Publications by authors named "Yvonne W Leung"

25 Publications

  • Page 1 of 1

The Impact of Radiologist Screening Mammogram Reading Volume on Performance in the Ontario Breast Screening Program.

Can Assoc Radiol J 2021 Aug 22:8465371211031186. Epub 2021 Aug 22.

Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.

Purpose: Although some studies have shown increasing radiologists' mammography volumes improves performance, there is a lack of evidence specific to digital mammography and breast screening program performance targets. This study evaluates the relationship between digital screening volume and meeting performance targets.

Methods: This retrospective cohort study included 493 radiologists in the Ontario Breast Screening Program who interpreted 1,762,173 screening mammograms in participants ages 50-90 between 2014 and 2016. Associations between annual screening volume and meeting performance targets for abnormal call rate, positive predictive value (PPV), invasive cancer detection rate (CDR), sensitivity, and specificity were modeled using mixed-effects multivariate logistic regression.

Results: Most radiologists read 500-999 (36.7%) or 1,000-1,999 (31.0%) screens annually, and 18.5% read ≥2,000. Radiologists who read ≥2,000 annually were more likely to meet abnormal call rate (OR = 3.85; 95% CI: 1.17-12.61), PPV (OR = 5.36; 95% CI: 2.53-11.34), invasive CDR (OR = 4.14; 95% CI: 1.50-11.46), and specificity (OR = 4.07; 95% CI: 1.89-8.79) targets versus those who read 100-499 screens. Radiologists reading 1,000-1,999 screens annually were more likely to meet PPV (OR = 2.32; 95% CI: 1.22-4.40), invasive CDR (OR = 3.36; 95% CI: 1.49-7.59) and specificity (OR = 2.00; 95% CI: 1.04-3.84) targets versus those who read 100-499 screens. No significant differences were observed for sensitivity.

Conclusions: Annual reading volume requirements of 1,000 in Canada are supported as screening volume above 1,000 was strongly associated with achieving performance targets for nearly all measures. Increasing the minimum volume to 2,000 may further reduce the potential limitations of screening due to false positives, leading to improvements in overall breast screening program quality.
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http://dx.doi.org/10.1177/08465371211031186DOI Listing
August 2021

Natural Language Processing-Based Virtual Cofacilitator for Online Cancer Support Groups: Protocol for an Algorithm Development and Validation Study.

JMIR Res Protoc 2021 Jan 7;10(1):e21453. Epub 2021 Jan 7.

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

Background: Cancer and its treatment can significantly impact the short- and long-term psychological well-being of patients and families. Emotional distress and depressive symptomatology are often associated with poor treatment adherence, reduced quality of life, and higher mortality. Cancer support groups, especially those led by health care professionals, provide a safe place for participants to discuss fear, normalize stress reactions, share solidarity, and learn about effective strategies to build resilience and enhance coping. However, in-person support groups may not always be accessible to individuals; geographic distance is one of the barriers for access, and compromised physical condition (eg, fatigue, pain) is another. Emerging evidence supports the effectiveness of online support groups in reducing access barriers. Text-based and professional-led online support groups have been offered by Cancer Chat Canada. Participants join the group discussion using text in real time. However, therapist leaders report some challenges leading text-based online support groups in the absence of visual cues, particularly in tracking participant distress. With multiple participants typing at the same time, the nuances of the text messages or red flags for distress can sometimes be missed. Recent advances in artificial intelligence such as deep learning-based natural language processing offer potential solutions. This technology can be used to analyze online support group text data to track participants' expressed emotional distress, including fear, sadness, and hopelessness. Artificial intelligence allows session activities to be monitored in real time and alerts the therapist to participant disengagement.

Objective: We aim to develop and evaluate an artificial intelligence-based cofacilitator prototype to track and monitor online support group participants' distress through real-time analysis of text-based messages posted during synchronous sessions.

Methods: An artificial intelligence-based cofacilitator will be developed to identify participants who are at-risk for increased emotional distress and track participant engagement and in-session group cohesion levels, providing real-time alerts for therapist to follow-up; generate postsession participant profiles that contain discussion content keywords and emotion profiles for each session; and automatically suggest tailored resources to participants according to their needs. The study is designed to be conducted in 4 phases consisting of (1) development based on a subset of data and an existing natural language processing framework, (2) performance evaluation using human scoring, (3) beta testing, and (4) user experience evaluation.

Results: This study received ethics approval in August 2019. Phase 1, development of an artificial intelligence-based cofacilitator, was completed in January 2020. As of December 2020, phase 2 is underway. The study is expected to be completed by September 2021.

Conclusions: An artificial intelligence-based cofacilitator offers a promising new mode of delivery of person-centered online support groups tailored to individual needs.

International Registered Report Identifier (irrid): DERR1-10.2196/21453.
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http://dx.doi.org/10.2196/21453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819785PMC
January 2021

Cocreating Meaning Through Expressive Writing and Reading for Cancer Caregivers.

J Palliat Care 2019 Sep 2:825859719871538. Epub 2019 Sep 2.

