Publications by authors named "Tracey Colella"

26 Publications

  • Page 1 of 1

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 3: Patient Perspectives.

CJC Open 2021 Mar 10;3(3):229-235. Epub 2021 Feb 10.

Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

In recent years, public awareness campaigns have targeted knowledge gaps and inequities in care while focusing on the unique female experience and heightened cardiovascular disease (CVD) risk profile. Recognizing and understanding the sex and gender constructs, barriers, facilitators, and factors that affect access, treatment, and recovery after an acute cardiac event from the unique patient perspective is a key step in transforming clinical practice and care patterns. The aim of this atlas chapter is to provide a knowledge review and to identify gaps regarding the experience of living with CVD from the perspective of the female survivor. The sections are as follows: (1) experiencing and living with CVD as a woman; (2) "stopped at the gate": barriers to accessing acute cardiovascular care; and (3) action items to "open the gate" to women: what our patients want and need. The final section culminates with targeted recommendations stemming from recent literature and most importantly, from women with the lived experience of CVD.
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http://dx.doi.org/10.1016/j.cjco.2020.11.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985007PMC
March 2021

Sex, Gender, and Equity in Cardiovascular Medicine, Surgery, and Science in Canada Challenges, Successes, and Opportunities for Change.

CJC Open 2020 Nov 2;2(6):522-529. Epub 2020 Jul 2.

Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.

Background: A previous review of sex, gender, and equity within cardiovascular (CV) medicine, surgery, and science in Canada has revealed parity during medical and graduate school training. The purpose of this study was to explore sex and gendered experiences within the Canadian CV landscape, and their impact on career training and progression.

Methods: An environmental scan was conducted of the Canadian CV landscape, which included an equity survey using Qualtrics software.

Results: The environmental scan revealed that women remain underrepresented within CV training programs as trainees (12%-30%), program directors (33%), in leadership roles at the divisional level (21%), and in other professional or career-related activities (< 30%). Our analysis also showed improvements of career engagement at these levels of women at over time. The thematic analysis of the equity survey responses (n = 71 respondents; 83% female; 9.7% response rate among female Canadian Cardiovascular Society members) identified the following themes reported within the socio-ecological framework: desire to report inequities vs staying the course (individual level); desire for social support and mentorship and challenges of dual responsibilities (interpersonal level); concerns over exclusionary cliques and desire for respect and opportunity (organizational level); and increasing awareness and actions to overcome institutional barriers and accountability (societal level).

Conclusions: Although women face challenges and remain underrepresented in CV medicine, surgery, and science, this study highlights potential opportunities for improving access of female medical, surgical, and research trainees and professionals to specialized cardiovascular training, career advancement, leadership, and research.
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http://dx.doi.org/10.1016/j.cjco.2020.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711008PMC
November 2020

Exploring the perspectives of outpatient rehabilitation clinicians on the challenges with monitoring patient health, function and activity in the community.

Disabil Rehabil 2020 Nov 30:1-10. Epub 2020 Nov 30.

KITE - Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.

Purpose: Rehabilitation clinicians need information about patient activities in the home/community to inform care. Despite active efforts to develop technologies that can meet this need, clinicians' perspectives regarding how information is collected and used in outpatient rehabilitation have not been comprehensively described. Therefore, we aimed to describe: (1) what data pertaining to a patient's health, function and activity in their home/community are currently collected in outpatient rehabilitation, (2) how these data can impact clinical decisions, and (3) what challenges clinicians encounter when they manage the care of outpatients based on this information.

Materials And Methods: Eight clinicians working in outpatient rehabilitation programs completed qualitative interviews that were analyzed using an inductive thematic analysis.

Results: Four themes were identified: "Nature of data about a patient's health, function and activity in the home/community and how it is collected by clinicians," "Value of data from the home/community," "Perceived drawbacks of current data collection methods," and "Improving data collection to understand patient trajectory."

Conclusions: Clinicians described the importance of understanding patient activities in the home/community, but perspectives varied regarding the suitability of current methods. These perceptions may inform the design of solutions to bridge the gap between the clinic and the community in outpatient rehabilitation. Implications for rehabilitation Clinical decision-making in outpatient rehabilitation is guided by verbal and written reports about a patient's health and function in the community and adherence to treatment plans. Differing perceptions on the suitability of current data collection methods indicate that the development of new solutions, such as rehabilitation technologies, needs to carefully consider clinician workflows and what data are perceived as meaningful. Potentially impactful directions for new solutions include providing well validated data on adherence, movement quality, or longitudinal progression, presented in formats that match clinical decision criteria.
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http://dx.doi.org/10.1080/09638288.2020.1849422DOI Listing
November 2020

Factors That Predispose Women to Greater Depressive Symptoms: A Sex-, Age-, and Diagnosis-Matched Cardiac Rehabilitation Cohort.

