Effectiveness of eHealth cardiac rehabilitation for health outcomes of patients with coronary heart disease

Ph.D.Background: The rapid global aging population and modern lifestyles imply an increment in incidence, prevalence, and mortality of coronary heart disease (CHD). Patients with CHD experience a high level of debilitation, fear of reoccurrence, clinical anxiety, and compromised quality of life, which would increase their morbidity and mortality risk. Cardiac rehabilitation (CR) is a standard treatment, including exercise training, education, and psychosocial support, which is advocated by international guidelines as an effective strategy to optimize health outcomes for CHD patients. Despite the apparent benefits of CR, its uptake and adherence rate remain suboptimal due to competing health priorities, limited health resources, lack of referral by health professionals, traffic and cost, and lack of motivation of patients. eHealth refers to the use of information and communication technology (ICT) for health, which has been proposed as an innovative strategy to improve CR accessibility and uptake. eHealth behavioral interventions and disease management enable instant contact, hypermedia information delivery, technology monitored functionality, and individualized progress page to enhance CR accessibility.Aims: This study aimed to develop an eHealth CR and investigate its effects of eHealth CR on health behaviors, self-efficacy, health-related quality of life, anxiety and depression, cardiovascular risk parameters, and unplanned health services use of CHD patients.Methods: A systematic review and meta-analysis was conducted to examine the effects of eHealth CR on health outcomes of patients with CHD and identify the critical program design that may lead to more effective health benefits. Based on the findings of the review, a nurse-led eHealth CR (NeCR) program was designed. The main study is a sequential mixed-method study with a randomized controlled trial to investigate the effects of the NeCR on lifestyle changes and health outcomes of CHD patients and qualitative descriptive phase to explore the experiences of participating in the NeCR.Results: The systematic review included 14 RCTs of eHealth CR. eHealth CR has significantly promoted physical activity (standardized mean difference (SMD)=0.24; 95% confidence interval (CI) 0.04-0.44, p=0.02), daily steps (SMD= 0.40; 95% CI 0.21-0.59, p<0.001), quality of life (SMD 0.95; 95% CI 0.12-1.79, p=0.02), and rehospitalization (risk ratio=0.49; 95% CI 0.27-0.89, p=0.02) among CHD patients. Comparative analysis of program design, between the eHealth CR intervention with effective and ineffective impact on behavior change, has indicated that comprehensive empowerment strategies and tele-monitoring may be the critical characteristics leading to significant treatment effects.The study randomized 146 patients from the inpatient cardiovascular units of Tongji hospital in Wuhan, China, to receive either the NeCR or the usual care. The intervention was provided in a hybrid approach, consisting of a brief face-to-face preparatory phase and a long-term empowerment phase delivered by ICT. The preparatory phase aims at identifying self-care needs and action plans, the orientation of the e-platform, and incorporating a peer support network. The ICT-based empowerment phase consists of the use of the interactive NeCR for monitoring lifestyle changes, promoting disease management, and offering psychological support. Health behaviors, risk parameters, and clinical outcomes were collected at baseline, 6-week, and 12-week post-intervention.By using the Generalized Estimation Equation models, the intervention group showed significant improvement in daily steps (p=.006), weekly overall physical activity