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Cardiac Rehabilitation Research

Abstract

Cardiac rehabilitation is essentially used to help patients come back to their normal life after they have undergone a cardiovascular treatment. There are times when long-term cardiac rehab is needed and this may be done in the home. The implementation of a long-term cardiac rehab program should be done with the needs of the patient in mind and consideration of the availability of resources. Through the use of technology, it is possible also to enlist online support group to assist the patient with activities in the prolonged cardiac rehab program. This paper provides a description of a prolonged cardiac rehab program with the assistance of an online support group.

Chapter 1: Introduction

Most patients who have undergone cardiac surgery require rehabilitation as a way of reversing the limitations experienced from adverse pathophysiologic and psychological consequences of the whole process. Cardiovascular diseases are the leading cause of morbidity and mortality in many developed countries with deaths caused reaching up to 50% each year. In the United States alone, more than 14 million people exhibit a form of coronary artery disease or its complicated forms like angina, heat failure, and arrhythmias (The Heart Research Centre, 1999). Out of this number, more than 1.5 million patients need cardiac rehabilitation services after successfully undergoing the surgery procedures. Traditionally, the prerequisite for providing cardiac rehabilitation has been the low-risk patients who are able to work out without risking their lives. Nonetheless, the rapid change in the management of coronary artery diseases has been changing the demographics for cardiac rehabilitation candidates. Presently, the number of patients who have undergone coronary angioplasty and may require cardiac rehabilitation has been on the increase. In addition, around 5 million patients with CHF are eligible for a modified program of rehabilitation (LoBiondo-Wood, & Haber, 2013). In all this efforts, a focus has always been on ways to provide better cardiac rehabilitation services that lead to better outcome measures, lower risks, ensures maximum benefit, and ensure cost-effective services to the patients.

Background and Significance of the Problem

The practice of cardiac rehabilitation has a long history starting in 1772 when Heberden, after describing the angina pectoris reported a patient who had shown improvement after working in the woods for 30 minutes every day (Mampuya, 2012). This finding was contrary to the recommendations at the time for cardiac surgery patients who were restricted from physical activity and mobility. As a result, many of these patients were affected by de-conditioning problems, prolonged hospital stay, decline in functional capacity, and ultimately increased mortality and morbidity rates. The incorrect attitude was further reinforced after the myocardial infarction description by Herrick in 1912. The 6 weeks of bed rest for coronary patients were introduced in the 1930s and chair therapy in 1940s. In the following decade, the medical professionals started allowing coronary patients to perform a 3 to 5 minutes walk for several weeks after coronary surgery (Lavie & Milani, 2011). Because of these activities, early ambulation was discovered in patient to be responsible for preventing the most complications related to bed rests and that this did not increase risks to the patient.

Early pioneers of cardiac rehabilitation experienced strong opposition following their activities to advocate for mobilization of patients. Nonetheless, the evidence for benefits to patients who have undergone ambulation in their early stages after a surgery helped to convince the skeptics about the benefits of cardiac rehabilitation to coronary patients (Lavie & Milani, 2011). Much of the support for cardiac rehabilitation came from studies that proved that immobilization increased the rate of coronary events. The studies were done on bus drivers in London and their ticket sellers to show that the rate of coronary events was higher among bus drivers, who were mostly immobile, than in ticket sellers. The Dallas Bed Rest and Exercise Study of 1968 provided further physiological evidence that there were benefits to patients who exercised regularly and therefore led to the development of cardiac rehabilitation program for cardiovascular patients (LoBiondo-Wood & Haber, 2013). These programs were also intended at optimizing the mental and functional status of the patients in preparation for recovery.

The practice of cardiac rehabilitation has evolved in the last fifty years to become one of the most used programs for the return to safe physical activities for cardiovascular patients. Many post-operative patients have benefited through cardiac rehabilitation in addition to nutritional counseling, medical treatment, risk reduction, and hypertension management. The World Health Organization conceptualizes cardiac rehabilitation as the sum of activities which can influence favorably the cause of the disease and ensure that the patient has the best mental, physical, and social conditions that can boost their efforts to resume normal activities in the community. Following the success of 6 week cardiac rehabilitation program for cardiovascular patients, there has been studies to examine the impact of increasing this period to 12 weeks.