1 Department of Psychiatry, University of Toronto, Ontario, Canada.

Purpose: Caregivers of patients with cancer cope with socioemotional challenges, which can adversely affect their well-being. We developed an intervention, expressive writing and reading (EWR), to promote emotional processing and social connectedness among caregivers. In a single-arm pilot study, we assessed its feasibility and perceived usefulness.

Methods: Caregivers participated in weekly 1.5-hour EWR workshops offered over 20 weeks. After 4 sessions, they completed semistructured interviews, which were analyzed using qualitative descriptive analysis.

Findings: Of 65 caregivers approached, 25 were eligible, 18 consented, and 9 (50%) caregivers completed at least 4 workshops and the interview. Their responses revealed 3 themes: "inner processing," "interpersonal learning," and "enhanced processing and preparedness." Perceived benefits of EWR included emotional and cognitive processing (individual and collaborative), learning from the emotions and experiences of other caregivers, and preparing for upcoming challenges.

Conclusions: Expressive writing and reading can be a safe and cost-effective supportive intervention for caregivers of patients with cancer.
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http://dx.doi.org/10.1177/0825859719871538DOI Listing
September 2019

Telephone versus in-person colorectal cancer risk and screening intervention for first-degree relatives: A randomized controlled trial.

Cancer 2019 07 12;125(13):2272-2282. Epub 2019 Mar 12.

Public Health Ontario, Toronto, Ontario, Canada.

Background: Having a first-degree relative (FDR) with colorectal cancer (CRC) is a significant risk factor for CRC. Counseling for FDRs regarding CRC risk factors and personalized risk is important to improve knowledge and screening compliance.

Methods: A 3-arm randomized controlled trial compared tailored in-person and telephone CRC counseling interventions with controls among FDRs who were not mutation carriers for known hereditary cancer syndromes, but who were considered to be at an increased risk based on family history. It was hypothesized that both telephone and in-person approaches would increase CRC knowledge, screening adherence, perceived risk accuracy, and psychosocial functioning compared with controls. The authors anticipated greater satisfaction with the in-person approach. CRC knowledge, risk perception, psychosocial functioning, and intention to screen were assessed at baseline and at 2-week and 2-month follow-ups (primary endpoint).

Results: A total of 278 FDRs (mean age, 47.4 years, standard deviation, 11.38 years) participated. At baseline, participants reported low to moderate CRC knowledge and overestimations of risk. Screening adherence was 73.7%. At 2 months, participants in the in-person arm and telephone arm demonstrated improvements in knowledge and perceived risk and were not found to be statistically different from each other. However, when comparing each intervention with controls, knowledge in the in-person arm was found to be statistically significantly higher, but the difference between the telephone and control arms was not. Cancer-related stress reduced over time in all groups. Intervention benefits were maintained at 1 year. Baseline screening intent/adherence were high, and therefore did not reach statistically significant improvement.

Conclusions: Tailored in-person or telephone formats for providing CRC risk counseling, incorporating behavioral interventions, appear to improve knowledge and risk perceptions, with high client satisfaction.
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http://dx.doi.org/10.1002/cncr.32032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6742581PMC
July 2019

Addressing Educational Needs in Managing Complex Pain in Cancer Populations: Evaluation of APAM: An Online Educational Intervention for Nurses.

Am J Hosp Palliat Care 2019 Jul 27;36(7):587-597. Epub 2019 Feb 27.

1 de Souza Institute, University Health Network, Toronto, Ontario, Canada.

Context: Cancer-related pain is associated with significant suffering and is one of the most challenging symptoms to manage. Studies indicate that front-line clinicians often lack the knowledge on best practices in cancer pain management.

Objectives: The current project, a quality improvement (QI) initiative, evaluated the outcome of an online educational intervention for nurses on complex cancer pain management.

Methods: An online 7-module educational intervention, Advanced Pain Assessment and Management, was offered from 2012 to 2017. Pre-post course evaluations included self-reported knowledge and confidence across cancer pain management domains. In-course competency assessments included knowledge examination, online discussion forum participation, opioid dosage calculation assignment, and small-group-based case study. A mixed-model statistical analysis was used to assess pre-post course change in pain management confidence level.

Results: In all, 306 nurses from 89 hospitals in Ontario, Canada, were enrolled in the course; 81.4% returned the precourse survey and 71.9% successfully completed the course. The average confidence level on pain management was low at baseline (57.5%) but improved significantly post-course. In-course competency assessments ranged from 81% to 89%. Mixed-model results showed post-course improvements in confidence levels, independent of sociodemographic background, clinical role, and professional educational level. Nurses with longer years of practice and more cancer cases reported greater confidence.

Conclusion: A facilitator-led online educational intervention focusing on complex cancer pain management can significantly improve nurses' knowledge, confidence, and skills. Low baseline knowledge among nurses highlights the pressing need for health-care organizations to implement cancer pain management training as an integral part of health-care QI initiative.
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http://dx.doi.org/10.1177/1049909119832819DOI Listing
July 2019

Symptom screening for constipation in oncology: getting to the bottom of the matter.