Can J Cardiol 2021 Mar 31;37(3):382-390. Epub 2020 Aug 31.

KITE Research Institute, Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

Background: Depressive symptoms (DS) disproportionately affect women with cardiac disease; however, no analyses have been conducted that would allow for focused sex-specific interventions.

Methods: Consecutively enrolled women (n = 663) were matched with men postcardiac revascularization at cardiac rehabilitation (CR) entry by primary diagnosis, age, and year of CR entry from database records (2006 to 2017). Multivariate analyses were conducted to determine predictors of DS (≥16 on the Center for Epidemiologic Studies Depression Scale) in all patients and men and women separately.

Results: In bivariate analysis, women were more likely than men to have DS (30.2% vs 19.3%; P < 0.001) in the matched cohort. A greater proportion of women than men had DS in all 10-year age categories (P < 0.05) except youngest (<50 years; 37% vs 30.4%; P = 0.7) and oldest (≥80; 12.3% vs 10.3%; P = 0.8). DS peaked in women aged 50 to 59 (42.5%) and men <50 years (30.4%). In all patients, independent predictors of DS were younger age, lower cardiorespiratory fitness (VO), being unemployed, greater comorbidities, smoking, anxiolytics, antidepressants, not being married, but not sex. Shared predictors in women-only and men-only analyses were younger age, lower VO, antidepressants, and being unemployed. Unique predictors for women were obesity, smoking, and delayed CR entry and, for men, hypertension, myocardial infarction, anxiolytics, and not being married.

Conclusions: Despite matching for age and diagnosis, women were more likely to have DS than men. However, sex was not a predictor of DS in multivariate analyses. This suggests that the profile of women predisposes them to greater DS. Obesity, smoking, and greater delayed CR entry were unique correlates for women and targets for intervention.
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http://dx.doi.org/10.1016/j.cjca.2020.08.019DOI Listing
March 2021

Effectiveness of an Education Intervention Among Cardiac Rehabilitation Patients in Canada: A Multi-Site Study.

CJC Open 2020 Jul 4;2(4):214-221. Epub 2020 Mar 4.

Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.

Background: Although patient education is considered a core component of cardiac rehabilitation (CR) programs, to our knowledge, no educational program designed for CR has been standardized in Canada. This absence of standardization may be due to a lack of reliable resources to educate these patients. The objective of this study was to assess the effectiveness of an education intervention in improving knowledge and health behaviours among CR patients in 3 sites in Canada.

Methods: CR patients were exposed to an evidence- and theoretically based comprehensive education intervention. Patients completed surveys assessing knowledge, physical activity, food intake, self-efficacy, and health literacy. All outcomes were assessed pre- and post-CR. Paired tests were used to investigate variable changes between pre- and post-CR, Pearson correlation coefficients were used to determine the association between knowledge and behaviours, and linear regression models were computed to investigate differences in overall post-CR knowledge based on participant characteristics.

Results: A total of 252 patients consented to participate, of whom 158 (63.0%) completed post-CR assessments. There was a significant improvement in patients' overall knowledge pre- to post-CR, as well as in exercise, food intake, and self-efficacy ( < 0.05). Results showed a significant positive correlation between post-CR knowledge and food intake (r = 0.203;  = 0.01), self-efficacy (r = 0.201; 0.01), and health literacy (r = 0.241; 0.002). Education level (unstandardized beta = -2.511;  = 0.04) and pre-CR knowledge (unstandardized beta = 0.433; < 0.001) were influential in changing post-CR knowledge.

Conclusion: In this first-ever multi-site study focusing on patient education for CR patients in Canada, the benefits of an education intervention have been supported.
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http://dx.doi.org/10.1016/j.cjco.2020.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365818PMC
July 2020

Capturing the perspectives of women with coronary artery disease regarding interval training or continuous exercise in cardiac rehabilitation.

Disabil Rehabil 2020 Apr 28:1-11. Epub 2020 Apr 28.

Cardiovascular Prevention and Rehabilitation Program, University Health Network/Toronto Rehabilitation Institute, Toronto, Canada.

