatory day services began: i n 1966, Diabetic Day Care; i n 1973, an Obesity C l i n i c and programs for Chronic Obstructive Lung Disease and A c t i v a t i o n of Coronary Patients; and i n 1971, P s y c h i a t r i c Day Care. Elsewhere i n the h o s p i t a l , daycare surgery began i n 1968. Meanwhile a l l f l o o r s i n the new hospital had been activated by 55 1967, and i n 1971 an additional 169 extended care beds were opened i n a separate unit. Service departments were overloaded. However, hos p i t a l expansion had peaked i n the 1960's, and i n 19 69, Task Force Reports on the Cost of Health Services i n Canada were recommending a s h i f t toward the development of a l t e r n a t e forms of care and a broad range of ambulatory services. The Pr o v i n c i a l Ministry of Health was receptive to such requests and when Lions Gate Hospital was funded to expand t h e i r central services i n 1978 plans were also underway to b u i l d the Medical Day Centre within a second phase of development. Subsequently the MDC opened i n February 1980 to house a wide range of ambulatory s e r v i c e s that now includes 6 programs c l a s s i f i e d as Daycare, 3 as Short Stay Services and 2 as Outpatient. The CEDS program was supported by hospital administration, MDC administration, physicians, and CCU and MDC s t a f f . One i n t e r n i s t was p a r t i c u l a r l y instrumental i n e s t a b l i s h i n g the program a f t e r founding the o r i g i n a l Coronary Activation/Cardiac Exercise Program. He obtained funds from the B.C. Health Care Research Foundation to confirm previous studies that e a r l y d i s c h a r g e of s e l e c t e d post i n f a r c t i o n p a t i e n t s was not associated with increased incidence of complications. The study also served as a small demonstration program and gained the confidence of r e f e r r i n g physicians i n 1981 and 1982. When the program was re-established i n December 1984 through i n t e r n a l h o s p i t a l funding the same physician served as c l i n i c a l d i r e c t o r . 56 Many of the elements i d e n t i f i e d as es s e n t i a l to strategic planning i n Chapter I (Wacker & Tseng, 1983) are evident i n the developments just described. There was in t e r n a l support from key decision makers i n administration and amongst physicians, as well as external support i n terms of timing and an appropriate p o l i t i c a l climate f o r the MDC and l a t e r the CEDS program. Implementation was dependent on a s p e c i f i c set of c r i t e r i a : f i r s t , i t needed to r e l i e v e pressure on acute beds, provide alternatives to r e s i d e n t i a l i n s t i t u t i o n a l care and improve or at least maintain a patient's l e v e l of function; second, i t must be supported by appropriate departments; t h i r d , a physician must be the c l i n i c a l d irector of a program; and fourth, each program must have an approved budget and cost centre r e s p o n s i b i l i t y (Corbett, 1980). F i n a l l y , evaluation was included as a required part of the process. B. A r t i c u l a t i o n of the Program Programs i n the MDC are designed to release pressure on inpatient services as well as to meet perceived needs of the patients i n the community. Prevention i s emphasized and there i s a large educational component based on the underlying b e l i e f that increase i n knowledge and changes i n l i f e s t y l e w i l l increase health status (Young & Romilly, 1981). Three goals are i d e n t i f i e d for the Cardiac Early Discharge Program: 1) To reduce the number of patient days i n hospital; 57 2) To s u p e r v i s e medication, s a f e p r o g r e s s i o n of physical a c t i v i t y , v i t a l signs and other orders; and 3) To organize the patient as required for home care, s e l f care and an organized exercise program. These goals are implemented by an experienced cardiac nurse s p e c i a l i s t who combines her technical s k i l l s and knowledge to s u p e r v i s e , educate and counsel p a t i e n t s i n the community s e t t i n g , and to e s t a b l i s h an e f f e c t i v e rapport with the r e f e r r i n g physicians. The majority of her time i s spent with patients. After the urgency of acute care treatment subsides, she s h i f t s the emphasis of r e h a b i l i t a t i o n to the d a i l y adaptations that are required of patients at home and at work af t e r an MI. Since patients commonly su f f e r from anxiety and/or "homecoming depression" at t h i s time, the nurse intervenes i n various and unique ways with each pat i e n t . Ultimately she provides an opportunity for them to develop t h e i r own s e l f -management s k i l l s for the future. In the remainder of t h i s section her a c t i v i t i e s w i l l be described i n more d e t a i l as they r e l a t e to the goals of the program. Patient centred a c t i v i t i e s begin with an i n i t i a l period of ho s p i t a l l i a i s o n each day. In the CCU reports are shared with physicians and nurses, r e f e r r a l s are accepted and patients are introduced to the program. R e f e r r a l s are completed by the attending p h y s i c i a n and p a t i e n t s sign a consent form when accepting service. 58 S u i t a b l e p a t i e n t s are s e l e c t e d on the basis of t h e i r willingness to p a r t i c i p a t e , t h e i r diagnosis and t h e i r area of residence. The majority of patients are diagnosed as having an acute MI which i s confirmed by 2 or 3 of the following: ECG abnormalities, elevated enzyme le v e l s and a compatible history. Occasionally p a t i e n t s with other diagnoses such as unstable angina are accepted into the program. A l l patients much reside i n North or West Vancouver and, preferably, not l i v e alone. In addition they c l e a r l y need to have the capacity to p a r t i c i p a t e i n e arly ambulation and progressive a c t i v i t y . I f they don't have the capacity due to age or other i n f i r m i t y , appropriate r e f e r r a l s are made to other nursing services. Upon r e f e r r a l , nursing s e r v i c e s are scheduled to begin within 48 hours of discharge and to include 3 v i s i t s i n the f i r s t week, 2 i n each of the next 2 weeks and 1 per week i n the l a s t 3 weeks. I n i t i a l l y emphasis i s placed on a c t i v a t i n g patients and monitoring t h e i r use of medications. On each v i s i t p a t i e n t s walk i n t h e i r neighbourhood with the nurse f o r p r o g r e s s i v e l y longer times or d i s t a n c e s . In a d d i t i o n to checking t h e i r v i t a l signs before and a f t e r walking, the nurse uses the monitor from the portable d e f i b r i l l a t o r to obtain a stationary ECG reading on return from t h e i r walk. I f concerns ar i s e she forwards the ECG recording with her written comments to the attending physician. Such supervision provides the opportunity for early intervention i f problems arise, as well as the opportunity to use b i o l o g i c a l feedback as required i n 59 teaching patients about t h e i r condition. On the days between v i s i t s , patients are instructed to maintain the same exercise pattern that they have established with the nurse and to monitor t h e i r own pulse rate. The majority of patients take 2 or 3 d i f f e r e n t medications, i n p a r t i c u l a r , beta blockers, calcium i n h i b i t o r s , vasodilators and a n t i p l a t e l e t agents but also antiarrhythmics, d i u r e t i c s , anticoagulants and other noncardiac medications. The nurse monitors the patient's compliance with the prescribed regime and any e f f e c t s of the drug as well as teaching patients the name, the purpose and the side effects of each medication. Other issues are discussed, such as the need to keep a fresh supply of n i t r o g l y c e r i n and to understand the e f f e c t s of alcohol i n combination with s p e c i f i c medications. Time i s taken on each v i s i t f or careful reporting of between v i s i t exercise patterns and medication use. D i e t a r y a d a p t a t i o n s and smoking c e s s a t i o n are a l s o emphasized on the i n i t i a l v i s i t s . While i n h o s p i t a l a l l patients and t h e i r partners receive written dietary information and an in d i v i d u a l v i s i t from the d i e t i c i a n to discuss general recommendations f o r car d i a c p a t i e n t s . At home the nurse r e i t e r a t e s the information and helps patients adapt i t to the i r personal t a s t e s and ro u t i n e s . I f hypercholesterolemia or hypertension are subsequently diagnosed, r e f e r r a l i s made to the n u t r i t i o n i s t i n the MDC for further counselling. 60 Smokers are encouraged to continue the period of cessation that has been enforced by t h e i r h o s p i t a l i z a t i o n . If t h i s f a i l s , encouragement i s given to g r e a t l y reduce t h e i r intake of cigarettes and to plan a date for q u i t t i n g i n the near future. Throughout the v i s i t s patients are observed for evidence of anxiety, depression and denial. Interventions are as d i r e c t and simple as possible. The problems are acknowledged and patients are encouraged to discuss t h e i r experiences and accept immediate short term solutions. I f the problems are severe r e f e r r a l i s made to t h e i r attending physician. If the problem appears to be a c h r o n i c a l l y s t r e s s f u l approach to l i f e , then r e f e r r a l i s made for i n d i v i d u a l or group counselling for stress management and relaxat i o n t r a i n i n g . Delivery of the service includes spending as much time with the patient's partner as necessary to deal with t h e i r concerns and reactions to the patient's MI. Frequently t h i s involves r e s o l v i n g i s s u e s of i n t e r p e r s o n a l c o n f l i c t a r i s i n g from uncertainty and fear i n both partners as well as the provision of p r a c t i c a l advice on matters such as changing patterns of eating and food preparation. Aft e r completing service with CEDS, patients are encouraged to complete a written evaluation and return i t to the MDC by mail. They are also i n v i t e d to contact the nurse as necessary f o r f u r t h e r information. Informal communication frequently continues when the patients are i n the hospital for stress 61 t e s t s , the cardiac exercise class and/or the occasional lecture or evening presentation on MI sponsored by the h o s p i t a l . E s t a b l i s h i n g an e f f e c t i v e rapport with p h y s i c i a n s i s necessary for the ongoing success of the program. As a routine, a l l r e f e r r i n g physicians receive written progress reports at the midpoint and at completion of t h e i r p a t i e n t ' s p e r i o d of r e h a b i l i t a t i o n . During service they are consulted by the nurse whenever medical problems a r i s e and a l s o , when the nurse i d e n t i f i e s an opportunity to f a c i l i t a t e better communication between the p h y s i c i a n and t h e i r p a t i e n t . Throughout, the nurse's l e v e l of e x p e r t i s e and ease of communication are fundamental to the process of estab l i s h i n g and maintaining a high r e f e r r a l rate. C. Implications for Evaluation Many possible purposes can be served by evaluation, so that i t i s important to determine, i n the beginning, what functions are to be served i n a p a r t i c u l a r case. Cronbach and Associates (1980) condense many years of experience i n t o "Ninety Five Theses" on e v a l u a t i o n and d i s c u s s the cu r r e n t trends of evaluation i n d e t a i l . They stress that the proper mission of evaluation i s "to f a c i l i t a t e a democratic, p l u r a l i s t i c process by e n l i g h t e n i n g a l l the p a r t i c i p a n t s " . The r e s u l t s of an evaluation w i l l not substitute for the p o l i t i c a l process but w i l l be i n c o r p o r a t e d i n t o i t and must p r o v i d e r e l e v a n t information for those i n decision making positions. 