Cross-sectional cardiac rehabilitation with a Nurse Case Manager (GoHeart) improves risk factors, self-care and
psychosocial outcomes. A 1-year follow-up study.
Vibeke Brogaard Hansen1 and Helle Terkildsen Maindal2
Vejle Hospital
Department of Cardiology, Lillebaelt Hospital Vejle, Denmark1. Health Promotion and Health Services,
Department of Public Health2, Aarhus University, Denmark
- A part of Lillebaelt Hospital
PURPOSE
In Denmark the local and regional health authorities share responsibility for cardiac
rehabilitation (CR). The aim of this study was to assess effectiveness of CR across sectors
coordinated by a Nurse Case Manager.
Figure 1. Flow chart of the cardiac multidisciplinary rehabilitation program (GoHeart)
Table 1. Outcome after CR for cohort at admission compared to 3 months at discharge and at 1year follow-up. Continuous clinical variable, self-care management, Short-Form 12 version 2 (SF12v2) and Hospital Anxiety and Depression (HADS).
Admission to CR
At 3 months discharge 12 months follow-up
Study Variable
Nursing consultation and
blood tests
Intervention
Intervention
Combined treadmill exercise /Borg 15
talk test with a nurse and physiotherapist
*
1-2 weeks after visitation
Beforehand oral information and
provided written material about
cardiac rehabilitation
Nursing consultation
and blood tests
Doctor consultation
Exercise training for 6 weeks; 1.5 hours
2 times a week
Final Borg15 test with a physiotherapist
Exercise training for 6 weeks; 1 hour 3
times a week*
Smoking counselling
Smoking counselling
Lifestyle counselling
Educational course 1-4 *
Introduction to food shopping and
practised shopping
Diet counselling
Telephone contact to GP if
high-risk*
Psychotherapist consultation at need
Additional nurse/doctor consultation by
need
Stratification
Stratification
Stratification
Stratification
* Improving handoff across interdisciplinary and sectors (Shared Care);
1) Combined treadmill exercise test/Borg 15 talk test with a nurse and physiotherapist at the hospital
2) A dietitian present at the educational course 3
3) A physiotherapist from the Municipal health center present at the final exercise training hour at the hospital
4) Telephone contact to the General Practitioner (GP) by the Nurse Care Manager if a high risk individual (Chronic Care Model)
METHODS
The Danish single-centre rehabilitation programme (GoHeart) was evaluated in a cohort
study in consecutive patients admitted to CR at Lillebaelt Hospital Vejle, DK from 2010 to
2011. The criteria for CR were the events of acute myocardial infarction or stabile angina
leading to assessment of invasive revascularisation (LVEF ≥ 45%). The rehabilitation status
was assessed at admission (phase IIa), at 3 months at discharge from hospital (phase IIb)
and at 1-year follow-up (phase III). Outcomes were cardiac risk factors measured
objectively and by self-report, stratified self-care status and self-reported psychosocial
factors (SF-12 and HADS). Intention-to-treat and predefined subgroup analysis on sex were
performed.