Motivators and barriers to exercise participation in women with coronary artery disease remain poorly understood. With evidence suggesting that women with coronary artery disease are less likely to adhere to exercise during cardiac rehabilitation and are more likely to drop out, it is important to understand these factors in order to optimize cardiac rehabilitation programs for women. We contribute to the discussion by presenting findings from a qualitative study using two focus groups with nine women with coronary artery disease sharing their experiences with attending cardiac rehabilitation and exercising in this setting, in addition to their perceived motivators and barriers to performing aerobic interval training. Focus group transcripts were analysed using a deductive thematic approach with Bandura's Social Cognitive Theory as the guiding conceptual framework. Four themes were identified regarding the attitudes and experiences of attending and exercising at cardiac rehabilitation, while five themes capturing the motivators and barriers for these women to perform aerobic interval training were identified for the first time. These novel themes encompassed the daunting nature of it, the physical discomfort associated with it, and conversely, the potential sense of enjoyment and accomplishment that it could bring. This study demonstrates the complexity of implementation of aerobic interval training into clinical practice, and suggests that further research is warranted to explore this domain.IMPLICATIONS FOR REHABILITATIONDespite challenges in feasibility of conducting a randomised controlled trial in female patients with coronary artery disease examining the effects of aerobic interval training versus moderate-intensity continuous exercise on aerobic exercise capacity, there was a significant per protocol treatment effect of 0.95 ml·kg·min in favour of aerobic interval training.The cardiac rehabilitation environment provides key facilitators and perceived benefits for exercising and attending cardiac rehabilitation for women, and thus emphasises the need for improving referral and enrolment processes specifically for women into cardiac rehabilitation programs.Aerobic interval training may elicit feelings of fear and physical discomfort, or may be precluded by comorbid conditions, therefore, judicious consideration must be taken in examining the suitability of implementation into clinical practice for each female patient.
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http://dx.doi.org/10.1080/09638288.2020.1756469DOI Listing
April 2020

Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers?

Phys Ther 2020 01;100(1):44-56

Toronto Rehabilitation Institute, University Health Network; and University of Toronto.

Background: People after stroke benefit from comprehensive secondary prevention programs including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use.

Objective: The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use.

Design: This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada.

Methods: Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators.

Results: Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, have poorer attendance at OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] vs 87.1% [SD = 16.6%], respectively) and completion (66.7% vs 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%).

Limitations: Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes.

Conclusions: An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.
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http://dx.doi.org/10.1093/ptj/pzz149DOI Listing
January 2020

Assessing the Clinical Competence of Health Care Professionals Who Perform Airway Suctioning in Adults.

Respir Care 2019 Jul 28;64(7):844-854. Epub 2019 May 28.

Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; the School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.

Airway suctioning is an important health care intervention that can be associated with serious adverse effects. Given the risks involved with suctioning, it is important to ensure the clinical competence of health care professionals who perform it. A scoping review was conducted to identify the nature and extent of research related to the assessment of airway-suctioning competence for health care professionals working with adults. This included an examination of the assessment context, the type of suctioning and health care professionals being assessed, and the methods used to assess competence. Four scientific electronic databases (MEDLINE, EMBASE, CINAHL, and the Cochrane Library) were searched from inception to March 9, 2018. A gray literature search was also performed. Two reviewers independently screened articles and resources for inclusion, and data were extracted using a form created by the authors. Seventy full text articles and resources were screened for eligibility, with 36 included in the review. Endotracheal suctioning was the most common type, and intensive or critical care units were the primary setting of interest (28 of 36, 78%). Competence or a component of competence for nurses, nursing students, nursing assistants, or nurse technicians was specifically addressed in 97% (35 of 36) of the included articles and resources; 4 of 36 (11%) also included physical therapists, 1 of 36 (3%) included respiratory therapists, and 1 of 36 (3%) was aimed toward all clinicians who perform suctioning. Nine (25%) used questionnaire-based assessments, 11 (31%) used checklists, audit forms, or other observational tools, and 16 (44%) used both. Directed content analysis revealed 3 major themes: consistency across overarching evaluation frameworks, inconsistency across detailed components, and inconsistency in the evaluation or reporting of assessment tool measurement properties. Additional gaps in the literature included limited consideration of health care professionals beyond nursing, limited consideration of settings beyond intensive and critical care, a lack of tools to assess nasotracheal and orotracheal suctioning, and limited detail regarding assessment tool development.
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http://dx.doi.org/10.4187/respcare.06772DOI Listing
July 2019

Frailty in the context of rehabilitation interventions for adults: protocol for a scoping review.

BMJ Open 2019 02 15;9(2):e024838. Epub 2019 Feb 15.

Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada.