Support Care Cancer 2019 Jul 30;27(7):2463-2470. Epub 2018 Oct 30.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 16th Floor, Room 749, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.

Purpose: This study seeks to determine whether specific screening for constipation will increase the frequency of clinician response within the context of an established symptom screening program.

Methods: A "constipation" item was added to routine Edmonton Symptom Assessment System (ESAS) screening in gynecologic oncology clinics during a 7-week trial period, without additional constipation-specific training. Chart audits were then conducted to determine documentation of assessment and intervention for constipation in three groups of patients, those who completed (1) ESAS (n = 477), (2) ESAS-C with constipation (n = 435), and (3) no ESAS (n = 511).

Results: Among patients who were screened for constipation, 17% reported moderate to severe symptoms. Greater constipation severity increased the likelihood of documented assessment (Z = 2.37, p = .018) and intervention (Z = 1.99, p = .048). Overall rates of documented assessment were 36%, with the highest assessment rate in the no ESAS group (χ = 9.505, p = .006), a group with the highest proportion of late-stage disease. No difference in the rate of assessment was found between the ESAS and ESAS-C groups. Overall rates for documentation of intervention were low, and did not differ between groups.

Conclusions: Specific screening for constipation within an established screening program did not increase the documentation rate for constipation assessment or intervention. The inclusion of specific symptoms in multi-symptom screening initiatives should be carefully evaluated in terms of added value versus patient burden. Care pathways should include guidance on triaging results from multi-symptom screening, and clinicians should pay particular attention to patients who are missed from screening altogether, as they may be the most symptomatic group.
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http://dx.doi.org/10.1007/s00520-018-4520-7DOI Listing
July 2019

A randomized controlled trial of a supportive expressive group intervention for women with a family history of breast cancer.

Psychooncology 2018 11 17;27(11):2645-2653. Epub 2018 Jul 17.

University Health Network, Toronto, Canada.

Objective: Women with a family history of breast cancer (BC) often overestimate their BC risk. Heightened psychological distress may interfere with risk comprehension and screening adherence. The primary purpose of this study was to test the efficacy of a 12-week manual-based supportive-expressive (SE) group intervention for this population.

Methods: Using a randomized control trial design, this study compared two interventions: a standard risk-counseling arm (RC) compared with that plus SE group intervention. The primary study outcome was BC anxiety. Secondary outcomes included psychosocial functioning, risk comprehension, BC knowledge, and screening behaviors.

Results: A total of 161 women with a family history of BC were randomized into SE (N = 108) or RC (N = 53). Participants in both study arms significantly improved on measures of BC anxiety, psychosocial functioning, risk comprehension, and BC knowledge, with no statistical difference between study arms. Benefits were sustained at 1 year. BC screening rates were high in both arms at baseline and follow-up.

Conclusions: SE group therapy as an added intervention to the risk counseling was well-received, however, did not demonstrate superiority to RC alone. Future studies on treatment matching are needed to further our understanding of interventions that can support women with a family history of BC to work through residual issues, including loss and grief.
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http://dx.doi.org/10.1002/pon.4822DOI Listing
November 2018

Feasibility and diagnostic accuracy of the Patient-Reported Outcomes Measurement Information System (PROMIS) item banks for routine surveillance of sleep and fatigue problems in ambulatory cancer care.

Cancer 2016 09 28;122(18):2906-17. Epub 2016 Jun 28.

Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Routine screening for problematic symptoms is emerging as a best practice in cancer systems globally. The objective of this observational study was to assess the feasibility and diagnostic accuracy of Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing (CAT) for fatigue and sleep-disturbance items compared with legacy measures in routine ambulatory cancer care.

Methods: Patients who attended outpatient clinics at the Princess Margaret Cancer Center completed PROMIS CAT item banks and legacy measures (the Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue scale and the Insomnia Severity Index [ISI]) using tablet computers during clinic visits. The completion rates, patient acceptability, and diagnostic accuracy of PROMIS CAT were evaluated against legacy measures using receiver operating characteristic (ROC) curve analysis.

Results: Participants consisted of 336 patients (mean age ± standard deviation, 57.4 ± 15.7 years; 55% females; 75% Caucasian). Over 98% of patients did not find symptom screening was burdensome, although only 65% were willing to complete the survey at every visit. PROMIS CAT scores were significantly correlated with both FACIT-Fatigue scores (r = -0.83) and ISI scores (r = -0.57; p < 0.0001 for all). Areas under the curve (AUC) by ROC analysis for fatigue were 0.946 using the FACIT-Fatigue cutoff ≤30, 0.910 for sleep disturbance, and 0.922 for sleep impairment using the ISI cutoff ≥15. The recommended T-score cut-off for PROMIS CAT Fatigue was 57, Sleep Disturbance was 57, and Sleep Impairment was 57.