62 Determining the purposes of e v a l u a t i o n was not d i f f i c u l t at L i o n s Gate s i n c e g o a l s f o r the MDC and the program had been c l e a r l y i d e n t i f i e d . Being i n the i n i t i a l stages, the program was d i r e c t l y a c c o u n t a b l e t o the h o s p i t a l a d m i n i s t r a t i o n f o r r e d u c i n g the use o f i n p a t i e n t s e r v i c e s , and t o p h y s i c i a n s f o r s e c u r i n g r e f e r r a l s . U l t i m a t e l y the program was a l s o accountable t o o t h e r p r o f e s s i o n a l s , the p a t i e n t and t h e i r f a m i l i e s and the g e n e r a l body o f knowledge s u p p o r t i n g the program i n terms of c l i n i c a l e f f e c t s . Purposes of the e v a l u a t i o n were, t h e r e f o r e , i d e n t i f i e d i n c o n s u l t a t i o n w i t h t h e MDC c o o r d i n a t o r , t h e c l i n i c a l d i r e c t o r and the c a r d i a c nurse s p e c i a l i s t . They were: t o p r o v i d e i n f o r m a t i o n t h a t w i l l be u s e f u l i n determining w h e t h e r o r n o t t h e program w i l l become p e r m a n e n t l y e s t a b l i s h e d w i t h i n the h o s p i t a l ; t o p r o v i d e i n f o r m a t i o n t h a t w i l l enhance understanding of the program between d i s c i p l i n e s and departments w i t h i n the h o s p i t a l ; and t o p r o v i d e i n f o r m a t i o n and recommendations t h a t can be used t o h e l p shape f u t u r e d i r e c t i o n s of the program. W i t h i n the c o n s u l t a t i v e process i t was a l s o determined t h a t l e n g t h o f s t a y data would be the dependent v a r i a b l e o f f i r s t c o n c e r n i n t h e e v a l u a t i o n and t h a t i n d i c a t o r s o f c l i n i c a l e f f e c t s w o u l d be d e v e l o p e d by t h e c a r d i a c n u r s e and the e v a l u a t o r . D e v e l o p i n g i n d i c a t o r s o f c l i n i c a l e f f e c t s was d i f f i c u l t s i n c e t h e program g o a l s were c o m p r e h e n s i v e i n a d d r e s s i n g t h e g e n e r a l a c t i v i t i e s o f an e a r l y c a r d i a c r e h a b i l i t a t i o n program. C l i n i c a l judgement was r e q u i r e d i n each s i t u a t i o n and t h e program was t a i l o r e d t o t h e needs o f 63 i n d i v i d u a l p a t i e n t s . Thus i t was important t o s e l e c t i n d i c a t o r s t h a t would assess changes ac r o s s a l l p a t i e n t s i n the group, and to m a i n t a i n a focus on outcomes r e l e v a n t t o program g o a l s r a t h e r t h a n i n d i v i d u a l g o a l s t a i l o r e d t o t h e c l i n i c a l s i t u a t i o n . D e t a i l s are d i s c u s s e d f u r t h e r i n Chapter IV, but s u f f i c e t o say, d e f i n i n g the d i f f e r e n c e between c l i n i c a l and program e v a l u a t i o n was d i f f i c u l t and, at times, a r b i t r a r y . U l t i m a t e l y the c h o i c e of c l i n i c a l v a r i a b l e s was l i m i t e d t o those most d i r e c t l y r e l a t e d t o g e n e r a l outcomes i d e n t i f i e d by the g o a l s o f the program. 64 CHAPTER IV: DESIGN AND METHODOLOGY The present evaluation comprises a descriptive study of the e f f e c t s of CEDS on h o s p i t a l s e r v i c e s f o r inpatients and on health r e l a t e d behaviours of patients i n the program. Each area of outcome i s evaluated d i f f e r e n t l y and, therefore, w i l l be discussed i n separate sections of the chapter. The study involves a 3 month planning phase, an 8 month phase of data c o l l e c t i o n and a subsequent phase of analysis, review and writing. Data c o l l e c t i o n for each area of the study began i n the eighth month of the program and was completed 5 months l a t e r when the l a s t patient received t h e i r follow up interview. Some r e s u l t s regarding decreased length of stay were immediately included i n the f i r s t year-end report of CEDS to the h o s p i t a l administrator. A few months l a t e r the program was given permanent status i n the MDC and, with that, an opportunity was provided for the MDC to use other r e s u l t s of the evaluation as needed for future planning. As mentioned e a r l i e r , length of stay was i d e n t i f i e d as a key variable for program evaluation by a l l concerned with CEDS. Consideration was also given to the use of readmission rates and variables were not included i n the study because a method for monitoring readmissions was not available i n the Department of A. E v a l u a t i o n o f the E f f e c t s on H o s p i t a l S e r v i c e s a l t e r n a t e usage of cardiac beds. However, these l a t t e r two 65 Medical Records nor was a monitoring system a v a i l a b l e f o r tracking alternate bed usage on a ward basis. Length-of-stay i s , therefore, the single dependent variable used to evaluate the e f f e c t s of CEDS on other hospital services. The rate of physician r e f e r r a l was i d e n t i f i e d as the most important independent v a r i a b l e since physician r e f e r r a l was required for admission to CEDS. Cooperation between the nurses i n CCU and CEDS was also recognized as an important factor i n f a c i l i t a t i n g early r e f e r r a l s . For the evaluation, data was c o l l e c t e d from the Medical Records Department by diagnostic category and used to e s t a b l i s h the t o t a l population of patients h o s p i t a l i z e d with MI during the f i r s t 10 months of CEDS, t h e i r i n d i v i d u a l length of stay and t h e i r d i s p o s i t i o n on discharge from h o s p i t a l . A l l patients included i n the t o t a l population were categorized as having e i t h e r a c o m p l i c a t e d or uncomplicated MI as t h e i r most responsible diagnosis at discharge. Patients i d e n t i f i e d as e l i g i b l e for CEDS were separated from the t o t a l population of MI patients and used i n determining the rate of physician r e f e r r a l . One set of p a t i e n t s , those l i v i n g out of the area, were i d e n t i f i e d as a comparison group to be used i n evaluating the length of stay data on CEDS patients. Otherwise length of stay data was described as the average length of stay for successive groups over a 10 month period. Differences between the average length of stay for patients i n CEDS and patients l i v i n g out of the area were analyzed using 66 a t - T e s t f o r d i f f e r e n c e s i n t h e means o f i n d e p e n d e n t o b s e r v a t i o n s . Length of s t a y data f o r the i n i t i a l 10 months of the program was grouped f o r the f i r s t 3 months, the second 3 months and the l a s t 4 months. W i t h i n each o f these groups data was c l a s s i f i e d s e p a r a t e l y f o r p a t i e n t s w i t h c o m p l i c a t e d and u n c o m p l i c a t e d MI i n both CEDS and l i v i n g out o f the a r e a . D i f f e r e n c e s i n the average l e n g t h o f s t a y were a l s o compared between groups c l a s s i f i e d as complicated o r uncomplicated MI w i t h i n each time p e r i o d , based on the n u l l h y p o t h e s i s t h a t there would not be a s i g n i f i c a n t d i f f e r e n c e between any of the groups. B. E v a l u a t i o n o f C l i n i c a l E f f e c t s A range o f v a r i a b l e s are used t o d e s c r i b e and e v a l u a t e the c l i n i c a l e f f e c t s o f the program u s i n g a sample of 40 p a t i e n t s . The v a r i a b l e s were s e l e c t e d a f t e r r e v i e w i n g the program g o a l s and the r e h a b i l i t a t i o n a c t i v i t i e s as they are d e s c r i b e d i n the p r e v i o u s c h a p t e r . The outcome v a r i a b l e s o f immediate importance t o t h e p r o g r a m e v a l u a t i o n a r e e x e r c i s e l e v e l s , d i e t a r y p r a c t i c e s , c i g a r e t t e smoking, compliance w i t h m e d i c a t i o n regimes and c l i e n t s a t i s f a c t i o n . The program i t s e l f i s t r e a t e d as the independent v a r i a b l e . The d e s c r i p t i v e v a r i a b l e s i n c l u d e the p r e c u r s o r s ( h y p e r t e n s i o n , h y p e r c h o l e s t e r o l e m i a , d i a b e t e s ) , the o t h e r r i s k f a c t o r s (overweight, coronary prone behaviour) and the r i s k markers (age, sex, f a m i l y h i s t o r y o f d i a b e t e s o r MI, p e r s o n a l h i s t o r y o f p r e v i o u s c a r d i a c e v e n t s ) c a t e g o r i z e d as 67 antecedents on the Health Behaviour Change Model (See Figure 2.3). These variables are considered to intervene primarily at a ph y s i o l o g i c a l l e v e l but, also, become part of the patient's personal perception of t h e i r health status. Data on 7 of the v a r i a b l e s (blood pressure, c h o l e s t e r o l , d i a b e t e s , f a m i l y history, obesity, smoking and exercise) i s analyzed by use of the Health Hazard Appraisal System and 2 i n d i v i d u a l appraisals of r i s k are provided f o r each pati e n t : one, based on the patient's report of pre i n f a r c t i o n r i s k s ; and the other on t h e i r report 3 months a f t e r MI. Other d e s c r i p t i v e v a r i a b l e s , c a t e g o r i z e d as s o c i o -psychological factors on the model, are considered to intervene at a cognitive l e v e l , and include the patients' perceptions of t h e i r p r e disposition to MI and t h e i r current health status as well as t h e i r b e l i e f s and plans about following recommended health behaviours. Evidence of denial, anxiety or depression, the disturbance of normal functions and interpersonal c o n f l i c t are included with the reports patients provide about perceptions of t h e i r health status. These variables are included to further understand the personal experience of many patients and, also, to describe some of the intervening factors that influence the course of events for the nurse d e l i v e r i n g the service. V a r i a b l e s were opera t i o n a l i z e d i n consultation with the program s t a f f and p i l o t e d verbally, i n a series of phone c a l l s to patients who had completed service with CEDS i n the f i r s t 8 months of the program. Subsequently, a written questionnaire 68 and interview was developed to be administered to a sample of patients r e c r u i t e d from the l a t e r admissions to CEDS. A single group design was u t i l i z e d and patients completed a pre and post assessment using the same questionnaire on 2 separate occasions, once approximately 1 week af t e r MI and, again, approximately 12 weeks l a t e r . A structured interview was included at the time of completing the second questionnaire and t h i s was usually done i n the patient's home or, i f the patient preferred, i n the MDC. A sample of 40 patients was rec r u i t e d over a 5 month period from 65 sequential admissions to CEDS. E l i g i b i l i t y was based on a d i a g n o s i s of MI, the l a c k of a language b a r r i e r and willingness to p a r t i c i p a t e . Of the 65 admissions, 15 patients were i n e l i g i b l e (7 due to diagnosis, 5 due to language, 3 due to unwillingness), 2 patients died, 3 moved out of the area and 5 were missed for recruitment. There was no loss to follow up. Outcome variables regarding exercise and dietary practices were analyzed for s i g n i f i c a n t differences between pre and post assessment. Variables were assessed either on an i n t e r v a l scale or on an ordinal scale. Interval data was tested with a paired t - T e s t f o r dependent observations with a one d i r e c t i o n a l hypothesis. 