Introduction: Although a growing number of frail adults can benefit from rehabilitation services, few are included in rehabilitation services, and reasons for their exclusion are not well understood. To inform research directions in rehabilitation for all adults (aged 18 years and older), we will conduct a scoping review to describe (1) the characteristics of frail adult individuals included in rehabilitation interventions (eg, age range, inclusion and exclusion criteria that are applied), (2) the type of rehabilitation interventions that are used for individuals who are considered frail and (3) the commonly reported outcome measures used for these rehabilitation interventions.

Methods: This scoping review will be guided by Arksey and O'Malley's methodological framework. Ageline, Cochrane CINAHL, Embase, MEDLINE, Pubmed, OTSeeker, PeDRO, PsycINFO and Scopus databases will be systematically searched for articles relevant to rehabilitation interventions and health services. To be eligible for inclusion, studies must report on the outcomes from an intervention that involves all individuals (aged 18 and older) who are considered frail. Only English-language, peer-reviewed publications between 1990 and 2018 will be included. A two-step screening process will consist of (1) a title and abstract review and (2) full-text review. In both levels of screening, a minimum of two investigators will independently screen the title and abstract of all retrieved citations for inclusion against a set of minimum inclusion criteria.

Analysis: Results will be presented as a narrative synthesis to facilitate the integration of diverse evidence.

Ethics And Dissemination: This study does not require ethics approval. By examining the current state of rehabilitation interventions for frail adults, this scoping review can offer insight into rehabilitation needs and models of care. It can also guide future rehabilitation research for frail adults. We will share our results with frail adults during a consultation meeting and publish a manuscript in a peer-reviewed rehabilitation journal.
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http://dx.doi.org/10.1136/bmjopen-2018-024838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398710PMC
February 2019

Validation of the Fitbit Flex in an Acute Post-Cardiac Surgery Patient Population.

Physiother Can 2018 ;70(4):314-320

Rehabilitation Sciences Institute.

This study examined the validity of the Fitbit Flex activity monitor for step count and distance walked among post-cardiac surgery patients. Participants (=20) from a major urban cardiac surgery centre were recruited 1-2 days before hospital discharge. The Fitbit Flex step count and distance walked outputs and video recording of each participant performing the 6-minute walk test were collected. Fitbit Flex output was compared with criterion measures of manual step count obtained from the video recording and manual measurement of distance walked. Statistical analysis compared the output and criterion measures using paired sample -tests, Pearson correlation coefficients, Lin's concordance correlations, and Bland-Altman plots. Sub-analysis compared slower walking (<0.8 m/s; =11) and faster walking (≥0.8 m/s; =8) group speeds (1 participant was excluded from analysis). Steps counted and distance walked were significantly different between the Fitbit Flex outputs and criterion measures (<0.05). The Fitbit Flex steps counted and distance walked showed moderate association with manual measure steps counted (=0.67) and distance walked (=0.45). Lin's concordance coefficients revealed a lack of agreement between the Fitbit Flex and the criterion measurement of both steps counted (concordance correlation coefficient [CCC]=0.43) and distance walked (CCC=0.36). The percentage of relative error was -18.6 (SD 22.7) for steps counted and 25.4 (SD 45.8) for distance walked. The Fitbit Flex activity monitor was not a valid measure of step count and distance walked in this sample of post-cardiac surgery patients. The lack of agreement between outputs and criterion measures suggests the Fitbit Flex alone would not be an acceptable clinical outcome measure for monitoring walking progression in the early postoperative period.
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http://dx.doi.org/10.3138/ptc.2017-34DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6361401PMC
January 2018

Response to: Does AOBP require a 5-minute rest period to screen for hypertension?

J Clin Hypertens (Greenwich) 2019 01 5;21(1):137. Epub 2018 Dec 5.

Cardiovascular Prevention and Rehabilitation Program, University Health Network/Toronto Rehabilitation Institute, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1111/jch.13444DOI Listing
January 2019

Response to the Letter to the Editor on "Antecedent rest may not be necessary for automated office blood pressure at lower treatment targets".

J Clin Hypertens (Greenwich) 2018 12 7;20(12):1749. Epub 2018 Nov 7.

Cardiovascular Prevention and Rehabilitation Program, University Health Network/Toronto Rehabilitation Institute, Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1111/jch.13421DOI Listing
December 2018

Validation of a self-administered version of the Mediterranean diet scale (MDS) for cardiac rehabilitation patients in Canada.

Int J Food Sci Nutr 2019 Mar 2;70(2):202-211. Epub 2018 Jul 2.

a Cardiovascular Prevention and Rehabilitation Program University Health Network Toronto Rehabilitation Institute , Toronto , ON , Canada.