Conclusions: The current results support the feasibility and accuracy of PROMIS CAT and its potential for use in routine ambulatory cancer care. Future research will assess feedback of these data to clinicians and evaluate effects on earlier identification of and intervention for these problems. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2906-2917. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30134DOI Listing
September 2016

Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program.

J Oncol Pract 2016 05 5;12(5):e513-26. Epub 2016 Apr 5.

Princess Margaret Cancer Centre, University Health Network; University of Toronto, Toronto, Ontario; and BC Children's and Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.

Purpose: Systematic screening for distress in oncology clinics has gained increasing acceptance as a means to improve cancer care, but its implementation poses enormous challenges. We describe the development and implementation of the Distress Assessment and Response Tool (DART) program in a large urban comprehensive cancer center.

Method: DART is an electronic screening tool used to detect physical and emotional distress and practical concerns and is linked to triaged interprofessional collaborative care pathways. The implementation of DART depended on clinician education, technological innovation, transparent communication, and an evaluation framework based on principles of change management and quality improvement.

Results: There have been 364,378 DART surveys completed since 2010, with a sustained screening rate of > 70% for the past 3 years. High staff satisfaction, increased perception of teamwork, greater clinical attention to the psychosocial needs of patients, patient-clinician communication, and patient satisfaction with care were demonstrated without a resultant increase in referrals to specialized psychosocial services. DART is now a standard of care for all patients attending the cancer center and a quality performance indicator for the organization.

Conclusion: Key factors in the success of DART implementation were the adoption of a programmatic approach, strong institutional commitment, and a primary focus on clinic-based response. We have demonstrated that large-scale routine screening for distress in a cancer center is achievable and has the potential to enhance the cancer care experience for both patients and staff.
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http://dx.doi.org/10.1200/JOP.2015.010066DOI Listing
May 2016

Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program.

J Oncol Pract 2016 05 5;12(5):e513-26. Epub 2016 Apr 5.

Princess Margaret Cancer Centre, University Health Network; University of Toronto, Toronto, Ontario; and BC Children's and Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.

Purpose: Systematic screening for distress in oncology clinics has gained increasing acceptance as a means to improve cancer care, but its implementation poses enormous challenges. We describe the development and implementation of the Distress Assessment and Response Tool (DART) program in a large urban comprehensive cancer center.

Method: DART is an electronic screening tool used to detect physical and emotional distress and practical concerns and is linked to triaged interprofessional collaborative care pathways. The implementation of DART depended on clinician education, technological innovation, transparent communication, and an evaluation framework based on principles of change management and quality improvement.

Results: There have been 364,378 DART surveys completed since 2010, with a sustained screening rate of > 70% for the past 3 years. High staff satisfaction, increased perception of teamwork, greater clinical attention to the psychosocial needs of patients, patient-clinician communication, and patient satisfaction with care were demonstrated without a resultant increase in referrals to specialized psychosocial services. DART is now a standard of care for all patients attending the cancer center and a quality performance indicator for the organization.

Conclusion: Key factors in the success of DART implementation were the adoption of a programmatic approach, strong institutional commitment, and a primary focus on clinic-based response. We have demonstrated that large-scale routine screening for distress in a cancer center is achievable and has the potential to enhance the cancer care experience for both patients and staff.
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http://dx.doi.org/10.1200/JOP.2015.010066DOI Listing
May 2016

Reducing blood pressure with Internet-based interventions: a meta-analysis.

Can J Cardiol 2013 May;29(5):613-21

Behavioural Cardiology Research Unit, University Health Network, Toronto, Ontario, Canada.

Background: Elevated blood pressure is a leading risk factor for cardiovascular disease and mortality. Internet-based interventions (e-counselling) have the potential to deliver a wide range of preventive counselling services. The purpose of this review was to (1) assess the efficacy of e-counselling in reducing blood pressure and (2) identify key components of successful trials in order to highlight factors that may contribute significantly to blood pressure control.

Methods: MEDLINE, PubMed, EMBASE, PsycINFO, and the Cochrane Library were searched up to June 2012 with the following key words: Web-based, Internet-based, e-counselling, mobile health, blood pressure, and hypertension. Trials were selected in which blood pressure was reported as a primary or secondary outcome and whose participants had baseline systolic and diastolic blood pressure within the prehypertensive (120-139/80-89 mm Hg) or hypertensive (≥ 140/90 mm Hg) range.

Results: The search strategy identified 13 trials, and the mean reduction of systolic and diastolic blood pressure was -3.8 mm Hg (95% confidence interval [Cl], -5.63 to -2.06 mm Hg; P < 0.01) and -2.1 mm Hg (95% CI, -3.51 to -0.65 mm Hg; P < 0.05), respectively. The greatest magnitude of blood pressure reduction was found for interventions that lasted 6 months or longer, used 5 or more behavior change techniques, or delivered health messages proactively.

