Yvonne W. Leung

The impact of premorbid and postmorbid depression onset on mortality and cardiac morbidity among patients with coronary heart disease: meta-analysis.

Background Depression is associated with increased cardiac morbidity and mortality in the general population and in patients with coronary heart disease (CHD). Recent evidence suggests that patients with new-onset depression post-CHD diagnosis have worse outcomes than do those who had previous or recurrent depression. This meta-analysis investigated the timing of depression onset in established CHD and CHD-free cohorts to determine what time frame is associated with greater mortality and cardiac morbidity. Methodology/Principal Findings The MEDLINE, EMBASE, and PsycINFO databases were searched systematically to identify articles examining a depression time frame that specified an end point of all-cause mortality, cardiac mortality, rehospitalization, or major adverse cardiac events. A meta-analysis was conducted to estimate effect sizes by time frame of depression. Twenty-two prospective cohort studies were identified. Nine studies investigated premorbid depression in CHD-free cohorts in relation to cardiac death. Thirteen studies in patient samples with CHD examined new-onset depression in comparison with previous or recurrent depression. The pooled effect size (risk ratio) was 0.76 (95% confidence interval (CI) = 0.48–1.19) for history of depression only, 1.79 (95% CI = 1.45–2.21) for premorbid depression onset, 2.11 (95% CI = 1.66–2.68) for postmorbid or new depression onset, and 1.59 (95% CI = 1.08–2.34) for recurrent depression. Conclusions/Significance Both premorbid and postmorbid depression onsets are potentially hazardous, and the question of timing may be irrelevant with respect to adverse cardiac outcomes. However, the combination of premorbid depression with the absence of depression at the time of a cardiac event (i.e., historical depression only) is not associated with such outcomes and deserves further investigation. Abbreviations CHD = coronary heart disease MI = myocardial infarction ES = effect size RR = risk ratio HR = hazard ratio CI = confidence interval DSM = Diagnostic and Statistical Manual

The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization.

BACKGROUND: While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral. METHODS: Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using &khgr;2. RESULTS: When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy. CONCLUSION: Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.

Post-traumatic growth among cardiac outpatients: Degree comparison with other chronic illness samples and correlates

This study evaluated the sociodemographic, clinical and behavioral correlates of post-traumatic growth (PTG) in coronary artery disease (CAD) patients, and the degree of PTG compared to other patient groups. Using a prospective design, 1497 CAD outpatients completed a survey assessing potential PTG correlates. A total of 1268 responded to a nine-month follow-up survey assessing PTG. Significant PTG correlates were being younger, non-white, having lower income, functional status, and depressive symptoms, greater social support, and positive illness perceptions. The degree of PTG was equivalent to that of cardiac patients in other countries, but was lower than that of breast cancer and multiple sclerosis patients.

Routine screening for suicidal intention in patients with cancer

Suicide rates are elevated in individuals with cancer, although suicidal intention is not typically assessed in cancer centers. We evaluated in a large comprehensive cancer center the utility of an electronic Distress Assessment and Response Tool (DART), in which suicidal intention is assessed with a single item.

Concordance of self- and program-reported rates of cardiac rehabilitation referral, enrollment and participation.

BACKGROUND Despite potential bias, researchers often rely on patient self-reported data of health care use. However, the validity and accuracy of self-reported data on cardiac rehabilitation (CR) use are unknown. OBJECTIVE To assess the concordance between patient self-report and site-verified CR referral, enrollment and participation. METHODS A consecutive sample of 661 coronary artery disease inpatients (mean [+/- SD] age 61.27+/-1.31 years; 157 women [23.8%]) treated at three acute care sites was recruited (75% response rate) as part of a larger study comparing automatic with usual referral methods. CR referral, enrollment (attendance at intake assessment) and participation (percentage of program attended) were discerned in a mailed survey nine months following discharge (n=506; 84.3% retention). A total of 24 CR sites were contacted for verification. RESULTS A total of 276 participants (54.5%) self-reported CR referral, and CR sites verified receipt of 262 referrals (51.8%) (Cohens kappa 0.899). A total of 232 participants (45.8%) self-reported CR enrollment, with site-verification for 208 participants (41.1%) (Cohens kappa 0.846). Self-reported data indicated that participants attended a mean of 81.78+/-25.84% of prescribed CR sessions, with CR sites reporting that participants completed 80.75+/-31.27% of the program (r=0.662; P<0.001). Equivalency testing revealed that the self-reported and site-verified rates of program participation were equivalent (z<1.96). CONCLUSIONS The almost perfect agreement between the self-reported and site-verified use of CR services suggests that self-administered items are highly valid in this population.

Geographic Issues in Cardiac Rehabilitation Utilization: A Narrative Review.

OBJECTIVE The purpose of this study was to review the current evidence regarding the relationship between geographic indicators and cardiac rehabilitation (CR) utilization among coronary heart disease (CHD) patients. RESULTS Seventeen articles were identified for inclusion, where nine studies assessed rurality, 10 studies assessed travel time/distance, and two of these studies assessed both. Nine of the 17 studies (52.9%) showed a significant negative relationship between geographic barrier and CR use. Four of the 17 studies (23.5%) showed a null relationship, while four studies (23.5%) showed mixed findings. Inconsistent findings identified appeared to be related to restricted geographic range, regional density, and socioeconomic status. CONCLUSIONS Overall, 52.9% of the identified studies reported a significant negative relationship between geographic indicators and CR utilization. This relationship appeared to be particularly consistent in North American and Australian settings, but somewhat less so in the United Kingdom where there is greater population density and availability of public transport.