The Mediterranean dietary pattern has been linked with lower incidence of cardiovascular disease and the Mediterranean diet scale (MDS) has been created to incorporate and test the inherent characteristics of this dietary pattern. This study aimed to psychometrically validate a self-administered version of the MDS in cardiac rehabilitation (CR) patients in Canada. To establish content validity, the scale was reviewed by an expert interdisciplinary panel. A final version of the tool was tested in 150 CR patients. Cronbach's alpha was 0.69. All ICC coefficients met the minimum recommended standard. Factor analysis revealed four factors, all internally consistent. Criterion validity was supported by significant differences in total scores by duration in CR. Construct validity was supported by agreements between the self-administered MDS and original MDS in all items and with the 3-day food record in 8 of 13 items. In conclusion, the self-administered version of the MDS demonstrated good reliability and validity.
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http://dx.doi.org/10.1080/09637486.2018.1486392DOI Listing
March 2019

Antecedent rest may not be necessary for automated office blood pressure at lower treatment targets.

J Clin Hypertens (Greenwich) 2018 Jun 14. Epub 2018 Jun 14.

Department of Medicine, University of Toronto, Toronto, ON, Canada.

In SPRINT (Systolic Blood Pressure Intervention Trial), use of the Omron 907XL blood pressure (BP) monitor set at 5 minutes of antecedent rest to record BP produced an automated office BP value 7/6 mm Hg lower than awake ambulatory BP at 27 months. The authors studied the impact on automated office BP of setting the Omron 907XL to 0 minutes instead of 5 minutes of rest in patients with readings in the lower normal BP range, similar to on-treatment BP in the SPRINT intensive therapy group. Patients (n = 100) in cardiac rehabilitation were randomized to three BP readings at 1-minute intervals using an Omron 907XL BP device set for 5 or 0 minutes of antecedent rest. Mean (±standard deviation) automated office BP (mm Hg) after 5 minutes of rest (120.2 ± 14.6/66.9 ± 8.6 mm Hg) was lower (P < .001/P < .01) than without rest (124.2 ± 16.4/67.9 ± 9.1 mm Hg). When target BP is in the lower normal range, automated office BP recorded without antecedent rest using an Omron 907XL device should be higher and closer to the awake ambulatory BP, compared with readings taken after 5 minutes of rest.
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http://dx.doi.org/10.1111/jch.13319DOI Listing
June 2018

The effect of a peer support intervention on early recovery outcomes in men recovering from coronary bypass surgery: A randomized controlled trial.

Eur J Cardiovasc Nurs 2018 06 14;17(5):408-417. Epub 2017 Aug 14.

2 Faculty of Nursing, Department of Community Health Sciences, University of Calgary, Alberta, Canada.

Background And Aim: Examine the effect of a professionally-guided telephone peer support intervention on recovery outcomes including depression, perceived social support, and health services utilization after coronary artery bypass graft surgery (CABG).

Methods: A randomized controlled trial was conducted with post-coronary artery bypass graft surgery men ( N=185) who were randomized before hospital discharge. The intervention arm received telephone-based peer support through weekly telephone calls from a peer volunteer over six weeks, initiated within 3-4 days of discharge.

Results: Although a significant difference was detected in pre-intervention depression scores at discharge, there were no differences between groups in changes in depression scores at six weeks ( p=0.08), 12 weeks (0.49) or over time ( p=0.51); and no significant differences in perceived social support scores over time ( p=0.94). At 12 weeks, the intervention group had significantly lower incidence of health services utilization (family physician ( p=0.02) and emergency room ( p=0.04)).

Conclusions: Healthcare providers need to continue to investigate novel interventions to enhance social support and reduce depression in cardiac patients.
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http://dx.doi.org/10.1177/1474515117725521DOI Listing
June 2018

Sex Differences in Cardiac Rehabilitation Adherence: A Meta-analysis.

Can J Cardiol 2016 11 27;32(11):1316-1324. Epub 2016 Apr 27.

York University, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Cardiac rehabilitation (CR) participation is associated with significantly lower mortality, and this benefit has been established as dose-dependent. Because it has been suggested that women are adherent to CR programs less than men, the objective of this study was to review CR adherence among women and men, and to determine whether a sex difference exists.

Methods: MedLine, CINAHL, EMBASE, PsycINFO, and the Cochrane databases were systematically searched. Titles and abstracts were screened, and selected full-text articles were independently considered on the basis of predefined inclusion/exclusion criteria. Data from included articles were extracted by 2 authors independently and assessed for quality. The meta-analysis was undertaken with predefined subgroup analyses.