Conclusion: Research on preventive e-counselling for blood pressure reduction is at an early stage of development. This review provides preliminary evidence of blood pressure reduction with Internet-based interventions. Future studies need to evaluate the contribution of specific intervention components in order to establish a best practice e-counselling protocol that is efficacious in reducing blood pressure.
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http://dx.doi.org/10.1016/j.cjca.2013.02.007DOI Listing
May 2013

The impact of premorbid and postmorbid depression onset on mortality and cardiac morbidity among patients with coronary heart disease: meta-analysis.

Psychosom Med 2012 Oct 21;74(8):786-801. Epub 2012 Sep 21.

Department of Kinesiology and Health Science, York University, Toronto, Canada.

Background: Depression is associated with increased cardiac morbidity and mortality in the general population and in patients with coronary heart disease (CHD). Recent evidence suggests that patients with new-onset depression post-CHD diagnosis have worse outcomes than do those who had previous or recurrent depression. This meta-analysis investigated the timing of depression onset in established CHD and CHD-free cohorts to determine what time frame is associated with greater mortality and cardiac morbidity.

Methodology/principal Findings: The MEDLINE, EMBASE, and PsycINFO databases were searched systematically to identify articles examining a depression time frame that specified an end point of all-cause mortality, cardiac mortality, rehospitalization, or major adverse cardiac events. A meta-analysis was conducted to estimate effect sizes by time frame of depression. Twenty-two prospective cohort studies were identified. Nine studies investigated premorbid depression in CHD-free cohorts in relation to cardiac death. Thirteen studies in patient samples with CHD examined new-onset depression in comparison with previous or recurrent depression. The pooled effect size (risk ratio) was 0.76 (95% confidence interval (CI) = 0.48-1.19) for history of depression only, 1.79 (95% CI = 1.45-2.21) for premorbid depression onset, 2.11 (95% CI = 1.66-2.68) for postmorbid or new depression onset, and 1.59 (95% CI = 1.08-2.34) for recurrent depression.

Conclusions/significance: Both premorbid and postmorbid depression onsets are potentially hazardous, and the question of timing may be irrelevant with respect to adverse cardiac outcomes. However, the combination of premorbid depression with the absence of depression at the time of a cardiac event (i.e., historical depression only) is not associated with such outcomes and deserves further investigation.
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http://dx.doi.org/10.1097/PSY.0b013e31826ddbedDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461377PMC
October 2012

Posttraumatic growth in coronary artery disease outpatients: relationship to degree of trauma and health service use.

J Psychosom Res 2012 Apr 28;72(4):293-9. Epub 2012 Jan 28.

York University, Canada.

Objectives: Posttraumatic growth (PTG) is frequently reported after the strike of a serious medical illness. The current study sought to: 1) assess the relationship between degree of cardiac "threat" and PTG one-year post-hospitalization; and 2) to explore the association between PTG and healthcare utilization.

Methods: In a cohort study, 2636 cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey; clinical data were extracted from charts. One year later, 1717 of these outpatients completed a postal survey, which assessed PTG and healthcare utilization. Morbidity data were obtained retrospectively through probabilistic linkage to administrative data. The predicted risk of recurrent events for each participant was calculated using a logistic regression model, based on participants' sociodemographic and clinical characteristics. The relationship among PTG, trauma and health service use was examined with multiple regression models.

Results: Greater PTG was significantly related to greater predicted risk of recurrent events (p<0.001), but not the actual rate of recurrent events (p=0.117). Moreover, greater PTG was significantly related to more physician visits (p=0.006), and cardiac rehabilitation program enrolment (p=0.001) after accounting for predicted risk and sociodemographic variables. PTG was not related to urgent healthcare use.

Conclusions: Greater PTG was related to greater objective risk of morbidity but not actual morbidity, suggesting that contemplation about the risk of future health problems may spur PTG. Moreover, greater PTG was associated with seeking non-urgent healthcare. Whether this translates to improved health outcomes warrants future study.
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http://dx.doi.org/10.1016/j.jpsychores.2011.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461374PMC
April 2012

The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization.

J Cardiopulm Rehabil Prev 2012 Jan-Feb;32(1):41-7

Kinesiology and Health Science, 368 Bethune College, York University, Toronto, Ontario, Canada.

Background: While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral.

Methods: Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using χ.

Results: When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy.

Conclusion: Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.
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http://dx.doi.org/10.1097/HCR.0b013e31823be13bDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508132PMC
May 2012

Quality of life following participation in cardiac rehabilitation programs of longer or shorter than 6 months: does duration matter?

Popul Health Manag 2011 Aug 17;14(4):181-8. Epub 2011 Jan 17.

Kinesiology & Health Science, York University, Toronto, Ontario, Canada.