However, there is a need to ascertain the impact on patients who receive usual activity instructions at their end of the six week period and compared to those patients who participate in a home-based supportive rehabilitation. To achieve this fete, there is a need to identify the individual needs with the view of optimizing the benefits and develop a risk profile through mental and physical evaluation at the start of the cardiac rehabilitation program (The Heart Research Centre, 1999). It is also essential to put in place contingencies that ensure a safe environment for patients and lower risks. When the period is elapsed, it is also important to perform an evaluation to verify whether the program has achieved its set goals and also determine ways to continue with the rehabilitation in the long term.

Statement of the Problem

Cardiac rehabilitation has been found to help patients to gain their normal life after a certain period of time. The period is normally recommended by doctors and physicians depending on the condition of the patient. Majority of patients who have undergone cardiac surgery require rehabilitation to enable them to return to their normal capacity. In order to get to this level, a multidisciplinary approach is used to focus on areas such as patient education, training exercises, and risk reduction. However, because of the costs associated with cardiac rehabilitation and the fact that there is no sufficient information about its effectiveness, cardiac rehabilitation remains one of the severely underutilized programs with the potential of helping patients to a large extent (Brownson & Heath, 2011).

Part of the misinterpretation has been the effect of lengthened cardiac rehabilitation services to a patient past the recommended six week period. The obscurity has been noted in recognizing the variation in quality of life for patients who decide to go for cardiac rehabilitation for 12 weeks as opposed to the recommended six week period. There is a necessity to determine the differences between patients who receive instructions at the end of the typical six week period and outpatient cardiac rehabilitation patient who receive the instructions beyond the typical six week through service such as online support group.

Significance

This research is significant in two ways. The first one is that it will help to identify ways to streamline cardiac rehabilitation activities through program development with the aim of entrenching the practice as the standard recommended practice for all cardiac surgery patients. Through this way, it will be possible for service providers to identify additional activities for which patients can be engaged beyond the typical six week period as a way of continuing with rehabilitation. It will also be essential in reinforcing the widespread use of cardiac rehabilitation and the mental capacity of patients to continue with rehabilitation activities beyond the recommended time. The second significant way is that the research will provide an in-depth understanding of how online support groups can be used to enhance the quality of life of a cardiac surgery patient. It is especially beneficial to patients who choose to continue with cardiac rehabilitation activities in their homes long after the typical six week period is over. Through online support groups, it is anticipated that patients will be exposed to lower risks. They will also benefit more from the information of experts and fellow patients on how to handle different situations while performing cardiac rehabilitation at home.

Purpose

The purpose of the current research is to explore the findings of researchers on the differences that exist between patients’ quality of life at 12 weeks post event and patients’ quality of life at the end of the typical six week outpatient cardiac rehabilitation activities. The researcher considered cases where the online support group is involved in the former case. The research will help to identify ways to improve the provision of cardiac rehabilitation services beyond the typical six week period through the help of the online support group.

In patients following cardiac surgery, is there a difference in quality of life at 12 weeks post-event between those who receive usual activity instructions at the end of the typical six week outpatient cardiac rehabilitation program and those who take part in online support group?

Chapter 2: Review of Literature

Research Pattern and Literature Review

The need for cardiac rehabilitation for people with heart diseases is to enable them to go back to their usual and fulfilling life and keep away from cardiac events. The provision of cardiac rehabilitation services is done in conjunction with a cardiac specialist or a health practitioner who retains the overall responsibility to the management of the patient’s activities. With extended cardiac rehabilitation terms, these assistants may not be available in the homes to give direction to cardiac patients. This requires the use of groups of people to assist in the management of cardiac rehabilitation related activities. Cardiac rehabilitation ought to be implemented within the parameters of well organized framework with clearly identified objectives and goals to achieve. The objectives form the foundation of the routinely management of cardiac patients. Once the objectives are identified, a list of services to be included should be made and may include services such as health education, behavior modification strategies, physical activity, and support for self-management. The services are designed in line with the individual and cultural needs of the patient and their family members. The caregivers, for example, must be able to participate in the giving of such services.

