Medically-directed exercise is a recognized therapy for optimal heart failure (HF) management. This pilot study evaluated the process of delivering brief connected health (CH) exercise consultations to a group of HF patients who elected to participate in a cardiology-based telemanagement program. Thirty patients were enrolled to receive medically-directed CH consultations from an interdisciplinary healthcare team over a 4-month period. Portable Bluetooth technology with Wi-Fi connectivity was used to remotely monitor health parameters in the home (weight, blood pressure, oxygen saturation, heart rate, steps/day). Pre and post exercise participation was evaluated with the Physical Activity Vital Sign (PAVS) and a 7-day recall. An exercise physiologist (EP) provided telephone HF exercise therapy education plus guidance with exercise prescription and short-term progressive goal setting. Patients received the option to enroll in supervised cardiac rehabilitation (SCR) close to home when feasible. Twenty-five patients (mean age=64.2 years, SD=13.4; 76% male) completed pre and post testing and participated in the exercise intervention. The mean ejection fraction was 31% (SD=15.7), 64% (n=16) had an ICD/pacemaker and 36% (n=9) were classified with a NYHA Functional Class III-IV. The total telephone exercise consultation time/patient was 83.0 (SD=26.4) minutes with a mean of 5.8 (SD=1.3) calls/patient over the 4-month period. The mean telephone call time was 14.3 minutes. The PAVS current (past week) number of days/week with 30+ minutes of accumulated continuous exercise significantly changed from a mean score of 1.1 (SD=1.8) day/week to 3.4 (SD=2.5) days/week (p<0.005). The PAVS typical (past 3-months) number of days/week significantly changed from 1.1 (SD=1.7) day/week to 2.7 (SD=2.2) days/week (p<0.005). Exercise participation quantified with the 7-day recall changed from 4.3 (SD=5.1) to 9.0 (SD=12.1) MET-hours/week (p>0.005). The mean time invested to structured continuous exercise changed from 1.3 (SD=1.6) hours/week to 2.5 (SD=3.4) hours/week (p>0.005). Pre and post SCR enrollment changed from 8% (n=2) to 36% (n=9). In this self-selected population, it was feasible for an EP to conduct CH exercise consultations within a comprehensive HF telemanagement program. CH may provide a process to deliver cardiac rehabilitation support away from the clinic.
Motivational interviewing (MI) is a method of communication that can significantly improve the health behaviors of cardiac rehabilitation (CR) patients. However, healthcare provider (HCP) skill levels may vary, and MI proficiency is not typically measured in CR patient consultations. This study was designed to assess MI proficiency during health education consultations in an outpatient CR program. Patients were given the Consultation and Relational Empathy (CARE) Measure immediately following a 30-minute CR consultation with a health educator who was trained in MI. The CARE Measure is a 10-item questionnaire that asks patients to anonymously assess the level of empathy that is expressed by a HCP during a consultation, which is considered to be a defining characteristic of MI. 411 questionnaires were completed and each item was scored on a 1-5 Likert scale (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). In addition, five patient consultations were randomly selected and the patients gave permission for their consultations to be confidentially audiotaped and analyzed by a MI coding expert. The Motivational Interviewing Treatment Integrity 3.0 (MITI 3.0) Coding Instrument was used to score the consultations on global ratings that used a 1-5 scale, and an objective behavioral count that determines MI proficiency. The overall mean score for the CARE Measure was 47.6 (SD=4.4) out of a possible maximum of 50. The overall mean global rating score for the MITI 3.0 was 4.2 (SD=0.5) out of a possible maximum of 5. The mean global rating score for MI spirit was 4.1 (SD=0.5) and the mean global rating score for empathy was 4, where all consultations were scored the same. On the behavioral count, reflections outweighed questions with a mean reflection-to question ratio of 1.4. The mean percentage for MI adherence was 100%. In this study, the health educator demonstrated MI consistent behavior. It appears that the CARE Measure and the MITI 3.0 are assessment tools that can be used in CR to provide feedback on MI proficiency. Further investigation is needed to determine the relationship between MI proficiency and patient outcomes in CR.
Healthcare providers are challenged to motivate patients to become physically active during brief clinical consultations. In a randomized-control trial, we previously demonstrated that Motivational Counseling (MC) added to traditional cardiac rehabilitation significantly enhances physical activity and exercise. This investigation was conducted to determine the feasibility of applying research to practice by adding MC to daily practice within an established clinical setting. Brief MC sessions (wks 1, 2 & 7) conducted by a health educator were added to a 12-wk early outpatient cardiac rehabilitation program of exercise, education and medical support. One hundred and one patients (71% males) were assessed at baseline and 12 wks. Physical activity was quantified with the Lo-PAR; an interview-administered recall of the previous week’s sleep and activity at work, in the home and during recreation. Patients ranged in age from 33-91 (Mean=63, SD=13) years and had experienced a recent cardiac event (angina, myocardial infarction, angioplasty or bypass surgery). A dependent sample t-test indicated a significant mean difference between baseline and 12-wk physical activity scores (p<0.05). The mean physical activity score changed from 228 (SD=21) to 267 (SD=37) METhrs/wk. The proportion of patients classified as very inactive (<225 MET-hrs/wk) changed from 43% at baseline to 11% at 12 wks. Inactive-somewhat active patients (225-250 MET-hrs/wk) changed from 44% to 27%. Active patients (251300 MET-hrs/wk) changed from 13% to 50%. None of the patients were very active (>300 MET-hrs/wk) at baseline compared to 12% at 12 wks. The mean difference between scores for exercise alone was also significant from baseline to 12-wks (p<0.05). The mean exercise scores changed from 3 (SD = 4) MET-hrs/wk to 18 (SD = 12) MET-hrs/wk. It was concluded that it is feasible for a non-mental health specialist to successfully integrate MC into a clinical setting and significantly improve physical activity in the early phase of recovery from heart disease.
Cardiac health may be compromised by non-adherence to prescribed medication. Therefore, the Medication Adherence Scale (MAS; Brooks et al., 1994) was used to assess adherence in patients with coronary artery disease. The study comprised 61 patients (71% males) who had experienced a cardiac event 40 days (SD=37) days earlier. The MAS consisted of 4 yes-no questions about adherence over the previous 3 months. Thirty-four percent self-reported full adherence to prescribed medication. The most common reasons for nonadherence included forgetfulness (57%) and carelessness (26%). In patients who were feeling better, 5% stopped taking medication and 7% took less than prescribed. It appears that the MAS may be a worthwhile method of identifying non-adherence to medication in patients with coronary artery disease.