Cardiac rehabilitation (CR) participation results in significant health benefits. However, there is wide variation in program duration, and little is known about the optimal duration of CR for patient outcomes. The objective of this study was to compare quality of life (QoL) of patients who participated in CR programs of < or ≥6 months duration versus patients who did not attend CR. A total of 1056 cardiac outpatients completed mailed surveys at baseline and 9 months later. Patients were categorized based on CR participation in one of 31 programs: a program of < or ≥6 months duration, or nonattendance. Outcomes were body mass index, activity status, depressive symptoms, physical activity, QoL, posttraumatic growth inventory (PTGI), and percentage of CR sessions attended. Generalized estimating equations were used. A total of 148 (14%) patients participated in a program of < 6 months, and 183 (17.3%) participated in a program of ≥6 months. Patients who participated in the former completed a greater percentage of CR sessions (P = 0.02). Activity status (P = 0.002), several domains of QoL (P > 0.0001), and PTGI (P = 0.007) were significantly greater regardless of CR duration when compared to those who did not attend CR. There were no significant differences in outcomes when comparing patients attending CR programs of < or ≥6 months duration. Patients achieve greater activity status and QoL when compared to those who did not attend CR, regardless of program duration. This could be a result of greater program adherence among those who attend shorter programs. Future research is needed using a randomized design to assess effects of program duration on cardiac events and mortality.
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http://dx.doi.org/10.1089/pop.2010.0048DOI Listing
August 2011

Geographic issues in cardiac rehabilitation utilization: a narrative review.

Health Place 2010 Nov 10;16(6):1196-205. Epub 2010 Aug 10.

School of Kinesiology and Health Science, York University, Toronto, Canada.

Objective: The purpose of this study was to review the current evidence regarding the relationship between geographic indicators and cardiac rehabilitation (CR) utilization among coronary heart disease (CHD) patients.

Results: Seventeen articles were identified for inclusion, where nine studies assessed rurality, 10 studies assessed travel time/distance, and two of these studies assessed both. Nine of the 17 studies (52.9%) showed a significant negative relationship between geographic barrier and CR use. Four of the 17 studies (23.5%) showed a null relationship, while four studies (23.5%) showed mixed findings. Inconsistent findings identified appeared to be related to restricted geographic range, regional density, and socioeconomic status.

Conclusions: Overall, 52.9% of the identified studies reported a significant negative relationship between geographic indicators and CR utilization. This relationship appeared to be particularly consistent in North American and Australian settings, but somewhat less so in the United Kingdom where there is greater population density and availability of public transport.
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http://dx.doi.org/10.1016/j.healthplace.2010.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4474644PMC
November 2010

Timing of depressive symptom onset and in-hospital complications among acute coronary syndrome inpatients.

Psychosomatics 2010 Jul-Aug;51(4):283-8

York University, 4700 Keele St., Toronto, ON, Canada.

Background: Recent research has reported an association between in-hospital depression and poorer long-term prognosis and a greater risk of in-hospital complications.

Objective: The purpose of the current study was to examine the relationship between past and incident depressive symptoms and in-hospital complications in acute coronary syndrome (ACS) inpatients.

Method: A group of 906 ACS inpatients from 12 coronary-care units participated in the study. Incident depressive symptoms were assessed through the Beck Depression Inventory, and participants' were asked about past history of prolonged depressed mood. In-hospital complications were noted as present or absent by nurses, and authors conducted logistic-regression analyses.

Results: A subset of 492 patients (58.4%) experienced an in-hospital complication, the most common being ischemia (48.8%) and cardiac arrest (7.2%). After adjusting for prognostic indicators, incident and past-combined-with-incident depressive symptoms were significantly associated with an increased risk of experiencing an in-hospital complication.

Conclusion: Incident symptoms, in particular, seem to be prognostic. This finding suggests that acute emotions may be triggering cardiac complications, and early identification of emotional symptoms is warranted.
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http://dx.doi.org/10.1176/appi.psy.51.4.283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4474645PMC
October 2010

Post-traumatic growth among cardiac outpatients: degree comparison with other chronic illness samples and correlates.

J Health Psychol 2010 Oct 14;15(7):1049-63. Epub 2010 May 14.

York University, Toronto, ON, Canada.

This study evaluated the sociodemographic, clinical and behavioral correlates of post-traumatic growth (PTG) in coronary artery disease (CAD) patients, and the degree of PTG compared to other patient groups. Using a prospective design, 1497 CAD outpatients completed a survey assessing potential PTG correlates. A total of 1268 responded to a nine-month follow-up survey assessing PTG. Significant PTG correlates were being younger, non-white, having lower income, functional status, and depressive symptoms, greater social support, and positive illness perceptions. The degree of PTG was equivalent to that of cardiac patients in other countries, but was lower than that of breast cancer and multiple sclerosis patients.
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http://dx.doi.org/10.1177/1359105309360577DOI Listing
October 2010

Access to cardiac rehabilitation among South-Asian patients by referral method: a qualitative study.

Rehabil Nurs 2010 May-Jun;35(3):106-12

University of Toronto, ON.