40 pairs of reported observations were taken from pre and post assessments on each v a r i a b l e and t e s t e d to d e t e r m i n e whether o r not they i n c r e a s e d or d e c r e a s e d s i g n i f i c a n t l y i n the desired d i r e c t i o n . Ordinal data was tested with the Sign t e s t . A l l patients with an increase or decrease 69 between pre and post assessment were i n c l u d e d i n the t e s t . Each p a i r o f pre and post o b s e r v a t i o n s were a s s i g n e d a p o s i t i v e or n e g a t i v e v a l u e and the number of changes i n e i t h e r d i r e c t i o n t e s t e d f o r s i g n i f i c a n c e . 70 C H A P T E R V : R E S U L T S A N D A N A L Y S I S Results of the evaluation are presented i n order of t h e i r i n i t i a l importance to those involved i n the consultative process at the h o s p i t a l . Analysis i s included with the r e s u l t s i n the f i r s t and t h i r d sections. Results i n the f i r s t section are concerned with the e f f e c t of CEDS on hospital services and focus on physician r e f e r r a l rates and length of stay data for CEDS pa t i e n t s . Length of stay data i s described for successive groups of CEDS patients over a 10 month period and compared with a separate group of patients h o s p i t a l i z e d with MI during the same p e r i o d o f time at L i o n s Gate H o s p i t a l . P a t i e n t c h a r a c t e r i s t i c s d e s c r i b e d i n the second s e c t i o n i n c l u d e information on demographic factors and antecedent factors to do with p r i o r r i s k f or MI. The information helps to describe the population of concern and some of the issues addressed during the r e h a b i l i t a t i o n process. Some of the data i s used again i n the l a s t s e c t i o n to provide r i s k appraisals. In the t h i r d s e c t i o n the c l i n i c a l e f f e c t s of CEDS are described and the re s u l t s given regarding pre and post assessments of exercise and a c t i v i t y l e v e l s , d i e t a r y p r a c t i c e s and c i g a r e t t e smoking. A d d i t i o n a l i n f o r m a t i o n i s p r o v i d e d r e g a r d i n g p a t i e n t s ' compliance with medication regimes and s a t i s f a c t i o n with the program. The f o u r t h s e c t i o n provides f u r t h e r d e s c r i p t i v e i n f o r m a t i o n about s o c i o - p s y c h o l o g i c a l f a c t o r s t h a t are considered to intervene i n the process of r e h a b i l i t a t i o n . In 71 the l a s t section, a summary of the re s u l t s from i n d i v i d u a l r i s k appraisal i s provided. The appraisals are produced through the use of the Health Hazard Appraisal System. A. E f f e c t o f CEDS on H o s p i t a l S e r v i c e s 1. P h y s i c i a n R e f e r r a l s Admission to CEDS was dependent on physician r e f e r r a l and from the s t a r t of the program physicians were cooperative about r e f e r r i n g t h e i r patients. In the f i r s t 10 months, 6 cardiac s p e c i a l i s t s and 55 general p r a c t i t i o n e r s referred a t o t a l of 91 p a t i e n t s to CEDS i n c l u d i n g : 74 w i t h acute m y o c a r d i a l i n f a r c t i o n ; 12 w i t h u n s t a b l e angina; and 5 i n s p e c i a l circumstances. The 74 patients with MI represent 92% of the MI patients considered to be e l i g i b l e for the program while the remainder represent additional requests for service. Further d e t a i l s f o l l o w regarding the t o t a l p o p u l a t i o n of patients h o s p i t a l i z e d with MI and t h e i r alternate outcomes during the 10 month period under study. According to the discharge summaries i n Medical Records, 187 patients had a discharge diagnosis of MI i n the 10 month period under study. From t h i s population, 85 were considered e l i g i b l e f or CEDS according to diagnosis, discharge status and area of residence. Of the remaining 102, 57 died while i n hos p i t a l , 22 were transferred to other i n s t i t u t i o n s and/or had other complications, and 23 resided outside the boundaries of North and West Vancouver. Of the 85 patients i d e n t i f i e d as 72 being e l i g i b l e for CEDS, only 74 were reported to be i n the program, which l e f t an apparent loss of 11 patients. In 5 cases the c a r d i a c nurse i d e n t i f i e d reasons f o r lack of r e f e r r a l i n c l u d i n g an immediate need f o r further medical procedures, i l l n e s s i n the supporting partner, and inappropriate l i v i n g arrangements. The circumstances of the remaining 6 could not be c l a r i f i e d p o s s i b l e due to m i s c l a s s i f i c a t i o n of e l i g i b i l i t y through Medical Records information and/or slippage i n the process of matching documentation i n Medical Records with p a t i e n t l i s t s maintained on the ward. Assuming, that 80 patien t s remained e l i g i b l e f o r the program, then physicians referred 92% to the program. Expressed d i f f e r e n t l y , the program appeared to be appropriate for 57% of the patients surviving an MI, and the great majority of these i n d i v i d u a l s were referred to the program. As mentioned a d d i t i o n a l r e f e r r a l s were accepted to the program and these i n c l u d e d 12 p a t i e n t s h o s p i t a l i z e d with unstable angina and 5 patients with cardiac conditions that were not h o s p i t a l i z e d at Lions Gate but l i v e d on the North Shore. The l a t t e r 5 included 2 postoperative patients that had ju s t had open heart surgery at St. Paul's Hospital; 1 patient returning home from vacation having suffered an MI one week e a r l i e r ; 1 patient returning home af t e r h o s p i t a l i z a t i o n for MI elsewhere i n Vancouver; and 1 patient with chronic d i s a b i l i t y due to three-v e s s e l i n o p e r a b l e c a r d i a c disease. Although the program focussed on MI, i t was agreed by those responsible that other 73 cases r e q u i r i n g c a r d i a c r e h a b i l i t a t i o n would be accepted i f time was a v a i l a b l e w h i l e t h e program was becoming e s t a b l i s h e d . T h e r e f o r e , as mentioned, the program r e c e i v e d 74 r e f e r r a l s f o r MI, 12 f o r u n s t a b l e angina and 5 f o r s p e c i a l circumstances with a t o t a l of 91 p a t i e n t s r e f e r r a l s . The h i g h r a t e o f r e f e r r a l s can be a t t r i b u t e d t o s e v e r a l f a c t o r s : the program was i n i t i a t e d by a well-known c a r d i a c s p e c i a l i s t ; i t was e s t a b l i s h e d i n the h o s p i t a l w i t h the support of o t h e r p h y s i c i a n s ; the p a t i e n t ' s p e r s o n a l p h y s i c i a n remained i n charge a l t h o u g h the program o p e r a t e d under the c l i n i c a l l e a d e r s h i p o f a c a r d i a c s p e c i a l i s t ; and f u r t h e r , the program s e r v i c e s were p r o v i d e d by a n u r s e who was well-known and r e s p e c t e d as a c a r d i a c nurse s p e c i a l i s t w i t h i n the h o s p i t a l . When asked t o respond w i t h a w r i t t e n e v a l u a t i o n of the program each o f the 6 s p e c i a l i s t s responded p o s i t i v e l y . They r e p o r t e d s a t i s f a c t i o n w i t h t h e i r p r o f e s s i o n a l r e l a t i o n s h i p t o the program and w i t h the r e p o r t s t h a t p a t i e n t s brought t o them o f the s e r v i c e . They wanted the program to be c o n t i n u e d and had no s p e c i f i c s u g g e s t i o n s r e g a r d i n g changes or improvements. Interdepartmental cooperation between the c a r d i a c nurse from the MDC and the CCU s t a f f was a l s o c o n s i d e r e d an e s s e n t i a l f a c t o r i n f a c i l i t a t i n g r e f e r r a l t o the program. Cooperation was observed i n terms o f open communication and ease o f access to t h e s t a f f , f a c i l i t i e s and n e c e s s a r y i n f o r m a t i o n . I n i t i a l c o o p e r a t i o n can be a t t r i b u t e d t o t h e f a c t t h a t t h e nurse p r o v i d i n g CEDS had j u s t t r a n s f e r r e d from CCU and was w e l l 74 respected and l i k e d as a s t a f f member. However, maintaining the same l e v e l of cooperation w i l l be equally important to the program when i t i s permanently established and/or when s t a f f changes occur, according to the coordinator of the MDC and program s t a f f . 2. Length of Stay i n Hospital The goals for reducing the average length of stay (ALOS) for CEDS patients i n 1985 were achieved. In 1984 the ALOS at Lions Gate for a l l patients with MI was 15.2 and 10.6 days for complicated and uncomplicated Mi's respectively. In 1985 the goal for CEDS was to reduce the ALOS for complicated Mi's when possible and to achieve an ALOS of 8 to 9 days for uncomplicated Mi's. The r e s u l t s (Table 5.1) confirm a downward trend for a l l Mi's over the f i r s t 10 months of the program and an ALOS of 8.6 days for uncomplicated Mi's i n the f i n a l 4 months. Over the 10 months, CEDS p a t i e n t s averaged 12.8 days (complicated) and 9.0 days (uncomplicated), while the ALOS for a l l patients i n Lions Gate with MI was 17.4 days (complicated) and 10.8 days (uncomplicated). The difference i s attributed to the e f f e c t s of CEDS as well as a s e l e c t i o n bias with CEDS pa t i e n t s since CEDS excluded patients who were often older and/or had other complications. 75 TABLE 5.1 AVERAGE NUMBER WITHIN CEDS OF DAYS LENGTH OF DURING THE INITIAL n=74 STAY FOR 10 MONTH MI PATIENTS PERIOD MONTHS 1 - 3 MONTHS 4 - 6 MONTHS 7 - 1 0 COMPLICATED MI n=18 12.8 14.7 11.0 UNCOMPLICATED MI n=56 9.7 8.9 8.6 In order to l a t e r compare the e f f e c t of CEDS, another group of patients were selected that were also i n hospital with an MI during the 10 month period but, due to l i v i n g out of the area, were e x c l u d e d from CEDS ( T a b l e 5.2). Comp l i c a t e d and uncomplicated groups were compared within the same time periods and the data tested with a t-Test. There was no s i g n i f i c a n t difference between the 6 groups with 1 exception, namely, the difference between complicated cases i n the 7 to 10 month period (p<.002). The reasons for t h i s are unclear since there was i n s u f f i c i e n t information on out of area patients to reach a conclusion. However, since the average length of stay for both groups remained below that for comparative hospital data i n previous year, i t i s surmized that physicians may have adopted the practice of early discharge for out of area patients also. 76 I t i s unknown whether or not patients referred to other services such as Home Care. TABLE 5.2 AVERAGE NUMBER OF DAYS LENGTH OF STAY FOR MI PATIENTS HOSPITALIZED WITHIN THE INITIAL 10 MONTH PERIOD OF CEDS BUT RESIDING OUT OF THE AREA n=23 MONTHS 1 - 3 MONTHS 4 - 6 MONTHS 7 - 1 0 COMPLICATED MI n=8 13 23 20.6 UNCOMPLICATED MI n=15 8.3 9 9.3 In addition to reducing the ALOS for h o s p i t a l i z e d patients, CEDS r e p o r t e d a c c e p t i n g 5 p a t i e n t s who were i n s p e c i a l circumstances. By accepting one of these r e f e r r a l s an admission to h o s p i t a l was avoided. Although monitoring non-admissions was not c o n s i d e r e d a f e a s i b l e i n d i c a t o r f o r the fut u r e , the information was incorporated with the other data to calculate the p o t e n t i a l number of bed days saved during the 10 month period. Projected savings were estimated by the MDC coordinator and found to be $50,000 or twice the cost of the program. Although a cost analysis was not a goal of t h i s evaluation, the cal c u l a t i o n s were made as part of the year end report to the hospi t a l administrator. 