Review of Theoretical Literature

The transformation that has occurred in the practice of cardiac rehabilitation since it was discovered to be beneficial has meant that patients have a wide variety of choices when it comes to improving their quality of life after a cardiac event. One of the commonly recommended forms of cardiac rehabilitation is the outpatient cardiac rehab, partly because of the options it provides to the patient (Tucker et al., 2012). The improvement in technology, which has impacted how people communicate, has also been instrumental in fast-tracking the uptake of outpatient cardiac rehabilitation for most patients. The technology enables models such as online support group and videoconferencing to flourish in support of the activities of a patient. The outpatient cardiac rehabilitation program is, therefore, recognized as a focal point when it comes to developing a life-long approach to prevention. It also allows the patient to be empowered to adopt self-management strategies as a major objective of the whole program (Mampuya, 2012). It must be developed as part of the strategy to empower the patient with skills and information to take care of themselves while in their homes.

Conventional practice has always seen patients with cardiac diseases referred to outpatient cardiac rehab from their hospital setting after an admission for surgery or any other cardiovascular procedure. Nonetheless, in the recent past, doctors are referring patients who show symptoms of coronary heart disease and those who have a high risk exposure to develop any form of cardiac event. The referrals, so far, are wide and encompassing of cardiologists, general practitioners, medical specialists, community health providers, and other outpatient institutions. But it is still feasible to provide cardiac rehabilitation services within the setting of a community health center, a hospital, and general medical practices without inhibiting the objective and goal of such programs. Most important though is that many cardiovascular patients that are being rehabilitated in their homes on an individual basis which increases the effectiveness. Online support groups are also emerging to encompass all the essential activities needed by patients who choose to continue with the rehabilitation in their homes and long after the typical six week period is elapsed.

Outpatient cardiac rehab has evolved to encompass different practices with the aim of improving the quality of life. For instance, home-based clinical visits as well as telephone and mail support are becoming too common in most parts of the world (Heran et al 2010). Patients are also deploying the internet, video, and teleconferencing to interact with medical practitioners and fellow patients on how to cope with the challenges they face in their homes and reduce the risks. There are also home-based educational resources that patients can access and have them in their homes to use while engaging in the activities. Even as these programs seek to improve the quality of life of the patients, there are areas where variations must be implemented to suit the needs of a particular patient. For instance, after the typical six week period, the length and content of the program must be varied in relation to the available resources and the specific needs of the patient. It must also be stated clearly when optimal recovery is anticipated to allow for planning on the resources and activities. The longest rehabilitation programs have stretched up to 12 weeks. But the ideal period depends on the needs of the individual patient.

One of the important aspects that define the success of the cardiac rehab programs is the inclusion of adult learning principles. Cardiac patients are generally adult people and they are expected to learn new things and how to cope with their life differently. This calls for the aspect of adult learning which defines the process of learning and clear statements about the formal learning objectives, specific knowledge to be gained, skills needed, and the possible benefits that the patient is guaranteed from the program. It is also required that adult cardiac rehab patients may want to know the benefits to them following their participation in the program (Lawrence et al, 2011). For this reason, the completion of a cardiac rehabilitation program should be considered in terms of the teaching strategies and the content therein. It must also be consistent so that the participants are not tossed into irregular activities. The consistency ensures that the participants get used to whatever activities they are asked to perform and therefore able to follow through with these activities without failure.

The level of any cardiac rehabilitation program can be evaluated through assessment and review of the milestones made. In some case, health care practitioners have used individual assessment sheet to get regular review in areas of psychological, social, and physical parameters). The participants are also referred to appropriate health care professionals in case of any complications or increased risks following the participation in rehab activities (Hanel, 2014). The information from the online support group can come in handy to help in minimizing the risks but also pointing the patient to areas where assistance could be sought in case of emergencies. Cardiac rehab activities that are depended on eHealth technology can include supervised individual events like cool-down and warm-up activities. These events are done in relation to the needs and capacity of a particular patient. The importance of written guidelines is to assist the user to comprehend day by day routines including easy but significant activities like a home walking program, accumulated time in physical activities, light physical activities, among others. It also empowers the patient to follow through the physical activity program on a regular basis as well as observe the self-monitoring instructions during the activities. These activities are especially applicable to patients who have chosen to continue with a cardiac rehab program beyond the typical recommended time with the help of online support group. It also gives them the impetus to continue with the rehabilitation as they get to learn from others and get encouragements from similar cases through online support groups.

