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PPO 09-283 – HSR&D Study

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PPO 09-283
Representational Telehealth Nursing Intervention for Veterans with CHD
Mark W Vander Weg PhD MS BA
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: April 2010 - April 2012

BACKGROUND/RATIONALE:
Past research has found that patients often fail to incorporate personally relevant behavioral risk factors into their coronary heart disease (CHD) representations and that such beliefs predict subsequent non-adherence to diet, exercise, and smoking cessation recommendations. These findings suggest that efforts to motivate behavior change among those with CHD often fail, in part, because patients hold misconceptions regarding their illness and its associations with behavior. In an effort to help address these misperceptions, we developed an intervention targeting inaccurate or incomplete representations of CHD representations in Veterans. However, before testing the efficacy of the intervention in a large, multi-site randomized clinical trial, we needed to refine and finalize the intervention materials and protocol and evaluate the feasibility of this approach in a small sample of Veterans with CHD.

OBJECTIVE(S):
The aims of the project were to: (1) refine the intervention materials based on results from ongoing work related to CHD representations in Veterans and (2) evaluate the feasibility of the intervention in a pilot sample of 24 Veterans with CHD recruited from the Iowa City VA Health Care System.

METHODS:
In Phase I of the project, the intervention protocol was modified and refined. The resulting intervention consisted of a semi-structured telephone interview designed with the following goals: 1) validating adaptive CHD beliefs, 2) exploring CHD misconceptions, 3) creating conditions conducive to conceptual change through a discussion of the links between misconceptions and post-CHD adaptation, 4) provision of more accurate information to counter and replace misconceptions, 5) assisting Veterans in developing one or more goals for positively modifying behaviors related to CHD, and 6) connecting patients to available resources to assist with lifestyle modification. The resulting intervention incorporated elements of psychoeducation, cognitive behavioral therapy, and motivational enhancement strategies.

The intervention was then pilot-tested in a small sample of Veterans with CHD. Participants' representations of their CHD were assessed by telephone at 1-week post-hospital discharge and medical record data were collected regarding health status and known CHD risk factors. Participants were then randomized to the telephone-based CHD cognitive representations intervention or to usual care. Outcome data were collected at 1-month and included self-report measures of representational change, quality of life, behavioral intentions, and health behaviors. In addition to self-reported outcomes, we also examined participants' referrals to and engagement in programs designed to modify CHD-related risk factors such as weight/diet, physical activity, tobacco use, and other chronic disease management interventions. This was accomplished by chart review.

FINDINGS/RESULTS:
Inpatient admissions were monitored from April 17th through June 28th for patients hospitalized for CHD. A total of 501 admissions were screened during that period. Of these, 56 (11.2%) met initial screening criteria based on medical status, and 46 (9.2%) were determined to be eligible for participation. Thirty seven (80.4% of eligible participants) were approached, and 14 (30.4% of eligible) agreed to participate and were subsequently enrolled. This represented 58.3% of the original enrollment target of 24 patients.

Five participants (35.7%) dropped out prior to the end of data collection. Three participants requested withdrawal due to insufficient time or a desire not to continue. A fourth participant was withdrawn by the PI following medical complications and relocation to a long-term care facility, while a fifth was withdrawn due to psychiatric emergency and subsequent re-hospitalization.

Baseline data were collected from 12 of the 14 participants who were enrolled. All participants were male. They averaged 67 (SD = 10.1) years of age. The majority (75%) had completed at least some college. Forty-two percent were married, and most (58%) lived alone. Four (29%) were current smokers. Half of participants rated their health as "fair" or "poor."

Of the 12 participants providing baseline data, six were randomly assigned to the intervention condition and six to usual care. Of the six assigned to the experimental condition, two dropped out prior to receiving the intervention. The phone intervention was completed among the other four. Note: because there were too few participants to conduct meaningful comparisons between groups, the following results are presented for the sample as a whole.

Phone interviews were completed at one-week and one-month post discharge. To assess motivation, participants were asked to rate their behavioral intentions to: 1) perform regular physical activity, 2) eat a low-fat diet, and 3) take their heart medications as prescribed on Likert-type scales ranging from 1 (I have no intention to doing this) to 7 (My intention to do this is extremely strong). Although changes in intentions to engage in regular physical activity (M = 0.2, SD = 0.9) and eat a low-fat diet (M = 0.6, SD = 1.1) were in the expected direction (indicating increased motivation over time), results were not statistically significant, a finding that may be partially attributable to the small sample size. Intentions to take medications as prescribed declined non-significantly over time (M = -0.4, SD = 0.7). Given the exceptionally high mean baseline ratings, however, which averaged 6.8 (SD = 0.6), this is not entirely surprising. Notably, participants reported significant reductions in the amount of time sitting daily. Overall, sedentary time declined approximately 2.5 hours (M = 156.0 minutes, SD = 208.2) from before their cardiac event to the time of the one-month follow-up (p = .042).

One-month chart reviews revealed the following. All 4 smokers remaining in the study received treatment during their inpatient stay in the form of brief counseling. Two patients also received pharmacotherapy to assist with cessation. No referrals to internal or external nicotine dependence treatment services were provided. With regard to weight management and dietary modification, six participants received dietary and/or physical activity counseling during hospitalization. One participant was referred to MOVE! for assistance with weight loss but did not attend. Following discharge, two patients received outpatient dietary counseling through the Cardiology Service, and one received nutritional and physical activity recommendations from a primary care provider. Four patients were referred to community programs for cardiac rehabilitation, while a fifth was referred to a home-based VA research telehealth cardiac rehabilitation program. Plans were made to refer one more participant for cardiac rehabilitation, but he was determined by the community program to be ineligible. One participant was also enrolled in a home telehealth program for patients with congestive heart failure.

IMPACT:
This pilot study has helped to establish the feasibility of a telephone-based intervention designed to modify misconceptions in patients' cognitive representations of CHD. Although the sample size was small due to fewer patients than anticipated meet eligibility requirements and a higher than expected drop-out rate, findings are encouraging with regard to the feasibility of the intervention approach. Strategies for reducing participant burden through a briefer assessment protocol and delaying enrollment until after hospitalization are expected to help to address the challenges experienced with regard to enrollment and retention. Results will provide the basis for a subsequent multi-site randomized clinical trial designed to evaluate the efficacy of the intervention on a larger scale.

PUBLICATIONS:
None at this time.


DRA: Cardiovascular Disease
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Behavior (patient), Quality of life, Telemedicine
MeSH Terms: none

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