77 B. Patient C h a r a c t e r i s t i c s 1. Demographics C h a r a c t e r i s t i c s described i n t h i s section are useful i n understanding the patient population i n terms of t h e i r home environment and t h e i r d a i l y l i v e s , and the d e l i v e r y of a r e h a b i l i t a t i o n services i n the community. For most patients these c h a r a c t e r i s t i c s remained unchanged a f t e r t h e i r MI. However, depending on t h e i r circumstances, a v a r i e t y of concerns were expressed by patients about having or wanting to change some of these fundamental aspects of t h e i r l i f e a f t e r t h e i r MI, i n c l u d i n g , f o r example, t h e i r employment o r m a r r i a g e commitments. In general the patient population was characterized as male with an average age of 60 years. Females averaged 64 years of age. Most patients were married, resided i n a single dwelling, and had grown children . Half of the patients were employed at the time of MI and of the remainder, one quarter were already r e t i r e d . Further d e t a i l s are included since differences were more important than g e n e r a l i t i e s to the various a c t i v i t i e s of r e h a b i l i t a t i o n . As mentioned, 77% of the study population was male with an average age of 60 years while the female patients averaged 64 years of age. Men ranged i n age from 34 to 89 years, and women range 54 to 75 years of age. The majority of the patients were married (33) and the remainder divorced (3), widowed (2) or never married (2). Most 78 of those who were married l i v e d alone with t h e i r spouse (27) while the others (6) also had children at home. 5 of the unmarried patients l i v e d alone, 1 with an e l d e r l y parent and 1 with a f r i e n d . The majority of patie n t s l i v e d i n s i n g l e dwellings (27) and the remainder i n apartments, nearly a l l of which were located on h i l l s due to the geography of the North Shore. At times that presented d i f f i c u l t y when walking. Several patients expressed pleasure at being i n one p a r t i c u l a r complex of high r i s e apartments that provided an opportunity to meet other "heart patients" while walking i n or outdoors with easy access to a large shopping mall on cold or rainy days. At the time of t h e i r MI, 21 patients were employed f u l l time and 3 part time, 11 were r e t i r e d , 1 was unemployed and on s o c i a l assistance, and 4 were involved f u l l time at home. A l l f u l l time employees were male, 11 of them over 60 years of age, 6 of them between 50 and 60 years and 4 of them between 34 and 47 years old. Women held the positions of part time employment, and f u l l time involvement at home. (4 of the r e t i r e d men had al s o secured part time employment). The group of r e t i r e d p a t i e n t s comprised 9 men and 2 women, while the unemployed patient was male and had chronic schizophrenia. Up to that point i n t h e i r l i v e s , 30 men and 2 women had been employed on a f u l l time basis for most of t h e i r l i v e s , 3 women had been employed on a part time basis, 4 women had been f u l l time at home and 1 man had been unemployable. Their primary c a r e e r s were reported as management by 8 patients, 79 private enterprise by 8, professional services by 5, s k i l l e d labour by 5, sales by 3, armed forces by 3 and homemaking by 8. 2. A n t e c e d e n t R i s k s f o r MI The majority of the antecedent r i s k s are p h y s i o l o g i c a l a n d / o r b e h a v i o u r a l , i n c l u d i n g h y p e r t e n s i o n , h y p e r c h o l e s t e r o l e m i a , o b e s i t y , smoking, l a c k of p h y s i c a l a c t i v i t y and family and personal h i s t o r y of diabetes and MI. C h a r a c t e r i s t i c s of the group are described since they are important to l a t e r reports of r i s k appraisal as well as to the patients actual and perceived health status. 24 p a t i e n t s were i d e n t i f i e d as having some degree of h y p e r t e n s i o n (140/90 or h i g h e r ) , 9 as h a v i n g e l e v a t e d c h o l e s t e r o l l e v e l s (>250 mgm/%) and 18 as being o v e r w e i g h t p r i o r to t h e i r MI. Of those with hypertension, 15 reported taking medication. Again of those patients with hypertension, 7 were also i d e n t i f i e d as those having elevated cholesterol l e v e l s (250 mg/% or higher), 11 as those being overweight by 20 to 65 pounds, and 7 as having experienced previous cardiac events. 14 patients reported themselves to be current smokers at the time of t h e i r MI and 17 to be exsmokers, 6 having quit more than 10 years ago, 9 from 1 to 10 years e a r l i e r and 2 within the year p r i o r to t h e i r MI. A l l c u r r e n t smokers p r e f e r r e d cigarettes except one man who smoked 10 to 12 p i p e f u l s d a i l y . Approximately hal f the patients were p h y s i c a l l y inactive 80 during the day ( s i t t i n g or standing) and 37% reported getting 0 days of walking or other l i g h t exercise each week. 8 patients reported a family h i s t o r y i n which 1 or both parents died of an MI before age 60. 2 p a t i e n t s reported family h i s t o r i e s of diabetes i n a parent or s i b l i n g , and 1 of these 2 personally reported having diabetes. Altogether 5 patients report having diabetes, one having been diagnosed during h o s p i t a l i z a t i o n for MI. 2 of the patients were poorly controlled. Previous cardiac events were reported for 12 patients and included: 4 patients with angina (2 unstable); 6 with MI (3 having had 1 MI, 2 having 2, and 1 having 4); 2 with cardiac arrests; and 1 with CVA. 2 of these 12 patients also reported h a v i n g had p r e v i o u s coronary bypass surgery and one an endarterectomy. C. C l i n i c a l E f f e c t s of CEDS The following r e s u l t s are the outcomes of importance i n e v a l u a t i n g the CEDS program. Reports of pre and post assessments on exercise and a c t i v i t y l e v e l s , dietary practices and c i g a r e t t e smoking are given as well as follow up reports of compliance with medication regimes and s a t i s f a c t i o n with the program. 81 1. E f f e c t s on E x e r c i s e and A c t i v i t y L e v e l s Frequency of exercise Overall, 65% (26) of the patients reported an increase i n the weekly amount of l i g h t exercise that they gained, e s p e c i a l l y from walking, a f t e r t h e i r MI and subsequent early r e h a b i l i t a t i o n program (Table 5.3). At follow up 84% of the patients (32 of 38) reported walking 30 minutes or more for 5 to 7 days per week i n c o n t r a s t to 47% p r i o r to MI. Further, 0% reported no exercise at follow up whereas 37% had reported t h i s lack of exercise before MI (Table 5.4). These increases i n exercise were s i g n i f i c a n t on a paired one t a i l t-Test, t=5.14, 40df, p<.0005. At follow up, 35 patients reported having had stress tests and of these patients, 27 reported an i n v i t a t i o n to attend the cardiac exercise program at Lions Gate. Of the 27 i n v i t e d patients, 16 reported attendance at the c l a s s . The remaining 11 f e l t they were getting enough exercise on t h e i r own and/or were unable t o come at the s c h e d u l e d times due to work or t r a n s p o r t a t i o n . Of the 8 p a t i e n t s who d i d not report an i n v i t a t i o n to attend the exercise program, 4 were undergoing further t e s t i n g and 4 were not aware of the program. TABLE 5 .3 FREQUENCY OF LIGHT EXERCISE BEFORE MI BY TYPE OF CHANGE n=40 REPORTED AT FOLLOW UP DAYS/WEEK OF EXERCISE BEFORE MI NO. OF PATIENTS REPORTING A DECREASE NO. OF PATIENTS REPORTING AN INCREASE NO. OF PATIENTS REPORTING NO CHANGE TOTAL 7 3 N/A 3 6 6 0 1 2 3 5 2 6 2 10 4 0 3 0 3 3 0 1 0 1 2 0 2 0 2 1 0 0 0 0 0 N/A 13 2 15 5 26 9 40 83 TABLE 5.4 FREQUENCY OF LIGHT EXERCISE BEFORE MI AND AT FOLLOW UP n=38 * DAYS/WEEK AFTER MI DAYS/WEEK BEFORE MI 5 to 7 2 to 4 0 to 1 5 to 7 17 2 0 19 2 to 4 6 0 0 6 0 to 1 9 4 0 13 32 6 0 38 * 2 patients p h y s i c a l l y incapacitated at time of follow up. Levels of d a i l y a c t i v i t y After t h e i r MI, the 8 patients who had reported being i n the heavy work category, a l l reduced to the 2 middle l e v e l s of a c t i v i t y (standing and walking, with or without climbing s t a i r s or carrying l i g h t loads), while the 5 who had reported the least a c t i v i t y (usually s i t t i n g , not walking much) remained i n t h i s category. In consequence, the 2 middle c a t e g o r i e s had a combined incr e a s e from 67% to 87%. Reduced a c t i v i t y was expected for patients i n the heavy work category at t h i s stage of recovery. However, an increase i n l i g h t e x e r c i s e was expected and on follow up, 7 of them reported an increase of between 4 and 7 days a week. The remaining patient previously 84 walked on a d a i l y b a s i s and had r e e s t a b l i s h e d h i s former p a t t e r n by the time o f f o l l o w up. TABLE 5.5 LEVELS OF DAILY ACTIVITY BEFORE MI AND AT FOLLOW UP n=40 14 WEEKS AFTER MI BEFORE MI 4 3 2 1 4 0 5 3 0 8 3 0 6 5 0 11 2 0 2 14 0 16 1 0 0 0 5 5 0 13 22 5 40 KEY: 4 Heavy work, carrying very heavy loads 3 Carrying l i g h t loads, often climbing s t a i r s or h i l l s 2 Standing or walking, not l i f t i n g or carrying 1 S i t t i n g , not walking much 5 p a t i e n t s reported that before MI they were us u a l l y s i t t i n g during the day and they remained i n t h i s category at the time of follow up. However, each reported an increase of 3 days a week of l i g h t exercise from t h e i r pre MI l e v e l s of 0 to 4 days. 85 O v e r a l l , r e d u c t i o n s i n d a i l y a c t i v i t y were a p p r o p r i a t e t o the circumstances and, i n most cases, accompanied by an i n c r e a s e i n e x e r c i s e l e v e l s . Recommendations t o r e s t r i c t s p e c i f i c a c t i v i t i e s were made by t h e i r p h y s i c i a n s a c c o r d i n g t o the r e p o r t s o f 15 p a t i e n t s . These i n c l u d e d not l i f t i n g o r moving o b j e c t s weighing more than 15 o r 20 pounds f o r 11 p a t i e n t s , no v i g o r o u s a c t i v i t y f o r 2 more and both r e s t r i c t i o n s f o r the remaining 2 cases. The m a j o r i t y of p a t i e n t s r e c e i v i n g such adv i c e were i n v o l v e d on a d a i l y b a s i s w i t h heavy work r o u t i n e s and/or v i g o r o u s e x e r c i s e p r i o r t o MI and were r e p o r t i n g reduced l e v e l s o f u s u a l d a i l y a c t i v i t y at f o l l o w up. Advice t o the othe r 25 p a t i e n t s was r e p o r t e d as c o n t i n u i n g t h e i r a c t i v i t i e s as us u a l u n l e s s e x p e r i e n c i n g chest p a i n , s h o r t n e s s o f b r e a t h o r d i z z i n e s s . Return t o work P r i o r t o MI, 21 p a t i e n t s were employed f u l l time, 6 i n management, 5 i n p r i v a t e e n t e r p r i s e , 2 i n s a l e s , 3 i n government and 5 i n s k i l l e d l a bour. Returning t o work, by f o l l o w up, was most common f o r th o s e i n management, p r i v a t e e n t e r p r i s e and s a l e s , and amounted t o 85% of the 13 p a t i e n t s i n v o l v e d . In c o n t r a s t o n l y 38% of the 8 p a t i e n t s i n government and s k i l l e d l a b o u r had r e t u r n e d t o work at f o l l o w up. S i m i l a r p a t t e r n s of r e t u r n i n g t o work were d e s c r i b e d i n t h e l i t e r a t u r e , most f r e q u e n t l y i n a s s o c i a t i o n w i t h b e n e f i t s r e l a t e d t o s i c k l e a v e . At f o l l o w up, e a r l y r e t i r e m e n t was the c h o i c e o f one p a t i e n t 86 working i n management, and was being considered by 2 others working i n s k i l l e d labour. Of the 7 part time employees, 3 reported returning to work by the time of follow up. Each had r e t i r e d from previous careers i n management or sales, and 2 of the 3 were i n related positions at the time of MI. The remaining 4 patients had not returned to any part time positions at follow up and reported that they would l i k e l y not do so. At follow up return to work was discussed as a concern by 12 of the 28 who had been employed at the time of MI. This was true whether or not they had already returned to work and f o c u s s e d on a range of c o n c e r n s from f e a r o f l o s i n g o p p o r t u n i t i e s f o r advancement to having to accept an e a r l y unplanned retirement, and included uncertainty about resuming the same r e s p o n s i b i l i t i e s at work or n e g o t i a t i n g f o r new arrangements. Driving A l l but 1 of the 35 patients who drove t h e i r own car reported they were again d r i v i n g at follow up. 6 weeks was generally recommended to be the time to resume d r i v i n g . In fact, 7 had resumed d r i v i n g within 2 weeks, 11 within 3 to 4 weeks, 10 within 5 to 6 weeks, 3 within 7 to 8 weeks and 3 a f t e r the 8th week. The patient who had not resumed d r i v i n g was i n her mid 70's, and was waiting to be retested for renewal of her 87 d r i v e r ' s l i c e n c e . She was t o be r e s t r i c t e d t o day time d r i v i n g f o r medical reasons r e l a t e d t o her c a r d i a c c o n d i t i o n . 