James Rosneck

The METER: A Brief, Self-Administered Measure of Health Literacy

BackgroundGiven rapidly accumulating evidence that health literacy is correlated with important health-related measures, assessing patients’ health literacy level is of increasing concern for researchers and practitioners. Practical limitations for use of existing health literacy measures include length of time and practitioner involvement in administration.ObjectiveTo develop and validate a brief, self-administered measure of health literacy, the Medical Term Recognition Test (METER).Participants155 participants were recruited from an outpatient cardiology program at an urban hospital.MeasuresPatients completed measures of health literacy (METER and REALM), neuropsychological function, psychosocial health, and self-report questionnaires about health behaviors. Indicators of cardiovascular health were also recorded from patients’ medical charts.Key resultsThe measure took 2 min to complete. The internal consistency of the METER was 0.93, and it correlated highly with REALM (r = 0.74). Regarding sensitivity and specificity for identifying individuals below REALM’s cutoff for functional literacy, METER resulted in 75% correct identifications and 8% false positives. METER and REALM were both associated with various health-related measures (including significant correlations with measures of neuropsychological function and cardiovascular health).ConclusionsThese initial findings show that the METER is a quick and practical measure of health literacy for use in clinical settings.

Improvements in Cognitive Function Following Cardiac Rehabilitation for Older Adults With Cardiovascular Disease

ABSTRACT Cognitive impairment is common in persons with cardiovascular disease (CVD). Cardiac rehabilitation (CR) improves many aspects of CVD linked to cognitive impairment. The current study explored whether CR may improve cognitive function. Potential mechanisms for cognitive changes were also examined through exploratory analyses, including changes in cardiovascular fitness and cerebral blood flow. Fifty-one older adults with CVD underwent neuropsychological assessment at baseline and discharge from a 12-week CR program. Cardiovascular fitness (i.e., metabolic equivalents [METs]) was estimated from a symptom-limited volitional stress test. Transcranial doppler quantified mean cerebral blood flow velocity and pulsatility indexes for the middle cerebral artery and anterior cerebral artery (ACA). Repeated measures ANOVA showed improvements in global cognition, attention-executive-psychomotor function, and memory. Exploratory analyses revealed improvement in METs and changes in ACA flow velocity, but only improvement in METs was related to improved verbal recall. CVD patients exhibited improvements in multiple cognitive domains following a 12-week CR program, suggesting that cognitive impairment is modifiable in this population. Although other studies are needed to elucidate underlying mechanisms, exploratory analyses suggest that cognitive improvements may be better explained by physiological processes other than improved cardiovascular fitness and cerebral blood flow.

Contemporary cardiac rehabilitation: patient characteristics and temporal trends over the past decade.

BACKGROUND Recent and dramatic therapeutic advances, aggressive care of the elderly, and a heightened awareness of secondary prevention have had a significant, albeit incompletely described, impact on cardiac rehabilitation (CR) programs. The authors did a retrospective analysis on 1,848 patients from their phase II CR program that were treated over the past decade. The authors sought to identify and analyze how advances in cardiovascular care might be related to temporal changes in demographics, medical comorbidities, coronary artery disease risk factors, and cardiovascular history among individuals with cardiac disease who have completed the phase II CR program over a 10-year period. METHODS Cardiac rehabilitation records were reviewed from 1986 to 1996 at Akron City Hospital. The data were compiled prospectively by nurses and exercise physiologists and were subsequently analyzed. The charts reviewed were from 1,848 patients who completed outpatient phase II CR. RESULTS The program began in 1986 with 53 patients completing CR and evolved to 309 in 1996. There has been an increase in the number of elderly patients referred to and completing the program. The number of participants older than 65 years of age increased from 28.3% in 1986 to 52.1% in 1996. Cardiac rehabilitation participants reflect the known demographics of patients with clinical coronary artery disease. Men outnumber women and, on average, the female participants are older than the male participants. There has been a statistically significant increase in medical comorbidities over the course of the study. Although the absolute number of patients entering CR after coronary artery bypass graft survey has remained fairly constant, there has been a dramatic increase in the absolute number of patients entering CR after percutaneous tansluminal coronary angioplasty (with the latter recently comprising a majority of CR participants). CONCLUSION There is a significant trend in the attendance and completion of CR programs by older individuals, which suggests a greater awareness of patients and their physicians. The growth of the program is fueled by high-risk patients with more comorbidities who potentially are the group of patients able to obtain the greatest absolute benefit from CR.