Results: The search identified 5148 articles, of which 149 were fully examined for inclusion consideration. Fourteen studies reporting data on 8176 participants (2234 [27.3%] women) were included. Overall, CR adherence ranged from 36.7% to 84.6% of sessions, with a mean of 66.5 ± 18.2% (median, 72.5%). Men and women enrolled in CR adhered to 68.6% and 64.2% of prescribed sessions, respectively (mean difference = -3.6; 95% confidence interval, -6.9 to -0.3). The sex difference persisted in studies of high quality, that were undertaken in Canada, published since 2010, and where programs were longer than 12 weeks' duration and offered fewer than 3 sessions per week.

Conclusions: To our knowledge, this is the first meta-analysis to systematically report CR adherence rates, and results suggest that patients adhere to more than two-thirds of prescribed sessions. CR adherence is significantly lower among women than men. Identified strategies to promote adherence need to be tested among women.
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http://dx.doi.org/10.1016/j.cjca.2016.01.036DOI Listing
November 2016

The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials.

Patient Educ Couns 2017 03 17;100(3):436-448. Epub 2016 Oct 17.

Program in Public Health, Stony Brook Medicine, Stony Brook University, Stony Brook, USA; The School of Health Technology & Management, Stony Brook University, Stony Brook, USA. Electronic address:

Objective: To determine the effects of patient navigation (PN) on healthcare utilization outcomes using meta-analysis and the quality of evidence.

Methods: Medical and social science databases were searched for randomized controlled trials published in English between 1989 and May 2015. The review process was guided by PRISMA. Included studies were assessed for quality using the Downs and Black tool. Data were extracted to assess the effect of navigation on: health screening rates, diagnostic resolution, cancer care follow-up treatment adherence, and attendance of care events. Random-effects models were used to compute risk ratios and I statistics determined the impact of heterogeneity.

Results: Of 3985 articles screened, 25 articles met inclusion criteria. Compared to usual care, patients who received PN were significantly more likely to access health screening (OR 2.48, 95% CI, 1.93-3.18, P<0.00001) and attend a recommended care event (OR 2.55, 95% CI, 1.27-5.10, P<0.01). PN was favoured to increase adherence to cancer care follow-up treatment and obtain diagnoses. Most studies involved trained lay navigators (n=12) compared to health professionals (n=9).

Conclusion: PN is effective to increase screening rates and complete care events.

Practice Implications: PN is an effective intervention for use in healthcare.
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http://dx.doi.org/10.1016/j.pec.2016.10.014DOI Listing
March 2017

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

JMIR Res Protoc 2016 Aug 1;5(3):e149. Epub 2016 Aug 1.

McMaster University, Hamiltion, ON, Canada.

Background: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom.

Objective: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT).

Methods: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups.

Results: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016.

Conclusions: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.
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http://dx.doi.org/10.2196/resprot.5763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999307PMC
August 2016

Loneliness, marriage and cardiovascular health.

Eur J Prev Cardiol 2016 08 13;23(12):1242-4. Epub 2016 Apr 13.

University Health Network/Toronto Rehab Cardiovascular Prevention & Rehabilitation Program, Canada Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada.

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http://dx.doi.org/10.1177/2047487316643441DOI Listing
August 2016

Observing temporal trends in cardiac rehabilitation from 1996 to 2010 in Ontario: characteristics of referred patients, programme participation and mortality rates.

BMJ Open 2015 Nov 4;5(11):e009523. Epub 2015 Nov 4.

Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

Objectives: We sought to describe temporal trends in the sociodemographic and clinical characteristics of participants referred to cardiac rehabilitation (CR), and its effect on programme participation and all-cause mortality over 14 years.

Setting: A large CR centre in Toronto, Canada.

Participants: Consecutive patients between 1996 and 2010.

Primary And Secondary Outcome Measures: Referrals received were deterministically linked to administrative data, to complement referral form abstraction. Out-of-hospital deaths were identified using vital statistics. Patients were tracked until 2012, and mortality was ascertained. Percentage attendance at prescribed sessions was also assessed.

Results: There were 29,171 referrals received, of which 28,767 (98.6%) were successfully linked, of whom 22,795 (79.2%) attended an intake assessment. The age of the referred population steadily increased, with more females, less affluent and more single patients referred over time (p<0.001). More patients were referred following percutaneous coronary intervention and less following coronary artery bypass graft surgery (p<0.001). The number of comorbidities decreased (p<0.001). Hypertension increased over time (p<0.001), yet the control of cholesterol steadily improved over time. The proportion of smokers decreased over time (p<0.001). Participation in CR significantly declined, and there were no significant changes in mortality. 3-year mortality rates were less than 5%.