People of South-Asian origin have an increased prevalence of coronary artery disease. Although cardiac rehabilitation (CR) is effective, South Asians are among the least likely people to participate in these programs. Automatic referral increases CR use and may reduce access inequalities. This study qualitatively explored whether CR referral knowledge and access varied among South-Asian patients. Participants were South-Asian cardiac patients receiving treatment at hospitals in Ontario, Canada. Each hospital refers to CR via one offour methods: automatically through paper or electronically, through discussion with allied health professionals (liaison referral), or through referral at the physician's discretion. Data were collected via interviews and analyzed using interpretive-descriptive analysis. Four themes emerged: the importance of predischarge CR discussions with healthcare providers, limited knowledge of CR, ease of the referral process for facilitators of CR attendance, and participants'needs for personal autonomy regarding their decision to attend CR. Liaison referral was perceived to be the most suitable referral method for participants. It facilitated communication between patients and providers, ensuring improved understanding of CR. Automatic referral may not be as well suited to this population because of reduced patient-provider communication.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461376PMC
http://dx.doi.org/10.1002/j.2048-7940.2010.tb00285.xDOI Listing
June 2010

Effects of cardiac rehabilitation referral strategies on referral and enrollment rates.

Nat Rev Cardiol 2010 Feb 8;7(2):87-96. Epub 2009 Dec 8.

Faculty of Health, 368 Norman Bethune College, York University, Toronto, ON M3J 1P3, Canada.

Despite recommendations in clinical practice guidelines, evidence suggests that utilization of cardiac rehabilitation (CR) following indicated cardiac events is low. Referral strategies, such as automatic referral, have been advocated to improve CR utilization. In this Review, we evaluate the effects of referral strategies on rates of CR referral and enrollment. Referral strategies are categorized as 'automatic' (the use of electronic health records or systematic discharge order sets), as 'liaison' (discussions with allied health-care providers), or as 'other' (for example, the use of motivational letter to patients). The highest rates of CR referral have been achieved in studies implementing automatic referral orders, whereas the highest rates of CR enrollment have resulted from a combination of automatic and liaison methods. Overall, innovative referral strategies significantly increase CR utilization. While further investigation is needed, institutions should evaluate their CR referral practice in light of these findings.
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http://dx.doi.org/10.1038/nrcardio.2009.223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4474642PMC
February 2010

Concordance of self- and program-reported rates of cardiac rehabilitation referral, enrollment and participation.

Can J Cardiol 2009 Apr;25(4):e96-9

York University, Toronto, Canada.

Background: Despite potential bias, researchers often rely on patient self-reported data of health care use. However, the validity and accuracy of self-reported data on cardiac rehabilitation (CR) use are unknown.

Objective: To assess the concordance between patient self-report and site-verified CR referral, enrollment and participation.

Methods: A consecutive sample of 661 coronary artery disease inpatients (mean [+/- SD] age 61.27+/-1.31 years; 157 women [23.8%]) treated at three acute care sites was recruited (75% response rate) as part of a larger study comparing automatic with usual referral methods. CR referral, enrollment (attendance at intake assessment) and participation (percentage of program attended) were discerned in a mailed survey nine months following discharge (n=506; 84.3% retention). A total of 24 CR sites were contacted for verification.

Results: A total of 276 participants (54.5%) self-reported CR referral, and CR sites verified receipt of 262 referrals (51.8%) (Cohen's kappa 0.899). A total of 232 participants (45.8%) self-reported CR enrollment, with site-verification for 208 participants (41.1%) (Cohen's kappa 0.846). Self-reported data indicated that participants attended a mean of 81.78+/-25.84% of prescribed CR sessions, with CR sites reporting that participants completed 80.75+/-31.27% of the program (r=0.662; P<0.001). Equivalency testing revealed that the self-reported and site-verified rates of program participation were equivalent (z<1.96).

Conclusions: The almost perfect agreement between the self-reported and site-verified use of CR services suggests that self-administered items are highly valid in this population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2706767PMC
http://dx.doi.org/10.1016/s0828-282x(09)70063-7DOI Listing
April 2009

The prevalence and correlates of mind-body therapy practices in patients with acute coronary syndrome.

Complement Ther Med 2008 Oct;16(5):254-61

222A Bethune College, York University, Toronto, Ont, Canada.

Objectives: While the benefits of mind-body therapy (MBT) for cardiac secondary prevention continues to be investigated, the prevalence of such practices by cardiac patients is not well known. The aim of this study was to quantitatively examine the prevalence of MBT practice and its sociodemographic, clinical, psychosocial and behavioral correlates among patients with acute coronary syndrome (ACS).

Methods: Six hundred and sixty-one ACS in-patients (75% response rate) recruited from three hospitals completed a demographic survey, and clinical data were extracted from charts. Four hundred and sixty five patients (81% retention rate; 110 (23.7%) female) responded to an 18-month post-discharge survey that queried about MBT use and its correlates.

Results: One hundred and sixty-three (35.1%) ACS patients practised MBT in their lifetime, and 118 (25.4%) were currently practising. MBT users were more often women (OR = 2.98), nonwhite (OR = 2.17), had higher levels of education (OR = 2.22), past smokers (OR = 3.33), reported poorer mental health (OR = 2.15), and engaged in more exercise (OR = 1.65).

