Neil B. Oldridge

Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction

Abstract This investigation was designed to determine the impact of a brief period of cardiac rehabilitation, initiated within 6 weeks of acute myocardial infarction (AMI), on both disease-specific and generic health-related quality of life, exercise tolerance and return to work after AMI. With a stratified, parallel group design, 201 low-risk patients with evidence of depression or anxiety, or both, after AMI, were randomized to either an 8-week program of exercise conditioning and behavioral counseling or to conventional care. Although the differences were small, significantly greater improvement was seen in rehabilitation group patients at 8 weeks in the emotions dimension of a new disease-specific, health-related Quality of Life Questionnaire, in their state of anxiety and in exercise tolerance. All measures of health-related quality of life in both groups improved significantly over the 12-month followup period. However, the 95% confidence intervals around differences between groups at the 12-month follow-up effectively excluded sustained, clinically important benefits of rehabilitation in disease-specific (limitations, −2.70, 1.40; emotions, −4.86, 1.10, where negative values favor conventional care and positive values favor rehabilitation) and generic health-related quality of life (time trade-off, −0.062, 0.052; quality of well-being, −0.042, 0.035) or in exercise tolerance (−38.5, 52.1 kpm/min); also, return to work was similar in the 2 groups (relative risk, 0.93; confidence interval, 0.71, 1.64). It is concluded that in patients with evidence of depression or anxiety, or both, exercise conditioning and behavioral counseling after AMI was associated with an accelerated recovery in some outcome measures at 8 weeks, but by 12 months similar improvements were seen in both diseasespecific and generic health-related quality of life and in other outcome measures when compared with conventional care in this community.

Compliance and exercise in primary and secondary prevention of coronary heart disease: A review☆

Abstract Compliance with exercise programs in the primary and secondary prevention of coronary heart disease is reviewed. The evidence suggests that compliance with health behavior changes such as exercise is necessary for potential benefits to become apparent. However, the compliance rate with exercise programs is low and particular care must be taken in the interpretation of exercise studies as well as clinical trials because of self-selection bias. There appear to be certain characteristics that may help to identify the potential dropout; there are also certain programmatic features which should be considered in designing compliance-improving strategies to reduce dropout. Behavior modification techniques appear to have significant potential in reducing program dropout; however, there is a need to carefully investigate compliance-improving strategies before recommendations for a particular approach can be made.

Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction

Abstract Although there are extensive clinical evaluations of cardiac rehabilitation after acute myocardial infarction (AMI), no full economic evaluation is available. Patients with AMI and mild to moderate anxiety or depression, or both, while still in hospital were randomized to either an 8-week rehabilitation intervention (n = 99) or usual care (n = 102). Comprehensive costs and health-related quality of life, measured with the time trade-off preference score, were obtained in a 12-month trial, and together with survival data derived from published meta-analyses, cost-utility and cost-effectiveness of early cardiac rehabilitation were estimated. The best estimate of the incremental net direct 12-month costs for patients randomized to rehabilitation was

Quality of life after myocardial infarction

480 (United States, 1991)/ patient. During 1-year follow-up, rehabilitation patients had fewer “other rehabilitation visits” (p

The health belief model: predicting compliance and dropout in cardiac rehabilitation.

The objective of this work was to develop and test a questionnaire to measure health-related quality of life for patients after myocardial infarction (MI). In a cross-sectional survey, 63 patients identified the most frequent and important problems following acute myocardial infarction. The Quality of Life after Myocardial Infarction (QLMI) instrument was developed on the basis of these most frequent and important problems. The QLMI was administered, along with instruments measuring health utilities, social function, and emotional function, in a randomized trial of rehabilitation versus conventional care. The most frequent and important problems fell into areas of symptoms, restriction, confidence, self-esteem, and emotions, each of which is represented in the 26-item QLMI. Effect sizes of the overall QLMI in differentiating between rehabilitation and control groups (0.35), and in detecting improvement over 12 months (1.22) were comparable or larger than any other instrument. The Pearsons correlation coefficient between QLMI administered at 8 and 12 months following AMI varied between 0.75 and 0.87 for the five domains and the overall score. We found substantial correlations of the QLMI with other measures with moderate concordance with predictions about how the instrument should behave if it is a valid measure of health-related quality of life. The QLMI demonstrates a high degree of reliability, and is more responsive than other questionnaires. Relations between the QLMI and other measures provide moderate to strong evidence of its validity in discriminating between patients following AMI according to their health-related quality of life, and in measuring changes in health-related quality of life over time.

Anxiety and depression after acute myocardial infarction

We investigated the health belief model and the health locus of control constructs as predictors of group membership (compliers or dropouts) with cardiac rehabilitation and whether they added predictive utility to routinely assessed patient demographics and health behaviors. Questionnaires were completed on entry into the study by 120 patients with coronary artery disease, and by the end of the 6 month program there were 58 compliers and 62 dropouts. Discriminant function analyses were carried out to determine prediction of group membership. The health belief model predicted group membership 64.6% of the time, explaining 5.2% of the variance. Demographics, health behaviors, and health belief model factors accounted for 21.1% of the variance between compliers and total dropouts with group membership correctly predicted 74.4% of the time; avoidable and unavoidable dropout was correctly predicted 84.2% of the time with 56.9% of the variance explained. Health locus of control did not distinguish between compliers and dropouts. The addition of the health belief model provided additional information about compliance with cardiac rehabilitation beyond that explained by demographic and health behavior variables alone, particularly when predicting avoidable/unavoidable dropout.

Profile of mood states and cardiac rehabilitation after acute myocardial infarction.