Conclusions: Characteristics of referred patients tended to reflect broader trends in risk factors and cardiovascular disease burden. Physicians appear to be referring more sociodemographically diverse patients to CR; however, programmes may need to better adapt to engage these patients to fully participate. More complex patients should be referred, using explicit criteria-based referral processes.
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http://dx.doi.org/10.1136/bmjopen-2015-009523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636616PMC
November 2015

Sex differences in cardiac rehabilitation enrollment: a meta-analysis.

Can J Cardiol 2014 Jul 12;30(7):793-800. Epub 2013 Nov 12.

Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada.

Background: The present systematic review and meta-analysis examines studies published in the past 10 years that described cardiac rehabilitation (CR) enrollment among women and men, to determine whether a significant sex difference persists despite the evidence supporting the benefits of CR to women as well as men.

Methods: Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases were systematically searched for peer-reviewed articles published from July 2000 to July 2011. Titles and abstracts were screened, and the 623 selected full-text articles were independently screened based on predefined inclusion/exclusion criteria (guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA) and assessed for quality using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement form. The meta-analysis was undertaken using Review Manager software.

Results: Twenty-six eligible observational studies reporting data for 297,719 participants (128,499 [43.2%] women) were included. On average, 45.0% of men and 38.5% of women enrolled in CR. In the pooled analysis, men were more likely to be enrolled in CR compared with women (female enrollment vs male enrollment odds ratio, 0.64; 95% confidence interval, 0.57-0.72; P < 0.00001). Heterogeneity was considered high (I(2) = 78%). In the subgroup analyses, systematic CR referral during inpatient tertiary care resulted in significantly greater enrollment among women than nonsystematic referral.

Conclusions: Overall, rates of CR enrollment among women are significantly lower compared with men, with women being 36% less likely to enroll in a rehabilitation program.
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http://dx.doi.org/10.1016/j.cjca.2013.11.007DOI Listing
July 2014

Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.

Eur J Prev Cardiol 2015 Apr 28;22(4):423-41. Epub 2014 Jan 28.

Stony Brook University, New York, USA.

Background: Cardiovascular disease continues to be among the leading causes of morbidity and mortality among men and women globally. However, research suggests that women are significantly underrepresented in cardiac rehabilitation (CR), programmes which are shown to reduce recurrent cardiac events and related premature death. However, sex differences in referral rates have not been systematically and quantitatively reviewed. Hence, the objective of the study was to assess whether a significant sex difference exists.

Methods: We searched Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases for studies reporting CR referral rates in women and men published between July 2000 and July 2011. Titles and abstracts were screened, and the selected full-text articles were independently screened based on predefined inclusion/exclusion criteria. Included articles were assessed for quality using STROBE.

Results: Of 623 screened articles, 19 observational studies reporting data for 241,613 participants (80,505 women) met the inclusion criteria. In the pooled analysis, women (39.6%) were significantly less likely to be referred to CR compared to men (49.4%; odds ratio 0.68, 95% confidence interval 0.62-0.74). Heterogeneity was considered significant (I (2 )= 90%). There was no change in significant findings when subgroup analyses were conducted, examining fee for service vs. no fee, high-quality studies vs. others, or studies pooled by different study methodologies.

Conclusions: CR referral remains low for all patients, but is significantly lower for women than men. Evidence-based interventions to increase referral for all patients, including women, need to be instituted. It is time to ensure broader implementation of these strategies.
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http://dx.doi.org/10.1177/2047487314520783DOI Listing
April 2015

Using the cardiac depression scale in men recovering from coronary artery bypass surgery.

J Clin Nurs 2009 Jun;18(11):1617-24

Faculty of Nursing, University of Calgary, Calgary, AB, Canada.

Aims: To examine the utility and validate the use of the Cardiac Depression Scale in patients who had first-time coronary artery bypass graft surgery.

Background: The Beck Depression Inventory, though frequently used, may not be sufficiently sensitive for use in cardiac patients. The Cardiac Depression Scale has been shown to identify the range of depression in medical cardiac patients.

Design: Survey.

Methods: The Beck Depression Inventory and Cardiac Depression Scale were administered to 120 men at hospital discharge, as well as six, 12 and 36 weeks postoperatively. Cronbach's alpha scores were calculated for the measures at each point. Changes in scores over time were analysed using repeated measures analysis of variance. Associations between the measures scores were calculated using Pearson product-moment correlations. Agreement between the measures' dichotomised scores (depression/no depression) was examined using Cohen's Kappa statistic.

