Louise Morrin

Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study

Background Little is known about physical activity levels in patients with coronary artery disease (CAD) who are not engaged in cardiac rehabilitation. We explored the trajectory of physical activity after hospitalization for CAD, and examined the effects of demographic, medical, and activity-related factors on the trajectory. Design A prospective cohort study. Methods A total of 782 patients were recruited during CAD-related hospitalization. Leisure-time activity energy expenditure (AEE) was measured 2, 6 and 12 months later. Sex, age, education, reason for hospitalization, congestive heart failure (CHF), diabetes, and physical activity before hospitalization were assessed at recruitment. Participation in cardiac rehabilitation was measured at follow-up. Results AEE was 1948 ± 1450, 1676 ± 1290, and 1637 ± 1486 kcal/week at 2, 6 and 12 months, respectively. There was a negative effect of time from 2 months post-hospitalization on physical activity (P<0.001). Interactions were found between age and time (P = 0.012) and education and time (P = 0.001). Main effects were noted for sex (men more active than women; P<0.001), CHF (those without CHF more active; P<0.01), diabetes (those without diabetes more active; P<0.05), and previous level of physical activity (those active before hospitalization more active after; P<0.001). Coronary artery bypass graft patients were more active than percutaneous coronary intervention (PCI) patients (P = 0.033). Conclusions Physical activity levels declined from 2 months after hospitalization. Specific subgroups (e.g. less educated, younger) were at greater risk of decline and other subgroups (e.g. women, and PCI, CHF, and diabetic patients) demonstrated lower physical activity. These groups need tailored interventions.

Impact of duration in a cardiac rehabilitation program on coronary risk profile and health-related quality of life outcomes.

BACKGROUND Optimal cardiac rehabilitation (CR) program length and the time course of changes in relevant outcomes are unknown. The purpose of this study was to assess changes in coronary risk factors and health-related quality of life (HRQoL) after 3 months and 6 months of cardiac rehabilitation. METHODS This is an observational study of a cohort of 126 consecutive cardiac rehabilitation patients who completed baseline, 3-month, and 6-month evaluations of coronary risk factors and HRQoL. The coronary risk factors included lipid profile, blood pressure, body mass index (BMI), and physical activity level. HRQoL was assessed using the Short Form-36 questionnaire (SF-36) comprising eight health concepts and two component scales (physical [PCS] and mental [MCS]). RESULTS There was significant improvement in all coronary risk factors and HRQoL measures, except BMI, over the 6-month period (P < 0.001). Significant changes in blood pressure, physical activity, PCS, and high-density lipoprotein cholesterol (HDL-C) were apparent at 3 months, and no additional significant changes in these variables occurred between 3 and 6 months. For total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and MCS, significant change was achieved between 3 and 6 months but not between baseline and 3 months. CONCLUSIONS Secondary prevention and HRQoL outcomes improved at variable rates. Physical activity and physical function peaked at 3 months and were maintained at program completion. Significant improvements occurred in mental health recovery beyond the traditional 12-week CR program length. Outcomes furthest from normative values showed the most rapid improvement. Optimal duration of participation may vary according to the outcome of interest.

Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease

Background: The CardioFit internet-based expert system was designed to promote physical activity in patients with coronary heart disease (CHD) who were not participating in cardiac rehabilitation. Design: This randomized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes. Methods: A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and randomly assigned to either CardioFit (n = 115) or usual care (n = 108). The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking. They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist. Usual care consisted of physical activity guidance from an attending cardiologist. Physical activity was measured by pedometer and self-reported over a 7-day period, 6 and 12 months after randomization. Results: The CardioFit internet-based physical activity expert system significantly increased objectively measured (p = 0.023) and self-reported physical activity (p = 0.047) compared to usual care. Emotional (p = 0.038) and physical (p = 0.031) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care. Conclusions: Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care. Use of the CardioFit program could extend the reach of rehabilitation and secondary-prevention services.