Differences
0-3 mo
3-12 mo
P-value
P-value
N
Mean
SD
N
Mean
SD
N
Mean
SD
183
27.5
3.8
178
27.5
3.8
183
27.3
4.0
0.890
0.026
183
183
183
135.5
79.8
4.2
19.5
11.4
1.0
182
182
183
136.9
81.2
3.9
18.6
9.8
0.8
182
182
183
138.7
83.9
3.9
19.8
9.7
0.7
0.345
0.073
0.000
0.299
0.0005
0.316
LDL
181
2.4
0.8
183
2.1
0.6
183
2.1
0.6
0.000
0.459
HDL
181
1.3
0.5
183
1.3
0.4
183
1.4
0.4
0.130
0.027
181
1.5
0.9
183
1.5
0.9
182
1.5
1.0
0.110
0.735
176
7.5
1.9
100
8.3
1.3
172
8.3
2.6
0.007
0.788
183
139
76.0
183
161
88.0
183
168.0
91.8
0.0002
0.071
183
44
24.0
183
22
12.0
183
15.0
8.2
137
44
9.9
137
48.8
9.1
-
-
-
0.000
-
SF-12 (mcs)
137
50
10.8
137
52.3
8.9
-
-
-
0.005
-
SF-12 (pcs)
-
-
-
141
48.7
9.2
141
47
10.4
-
0.002
SF-12 (mcs)
Anxiety
HADS-A < 8
-
-
-
141
53.0
8.4
141
53
9.7
-
0.899
161
125
77.6
161
134
83.2
161
137
85.1
HADS-A ≥ 8
Depression
HADS-D < 8
161
36
22.4
161
27
16.8
161
24
14.9
0.083
0.564
161
138
85.7
161
148
91.9
161
149
92.5
HADS-D ≥ 8
161
23
14.3
161
13
8.1
161
12
7.4
0.0075
0.705
Cardiovascular risk factors
BMI (kg/m²)
Blood pressure (mmHg)
Systolic
Diastolic
Total cholesterol (mmol/l)
Triclycerider
Lifestyle behaviours
Combined treadmill exercise/Borg 15 talk
test
METS at Borg 15 (3.5 ml O²/kg/min)
Psychosocial, % SD
Self-care management
High
Low
Health status
SF-12 (pcs)
mo; months
No differences were found in (data not shown); HbA1c (only meaured for diabetic), medication intake, alcohol concumption (>7/14 untis per week), smoking status.
Self-care management was determined after stratification; According to the Chronic Care Model
SF-12 pcs, physical component score
SF-12 mcs, mental component score
RESULTS
CONCLUSION
183 of 241 (75.9%) patients were included (mean age 63.8 years). At discharge improvements
were found in total-cholesterol, LDL, functional capacities, self-care management, SF12 and in
depression symptoms (Table 1). At 1-year follow-up these outcomes were maintained; in addition
there was improvement in BMI and HDL (Table 1). Some variables deteriorated at 1 year; an
increase in diastolic blood pressure (p < 0.001) and a decrease in SF12, pcs (P < 0.01). There were
no sex differences.
CR shared between local and regional health authorities led by a NCM (GoHeart) improves risk factors,
self-care and psychosocial factors. Further improvements in most variables were at one-year follow-up.
No differences in sex were found suggesting that GoHeart may be the CR program to enhance women
compliance which otherwise can be a challenge in cardiac rehabilitation.
Correspondence: Vibeke Brogaard Hansen, md PhD. E-mail: vibeke.brogaard.hansen@rsyd.dk
Nothimg to declare
Table 1. Outcome after CR for cohort at admission compared to 3 months at discharge and at 1-year follow-up.
Continuous clinical variable, self-care management, Short-Form 12 version 2 (SF-12v2) and Hospital Anxiety
and Depression (HADS).
Mean
Phase IIb
SD
Mean
Phase III
SD
Median
Difference
P-value
Median
Patient activation
Delivery system design/decision support
Goal setting/tailoring
Problem solving/contextual
Follow-up/coordination
2.8
1.10
2.7
2.8
1.03
2.7
0.835
4.0
3.8
3.4
2.6
0.84
0.92
1.09
0.99
3.0
4.0
3.5
2.4
3.9
3.4
3.1
2.5
0.88
1.05
1.09
0.95
4.0
3.6
3.3
2.4
0.140
0.000
0.004
0.134
Overall PACIC score
3.3
3.3
3.2
0.76
0.73
0.89
3.3
3.4
3.2
3.1
3.1
2.9
0.82
0.81
0.85
3.1
3.2
3.0
0.001
0.004
0.166
PACIC subscales
Male
Female
n = 89
n = 22
Range 1 to 5 higher values indicating patient`s perception of a greater involvement in self-management and receipt of chronic care delivery