2. E f f e c t s on Dietary Practices D i e t a r y recommendations were p r o v i d e d t o p a t i e n t s and t h e i r p a r t n e r s by the n u t r i t i o n i s t i n h o s p i t a l and, i n some cases, by t h e i r f a m i l y p h y s i c i a n . G u i d e l i n e s i n c l u d e d balanced meals wi t h l i m i t e d consumption o f s a l t and s a t u r a t e d f a t s , as w e l l as r e d u c i n g c a l o r i e s and e x c e s s consumption o f c a f f e i n e and a l c o h o l . I n d i v i d u a l i n s t r u c t i o n s were i n c l u d e d as r e q u i r e d . At f o l l o w up, 14 weeks a f t e r MI, p a t i e n t s r e p o r t e d t h a t t h e i r p h y s i c i a n had recommended new d i e t a r y p r a c t i c e s i n 19 ca s e s , and c o n t i n u i n g p r e v i o u s l y recommended p r a c t i c e s i n 11 ot h e r cases. When asked about t h e i r main sources o f i n f o r m a t i o n on changing d i e t a r y p r a c t i c e s , 29 i d e n t i f i e d the n u t r i t i o n i s t i n h o s p i t a l and, i n a d d i t i o n 16 i d e n t i f i e d the c a r d i a c n urse. Since women were g e n e r a l l y p r e p a r i n g the meals, many husbands commented on the f a c t t h a t t h e i r w i f e was b e t t e r informed about the d e t a i l s and l a r g e l y r e s p o n s i b l e f o r e n a b l i n g them t o make the changes. With female p a t i e n t s , c o n c e r n was r e p e a t e d l y expressed about resuming t h e i r r o l e as q u i c k l y as p o s s i b l e and t a k i n g r e s p o n s i b i l i t y f o r p l a n n i n g t h e i r own d i e t a r y changes. D e t a i l s about r e p o r t e d changes i n consumption of s a l t , s a t u r a t e d f a t s , c a l o r i e s , c a f f e i n e and a l c o h o l f o l l o w . In g e n e r a l , i t had been recommended t o reduce each item from high t o low o r moderate l e v e l s o f consumption. 88 Consumption of Salt There were s i g n i f i c a n t reductions reported i n the use of ta b l e s a l t as well as i n the frequency of consuming salted foods. Reports of the regular use (always or usually) of table s a l t were reduced from 55% p r i o r to MI to 7% at follow up (Table 5.6). These reductions by 19 ind i v i d u a l s were s i g n i f i c a n t on a one t a i l Sign test, z>_4.18, p=.00003. TABLE 5.6 FREQUENCY OF USING TABLE SALT BEFORE MI AND AT FOLLOW UP n=40 LEVEL OF FREQUENCY BEFORE MI 14 WEEKS AFTER MI 1 and 2 22 3 3 and 4 18 37 40 40 LEVELS: 1 2 3 4 ALWAYS USUALLY SOMETIMES NEVER Patients consumed s a l t y foods less frequently a f t e r MI. At follow up 95% li m i t e d t h e i r consumption to 0 to 1 day per week 89 whereas p r i o r t o MI, o n l y 55% d i d so ( T a b l e 5.7). T h i s d i f f e r e n c e was s i g n i f i c a n t on a p a i r e d one t a i l t - T e s t , t=5.05, 40df, p<.0005. TABLE 5.7 FREQUENCY OF CONSUMING 1 OR MORE SERVINGS OF SALTY FOODS BEFORE MI AND AT FOLLOW UP n=40 DAYS/WEEK AFTER MI 5 t o 7 DAYS/WEEK BEFORE MI 2 t o 4 0 t o 1 5 t o 7 2 t o 4 0 t o 1 0 0 2 2 0 2 14 16 0 0 22 22 0 2 38 40 Consumption o f Sa t u r a t e d Fats The r e p o r t e d u s e o f low f a t d a i r y p r o d u c t s and t h e f r e q u e n c y o f consuming f r i e d foods were bot h s i g n i f i c a n t l y changed. The r e g u l a r use (always and u s u a l l y ) o f low f a t d a i r y p r o d u c t s was r e p o r t e d t o i n c r e a s e from 50% of p a t i e n t s p r i o r t o MI t o 85% a t f o l l o w up (Table 5.8). These i n c r e a s e s by 14 p a t i e n t s were s i g n i f i c a n t with the one t a i l S i g n t e s t , z>3.5, p=.0003. 90 TABLE 5.8 FREQUENCY OF USING LOW FAT DAIRY PRODUCTS BEFORE MI AND AT FOLLOW UP n=40 LEVEL OF BEFORE MI 14 WEEKS AFTER MI FREQUENCY 1 and 2 20 34 3 and 4 20 6 40 40 LEVELS: 1 = ALWAYS 2 = USUALLY 3 = SOMETIMES 4 = NEVER In turn patients consumed f r i e d foods less frequently af t e r MI. At follow up 80% limi t e d t h e i r consumption to 0 or 1 day per week whereas p r i o r to MI, only 37% did so (Table 5.9). This difference was s i g n i f i c a n t on a paired one t a i l t-Test, t=6.2, 40df, p<.0005. 91 TABLE 5.9 FREQUENCY OF CONSUMING 1 OR MORE SERVINGS OF FRIED FOODS BEFORE MI AND AT FOLLOW UP n=40 DAYS/WEEK AFTER MI 5 to 7 DAYS/WEEK BEFORE MI 2 to 4 0 to 1 5 to 7 2 to 4 0 to 1 1 3 2 6 0 3 16 19 0 1 14 15 1 7 32 40 Ca l o r i c R e s t r i c t i o n s Although c a l o r i c r e s t r i c t i o n s were not required of patients who were of inappropriate body weight, there was no difference between t h e i r reports about l i m i t i n g c a l o r i c intake and/or consumption of r i c h or sweet foods, and those of the 18 patients described as overweight. Therefore, a l l patients and t h e i r r e s u l t s are treated as a group. More patients regularly reduced t h e i r c a l o r i c intake after MI (37%) than before (20%) (Table 5.10). These changes, reported by 7 patients, were s i g n i f i c a n t on a one t a i l Sign t e s t , z>2.6, p=.0003. Patients also reduced by t h e i r consumption of r i c h or sweet foods more frequently a f t e r MI. At follow up, 72% li m i t e d t h e i r 92 consumption of such foods to 0 or 1 day per week, whereas before MI only 52% reported doing so (Table 5.11). This change was s i g n i f i c a n t on a one t a i l t-Test, t-3.49, 40 df, p<.005. TABLE 5.10 FREQUENCY OF REDUCING CALORIES TO BEFORE MI AND AT FOLLOW n=40 REDUCE WEIGHT UP LEVEL OF BEFORE MI 14 WEEKS AFTER MI FREQUENCY 1 and 2 8 15 3 and 4 32 25 40 40 LEVELS: 1 = 2 = 3 = 4 = ALWAYS USUALLY SOMETIMES NEVER Further to t h i s , weight l o s s was reported by only 3 patients; 2 reported losing the desired amounts of weight (20 and 30 pounds respectively) and the other reported losing 15 of the desired amount of 40 pounds. In contrast, 4 patients had not gained any weight and were concerned about lo s i n g 10 pounds 93 a f t e r t h e i r MI or being underweight to begin with. For the remainder weight was not of overt concern during the interview. TABLE 5.11 FREQUENCY OF CONSUMING 1 OR MORE SERVINGS OF RICH/SWEET FOODS BEFORE MI AND AT FOLLOW UP n=40 DAYS/WEEK AFTER MI 5 to 7 DAYS/WEEK BEFORE MI 2 to 4 0 to 1 5 to 7 2 to 4 0 to 1 1 3 4 8 2 4 5 11 0 1 20 21 3 8 29 40 Consumption of Caffeine Considerable change was reported i n caffeine consumption through the reduced use of regular c o f f e e . Before MI 30 patients reported consuming an average of 3 cups of regular coffee per day, with a range of 1 to 20 cups, and 2 patients reported consuming 1 to 2 cups of decaffeinated coffee. At the time of follow up, 12 of the regular coffee drinkers reported switching to decaffeinated coffee and reducing t h e i r consumption by an average of 40%. The remaining 18 reduced t h e i r consumption of regular coffee by an average of 25%. 94 Consumption of Alcohol The majority of patients (23) consumed from 1 to 10 drinks per week, while 2 had 11 to 30 drinks and 3 had 31 to 40 drinks. The remaining 12 patients reported not drinking, 3 because of former alcohol-related problems. Changes i n consumption were reported by 2 of the 3 patients whose consumption was i n the range of 31 to 40 drinks per week, and amounted to reductions of 50% of t h e i r former intake. 3. E f f e c t s of Smoking At the time of MI, 14 patients reported being current smokers and at follow up half of these reported having stayed o f f cigarettes since t h e i r MI. The other 7 reported returning to c i garette smoking, 1 immediately and 6 a f t e r 5 to 6 weeks. However, 4 of these reported reducing t h e i r consumption from 1 or more packs per day to less than 1/2 a pack per day. The further 3 remained at t h e i r previous consumption l e v e l s , 1 at more than a pack and 2 at 1/2 to 1 pack a day. Quitters and nonquitters were s i m i l a r i n the number of years smoking and the amount smoked. 4. Compliance with Medication Regimes M e d i c a t i o n s were reviewed b r i e f l y i n the f o l l o w up interview and 37 of the 40 patients reported being on medication as a consequence of t h e i r MI. 24 of the patients i d e n t i f i e d t h e i r medications by name, amount taken and purpose of the drug, 95 9 of the patients by amount taken and purpose of the drug and the remainder (4) by the amount taken although they were unsure of the purpose or the name. One of the 3 patients that reported not taking medication had a p r e s c r i p t i o n for an antihypertensive drug but f e l t he didn't need i t . The other 2 reported that they didn't need regular medication. 