Timing of Depressive Symptom Onset and In-Hospital Complications Among Acute Coronary Syndrome Inpatients

Background Recent research has reported an association between in-hospital depression and poorer long-term prognosis and a greater risk of in-hospital complications. Objective The purpose of the current study was to examine the relationship between past and incident depressive symptoms and in-hospital complications in acute coronary syndrome (ACS) inpatients. Method A group of 906 ACS inpatients from 12 coronary-care units participated in the study. Incident depressive symptoms were assessed through the Beck Depression Inventory, and participants’ were asked about past history of prolonged depressed mood. In-hospital complications were noted as present or absent by nurses, and authors conducted logistic-regression analyses. Results A subset of 492 patients (58.4%) experienced an in-hospital complication, the most common being ischemia (48.8%) and cardiac arrest (7.2%). After adjusting for prognostic indicators, incident and past-combined-with-incident depressive symptoms were significantly associated with an increased risk of experiencing an in-hospital complication. Conclusion Incident symptoms, in particular, seem to be prognostic. This finding suggests that acute emotions may be triggering cardiac complications, and early identification of emotional symptoms is warranted.

Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program

PURPOSE Systematic screening for distress in oncology clinics has gained increasing acceptance as a means to improve cancer care, but its implementation poses enormous challenges. We describe the development and implementation of the Distress Assessment and Response Tool (DART) program in a large urban comprehensive cancer center. METHOD DART is an electronic screening tool used to detect physical and emotional distress and practical concerns and is linked to triaged interprofessional collaborative care pathways. The implementation of DART depended on clinician education, technological innovation, transparent communication, and an evaluation framework based on principles of change management and quality improvement. RESULTS There have been 364,378 DART surveys completed since 2010, with a sustained screening rate of > 70% for the past 3 years. High staff satisfaction, increased perception of teamwork, greater clinical attention to the psychosocial needs of patients, patient-clinician communication, and patient satisfaction with care were demonstrated without a resultant increase in referrals to specialized psychosocial services. DART is now a standard of care for all patients attending the cancer center and a quality performance indicator for the organization. CONCLUSION Key factors in the success of DART implementation were the adoption of a programmatic approach, strong institutional commitment, and a primary focus on clinic-based response. We have demonstrated that large-scale routine screening for distress in a cancer center is achievable and has the potential to enhance the cancer care experience for both patients and staff.

Gender differences in motivations and perceived effects of Mind-Body Therapy (MBT) practice and views on integrative cardiac rehabilitation among acute coronary syndrome patients: why do women use MBT?

BACKGROUND Over one-third of cardiac patients practice Mind-Body Therapy (MBT), particularly women. Considering women are less likely to engage in conventional physical activity, few studies have examined why MBT is well-accepted by women. OBJECTIVES To qualitatively explore gender differences in the motivations for, and perceived effects of MBT, and the inter-relationships among alternative and conventional physical activities and secondary prevention programs. METHODS A random subsample of 16 participants (8 female) who reported practicing MBT in a larger study of 661 cardiac patients was interviewed until theme saturation was achieved. Audiotapes were transcribed and coded based on interpretive-descriptive technique within Nvivo-7 software. An audit trail and second coder were utilized to ensure the transparency and validity of results. After main themes emerged, the data were split by gender to identify differences for each theme. RESULTS Five themes emerged: (1) promotes positive well-being, (2) physical health benefits, (3) intrinsic and extrinsic motivations, (4) proactive health orientation, and (5) MBT as a preferred complementary and/or alternative physical activity. Men more often expressed preference for MBT for increased positive mood and cardiac-specific benefits, whereas women emphasized stress reduction, increasing self-efficacy, and physical activity, and were eager to see MBT offered in cardiac rehabilitation (CR). CONCLUSIONS Both male and female users perceived substantial psychosocial and physical benefits of MBT practice. MBT addresses some of womens common barriers to CR.

Quality of Life Following Participation in Cardiac Rehabilitation Programs of Longer or Shorter than 6 Months: Does Duration Matter?

Cardiac rehabilitation (CR) participation results in significant health benefits. However, there is wide variation in program duration, and little is known about the optimal duration of CR for patient outcomes. The objective of this study was to compare quality of life (QoL) of patients who participated in CR programs of < or ≥6 months duration versus patients who did not attend CR. A total of 1056 cardiac outpatients completed mailed surveys at baseline and 9 months later. Patients were categorized based on CR participation in one of 31 programs: a program of < or ≥6 months duration, or nonattendance. Outcomes were body mass index, activity status, depressive symptoms, physical activity, QoL, posttraumatic growth inventory (PTGI), and percentage of CR sessions attended. Generalized estimating equations were used. A total of 148 (14%) patients participated in a program of < 6 months, and 183 (17.3%) participated in a program of ≥6 months. Patients who participated in the former completed a greater percentage of CR sessions (P = 0.02). Activity status (P = 0.002), several domains of QoL (P > 0.0001), and PTGI (P = 0.007) were significantly greater regardless of CR duration when compared to those who did not attend CR. There were no significant differences in outcomes when comparing patients attending CR programs of < or ≥6 months duration. Patients achieve greater activity status and QoL when compared to those who did not attend CR, regardless of program duration. This could be a result of greater program adherence among those who attend shorter programs. Future research is needed using a randomized design to assess effects of program duration on cardiac events and mortality.