Barrier Self-Efficacy and Physical Activity Over a 12-Month Period in Men and Women Who Do and Do Not Attend Cardiac Rehabilitation

Objectives: Two primary objectives were to examine (a) changes in physical activity (PA) over a 12-month period in people living with cardiac disease who did not attend cardiac rehabilitation (CR), and (b) the role of barrier self-efficacy in explaining these changes from a gender perspective. A secondary objective was to examine whether attending CR (or not) moderated the gender‐barrier self-efficacy relationship with PA. Design and Setting: Participants (N 801) completed a questionnaire in the hospital and at 2, 6, and 12 months after hospitalization, as well as a telephone-administered 7-day PA recall at 2, 6, and 12 months. Main Outcome Measures: PA and barrier self-efficacy. Results: Hierarchical linear modeling showed significant declines in PA over time, which were especially pronounced for women. Moreover, the association between barrier self-efficacy and PA became significantly weaker over time, especially for women. This trend was similar for participants who did and did not attend CR. Conclusion: Interventions that focus on increasing barrier self-efficacy in people living with heart disease after hospitalization will likely equally benefit men and women in the short term but may disproportionately benefit men in the longer term regardless of participation in CR.

Demographic and Clinical Determinants of Moderate to Vigorous Physical Activity During Home-Based Cardiac Rehabilitation: THE HOME-BASED DETERMINANTS OF EXERCISE (HOME) STUDY

PURPOSE: Little is known concerning moderate to vigorous physical activity (MVPA) levels in patients attending home-based cardiac rehabilitation (CR) programs and whether demographic/clinical characteristics moderate these levels. METHODS: Patients (N = 280, 77 female) who were referred to home-based CR, mainly because of myocardial infarction (34%), coronary artery bypass graft (17%), and percutaneous coronary intervention/ stent/atherectomy (32%), completed a questionnaire assessing demographic and clinical characteristics as well as MVPA, measured at the beginning and end of a 3-month home-based CR program. Charts were reviewed for blood work, blood pressure, stress tests, and diagnosis. RESULTS: Patients averaged 88.5 minutes per week of MVPA before starting home-based CR, which increased to 191.1 minutes during the program. Multiple regression analyses showed that patients who were male (&bgr; = −.11), did not have metabolic syndrome (&bgr; = −.14), and were meeting the MVPA guideline before starting home-based CR (&bgr; = .25) engaged in significantly more MVPA during home-based CR than their counterparts. Furthermore, the increase in MVPA was significantly larger for males (&bgr; = −.20), patients without metabolic syndrome (&bgr; = −.13), and patients who did not meet the MVPA guideline at baseline (&bgr; = −.29) than their counterparts. CONCLUSIONS: The MVPA levels of patients attending home-based CR tend to vary depending on gender, whether or not metabolic syndrome was present, and prior MVPA levels, suggesting the need to potentially target these particular groups in future behavioral interventions aimed at increasing MVPA.

Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation

Background: Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. Design: A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. Method: One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. Results: Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µadd = 0.69, p < 0.05). Conclusion: Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.

Who will be active? Predicting exercise stage transitions after hospitalization for coronary artery disease

We describe transitions between exercise stages of change in people with coronary artery disease (CAD) over a 6-month period following a CAD-related hospitalization and evaluate constructs from Protection Motivation Theory, Theory of Planned Behavior, Social Cognitive Theory, the Ecological Model, and participation in cardiac rehabilitation as correlates of stage transition. Seven hundred eighty-two adults hospitalized with CAD were recruited and administered a baseline survey including assessments of theory-based constructs and exercise stage of change. Mailed surveys were used to gather information concerning exercise stage of change and participation in cardiac rehabilitation 6 months later. Progression from pre-action stages between baseline and 6 month follow-up was associated with greater perceived efficacy of exercise to reduce risk of future disease, fewer barriers to exercise, more access to home exercise equipment, and participation in cardiac rehabilitation. Regression from already active stages between baseline and 6 month follow-up was associated with increased perceived susceptibility to a future CAD-related event, fewer intentions to exercise, lower self-efficacy, and more barriers to exercise.