11 patients reported s p e c i f i c occasions on which the c a r d i a c nurse was instrumental i n d i r e c t i n g them to t h e i r physician for medication changes as a r e s u l t of t h e i r signs or symptoms at home. Most pati e n t s reported taking a combination of cardiac medications on a regular basis: 3 patients reported 4 d i f f e r e n t medications on a d a i l y basis; 16 reported 3; 13 reported 2; and 5 reported only 1 medication. Beta blockers were i d e n t i f i e d most f r e q u e n t l y (26 p a t i e n t s ) and calcium i n h i b i t o r s (16 pat i e n t s ) and long term vasodilators (17 patients) followed. Also included were 14 reports of a n t i p l a t e l e t agents, 5 of d i g o x i n , 4 o f a n t i a r r h y t h m i c s , 4 o f d i u r e t i c s , 2 of anticoagulants and 1 of cholesterol lowering medication. In addition, 37 patients reported having n i t r o g l y c e r i n on hand, 15 of whom reported never having used i t ; the other 22 reported using i t on some occasion(s) i n the f i r s t 3 or 4 weeks at home and 12 were continuing i t s use at the time of follow up. Of the l a t t e r 12, 8 were using i t rarely, and usually only on exertion, while 4 used i t 2 to 3 times a week. A l l but 5 were aware of m a i n t a i n i n g a f r e s h supply of n i t r o g l y c e r i n . A d d i t i o n a l medications were reported by 8 patients for the management of 96 diabetes or other conditions unrelated to MI. S p e c i f i c mention was made about taking anti-anxiety medications (3) and sleeping p i l l s (4) for the f i r s t time, but i n q u i r i e s about the use of old pr e s c r i p t i o n s were not made. 5. S a t i s f a c t i o n w i t h the Program When asked how the r e h a b i l i t a t i o n program had s p e c i f i c a l l y a f f e c t e d them each patient made several comments. Although unique i n t h e i r personal expressions, four common themes ran throughout t h e i r comments. Cl e a r l y i t i s d i f f i c u l t to separate the nurse from the program and they are synonymous i n the discussion. F i r s t , the program was described as timely. Most patients reported reassurance at knowing the nurse would be at t h e i r home within 1 or 2 days, and a few who had uncertainty about accepting r e f e r r a l to the program, reported on i t s usefulness once they were at home. Repeatedly reports were made of "having enough time to get my questions answered" and most often t h i s was during walks with the nurse. Secondly, the program was described as highly informative. Patients reported the nurse to be a "fountain of information" i n answering t h e i r questions on a broad range of issues related to MI. Frequently they reported uncertainty about c a l l i n g t h e i r doctor i n case t h e i r concern might be seen as t r i v i a l although i t may have caused considerable personal concern or confusion at home. They reported the nurse as extremely h e l p f u l i n c l a r i f y i n g t h e i r concerns and/or d i r e c t i n g them to t h e i r physician. P r a c t i c a l i t y 97 was the t h i r d theme i n patient's comments on the program. "She t o l d me exactly what to do" was a comment frequently used to d e s c r i b e the nurses approach with patients who experienced d i f f i c u l t y i n knowing how far and how fast to walk, which h i l l s to climb, which foods to exclude, what tasks to postpone and a host of other questions. Many times they reported surprise at t h e i r i n a b i l i t y to make what appeared l a t e r to have been a simple d e c i s i o n . One p a t i e n t described the experience as "teaching one large, frightened and usually competent man to again b e l i e v e he could make wise d e c i s i o n s f o r himself". Lastly, t h e i r reports regularly emphasized an increased sense of confidence from t h e i r experience i n the program. The nurse was seen to hear and recognize t h e i r fears while being frankly honest and " c a l l i n g a spade a spade". More than once they reported that she gently but f i r m l y d i r e c t e d them to "quit w o r r y i n g about i t and get on w i t h i t " when they were procrastinating. One patient described her as "a professional mother who kept me accountable while I was learning what to do. I knew she was concerned but she couldn't do i t for me." In conclusion patients were able to describe t h e i r perceptions of the program i n terms of s p e c i f i c e f f e c t s on t h e i r recovery and reported s a t i s f a c t i o n with t h e i r experience. D. Intervening Factors The goals of the program were ultimately of shared concern to the cardiac nurse and patient i f progress was to be made 98 toward t h e i r achievement. During the process of c l a r i f y i n g and achieving the goals, a variety of factors t y p i c a l l y intervened, requiring alternative strategies on the part of the nurse and/or patient. Four of the most common factors are described i n t h i s section, as they were perceived and reported by patients i n t h e i r f o l l o w up i n t e r v i e w . They include, i n order, the patient's perceived d i s p o s i t i o n to MI; t h e i r perceived health status during r e h a b i l i t a t i o n ; t h e i r b e l i e f s and plans about making recommended changes; and t h e i r experience with developing alternative personal strategies. 1. P e r c e i v e d P r e d i s p o s i t i o n t o MI D u r i n g the f o l l o w up i n t e r v i e w the p a t i e n t s were interes t e d , and often eager, to r e c a l l the circumstances i n which t h e i r MI occurred, t h e i r experience of h o s p i t a l i z a t i o n and some of t h e i r i n s i g h t s from the experience. During the discussion they were asked whether or not they had ever thought they might have an MI before i t occurred. 22 responded negatively, stating that they never expected i t ; 8 responded l e s s c e r t a i n l y , q u a l i f y i n g that i t seemed u n l i k e l y ; and 9 reported that i t seemed p o s s i b l e but not at the time i t happened. Information on 1 patient was missing. 2. P e r c e i v e d H e a l t h Status There was general discussion about t h e i r current condition i n the course of the interview. Most patients described a basic 99 understanding of how a heart attack occurs, whether t h e i r s was " l a r g e or s m a l l " , whether or not t h e i r medications were "working" i n terms of t h e i r intended purpose ( f o r example, reducing blood pressure) and what was expected of them i n terms of d a i l y a c t i v i t i e s , exercise and dietary modifications. Many p a t i e n t s expressed i n t e r e s t i n the r e s u l t s of t h e i r l i p i d p r o f i l e s as an i n d i c a t o r of the e f f e c t s of d i e t a r y change although few knew t h e i r r e s u l t s . They were less c e r t a i n of achieving the desired e f f e c t s from rest and relaxation. They generally assessed the e f f e c t s of rest and relaxation i n terms of w e l l being or " f e e l i n g b e t t e r " and " g e t t i n g back to a c t i v i t i e s " they had been missing. Some described i t i n terms of "having a d i f f e r e n t point of view now" and "knowing when to quit . " 3. B e l i e f s and Plans An attempt to assess the formation of patients intentions on the questionnaire met with l i m i t e d success. As seen i n Table 5.12, the vast majority of patients already believed i n the importance of acquiring or maintaining behaviours that involved s p e c i f i c dietary practices and exercise l e v e l s , at week 1 afte r discharge. A l l smokers expressed b e l i e f i n the importance of cessation 1 week afte r MI, except for 2 patients, of whom 1 "doubted 4 or 5 cigarettes mattered at her age" and the other expressed d i s l i k e f o r "playing the odds when there was no guarantee anyhow." By the 14th week one patient who continued 100 to smoke reported a reversal i n h i s i n i t i a l b e l i e f i n the need to quit. Approximately half of the patients reported b e l i e f i n the importance of managing t h e i r time d i f f e r e n t l y , and t h i s number increased s l i g h t l y by the 14th week. The only reported decline of b e l i e f was i n the need to reduce p e r s o n a l concerns, i d e n t i f i e d as important by 70% of the patients at 1 week and on l y 50% at f o l l o w up. Whether the d e c l i n e was due to r e s o l u t i o n of the concerns, a change i n perception of t h e i r importance or a lack of reporting i s unknown. The number of patients reporting p l a n s for change at weeks 1 and 14 were nearly i d e n t i c a l with those for b e l i e f s , as seen i n Tables 5.12 and 5.13. S i m i l a r l y most patients reported adequate knowledge and confidence i n making the desired changes at both assessment points. In summary, patients reported a consistency between l e v e l s of b e l i e f s , plans, knowledge and confidence. The number of patients reporting p o s i t i v e b e l i e f s and plans increased s l i g h t l y r e g a r d i n g e x e r c i s e and recommended d i e t a r y p r a c t i c e s and decreased regarding smoking cessation. Outcome indicators of time management and resolution of personal concerns were not in c l u d e d . However, at follow up approximately 50% of the patients continued to report concern i n the area of managing t h e i r time d i f f e r e n t l y as well as t h e i r personal concerns. 101 TABLE 5.12 BELIEF IN THE NEED FOR SPECIFIC BEHAVIOURAL CHANGES 1 WEEK AND 14 WEEKS POST INFARCTION n=40 POST INFARCTION TIME 1 WEEK 14 WEEKS DIETARY PRACTICES 33 36 SMOKING * 12 11 EXERCISE 36 39 TIME MANAGEMENT 18 21 PERSONAL CONCERNS 28 20 * Exception n=14 102 TABLE 5.13 PLANS TO MAKE 1 WEEK AND SPECIFIC BEHAVIOURAL CHANGES 14 WEEKS POST INFARCTION n=40 POST INFARCTION TIME 1 WEEK 14 WEEKS DIETARY PRACTICES 33 36 SMOKING * 12 10 EXERCISE 33 39 TIME MANAGEMENT 18 20 PERSONAL CONCERNS 28 20 * Exception n=14 4. Alternate Personal Strategies Various other new behaviours were described by ind i v i d u a l s i n response to the advice to "just relax and rest often". As a group, with the exception of 2 patients, there was no esse n t i a l difference i n the number of hours of sleep per day either before MI or at the time of follow up. There was an o v e r a l l average decrease of 2 1/2 hours spent at work and related a c t i v i t i e s while a corresponding increase i n l e i s u r e time was reported with considerable i n d i v i d u a l v a r i a t i o n . Some in d i v i d u a l s reported f r u s t r a t i o n with t h e i r attempts to relax and rest, since they were unsure i f t h e i r e f f o r t s were e f f e c t i v e nor how much time 103 should be i n v o l v e d . However, at f o l l o w up the majority indicated they were taking time out from t h e i r routines during the day i n an e f f o r t to relax or nap. A v a r i e t y of anecdotal r e p o r t s were o f f e r e d during the interview. Some reported delegating more work to others and of accepting assistance when i t was offered. Other changes were reported as: f l y i n g rather than d r i v i n g on business t r i p s , leaving a l l work at the o f f i c e when the work day ends, going out for lunch to avoid being i n t e r r u p t e d and a r r a n g i n g and w r i t i n g music r a t h e r than d i r e c t i n g musical groups. Two others reported c u r t a i l i n g choir a c t i v i t i e s t h a t were e x c i t i n g but l e f t them too t i r e d afterwards. Several reported reminding themselves "Take one day at a time; don't push i t , etc." i n an e f f o r t to change t h e i r perspective. E. Use of H e a l t h Hazard A p p r a i s a l Health Hazard Appraisal (HHA) i s a method for evaluating a v a r i e t y of s p e c i f i c r i s k factors on an i n d i v i d u a l basis and r e l a t i n g the information to the person's l i f e expectancy. Three d i f f e r e n t a g e s are p r e s e n t e d i n i t s e v a l u a t i o n : the i n d i v i d u a l ' s c h r o n o l o g i c a l age, an a p p r a i s e d age based on the present r i s k factors and an a c h i e v a b l e age based on adherence to recommended changes i n the given r i s k factors. Differences between the appraisal age and achievable age can then be reduced by changing health related behaviours. 104 For the purposes of t h i s study, r i s k factor data on each p a t i e n t was entered and evaluated twice: once as i t was reported to have been p r i o r to MI and again as i t was at follow up. From the r e s u l t s i n Table 5.14 the average appraised age of both men and women i s seen to be lower at follow up and t h i s i s p r i m a r i l y the r e s u l t of increased exercise l e v e l s achieved during the period of r e h a b i l i t a t i o n . The remaining difference between the average appraised ages at outcome and the lower average achievable ages represents the p o t e n t i a l benefit of a d d i t i o n a l behaviour changes and/or the benefits accrued by maintaining the changes over longer periods of time. I t i s useful to r e a l i z e that 2 of the 3 most frequently recommended changes were the same as the goals of the r e h a b i l i t a t i o n program, t h a t i s i n c r e a s e d p h y s i c a l a c t i v i t y and smoking cessation. The t h i r d recommendation was for weight loss and would be a goal f o r long term r e h a b i l i t a t i o n i n terms of hypertension, elevated c h o l e s t e r o l l e v e l s and general well being. 