OBJECTIVES To assess the following: (1) symptoms of anxiety and depression in hospitalized patients who had acute myocardial infarction (AMI); (2) the association between sex, infarct severity, history of previous AMI, and symptoms of anxiety and depression in hospitalized patients; (3) symptoms of anxiety and depression during the first year after AMI in a select group of patients; and (4) the association between educational and occupational status and symptoms of anxiety and depression at the time of hospitalization in a select group of patients. DESIGN Cross-sectional survey (objectives 1 and 2) and prospective trial with random assignment (objectives 3 and 4). SETTING Six university-affiliated hospitals in a Canadian city. PATIENTS Seven hundred eighty-five hospitalized patients with AMI, with 1-year follow-up of 201 selected patients from this sample. INSTRUMENTS State-Trait Anxiety Inventory and the short form of the Beck Depression Inventory. INTERVENTION Data collection was initiated in the hospital 3 days after AMI, and patients were followed-up 14, 24, 41, and 56 weeks after AMI. RESULTS Student t tests, analysis of variance, and descriptive statistics were used. When the patients were in the hospital the mean state (S-anxiety) and trait (T-anxiety) scores were 43 and 44, respectively. Ten percent had S-anxiety scores and 14% had T-anxiety scores that were higher than the mean scores reported for psychiatric patients. During the 1-year follow-up in the select group of subjects, the mean S-anxiety and T-anxiety scores were both 48 in-hospital, and decreased to 42 and 46, respectively, by 14 weeks and remained at these levels for the remainder of the year. During the course of the year, 16% of the patients had State-Trait Anxiety Inventory scores consistent with psychiatric conditions. The in-hospital Beck Depression Inventory mean score was 3, and 9% of the patients had scores consistent with moderate to severe depression. During the first 24 weeks, symptoms of moderate to severe depression were reported by 10% of the select group of patients. No associations were found between anxiety and depression and sex, creatine phosphokinase level, previous AMI, education, or occupational status. CONCLUSIONS Symptoms of anxiety were prevalent among hospitalized patients who had an AMI, whereas depressive symptoms were rare. There was no association between anxiety and depression and sex, infarct severity, history of previous AMI, or educational or occupational status.

Measuring quality of life in cardiac spouses.

Following an acute myocardial infarction, evaluation of a patients own perceptions of health, including mood state, provides useful information about the efficacy of rehabilitation when data are available for patients randomized to both control and intervention. Data are presented on the Profile of Mood States (POMS) in 187 patients, with mild to moderate scores for Spielberger state anxiety and/or Beck depression, who were randomized within 6 wk of acute myocardial infarction to usual care or to brief cardiac rehabilitation lasting 8 wk and who were followed-up during the 12 months following the acute event. Repeated measures multivariate analysis of covariance identified significant main as well as time effects in POMS scores over 12 months. Repeated measures analysis of variance over the 12 months demonstrated significant improvement for both depression and anxiety in both groups. At 8 wk, improvement was greater in the rehabilitation patients than usual care patients but only in the tension-anxiety, depression-dejection and vigor-activity dimensions of POMS and only in anxiety in those patients with above mean anxiety scores. Overall, rehabilitation and control patients showed similar and significant improvements in anxiety, depression and in mood states over the duration of the 12-month trial.

QUALITY OF LIFE AFTER MYOCARDIAL INFARCTION

The purpose of this study was to develop an objective instrument to measure changes in quality of life of spouses of post-myocardial infarction (MI) patients, and to determine its responsiveness and validity. A 70-item list of potential areas of concern was compiled; the 25 most frequent and important concerns comprised the framework of the final questionnaire. The questions on the Quality of Life Questionnaire for Cardiac Spouses (QL-SP) were categorized into the Emotional Function Dimension (EFD), and the Physical and Social Function Dimension (PSFD). Subjects (n = 39) completed the QL-SP and a battery of established questionnaires at home, 1-2 weeks post-hospital discharge for the patient, and 8 weeks later. Scores on the QL-SP between visits were improved for both the EFD (t = 5.56, p less than 0.001), and the PSFD (t = 6.11, p less than 0.001). The agreement between predicted and observed relationships between the dimension changes and other index changes, as measured statistically by a kappa with Cicchetti weights, was significant (kappa w = 0.43, p = 0.0012). The QL-SP appears to be responsive and valid, and may be useful in evaluating clinical and research intervention strategies.

Determinants of physical activity and interventions in adults.

The objective of this work was to develop and test a questionnaire to measure health-related quality of life for patients after myocardial infarction (MI). In a cross-sectional survey, 63 patients identified the most frequent and important problems following acute myocardial infarction. The Quality of Life after Myocardial Infarction (QLMI) instrument was developed on the basis of these most frequent and important problems. The QLMI was administered, along with instruments measuring health utilities, social function, and emotional function, in a randomized trial of rehabilitation versus conventional care. The most frequent and important problems fell into areas of symptoms, restriction, confidence, self-esteem, and emotions, each of which is represented in the 26-item QLMI. Effect sizes of the overall QLMI in differentiating between rehabilitation and control groups (0.35), and in detecting improvement over 12 months (1.22) were comparable or larger than any other instrument. The Pearsons correlation coefficient between QLMI administered at 8 and 12 months following AMI varied between 0.75 and 0.87 for the five domains and the overall score. We found substantial correlations of the QLMI with other measures with moderate concordance with predictions about how the instrument should behave if it is a valid measure of health-related quality of life. The QLMI demonstrates a high degree of reliability, and is more responsive than other questionnaires. Relations between the QLMI and other measures provide moderate to strong evidence of its validity in discriminating between patients following AMI according to their health-related quality of life, and in measuring changes in health-related quality of life over time.