The effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery: a systematic review protocol

Review question/objective Do nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery improve patients' health-related quality of life and reduce hospital readmissions? Background Cardiovascular diseases (CVDs) are an emerging epidemic and the primary cause of premature death, disability, hospitalization and healthcare expenditure throughout the world.1,2 CVDs include vascular diseases of the brain and diseases of the blood vessels and heart. More people die annually from CVDs - primarily from stroke and heart attack - than from any other cause.2 In 2008, of the 57 million deaths globally, 17.3 million (30%) were due to CVDs; a figure that is projected to rise to 25 million by 2030.2,3 The worst affected populations are those from low and middle income countries (LMICs), where over 80% of cardiovascular deaths occur, with approximately equal prevalence among men and women.2 There are 3.5 million (17%) Australians living with chronic CVD; the main types are coronary heart disease (CHD), cardiomyopathy or stroke and heart failure. In 2007-08, CHD was the principal diagnosis of 161,417 hospitalizations with rates twice as high for males than females, 60% of which occurred among those 65 years and over.4 In 2008, an estimated 48,453 deaths were due to CVD, with death rates in males aged 45 to 64 years almost three times higher than females of a similar age. However, a higher percentage of the female population is living longer and 78% of CVD deaths occur in females aged 75 years and over. The direct and indirect costs of CVD places great strain on healthcare resources worldwide.5 In 2004-05, Australia spent $5,942 million worth (11%) of healthcare expenditure on CVD; more than any other disease,5 and in excess of $500 billion is spent on CVD annually in the USA.5 According to Weerasinghe et al., 17,000 coronary artery bypass graft (CABG) surgeries are performed in Australia annually with the CABG rate second only to the US.6 The safety and efficiency of cardiac operations and surgical procedures has improved over the last three decades.6 In recent years, percutaneous coronary intervention (PCI), a non-surgical procedure, has become the treatment of choice for patients who may not survive CABG surgery.7,8 However, while PCI may be universally applicable, findings from meta-analysis have consistently shown increased rates of repeat procedures.8,9 Over the last decade, despite patients presenting with co-morbidities including hypertension and obesity, CABG remains superior to PCI as an excellent revascularization procedure for complex CHD, such as left ventricular dysfunction and diabetes mellitus. CABG enhances blood flow to the heart and offers long term survival, freedom from re-intervention due to failure of the initial procedure and adverse cardiac events, notably heart failure or stroke, as well as being a more cost-effective procedure.7,8 Data collected from the Australia and New Zealand Global Registry of Acute Coronary Events (GRACE) - a large multinational acute coronary syndrome registry - reported that between 1999 and 2007, 20% of the 1048 patients that were readmitted within 6 months of discharge were from the CABG population.10 According to Sangu et al., revascularization by CABG surgery is associated with a lower risk of early readmission within 30 days after discharge, suggesting that better detection and appropriate revascularization treatment for patients with recurrent coronary occlusion and ST segment elevation myocardial ischemia may avoid early hospital readmission.10 Often preventable, readmission is a costly and common outcome among patients who survive a cardiac event.10 In a study by Price et al., CABG surgery accounted for most of the frequent causes for hospital readmission.11 Due to the high cost of in-hospital care, the introduction of guidelines and protocols has been successful in reducing hospital length of stay from 11 to 8 days to contain healthcare costs for patients following CABG surgery.12 However, findings from a number of studies have found that early discharge can lead to poorer outcomes and higher costs as the patient's condition may be less stable and is more likely to result in major complications such as bleeding, wound infection and death.11,12,10 Quality improvement initiatives and cost containment should focus on the entire episode of care from initial hospitalization and the care that is required subsequently.12 Over the past two decades, there has been a dramatic decline in CVD mortality rates in developed countries through individual healthcare approaches including screening of people in different care settings for early detection. In addition, population-wide primary prevention strategies, such as public awareness promotion about the risk factors for CVD (e.g., smoking, alcohol use and unhealthy eating), provides foundational knowledge for policy makers to deliver or support prevention and treatment programs.2 Current guidelines highlight the importance of patients participating in cardiac rehabilitation (CR) as is also recommended by cardiovascular experts for the management of CVD.1,13 CR has been defined as measures designed to help patients minimize recovery time following a cardiac event and maximize physical, social and psychological functioning by encouraging positive behaviors.4 Intervention consists of medical evaluation, cardiac risk factor modification, education, behavioral change and supervised exercise training for two to three days a week over a number of weeks, months or years to produce optimum improvements in patients' health-related quality of life (HRQoL).14,15,16 Patients' perceptions of health are significant indicators of outcomes following a cardiac event. HRQoL assessments after CABG surgery and acute myocardial infarction (AMI) further provide extra measures of evaluating the effectiveness of medical and surgical treatments.17 Furthermore, with the increasing health and social care costs, CR has shown to be cost effective. There is consensus that the short-term and long-term benefits of CR programs reduce hospital readmission rates, improve health-related quality of life and lessen subsequent mortality and myocardial infarct in patients with CVD, justifying the use of health related budget.11,16,18-26 Comprehensive reviews have concluded that a physician's recommendation to CR is a strong indicator of participation, however as nurses spend more time with patients, patients who received recommendations from nurses demonstrated significantly higher CR attendance.13 Nurses are essential to the delivery of CR interventions as they encourage adherence and participation.24 Nurse-led CR programs can be distinguished by certain structures or features related to their purpose. These include emphasis on life management rather than intervention and diagnosis and a focus on health rather than illness.27 In addition to providing autonomy, nurse-led CR programs increase the opportunity for professional development among nurse practitioners. Nurse-led CR programs are staffed and managed solely by nurses with the ability to treat and consult, evaluate and refer patients to other health professionals as needed.27 Nurse-led services can optimize quality of care in managing patients with established CHD by diverting health consumers from busy general practice and hospital settings.27 This supports the view expressed by Johnson et al., that CR endorsement from nurses should be included in strategies to increase participation.13 Uptake for CR remains poor due to many reasons, such as lack of ease of access and varies between individuals who have work commitments or competing roles and responsibilities.28,29 Usual care for non-participation in CR provides mandatory patient education including phone interaction or face-to-face contact with healthcare professionals, written materials available as pamphlets, brochures or online and audio-visual resources. Topics covered are related to pain and medication management, signs and symptoms of complications, activity performance and follow up procedures. Education included in usual care is provided free of charge in the form of either a group discussion or one-on-one, for a number of sessions and for a predetermined length of time.30 Tailored approaches such as coordination of care supported by liaison nurses, motivational communication and home visits may improve uptake and adherence in CR.28 Optimum gains for patients participating in nurse-led CR are clear. This systematic review aims to investigate the effects of nurse-led CR programs on the HRQoL of patients and hospital readmissions following coronary artery bypass graft surgery. The review will add to the evidence base for nurse-led CR programs using the JBI review methodology.