Specialists and general practitioners must use the community-based approach to promote the ability of the outpatient cardiac rehab patients to re-adapt to their normal lifestyle. Considerations are also given to the needs and available resources as determinants of the services included in the program. Most cardiac rehab programs meant to be used by patients through online support groups are all self-sufficient in the sense that they present a broad variety of options for patients with diverse cardiac problems (Lavie & Milani, 2011). Essentially, patients who chose to continue with an online support group for education and guidance must have appropriate medical clearance to allow them to participate in the structured physical activity. The program coordinator, however, must have the discretion to allow for participation of any of the patient having reviewed their risk levels. The condition of the patient and the needs at hand are also factors that can influence how efficient the program is going to be implemented. Generally, the level of physical activity should not exceed the already maximum recommended for the patient (Biing-Jiun, Eisenberg & Maeda, 2011). Some patients are having conditions that may require further assessment such as unstable angina, severe aortic stenosis, uncontrolled hypertension, or uncontrolled diabetes, complicated myocardial infarction, among other conditions. This group of patients may require the approval of a physician to participate in the program.

In summary, cardiac rehabilitation program for outpatient have evolved to encompass home and community-based approaches that are helping many patients (Dietrick et al., 2012). The proliferation of technology tools aided with the internet is also allowing for linking of online support groups to educate the patient about self-management and the principles of outpatient cardiac rehab. The ease in access to information and opening of numerous opportunities for discussion and interaction has allowed many patients to embrace cardiac rehab activities outside the normal recommended time. Despite of the numerous studies indicating the benefits of cardiac rehab for outpatient users and the ongoing strategies to reduce risks, online support groups are under-utilized in many parts of the world. Part of the reason is a lack of initial referral or the failure to emphasize the importance of the program by medical practitioners. It is essential that referrals for outpatient cardiac rehab should be done in line with the needs of the patient and the community and family support must be considered as well. Patients should also have varied program models and methods which they can use to improve the quality of their life.

Empirical Literature

Sagar et al (2015) performed a meta-analysis study to determine how telephone support interventions were comparing to the standard post-discharge practice for CAD patient outcomes. The authors used a one-group pre- and post-test experimentation of 60 patients who had been discharged recently from hospital following a cardiac event. The study was carried out over a period of 9 weeks primarily focused on the activities and support to the patient during the whole of this period. The findings in the study suggest medium term positive health outcomes.

Oldridge, N. (2014) explored the role of additional training on the psychosocial, educational ability, and the risk factor management of the cardiac patient. Using observational study (Grade C), researcher used randomized clinical trials of 13, 824 patients to demonstrate clinical outcomes after enlisting on an online support group. Among the elements that the researcher focused on included non-fatal reinfarction, reduced hospitalization rates, and cardiac mortality. The researcher observed that low socioeconomic status and co-morbidities were not uniformly represented in the randomized clinical trials. The author concluded that prolonged cardiac rehab should be promoted by medical specialists before patients are allowed to get information from nonprofessional places.

Lie et al. (2012) investigated the need of coronary artery bypass graft (CABG) patients to determine their needs during the early stages of rehabilitation and examine future CR requirements. The researchers used a Grade B randomized controlled study with 93 CABG patients. Home interviews were done after 2 and 4 weeks and sought information in the areas psychological experience, anxiety, sexuality, patient defined experiences, and contact persons. The results indicate that patient experience was improved with the extended CR activities which improved the physical experience reduced irritability and post-operative pain. When patients were exposed to situations that assured them of future CR, their experience improved significantly to reflect their willingness to participate in CR activities.

The meta-analysis randomized controlled trials (RCTs) study by Lawler, Filion & Eisenberg (2011) sought to estimate the effect of CR on the cardiovascular outcomes and also examine the effect that this had on the magnitude of CR benefits. The researchers had used 34 RCTs with patients randomized to lower risks of re-infarction, low cardiac mortality, and all cause mortality. The authors used MEDLINE to identify the effects of exercise-based CR for post-MI patient. Aggregation of data was done using the random effect models and later stratified analysis done to examine the impact. Lawler, Filion & Eisenberg (2011) concluded that even shorter CR programs done in a home-based environment presented the potential for improved long-term outcomes even though such results must be confirmed in RCTs.

Blair (2010) conducted a study to help understand the differences between home-based and community based cardiac rehabilitation. The study was conducted in a case study design where data from PubMed, EMBASE, CINAHL and the Cochrane Controlled Trials Register (CCTR) were used. The objective of the study was to systematically review the current evidence that relate to community and home-based cardiac rehabilitation with a focus on issues for rural populations. In the study, an electronic search was conducted and articles between the dates of January 1970 and March 2010 were included in the study. The articles involved human subjects, they were published in English and they had only adult subjects above 19 years included. A total of 35 full-text articles were retrieved and five relevant articles were finally used in the review.