Conclusion: One-third of ACS patients practised some form of MBT. The greater MBT practice among female ACS patients is noteworthy, given their generally lower physical activity and lower receipt of evidence-based treatments including cardiac rehabilitation. In addition, there is some evidence that MBT can promote mental well-being, and thus such practice might reduce risk related to negative affect in cardiac patients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924365PMC
http://dx.doi.org/10.1016/j.ctim.2007.05.003DOI Listing
October 2008

Gender differences in motivations and perceived effects of Mind-Body Therapy (MBT) practice and views on integrative cardiac rehabilitation among acute coronary syndrome patients: why do women use MBT?

Complement Ther Med 2008 Dec 22;16(6):311-7. Epub 2008 Jul 22.

Kinesiology and Health Science, York University, 222B Bethune College, Toronto, Ontario, Canada.

Background: Over one-third of cardiac patients practice Mind-Body Therapy (MBT), particularly women. Considering women are less likely to engage in conventional physical activity, few studies have examined why MBT is well-accepted by women.

Objectives: To qualitatively explore gender differences in the motivations for, and perceived effects of MBT, and the inter-relationships among alternative and conventional physical activities and secondary prevention programs.

Methods: A random subsample of 16 participants (8 female) who reported practicing MBT in a larger study of 661 cardiac patients was interviewed until theme saturation was achieved. Audiotapes were transcribed and coded based on interpretive-descriptive technique within Nvivo-7 software. An audit trail and second coder were utilized to ensure the transparency and validity of results. After main themes emerged, the data were split by gender to identify differences for each theme.

Results: Five themes emerged: (1) promotes positive well-being, (2) physical health benefits, (3) intrinsic and extrinsic motivations, (4) proactive health orientation, and (5) MBT as a preferred complementary and/or alternative physical activity. Men more often expressed preference for MBT for increased positive mood and cardiac-specific benefits, whereas women emphasized stress reduction, increasing self-efficacy, and physical activity, and were eager to see MBT offered in cardiac rehabilitation (CR).

Conclusions: Both male and female users perceived substantial psychosocial and physical benefits of MBT practice. MBT addresses some of women's common barriers to CR.
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http://dx.doi.org/10.1016/j.ctim.2008.04.009DOI Listing
December 2008

A prospective examination of antidepressant use and its correlates in patients with acute coronary syndrome.

Psychosomatics 2008 May-Jun;49(3):199-207

York University and University Health Network Women's Health Program, York University.

Background: Depression has been implicated in the occurrence of recurrent coronary events and cardiac or all-cause mortality in acute coronary syndrome (ACS) patients.

Objective: The authors describe the frequency and type of antidepressant use and its correlates 18 months after ACS hospital discharge.

Method: A sample of 661 ACS inpatients, recruited from three hospitals, completed a sociodemographic survey and the Hospital Anxiety and Depression Scale (HADS), and clinical data were extracted from charts. A mailed survey 9 months and 18 months post-discharge assessed self-reported antidepressant use, and the HADS was re-administered.

Results: Approximately 9% of participants reported antidepressant use both 9 and 18 months post-hospitalization, with 77% concordance in usage over time. Participants most frequently reported using selective serotonin reuptake inhibitors and least often tricyclics. Logistic regression revealed that antidepressant users were more likely to be anxious and have more comorbidity, and were less likely to work full-time, whereas number of medications, age, and marital status were not related.

Conclusion: Patients with comorbid physical and mental conditions who are unemployed may be more likely to receive an antidepressant because of greater depression symptoms or greater exposure to healthcare providers, which increases the potential for symptom recognition and treatment.
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http://dx.doi.org/10.1176/appi.psy.49.3.199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2927525PMC
June 2008

A prospective examination of patterns and correlates of exercise maintenance in coronary artery disease patients.

J Behav Med 2007 Oct 7;30(5):411-21. Epub 2007 Jul 7.

Kinesiology and Health Science, 222A Bethune College, York University, 4700 Keele Street, Toronto, ON, M3J1P3, Canada.

This longitudinal study examined exercise behavior patterns (i.e., maintainers, irregular, and inactive) in cardiac patients, and investigated the sociodemographic, clinical, psychosocial, and environmental correlates of exercise patterns. A total of 661 cardiac in-patients from three hospitals consented to participate (75% response rate) and were re-assessed 9 and 18 (81% retention) months post-discharge. Exercise patterns were assessed via the Health-Promoting Lifestyle Profile II subscale using a median split. Of 417 participants (mean age 63.1+/-10.2) with complete data, 42.2% were classified as Exercise Maintainers, 21.3% as Irregular Exercisers, and 26.1% as Inactive. Multinomial logistic regression revealed that Exercise Maintainers were more likely to be male, have exercised prior to their diagnosis, attend cardiac rehabilitation, perceive fewer exercise barriers, and were less likely to be current-smokers, past-smokers, or attribute the cause of their disease to their own behavior. Patients more likely to maintain exercise have positive perceptions and utilize cardiac rehabilitation.
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http://dx.doi.org/10.1007/s10865-007-9117-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924366PMC
October 2007
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