105 TABLE 5.14 HEALTH HAZARD APPRAISAL: DIFFERENCES IN THE AVERAGE APPRAISED AGE AND AVERAGE ACHIEVABLE AGE AS A RESULT OF BEHAVIOURAL CHANGES MADE IN THE 14 WEEK PERIOD POST INFARCTION AVERAGE ACTUAL AGE MALE 59.9 FEMALE 64.6 AVERAGE APPRAISED AGE BEFORE MI 61.2 64.5 14 WEEKS POST MI 58.8 63.1 AVERAGE ACHIEVABLE AGE BEFORE MI 60.3 62.7 14 WEEKS POST MI 57.2 61.6 106 CHAPTER V I : CONCLUSIONS AND RECOMMENDATIONS In 1985, IHD remained the leading cause of death i n Canada, although mortality rates for IHD have been de c l i n i n g since the early 1970's. Debate continues on whether the decline i s due to a decrease i n the incidence or severity of the disease, to improved s u r v i v a l or to a combination of the two. Meanwhile, d i r e c t h o s p i t a l costs alone were estimated to be $2 b i l l i o n i n 1985 and are expected to remain that way i n the foreseeable future. C u r r e n t c a r d i a c r e h a b i l i t a t i o n p r a c t i c e s began approximately 30 years ago. In 1952 e a r l y ambulation for patients with MI began with the establishment of Levine's "chair treatment" and since then developments have been dramatic. Non i n v a s i v e d i a g n o s t i c t e c h n i q u e s have enhanced p r o g n o s t i c c a p a b i l i t i e s f o r the post i n f a r c t i o n period, i n c l u d i n g the expanded use of ECG's for early stress t e s t i n g and ambulatory m o n i t o r i n g , and the use o f r a d i o n u c l i d e a n g i o g r a p h y . Re h a b i l i t a t i o n has been recognized as part of the acute care services provided i n the hospital and i s formally organized into 3 separate phases, the l a s t of which focusses on the maintenance of a c q u i r e d e x e r c i s e l e v e l s . R e c e n t l y the f o c u s of r e h a b i l i t a t i o n has expanded to include a range of educational and other p s y c h o l o g i c a l interventions that aim at reducing behaviours known to increase the r i s k of further cardiac events. In Canada, the f i r s t cardiac r e h a b i l i t a t i o n program began at the 107 Toronto R e h a b i l i t a t i o n Centre i n 1967. At Lions Gate Hospital the i n i t i a l Coronary Ac t i v a t i o n Program began i n 1972 and i s now accompanied by the Cardiac Early Discharge Service (CEDS), thus providing 2 regular cardiac programs i n the Medical Day Centre (MDC). E v a l u a t i o n s t u d i e s of the e f f e c t s of regular exercise d u r i n g c a r d i a c r e h a b i l i t a t i o n have r e p o r t e d improved psycho l o g i c a l well being but no s i g n i f i c a n t decrease i n the t r a d i t i o n a l measures of mortality and/or r e i n f a r c t i o n rates. There i s a reported need to develop new indi c a t o r s that are more s e n s i t i v e to the psychological components of r e h a b i l i t a t i o n including issues to do with the q u a l i t y of l i f e . In addition to e v a l u a t i n g the e f f e c t s of e x e r c i s e , r e c e n t s t u d i e s have i n c r e a s i n g l y focussed on p s y c h o l o g i c a l i n t e r v e n t i o n s and outcomes i n cardiac r e h a b i l i t a t i o n . Most notable i s the report of s i g n i f i c a n t reductions i n the r e i n f a r c t i o n rate of patients modifying coronary prone behaviours i n the Recurrent Coronary Prevention Project. The present evaluation describes the e f f e c t s of CEDS on the length of stay i n hospital and on the c l i n i c a l outcomes and s a t i s f a c t i o n of patients i n the program. The study i s designed to f u l l y describe the background of such a program, to assess the outcomes of f i r s t concern to those developing the program and to consider recommendations relevant to future developments i n the program. 108 Results of the evaluation indicate that the goals of the program were achieved. Reduced length of stay reached an average of 8.6 days for uncomplicated Mi's and the goal was 8 or 9 days. Complicated Mi's reached an average of 11 days length of stay which was considered an appropriate reduction although a s p e c i f i c goal had not been set. Estimates from Medical Records indicated that physicians were r e f e r r i n g 92% of the e l i g i b l e patients. One unexpected r e s u l t was found i n the comparison of length of stay data between patients i n CEDS and those l i v i n g out of the area (and so not referred to CEDS). Complicated and uncomplicated Mi's were compared between groups w i t h i n 3 sequential time periods, and 5 of the 6 comparisons were not s i g n i f i c a n t l y d i f f e r e n t on s t a t i s t i c a l t e s t i n g . Therefore, there was no s i g n i f i c a n t difference i n length of stay between the CEDS group and a comparison group that did not receive the CEDS program. The reason f o r t h i s i s not known due to i n s u f f i c i e n t information about patients l i v i n g out of the area. Since the average length of stay for both groups (CEDS and out of area) was below that for comparative hospital data i n the previous year, i t i s suggested that, perhaps, physicians may have also adopted the practice of early discharge for out of area patients. Patient outcomes were p o s i t i v e . There were s i g n i f i c a n t increases i n the frequency of l i g h t exercise (p<.0005), i n the regular use of low f a t dairy products (p=.0003) and i n the p r a c t i c e of r e s t r i c t i n g c a l o r i e s (p=.003), while s i g n i f i c a n t 109 d e c r e a s e s were r e p o r t e d i n the frequency of consuming f r i e d f o ods (p<.0005), and s a l t e d foods (p<.0005) and r i c h foods (p<.005) and i n the r e g u l a r use o f t a b l e s a l t (p=. 00003). C a f f e i n e consumption was e l i m i n a t e d by 12 p a t i e n t s and reduced by an average of 25% i n 18 o t h e r s . Consumption o f a l c o h o l was reduced by 50% f o r 2 of the 3 p a t i e n t s r e p o r t i n g an i n t a k e of between 31 and 40 d r i n k s per week. In a d d i t i o n 50% of the smokers r e p o r t e d c e s s a t i o n of smoking on f o l l o w up. P a t i e n t s r e p o r t e d a h i g h l e v e l o f s a t i s f a c t i o n w i t h t h e program, d e s c r i b i n g the s e r v i c e as w e l l timed, i n f o r m a t i v e , p r a c t i c a l and v a l u a b l e i n r e s t o r i n g t h e i r s e l f c o n f i d e n c e . Due t o the d e s i g n of the e v a l u a t i o n , the e f f e c t of the program cannot be d i f f e r e n t i a t e d from o t h e r i n t e r v e n i n g f a c t o r s , however, and d i s c u s s i o n of the r e s u l t s must remain w i t h i n the d e s c r i p t i v e c o n t e x t of a s i n g l e group d e s i g n . F u r t h e r , the r e s u l t s are based on s e l f r e p o r t and may be b i a s e d i n favour of meeting the recommendations g i v e n d u r i n g r e h a b i l i t a t i o n . On s e v e r a l o c c a s i o n s , however, a spouse v a l i d a t e d p a t i e n t responses d u r i n g the i n t e r v i e w and/or p a t i e n t s r e p o r t e d "unfavourable" r e s u l t s w h i c h c o u l d i n d i c a t e a r e l a t i v e l y h i g h l e v e l o f v a l i d i t y . N e v e r t h e l e s s , t h e l a t t e r e v e n t s d i d n o t o c c u r c o n s i s t e n t l y throughout the e v a l u a t i o n and are not s u f f i c i e n t e v i d e n c e f o r i n f e r r i n g t h e l e v e l o f v a l i d i t y o f the s e l f r e p o r t s . F u r t h e r o p p o r t u n i t y f o r e v a l u a t i o n w i l l r e s t w i t h the p a r t i c u l a r c l i n i c a l , a d m i n i s t r a t i v e and r e s e a r c h needs o f the 110 program. Several avenues of inv e s t i g a t i o n are possible with the use of a l t e r n a t i v e designs and the assessment of d i f f e r e n t v a r i a b l e s . I n t e r - h o s p i t a l comparisons would be usefu l i n evaluating length of stay data, readmission data and other i n d i c a t o r s of h o s p i t a l e f f e c t s . This could be f a c i l i t a t e d through the use of e x i s t i n g shared data bases. Sim i l a r l y , c l i n i c a l e f f e c t s could be studied through the use of comparison groups from other l o c a l hospitals. Further areas of c l i n i c a l i n v e s t i g a t i o n could include the assessment and/or intervention of concerns not addressed i n t h i s study. Two examples of concerns arose during t h i s evaluation. One area was raised informally by three male patients during t h e i r interviews and i t involved a v a r i e t y of concerns regarding sexual functioning. The other area arose when patients were asked i n the interview to i n f o r m a l l y complete a short questionnaire regarding t h e i r p r e d i s p o s i t i o n towards coronary prone behaviour. Most patients spontaneously stated that the informal questionnaire was very i n t e r e s t i n g to complete and i n several cases, patients asked additional questions regarding stress related matters.' On both issues, patients appeared to be interested and responsive during the d i s c u s s i o n . Many other areas of concern could also be c o n s i d e r e d such as the long term e f f e c t s r e g a r d i n g the maintenance of new behaviours and integration of services with the community. I l l In conclusion some recommendations have been developed from the evaluation that could be adopted i n the foreseeable future. These are: 1. The development of a computerized data base to f a c i l i t a t e ongoing program evaluation. 2. The e x p l o r a t i o n of e x i s t i n g data bases f o r i n t e r -h o spital comparisons. 3. 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APPENDIX A: INTRODUCTORY LETTER APPENDIX B: QUESTIONNAIRE AT 1 WEEK POST INFARCTION QUESTIONNAIRE AT 1 WEEK POST INFARCTION 122 NAME . ; PHYSICAL ACTIVITY Please think of your usual a c t i v i t i e s in the last year when answering these questions. 1.Which one of the following would best describe your usual d a i l y a c t i v i t i e s ? • I was usually s i t t i n g and did not walk very much • I stood or walked quite a l o t but did not often l i f t or c a r r y • I usually l i f t e d or c a r r i e d l i g h t loads and climbed s t a i r s or h i l l s often • I did heavy work or c a r r i e d very heavy loads Please comment i f this does not describe your a c t i v i t i e s well 2.How many days a week did you get the following kinds of exercise? (Write 0 i f you did not get that kind of exercise.) a) 30 minutes or more of l i g h t exercise such as walking or bowling. days per week b) 15 minutes or. more of moderate to days per week vigorous exercise such as jogging or bi c y c l i n g . Please comment i f t h i s does not include your usual kind of exercise . SMOKING HABITS (IF YOU HAVE NEVER SMOKED SKIP THIS SECTION) 3. For how many years have you smoked ci g a r e t t e s ? years 4. What is the average number of cig a r e t t e s per day t h a t you smoked during that period of time ? • 5 or less • Z 6 to 10 C 11 to 20 C 21 or more 5. Were you smoking regularly at the time of this admission to hospital ? G Yes • No »o When did you quit ? (Go to Q.8) 6. Had you attempted to stop smoking in the l a s t year ? — yes «**• How many attempts have you made ? attempts r. NO i 123 EATING HABITS P l e a s e t h i n k of your us u a l e a t i n g h a b i t s i n the l a s t few months when answering the next q u e s t i o n s . 