From the study, Blair (2010) ascertained that home-based and hospital-based cardiac rehabilitation are both effective in helping patients. They have proved helpful in increasing quality of life through improved patients’ quality of life, morbidity and mortality. However, the study revealed that the level of compliance to home-based cardiac rehabilitation is higher than that of hospital-based rehabilitation. It was realized that the level of compliance to hospital-based cardiac rehabilitation is lowered by transport or accessibility constraints. Residents of rural areas find difficulties accessing hospitals for rehabilitation services hence they record a low percentage of compliance. The findings confirm the hypothesis of the study that home-based cardiac rehabilitation is more effective than hospital based cardiac rehabilitation based on the understanding that the level of compliance to the former is high. There are several positive implications that a comprehensive cardiac rehabilitation has on cardiac risk factors like physical activity, cholesterol, anxiety, smoking status and depression. It is believed that a comprehensive cardiac rehabilitation can help improve patients’ quality of life, morbidity and mortality. In the UK, a majority of cardiac rehabilitation are offered in the hospital setting.

In some cases, the provision of rehabilitation services in hospital and center settings is not convenient to many patients. Most patients are unable to benefit from the rehabilitation services since they are offered in hospital settings that are not easily accessible to those in remote areas (Blair, 2011). According to Blair (2011), home-based cardiac rehabilitation appears to be more cost-effective to patients who are unable to access their local centers or hospitals. For a very long time, cardiac rehabilitation is viewed as hospital-based intervention. Home-based cardiac rehabilitation programs are not routinely offered to patients who are less likely to visit traditional hospital-based cardiac rehabilitation programs. It is believed that the interventions can be tailored to each patients needs by increasing the provision of home-based cardiac rehabilitation. More so, home-based cardiac rehabilitation programs should be increased for rural populations so that patients are in a better position to benefit from the services. Limiting the services to out-patient programs makes it difficult for patients in rural areas to benefit from the interventions that can help improve patients’ health condition.

In a study to determine the impact of vicarious experience of former cardiac patients on anxiety and self, efficacy, Blair et al., (2011) used a randomized trial for male first time cardiac surgery patients. The study was designed to evaluate the impact of intervention program on cardiac surgery recovery and the dyadic support given to patients. The authors established the relationship from hospital visits and recovery period for cardiac surgery patients. The study used 56 first-time male patients with a mean age of 56.6 years randomly assigned to experimental group of 27 people and control group of 29 people. The study measured anxiety at 48 hours before the surgery, 5 days after the surgery, and 4 weeks after the surgery. The result indicated that the investigational group experienced reduction in anxiety during hospitalization with lower levels of anxiety compared to the control group. The investigational group reported high self-efficacy and self-reported activities after walking or climbing stairs after having undergone a surgery. Following the observations from the study, Blair et al. (2011) concluded that dyadic support after cardiac surgery effectively helped the patients to cope during the post-surgery period. The surgical anxiety, for example, could inhibit self-efficacy and self-reported activities such as physical exercises which are a crucial part of the cardiac rehabilitation program.

In a study to investigate the effectiveness of electronic health to support cardiac recovery efforts, Nguyen et al. (2004) sought how recently discharged cardiac patients sought to use their mobile devices to find information about their health while at home. The authors provides an explorative study of published articles that address how different patients use peer support communities automated information support through patient education, and professionally facilitated program to support the cardiac rehabilitation activities in the homes. Following the scrutiny, the authors established that more than 55% of the patients who were discharged after a cardiac surgery were conscious of the cardiac rehab activities that might be done from their homes. Even though these patients are able to get the information from online sources using their devices, they still require support from their family members and medical professionals to make use of the information they have. Those who are not aware of the information also try to inquire from their physicians on ways to improve their activity while at home rather than spend all the time in bed. Nguyen et al. (2004) concluded that online support groups were particularly critical to the implementation of cardiac rehab activities for long term achievement especially for patients who have completed the typical timeline.