metabolic equivalent (MET) (p=.015), walking MET (p<.001), sitting time (p=.004), health-promoting lifestyle habits (p<.001), self-efficacy (p=0.005) compared with the control group. The intervention group also demonstrated a significant improvement in the physical domain and social domain health-related quality of life (p=.048). The fisher’s exact test has indicated a significant improvement in the smoking cessation of the intervention group compared with the control group (p=0.04). There was no significant improvement in psychological status, blood pressure, and the bodyweight of the intervention group compared with the control group.Qualitative findings have shown that the NeCR has promoted participants’ health behavior and improved emotional management through strengthening the cognitive and social interactional determinants. Participants identified that acquiring knowledge and skills from the website, conducting self-monitoring of behavior changes, improving self-evaluation and resolution findings, and obtaining professional and peer support is critical. The NeCR is perceived as accessible, affordable, and reliable for facilitating positive behavior change and disease management.Conclusion: The findings demonstrated the effectiveness of NeCR intervention in engaging patients with CHD in an active lifestyle, modifying behavioral risk factors, and improving health-related quality of life. The qualitative findings also indicated the favorable role of NeCR in CHD management, as described by participants of the intervention group. The results are supportive in view of future implementation in providing cardiac care to the early convalescence stage of patients with CHD.研究背景：全球人口的迅速老齡化和現代生活方式意味著冠心病的發病率，患病率和死亡率都有所上升。患有冠心病的患者常會經歷身體機能下降、害怕再次發作、臨床焦慮、以及生活品質下降，這些都會增加他們的發病率和死亡率。心臟康復是一種標準治療方法，包括運動訓練，教育和社會心理支援，國際指南認為這是優化冠心病患者健康結果的有效策略。儘管心臟康復有明顯的健康益處，但是由於健康競爭優先，有限的醫療衛生資源，缺乏醫護專業人員的轉診，交通和成本以及患者缺乏動力，心臟康復的參與和堅持率仍然欠佳。基於網路平臺的心臟康復是使用資訊和通信技術提供心臟康復支援。基於網路資訊技術的心臟康復逐步發展成為一個提高可及性和堅持率的創新戰略。 網路資訊心臟康復提供的生活方式干預和疾病管理可實現即時聯繫，多媒體資訊傳遞，技術監控功能以及個性化的網頁，以此增強心臟康復的可及性。研究目的：這項研究的目的設計一個基於網路資訊技術的心臟康復，並探討該項目對冠心病患者的生活方式，自我效能，與健康相關的生活品質，焦慮和抑鬱，心血管風險參數以及計畫外的衛生服務使用的影響。系統評價和薈萃分析綜合了關於網路平臺心臟康復對冠心病患者健康結局的影響的隨機對照試驗。該系統評價和薈萃分析研究了網路平臺心臟康復對冠心病患者健康的效果，重要的有效干預設計和內容。該系統評價對本研究的干預內容和方法提供了重要的指導，在此基礎上，本研究設計了由‘護士主導的基於網路資訊技術的心臟康復’。該研究是一項順序混合方法研究，包括隨機對照試驗，以調查該項目對冠心病患者生活方式改變和健康結局的影響，以及質性描述性研究，以探討參與該專案的經驗。結果：系統評價包括了14 項基於網路資訊技術的心臟康復。 系統評價表明基於網路資訊技術的心臟康復顯著促進了日常鍛煉（標準差（SMD）= 0.24; 95％置信區間（CI）0.04-0.44，p = 0.02），每日步數（SMD = 0.40; 95% CI:0.21-0.59，p <0.001），生活品質（SMD 0.95; 95％CI 0.12-1.79，p = 0.02）和重新住院（風險比= 0.49; 95%CI: 0.27-0.89，p = 0.02）。通過對有效和無效的基於網路資訊技術的心臟康復的研究設計進行比較分析，包括網路資訊平臺，行為改變策略，康復內容和社會支援，結果發現綜合的健康行為改變策略和遠端監控可能是導致有效研究的關鍵特徵。該研究從中國武漢同濟醫院內科心血管病房中招募了146 名患者，並隨機接受‘護士主導的基於網路資訊技術的心臟康復’或常規治療。干預措施採用面對面和網路兩種途徑，該研究包括進行簡短的面對面個體化評估和諮詢，以及小組專案使用培訓。面對面干預是一個準備階段旨在制定個性化的行為改變目標以上傳對個人網站，納入同伴支援，並提供網路和電子資訊心臟康復的使用指導。網路資訊平臺使用包括使用多媒體互動式‘護士主導的基於網路資訊技術的心臟康復’來幫助病人監測生活方式的變化，促進症狀管理和獲取心理支持。健康行為，風險參數和臨床結果在基線，干預後的6 周和12 周收集。通過使用廣義估計方程模型，干預組每日步數（p = .006），每週體育活動（代謝當量）（p = .015），走步（代謝當量）（p <.001），靜坐時間（p= .004），健康生活方式（p <.001），自我效能感（p = 0.005）呈現顯著改善。干預組還顯示出身體（p = .049）和社交（p=.025）兩個亞維度健康相關生活品質有顯著改善。Fisher’s exact test 表明，干預組的戒煙情況與對照組相比有顯著提高（p = 0.04）。與對照組相比，干預組的心理狀態，血壓和體重均無明顯改善。定性研究表明，‘護士主導的基於網路資訊技術的心臟康復’通過增強認知和社交互動因素，促進了參與者的健康行為並改善了情緒管理。參與者認為，從網站獲取知識和技能，對行為變化進行自我監控，自我評估和發現解決方案，以及獲得專業人員和同伴的支持至關重要。 ‘護士主導的基於網路資訊技術的心臟康復’被認為實惠，易獲取，專業，有利於促進積極的行為改變和疾病管理。研究結論：研究結果表明，‘護士主導的基於網路資訊技術的心臟康復’干預可以有效地使冠心病患者融入積極的生活方式，改變行為風險因素並改善與健康相關的生活品質。定性研究結果還表明，干預組參與者描述了‘護士主導的基於網路資訊技術的心臟康復’在冠心病管理中的有利作用。本研究結果為將來對冠心病患者展開早期康復階段提供心臟護理方面的實施是有幫助的。Su, Jingjing.Thesis Ph.D. Chinese University of Hong Kong 2020.Includes bibliographical references (leaves 414-495).Abstracts and some appendixes also in Chinese.Title from PDF title page (viewed on 17, September 2021)