7.On the average d i d you eat th r e e r e g u l a r meals a day ? • Yes GNo I f you answered no , p l e a s e d e s c r i b e your u s u a l h a b i t s 8.How many days a_ week would you u s u a l l y have eaten the f o l l o w i n g ? 1 or more s e r v i n g s of f r i e d foods days per week 1 or more s e r v i n g s of c o o k i e s , days per week cake or r i c h d e s s e r t 1 or more s e r v i n g s of s a l t y foods days per week such as c h i p s or s a l t e d c r a c k e r s 9.How o f t e n would you have done the f o l l o w i n g ? Ple a s e c i r c l e the best answer. Always U s u a l l y Sometimes Never Added s a l t to your food at the t a b l e ? • L i m i t e d your c a l o r i c i n -take to reduce weight ? Eaten low f a t d a i r y products such as 2% or skim milk ? 10.On the average , how many a l c o h o l i c d r i n k s d i d you have per week ? ' beer per week gl a s s e s of wine per week (4 oz. g l a s s e s ) d r i n k s of hard l i q u o r per week (1 1/2 oz. ) 2 / . 1 2 4 OTHER HABITS A l t h o u g h the f o l l o w i n g q u e s t i o n s may not seem as d i r e c t l y r e l a t e d to your h e a l t h , the q u e s t i o n s w i l l be about t o p i c s t h a t may i n -f l u e n c e your h e a l t h . P lea se t h i n k of your h a b i t s i n the l a s t 6 months and answer as a c c u r a t e l y as p o s s i b l e . 11. How many hours of your day were u s u a l l y spent i n e a c h of the f o l l o w i n g a c t i v i t i e s ? Working & r e l a t e d a c t i v i t i e s h o u r s T r a v e l l i n g t o / f r o m work • In a c t i v i t i e s not r e l a t e d to work " S l e e p i n g " T o t a l • 24 h o u r s 12. How would you d e s c r i b e the amount of s l e e p t h a t you had ? O More than I needed • J u s t the r i g h t amount • Somewhat l e s s than I r e q u i r e d • Much l e s s than I r e q u i r e d 13. How o f t e n d i d you f e e l you had t ime to y o u r s e l f when i t was needed ? • Always • U s u a l l y G O c c a s i o n a l l y ~] R a r e l y 14. How o f t e n were your mealt imes r e l a x i n g and l e i s u r e l y ? • Always • U s u a l l y • O c c a s i o n a l l y T2 R a r e l y 15. which of the f o l l o w i n g , i f any , do you b e l i e v e you s h o u l d do f o r the sake of your recovery ? P l e a s e mark those that you b e l i e v e a re i m p o r t a n t f o r v o u r s e l f . • Make d i e t a r y changes C Stay o f f c i g a r e t t e s ( Sk ip i f a nonsmoker) • F o l l o w an e x e r c i s e r o u t i n e -• A d j u s t the way you spend your time • Reduce p e r s o n a l w o r r i e s r e g a r d i n g work, f i n a n c e s or f a m i l y mat ter s 3 125 16.IJ you marked above t h a t you b e l i e v e you should make d i e t a r y changes , do you know which changes to make ? • Yes • No • U n c e r t a i n 1 7 . I f you marked above t h a t you b e l i e v e you. s h o u l d f o l l o w an e x e r c i s e r o u t i n e , do you know what r o u t i n e would be b e s t f o r you ? C3 Yes C No G U n c e r t a i n 1 8 . I f you have been smoking , and marked above t h a t you b e l i e v e t h a t you should stay o f f c i g a r e t t e s , do you know what s t e p s  t o take co stay o f f ? ( S k i p i f a nonsmoker) • Yes O No C U n c e r t a i n 1 9 . I f you marked above t h a t you b e l i e v e you should a d j u s t the way you spend your time , do you know what adjustments to make ? • Yes c No • U n c e r t a i n 20.1_f you marked above t h a t you b e l i e v e you s h o u l d reduce p e r s o n a l worries about work , f i n a n c e s or f a m i l y , dp you know  how you might go about doing so? • Yes • No • U n c e r t a i n 2 1 . M a r k the areas i n which you p l a n to make changes. I f you plan to make changes i n an area , c i r c l e your l e v e l of co n f i d e n c e about m a i n t a i n i n g the change . Plan to L e v e l of Conf i d e n c e Change? Strong Weak U n c e r t a i n No Yes D i e t a r y changes • C S t a y i n g o f f c i g a r e t t e s ( S k i p i f nonsmoker) F o l l o w i n g an e x e r c i s e r o u t i n e • A d j u s t i n g the way you spend f3 your time Reducing personal w o r r i e s r e - • ga r d i n g work , f i n a n c e s or f a m i l y • l • »* • l 2 2 2 2 3 3 3 3 Thank you. That completes the q u e s t i o n s to be answered. P l e a s e r e t u r n the q u e s t i o n n a i r e to your nurse i n the envelope p r o v i d e d . 4 A P P E N D I X C : Q U E S T I O N N A I R E A T 14 WEEKS POST I N F A R C T I O N QUESTIONNAIRE AT 14 WEEKS POST INFARCTION NAME 127 PHYSICAL ACTIVITY P l e a s e t h i n k of your u s u a l a c t i v i t i e s i n the l a s t two weeks when you a re answering these q u e s t i o n s . 1 . W h i c h one of the f o l l o w i n g would bes t d e s c r i b e your u sua l d a i l y a c t i v i t i e s ? G I w as u s u a l l y s i t t i n g and d i d not walk v e r y much • I s tood or walked q u i t e a l o t but d i d not o f t e n l i f t or c a r r y G I u s u a l l y l i f t e d or c a r r i e d l i g h t l o a d s and c l i m b e d s t a i r s or h i l l s o f t e n G I d i d heavy work or c a r r i e d very heavy l o a d s P l e a s e comment i f t h i s does not d e s c r i b e your a c t i v i t i e s w e l l 2.How many days a week d i d you get the f o l l o w i n g k i n d s of e x e r c i s e ? ( W r i t e 0 i f yoa d i d not get t h a t k i n d of e x e r c i s e . ) a) 30 minutes or more of l i g h t e x e r c i s e such as w a l k i n g or b o w l i n g . days per week b) 1 5 minutes or more of moderate to days per week v i g o r o u s e x e r c i s e such as j o g g i n g or b i c y c l i n g . P l e a s e comment it t h i s does not i n c l u d e your u s u a l k i n d of e x e r c i s e . SMOKING HABITS ( IF YOU HAVE NEVER SMOKED SKIP THIS SECTION) 3. Have you managed to s tay o f f c i g a r e t t e s s i n c e being in h o s p i t a l ? • Yes ( Go to q u e s t i o n 5 ) • No *t> How soon d i d you r e t u r n to smoking ? I • .. 4. What i s the average number of c i g a r e t t e s per day that you a re now smoking ? • 5 or l e s s • 6 to 10 • 11 to 20 • 21 or more 128 EATING HABITS P l e a s e th ink of your u s u a l e a t i n g h a b i t s i n the l a s t two weeks when answering the next q u e s t i o n s . 5.On the average d i d yo.u eat t h r e e r e g u l a r meals a day ? • Yes • No I f you answered no , p l e a s e d e s c r i b e your u s u a l h a b i t s 6.How many days a week would you u s u a l l y have eaten the f o l l o w i n g ? 1 or more s e r v i n g s of f r i e d foods days pe r week 1 or more s e r v i n g s of c o o k i e s , days p e r week cake or r i c h d e s s e r t 1 or more s e r v i n g s of s a l t y foods days p e r week such as c h i p s or s a l t e d c r a c k e r s 7.How o f t en would you have done the f o l l o w i n g ? P lease c i r c l e the bes t answer . A lways U s u a l l y Sometimes Never Added s a l t to your food a t 1 2 3 4 the t a b l e ? L i m i t e d your c a l o r i c i n - 1 2 3 4 take to reduce weight ? Eaten low fat d a i r y p r o d u c t s 1 2 3 4 such as 2% or skim m i l k ? 8.On the averaoe , how many a l c o h o l i c d r i n k s d i d you have per week ? beer per week g l a s s e s of wine per week (4 o z . g l a s s e s ) d r i n k s of hard l i q u o r per week (1 1/2 o z . ) 129 OTHER HABITS T h i n k of your h a b i t s i n the l a s t 2 weeks when answering the next few q u e s t i o n s . P lea se be as a c c u r a t e as p o s s i b l e . 9 . How many hours of your day were u s u a l l y spent in each of the f o l l o w i n g a c t i v i t i e s ? Working & r e l a t e d a c t i v i t i e s h o u r s T r a v e l l i n g t o / f r o m work " In a c t i v i t i e s not r e l a t e d to work " S l e e p i n g T o t a l « 24 h o u r s 10. How would you d e s c r i b e the amount of s l e e p that you had ?. • More than I needed D J u s t the r i g h t amount • Somewhat l e s s than I r e q u i r e d • M u c h l e s s than I r e q u i r e d 1 1 . How o f t e n d i d you f e e l you had t ime to y o u r s e l f when i t was needed ? • Always • U s u a l l y • O c c a s i o n a l l y D R a r e l y 1 2 . How o f t e n were your meal t imes r e l a x i n g and l e i s u r e l y ? • Always • U s u a l l y • O c c a s i o n a l l y • R a r e l y 1 3 . Which of the f o l l o w i n g do you b e l i e v e you should s t a r t or c o n -t i n u e d o i n g fo r the sake of your r e c o v e r y ? P l e a s e mark those tha t you b e l i e v e a re important for y o u r s e l f . • Make or m a i n t a i n d i e t a r y changes • Stay o f f c i g a r e t t e s ( S k i p i f a nonsmoker) • F o l l o w an e x e r c i s e r o u t i n e * • A d j u s t the way you spend your t ime • Reduce p e r s o n a l w o r r i e s r e g a r d i n g work, f i n a n c e s or f ami ly mat te r s 130 1 4 . I f you marked above t h a t you b e l i e v e you shou ld make or c o n -t i n u e wi th d i e t a r y changes , do you know which changes to make or c o n t i n u e ? • Yes O No • U n c e r t a i n 1 5 . I f you have been smoking , and marked above tha t yc>u b e l i e v e t h a t you s h o u l d s tay o f f c i g a r e t t e s , do you know what s t e p s  to, take to s tay o f f ? ( S k i p i f a nonsmoker) • Yes • No • U n c e r t a i n 1 6 . I f you marked above t h a t you b e l i e v e you shou ld f e l l o w an e x e r c i s e r o u t i n e , do you know what r o u t i n e i s best fo r you ? • Yes • No • U n c e r t a i n 1 7 . H you marked above t h a t you b e l i e v e you s h o u l d a d j u s t the way you spend your time , do you know what ad jus tments to make ? • Yes • No • U n c e r t a i n 1 8 . I f you marked above t h a t you b e l i e v e you shou ld r e d u c e p e r s o n a l w o r r i e s about work , f i n a n c e s or f a m i l y , have you  done so ? • Yes • No » * a ) I f n o t . d o you know how you might go about r e d u c i n g such w o r r i e s ? • Yes • No • U n c e r t a i n 19.Mark the areas i n which you p l a n to make or m a i n t a i n c h a n g e s . I f you p l a n to make or m a i n t a i n changes i n an area , c i r c l e  your l e v e l of c o n f i d e n c e about m a i n t a i n i n g the change . P l a n tfi make/keep L e v e l of C o n f i d e n c e  change? S t rong Weak U n c e r t a i n No Y£S D i e t a r y changes • • x» 1 2 3 S t a y i n g o f f c i g a r e t t e s ( S k i p i f nonsmoker) • . • w> , 2 3 F o l l o w i n g an e x e r c i s e r o u t i n e • • • * 1 2 3 A d j u s t i n g the way you spend your time • • «•» 1 2 3 Reducing p e r s o n a l w o r r i e s r e -g a r d i n g work , f i n a n c e s or f a m i l y • • 1 2 3 Thank you . That comple te s the q u e s t i o n s to be answered. ADDENDIX D: FOLLOW UP INTERVIEW AT 14 WEEKS POST INFARCTION 132 FOLLOW UP INTERVIEW AT 14 WEEKS POSTINFARCTION Demographic Information Occupation Employment Status Residence A c t i v i t y Level Did 'you have a stress test? If yes, were you directed to the Phase II class? If yes, are you attending? Do you drive? If yes, how soon a f t e r your MI did you return to driving? Dietary Patterns Were dietary changes recommended to you? If yes, were they new? Have you had si m i l a r recommendations i n the past? Where did you get the necessary information to follow recent recommendations? Medications What medications are you on? Are you taking them as prescribed? Do you have nitr o g l y c e r i n ? When have you used i t ? Is i t fresh? Are there any other changes you would l i k e to mention? How did the r e h a b i l i t a t i o n program a f f e c t your recovery? Had you ever expected this MI might have happened? 

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