In a study to explore the risks of future cardiovascular disease, Rahman et al. (2013) sought to determine the impact of cardiac rehab on the possibility of developing cardiovascular diseases in the future. The researchers used a group of randomly selected participants who have undergone cardiac surgery and being rehabilitated either in their homes or in a hospital setting. The authors also explored the morbidity and mortality of the population who were selected based on their health condition and the year of birth. All participants were born after 1911 and before 1958. The study also sought to establish the link between coronary heart disease occurrence and ischemic stroke as a measure of how effective the cardiac rehab activities are in terms of reducing future risks for cardiovascular disease development. The findings of the study indicate that continued use of antidepressant did not reduce future risks to develop cardiovascular diseases. However, the study found that cardiac surgery patients who participated regularly in cardiac rehab activities by collaborating with others, through online support group and seeking instruction from a professional medical officer, had low risk of future cardiovascular disease recurring again. Rahman et al (2013) concluded, in their study that cardiac rehab activities carried out for an extended period of time could help to improve the quality of life of a patient by lowering the risk of the cardiac event recurring again.

Delal et al. (2011) conducted a study using a systematic review of randomized controlled trials. The objective of the study was to compare the effectiveness of home-based and supervised center based cardiac rehabilitation on the rate of morbidity and mortality, quality of life and the modifiable cardiac risk factors. It was based on the hypothesis that home-based cardiac rehabilitation is more effective in comparison to supervised centre based cardiac rehabilitation with respect to morbidity, mortality and quality of life. The population used in the study was made up of adults with myocardial infarction, angina, or heart failure. It included patients who had gone through revascularization and the entire study population had been invited to or taken part in cardiac rehabilitation. Validity was ensured in the study through identification of randomized controlled trials of systematic review that had been published. 21 articles that met the selection criteria were included in the review. The reviews that were used are those that were published between 2001 and January 2008.

Delal et al (2011) found out that home and center based cardiac rehabilitation are almost equally effective in facilitating improvement of clinical and health related quality of life outcomes in patients whose risk of further events are low. The findings dispute the hypothesis that home-based cardiac rehabilitation is superior to center based cardiac rehabilitation. As such, the study suggests that individual patients should be given time to select their program of choice among the two options. However, Dalal et al (2011) argue that home-based cardiac rehabilitation gives long lasting results to effective maintenance of patient’s physical activity levels in comparison to outpatient supportive cardiac rehabilitation programs. The study shows that the increased accessibility of home-base cardiac rehabilitation programs makes it more effective in improving cardiac risk factors. Delal et al (2010) stated that several barriers exist to hinder the uptake of hospital-based cardiac rehabilitation. The authors argue that the physical distance patients have to cover to reach hospitals for cardiac rehabilitation poses a challenge to effective implementation of the programs. They also suggest that ease of access to the services increases chances of benefiting from the services. Although several challenges like poor public transport and difficulty in parking are mainly witnessed in urban areas, there are other difficulties that are experienced by residents of rural and remote locations. For example, patients who live in rural and remote environments can hardly access the rehabilitation services due to transport hardships. Application of telephone follow-up and home-based cardiac rehabilitation can lead to a high reduction in serum cholesterol in comparison to usual care as the patients are closely monitored and encouraged to comply with the doctor’s prescriptions.

Heran et al. (2011) also conducted a study in form of a systematic review of randomized controlled trials. Past studies were selected for inclusion and data was independently extracted from the studies. The study was based on the hypothesis that exercise-based cardiac rehabilitation is more effective in restoring patients with heart disease back to health. The objective of the study was to determine the level of effectiveness of exercise-based cardiac rehabilitation or its combination with educational or psychosocial interventions on morbidity, mortality and quality of life of patients with CHD. Heran et al. (2011) analyzed 47 studies that were randomly selected amounting to 10,794 patients to exercise-based cardiac rehabilitation or usual care. The population used in the study was made up of adults with myocardial infarction, angina, or heart failure. It included patients who had gone through revascularization. The entire population had been invited to or taken part in cardiac rehabilitation.

The authors found out that total and cardiovascular mortality can be effectively reduced by participating in exercise-based cardiac rehabilitation. Hospital stay can be reduced by participation in exercise-based cardiac rehabilitation. The findings also confirm the hypothesis that exercise-based cardiac rehabilitation is more effective in restoring patients with heart disease back to health. It is almost impossible to avoid all hospital re-admissions by use of cardiac rehabilitation programs; however, there is sufficient evidence to confirm that home-based or community-base programs that are given in different forms are very effective in reducing the number of patients’ re-admissions to hospital with the few patients who are re-admitted having a shorter hospital stay. This explains the reason why there is a lot of emphasis on the need to provide home-based cardiac rehabilitation to patients as it helps to limit chances that they will be re-admitted or shortens the duration that they can take in hospitals in case they are re-admitted (Heran et al, 2011).