Does protection motivation theory explain exercise intentions and behavior during home-based cardiac rehabilitation?

OBJECTIVE Home-based cardiac rehabilitation (CR) programs have been shown to be effective in increasing exercise capacity, which is a significant predictor of longevity for patients with heart disease. However, adherence to these programs has been problematic. Therefore, it is important to identify key theoretical correlates of exercise for these patients that can be used to inform the development of behavioral interventions to help tackle the adherence problem. The purpose of this study was to determine whether protection motivation theory (PMT) explained significant variation in exercise intentions and behavior in patients receiving home-based CR. METHODS Patients (N = 76) completed a questionnaire that included PMT constructs at the beginning and midpoint (ie, 3 months) of the program and an exercise scale at 3 and 6 months (ie, at the end of the CR program). RESULTS Path analyses showed that response efficacy was the sole predictor of 3-month (β = .53) and 6-month (β = .32) intentions. However, the indirect effect of baseline response efficacy on 3-month exercise behavior through intention was nonsignificant (β = −.01), whereas it was significant (β = .11) for 3-month response efficacy on 6-month exercise behavior. Self-efficacy significantly predicted 3-month (β = .36) and 6-month (β = .32) exercise behaviors, whereas 3-month intention significantly predicted 6-month exercise behavior (β = .23). CONCLUSIONS Coping appraisal variables (ie, response efficacy and self-efficacy) are potentially useful in explaining exercise behavior during home-based CR.

Correlates of physical activity change in patients not attending cardiac rehabilitation.

OBJECTIVE Limited research has identified theoretical correlates of physical activity (PA) change in patients not receiving cardiac rehabilitation. The purpose of the present study was to determine whether changes in self-efficacy, PA intention, perceived severity and susceptibility, and PA benefits/barriers were associated with changes in PA over a 12-month period in these patients. METHODS Patients (N = 555) not attending cardiac rehabilitation completed a psychosocial questionnaire in hospital and 6 and 12 months after hospitalization for a cardiac event. RESULTS Hierarchical regression analyses showed that the increase in PA from baseline to 6 months was significantly related to an increase in self-efficacy and PA intentions and a decrease in the impact of health-related barriers. Furthermore, the decrease in PA from 6 to 12 months was significantly related to a decrease in health-related benefits and PA intentions and an increase in time and health-related barriers. Finally, the increase in PA from baseline to 12 months was significantly related to an increase in health-related benefits and intentions and a decrease in health-related barriers. CONCLUSIONS Changes in PA levels over a 12-month period were associated with changes in various theoretical variables. Interestingly, the associations among these variables with PA varied as a function of time after hospitalization.

Alberta Healthy Living Program--a model for successful integration of chronic disease management services.

The most common presentation of chronic disease is multimorbidity. Disease management strategies are similar across most chronic diseases. Given the prevalence of multimorbidity and the commonality in approaches, fragmented single disease management must be replaced with integrated care of the whole person. The Alberta Healthy Living Program, a community-based chronic disease management program, supports adults with, or at risk for, chronic disease to improve their health and well being. Participants gain confidence and skills in how to manage their chronic disease(s) by learning to understand their health condition, make healthy eating choices, exercise safely and cope emotionally. The program includes 3 service pillars: disease-specific and general health patient education, disease-spanning supervised exercise and Better Choices, Better Health(TM) self-management workshops. Services are delivered in the community by an interprofessional team and can be tailored to target specific diverse and vulnerable populations, such as Aboriginal, ethno-cultural and francophone groups and those experiencing homelessness. Programs may be offered as a partnership between Alberta Health Services, primary care and community organizations. Common standards reduce provincial variation in care, yet maintain sufficient flexibility to meet local and diverse needs and achieve equity in care. The model has been implemented successfully in 108 communities across Alberta. This approach is associated with reduced acute care utilization and improved clinical indicators, and achieves efficiencies through an integrated, disease-spanning patient-centred approach.