Reduced Heart Rate Recovery Is Associated with Poorer Cognitive Function in Older Adults with Cardiovascular Disease

Cardiovascular disease (CVD) in older adults has been associated with varying degrees of cognitive dysfunction. Several mechanisms may explain this association, including impaired cardiovascular reactivity to autonomic nervous system (ANS) signaling. Reduced heart rate recovery following a stress test may be considered an indication of impaired ANS function (i.e., reduced parasympathetic activity). Participants were 47 older adults (53–83 years) who underwent a treadmill stress test and were administered a comprehensive neuropsychological battery upon entry to phase II cardiac rehabilitation. Reduced parasympathetic activity was associated with impaired cognitive performance on a measure of global cognitive function and on tasks of speeded executive function and confrontation naming. These relationships suggest that changes in autonomic function may be mechanistically related to the impaired cognitive function prevalent in CVD patients.

Depression and Heart Rate Variability in Cardiac Rehabilitation Patients: Exploring the Roles of Physical Activity and Fitness

Cardiac patients with depression have shown altered autonomic nervous system functioning, expressed as reduced heart rate variability. This may be associated with poorer physical fitness and less physical activity among depressed patients. These relationships were explored among patients enrolled in outpatient cardiac rehabilitation. 22 depressed and 22 nondepressed patients, matched for sex and age, were assessed at enrollment. The Beck Depression Inventory and structured interviews were used to measure depression. Patients completed ambulatory monitoring of ECG (i.e., Holter) and physical activity, as well as a treadmill stress test. Depression was associated with several measures of heart rate variability. Activity and fitness were lower among the depressed patients. Although exploratory, accounting for activity and fitness attenuated the relationship between depression and heart rate variability. This suggests that altered fitness and activity may help explain altered autonomic tone that characterizes patients with cardiovascular diseases who are psychologically depressed.

Health literacy predicts cardiac knowledge gains in cardiac rehabilitation participants

Objective: Health literacy is increasingly recognised as a potentially important patient characteristic related to patient education efforts. We evaluated whether health literacy would predict gains in knowledge after completion of patient education in cardiac rehabilitation. Method: This was a re-post observational analysis study design based on Summa Health System’s Phase-II cardiac rehabilitation programme in Akron, Ohio, USA. The Medical Term Recognition Test, the Short Test of Functional Health Literacy in Adults, and the Newest Vital Sign were administered to 191 patients enrolled in cardiac rehabilitation between May 2010–April 2011. The Cardiac Knowledge Assessment Tool is routinely administered at the beginning and prior to discharge from cardiac rehabilitation. Consent was obtained in order to access patients’ cardiac rehabilitation medical chart for information such as age and education level. Results: Participants were 72% men with a mean of 66.4 years of age, and with an average level of education of 13.7 years. Health literacy was strongly related to cardiac knowledge at both the beginning and end of cardiac rehabilitation (r=0.46, p<0.001; r=0.41, p<0.001). Controlling for cardiac knowledge at the beginning of cardiac rehabilitation, health literacy predicted gains in cardiac knowledge at the end of cardiac rehabilitation (p<0.01). Conclusion: Health literacy can be used to predict gains in knowledge from patient education programming in cardiac rehabilitation. Health literacy screening may help to identify those who may struggle with patient-education portions of cardiac rehabilitation or who may need additional education to reach a desired knowledge level.

Development and psychometric evaluation of a cardiovascular risk and disease management knowledge assessment tool.

Purpose:This article describes the systematic construction and psychometric analysis of a knowledge assessment instrument for phase II cardiac rehabilitation (CR) patients measuring risk modification disease management knowledge and behavioral outcomes derived from national standards relevant to secondary prevention and management of cardiovascular disease. Methods:First, using adult curriculum based on disease-specific learning outcomes and competencies, a systematic test item development process was completed by clinical staff. Second, a panel of educational and clinical experts used an iterative process to identify test content domain and arrive at consensus in selecting items meeting criteria. Third, the resulting 31-question instrument, the Cardiac Knowledge Assessment Tool (CKAT), was piloted in CR patients to ensure use of application. Validity and reliability analyses were performed on 3638 adults before test administrations with additional focused analyses on 1999 individuals completing both pretreatment and posttreatment administrations within 6 months. Results:Evidence of CKAT content validity was substantiated, with 85% agreement among content experts. Evidence of construct validity was demonstrated via factor analysis identifying key underlying factors. Estimates of internal consistency, for example, Cronbach’s &agr; = .852 and Spearman-Brown split-half reliability = 0.817 on pretesting, support test reliability. Item analysis, using point biserial correlation, measured relationships between performance on single items and total score (P < .01). Analyses using item difficulty and item discrimination indices further verified item stability and validity of the CKAT. Conclusions:A knowledge instrument specifically designed for an adult CR population was systematically developed and tested in a large representative patient population, satisfying psychometric parameters, including validity and reliability.