The typical cardiac rehabilitation exercises involve psychological, physical, and vocational activities that seek to restore and sustain maximum health experience for a cardiac patient. Short et al. (2013) in their study, sought to use music therapy to determine how cardiac patients experience quality of life during cardiac rehabilitation. The authors of the study used 6 participants who were arbitrarily recruited for a 6 week time to undertake a music therapy. The participants were beginning their 6 to 15 weeks cardiac rehab exercise after undergoing cardiac operation. The authors used a semiotic structure to carry out qualitative analysis of the life enhancement in quality and the effect of music therapy on the recovery process. During the study, five main themes were identified as looking through the frame, inspiring plateau, experiencing the impact, rehearsing, and escalating into the unknown. The themes were used to record the substantial changes and the change in the lifestyle of the patient. From this study, Short et al. (2013) concluded that music therapy could be used as a means to understand the internal recovery process for cardiac rehab patients. The music therapy provided an additional clinical tool that improved the external environment in which the process of rehabilitation was taking place.

The impact of cardiac rehab on the mortality of cardiac patients is investigated by Goel et al (2011) in a study to establish the association of percutaneous coronary intervention and cardiac rehab. The objective is to determine how cardiovascular events and cardiac rehab are interlinked. The authors performed a retrospective analysis of data from 2395 patients who have had percutaneous coronary intervention within a period of 14 years in Olmsted County in Minnesota. The study was based on the opinion that all grounds of mortality and cardiac mortality can be assessed using tendency score stratification and propensity score-matched analysis. At the time for follow-up, the authors reported death in all cause mortality factors. There was an examination of a trend whereby the cardiac mortality was apparent in the cardiac rehab participants. Nonetheless, the authors reported no observation in the myocardial and revascularization following intensive but controlled participation in cardiac rehab activities. Ultimately, Goel et al (2011) noted in their analysis that reduced mortality rates and cardiac rehab participation was highly observed in patients who had participated actively in the physical activities and followed through with the recommended practices. The authors made a conclusion that engaging in cardiac rehab could reduce the mortality rates for cardiac operation patients. The findings were supported by previous clinical findings where patients had improved performance measures after undergoing through prolonged cardiac rehab.

Summary

The implementation of a long-term cardiac rehab program should consider the needs of the patient and the available resources. Following the analysis of several empirical studies, it follows that cardiac rehab activities can enhance the experience of cardiac patients during post-recovery process. Long-term exposure to physical and mental activities has proved to improve the quality of life for cardiovascular patients and also reduces the mortality rates among the patients. The exercise provided an opportunity for cardiac patients to engage among themselves through e-health and also access the information crucial to their activities in their homes. Furthermore, the review of empirical studies show that most patients living in remote areas with inadequate provision and accessibility of cardiac rehabilitation. As such, there is a need for an increased provision of home-based rehabilitation to increase the ease of accessibility of the services to patients. In such areas, home-based programs are viewed as safe, viable and effective. It also provides convenient way of passing across information that would not be communicated to patients who are unable to attend hospital-based programs. From the literature reviewed, it is evident that although out-patient rehabilitation can also help patients improve their health, home-based cardiac rehabilitation has proved to be more accessible to patients in urban and in remote geographic locations. The programs help solve transport difficulties that can at times be used as an excuse for not attending out-patient cardiac rehabilitation programs. All eligible cardiac patients can be advised to take advantage of home-based cardiac rehabilitation to help them maintain their physical activity.

Chapter 3: Conceptual Framework

Introduction

Prolonged cardiac rehab for cardiac patients with the assistance of online support group is going to be used as the model of implementing the current program. In this approach, there is a need to focus on the prevailing conditions that could affect the level of success of any prolonged cardiac rehab activities. The use of this approach will require the patients to be informed about a number of concepts before they are allowed to carry on with the rehab activities in collaboration with an online support group. The patient education will include the understanding of what a cardiac event are, the expected cardiovascular outcomes, and the available eHealth technology such as use of online conferencing tools to communicate with members of the support group while at home. They must also be taught about the exercise adherence strategies because majority of patients who have had home based cardiac rehab program have had challenges with exercise adherence. This is a critical component of cardiac rehab which should not be ignored if the cardiac outcomes are going to be positive. Other areas of focus should be measuring the quality of life because some of the patients might not understand whether the activities they have been having are having an impact on their health and subsequently whether the quality of their life has improved since they began with the program.