Results: Internal consistency was similar for the Beck Depression Inventory (0.793-0.904) and Cardiac Depression Scale (0.859-0.910). Depression scores decreased over time with the Beck Depression Inventory [F(2.50, 175.29) = 22.27, p < 0.001] and Cardiac Depression Scale [F(2.68, 190.37) = 13.18, p < 0.001]. The measures had similar power [Cohen's f = 0.65 (Beck Depression Inventory) and 0.43 (Cardiac Depression Scale)] to reveal changes over time. The continuous scores were highly correlated at each point [0.737 (p < 0.001)-0.819 (p < 0.001)]. However, when dichotomised scores were compared, the chance corrected level of agreement was less impressive [0.198 (p = 0.014)-0.381 (p < 0.001)].

Conclusions: The Cardiac Depression Scale may have utility for use with surgical cardiac patients. However, continued examination of this measure of depression is warranted.

Relevance To Clinical Practice: Given the prevalence of depression and its negative impact on coronary artery disease, it is important to identify even mild depression in cardiac patients. Using a measure of depression specifically for cardiac patients, rather than a generic measure, may best accomplish this goal.
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http://dx.doi.org/10.1111/j.1365-2702.2009.02800.xDOI Listing
June 2009

Peer support. An under-recognized resource in cardiac recovery.

Eur J Cardiovasc Nurs 2004 Sep;3(3):211-7

University of Calgary, 2500 University Drive NW, Calgary, AB, Canada.

Background: Cardiovascular disease remains the leading cause of mortality and premature death in western societies. Thus, rates of interventions such as coronary artery bypass surgery are continuing to grow. Health care reform and initiatives to reduce health care expenditures have resulted in early patient discharge from hospital following cardiac surgery. With subsequent cutbacks in nursing support and community-based care, patients are leaving hospital less prepared and supported to deal with the changes that occur during the first weeks of recovery.

Aims: To examine the theoretical assumptions that support the contention that peer support is an under-utilized resource for patients who are recovering from cardiac surgery and the challenges to evaluating peer support interventions.

Methods: A review of current literature, which focuses on cardiac surgery recovery, transitions, social support, and peer support interventions.

Results: Peer support (lay assistance from individuals who possess experiential knowledge and similar characteristics), a form of social support, is a viable and potentially sustainable mechanism to put in place during transitional life events such as recovery from cardiac surgery.

Conclusions: Further investigation is needed of peer support interventions for cardiac surgery patients. Specifically, investigations of the influence of peer support interventions on recovery and health outcomes are necessary in this patient population. Yet, challenges exist to undertaking well-designed investigations of social interventions such as peer support.
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http://dx.doi.org/10.1016/j.ejcnurse.2004.04.001DOI Listing
September 2004

COPD-intuition or template: nurses' stories of acute exacerbations of chronic obstructive pulmonary disease.

J Clin Nurs 2004 Sep;13(6):756-64

School of Nursing, Laurentian University, Ontario, Canada.

Unlabelled: STUDY RATIONAL: A number of nurse-researchers have examined the experience of dyspnoea reduction during non-acute phases of the chronic obstructive pulmonary disease (COPD). However, nurses working on in-patient hospital units are frequently required to care for individuals suffering from acute exacerbations of their disease (AECOPD). These critically ill individuals present at health care institutions incapacitated by severe shortness of breath/dyspnoea that is frequently refractory to treatment. To date, little is known about the nurses' understanding of the care they provide for individuals hospitalized because of these acute episodes of their chronic illness.

Study Objectives: The research project was undertaken, in part, to develop an understanding of nurses' experience of caregiving for individuals hospitalized for in-patient care during an AECOPD.

Methodological Design: This focused ethnographic narrative examined the caregiving stories of 10 nurse caregivers. The 10 nurse caregivers were interviewed while caring for a patient and their family during an experience of an AECOPD characterized by incapacitating breathlessness.

Results: The nurse caregivers told a number of caregiving stories that illustrated a common care template that appears to be based on intuition or pattern recognition focusing on anxiety sometimes to the exclusion of dyspnoea.

Conclusions: Analysis of these stories emphasized the need to facilitate nurses individualization of standard templates. More importantly, this analysis illustrated the critical need to develop strategies to facilitate the reshaping of inaccurate templates in the presence of new knowledge.
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http://dx.doi.org/10.1111/j.1365-2702.2004.00927.xDOI Listing
September 2004