The patient led initiative for cardiac rehab will incorporate most of the concepts identified in the literature review and as shown in the previous studies on implementation of prolonged cardiac rehab activities in the home. The concept framework as presented in Appendix A is a diagrammatic representation of the essential areas that must be taken into account to get a positive outcome. From the conceptual framework, home-based factors work together to deliver the long-term cardiac rehab benefits. Through the interrelationship, the patient is able to experience anticipated outcomes depending on their exercise adherence, family and patient characteristics and health care professional. eHealth technology facilitate the interaction with online support members through sharing of information, information access, and getting encouragement from members. The concept is divided into five major segments depended on each other which will lead to the anticipated long term benefits to the patient. The first is the online support group and in this segment, the patient will be exposed to eHealth and information sharing. The second is the individual characteristics including the knowledge, attitude and belief. The third area is the role of health care professionals. It covers on-site visits, patient education, prescriptions, and professional advice. The fourth segment consists of home-based factors such as resources, self-efficacy, and self-specific needs. The anticipated outcomes segment which will form the measure of the improved quality of life is the last one.

Research Question

In patients following cardiac surgery, is there a difference in quality of life at 12 weeks post-event between those who receive usual activity instructions at the end of the typical six week outpatient cardiac rehabilitation program and those who take part in home-based online support group rehabilitation?

Conceptual Definitions of Main Study Concepts

For the present study, the independent variables are cardiac event and the duration of cardiac rehab. Other independent variables are the professional advice and patient and family characteristics. The dependent variables are improved quality of life, reduced mortality rates, and mental and physical stability. Outpatient cardiac rehabilitation programs encompass a comprehensive list of services including medical evaluation, prescribed exercises, risk factor modification activities and behavioral interventions for cardiovascular patients. Online support groups denote a collection of people with similar interests who come together to share information and find solutions to their problems. Quality of life implies the experiences that a cardiac patient has after undergoing the surgery. It is the ability to lead a normal life free from pain or inhibitors caused by their illness.

Cardiac event is an all encompassing term that covers all illnesses related to cardiovascular area including coronary heart disease, ischemic stroke, myocardial infarction, heart attack and angioplasty among other events. Self-efficacy expectation denotes the activities that a patient is expected to perform by themselves without the influence of external forces. Self-efficacy is important in achieving improved quality of life since it demarcates the boundary on what the patient can and cannot do without being pushed by someone. E-health technology is used to transfer health resources through electronic means. E-health covers three major areas of health information delivery through telecommunications and the internet, using e-commerce and IT services to educate and train, and use of e-business and e-commerce practices in the management of health systems.

Exercise Adherence is the level of continued existence and the capacity of the patient to act in relation to the instructions as given by the medical specialist. It is also the ability to maintain an exercise regimen for an extended period of time following the initial adoption phase

Study Hypothesis

In this study, the null hypothesis is that there is no connection between that morbidity and mortality rates the duration of cardiac rehab for patients undergoing this program. The research hypothesis is that patients who undergo an extended period of cardiac rehab beyond the typical six week period normally record an improved quality of life especially when there is an involvement of an online support group to aid in performing cardiac rehab activities. Online support group can ideally be depended on to provide all the necessary information that a patient requires to carry on with cardiac rehab in the long term. The improved quality of life for cardiac patient is entirely depended on how much they engage in cardiac rehab activities especially those that involve physical exercises

Assumptions

It is assumed that home-related factors will promote the individual involvement in the long-term cardiac rehab. It is also assumed that the participants have the adequate resources to allow them enlist the eHealth technologies which they require to access information and participate in online discussions. The other assumption is that the patients have been exposed to patient education on how to performance cardiac rehab related activities in their homes without the supervision of a medical specialist. The patients are also capable of sharing this information with their peer through online support group where they engage in regular discussions.

Conclusion

Medical professionals play a crucial role in providing guidance to cardiac surgery patients during cardiac rehab. These medical specialists are the custodians of behavior change for such patients and are important to the improved quality of life for most of the patients who undertake the typical six week period for rehabilitation. Generally changing the health outcomes of a population requires that the entire group is involved in educational activities. This will require these people working closely with the medical specialists for advice and prescription on how to benefit from the cardiac rehab activities maximum and improve the quality of life of the people.

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