The impact of knowledge and beliefs on adherence to cardiac rehabilitation programs in patients with Heart Failure: A systematic review

Centre conducting review Singapore National University Hospital (NUH) Centre for Evidence Based Nursing: A Collaborating Centre of the Joanna Briggs Institute Primary reviewer Tan Jia Xing Jasmine Bachelor of Science (Nursing) Honours student Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore Email: [email protected] Secondary reviewer Professor Sally Wai-chi Chan (PhD, MSc, BSc, RN, RMN, Dip. Nursing Ed.) Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore Email: [email protected] Third reviewer Professor Desley Gail Hegney (PhD, BA(Hons), DNE, COHN, CNNN, RN, RM) Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore Email: [email protected] Commencement date October 2010 Expected date of Completion April 2011 Background Heart failure (HF) is a complex condition arising from cardiac disorders which impair the ability of the ventricles to fill with and effectively pump blood. This results in an inability of the heart to pump sufficient blood to meet the metabolic needs of the body. There are several classifications of HF, depending on the underlying cause. They include systolic or diastolic failure, left-sided or right-sided failure, high output or low output failure, and acute or chronic heart failure.1 The presence and severity of this condition can be assessed by the presence of characteristic symptoms and signs such as breathlessness, edema and reduced activity tolerance. However, these classical signs of HF may also present in other conditions such as pulmonary disease, obesity and even pregnancy.2 Other diagnostic tests are therefore used in order to prevent wrongful diagnoses of HF, such as echocardiography, electrocardiography (ECG), chest X-rays and blood tests. HF is commonly associated with a low ventricular ejection fraction, raised atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in the blood and cardiomegaly, just to name a few.1 HF is at present a global health problem, with 5.7 million new cases emerging annually.3 Its incidence and prevalence increase with age, and sadly, most patients with HF die within 8 years of their diagnosis.1 Alongside the rising prevalence of HF, another healthcare problem emerges - cost. It has been found that the greatest contributor to the cost of treatment and care for HF patients is hospitalization, which makes up almost 70% of total healthcare costs.4 It was also reported that 25% of HF patients would end up being readmitted six to nine months after an initial HF admission.5 These subsequent readmissions result in an increased financial burden for these patients and the health care system.6 However, evidence shows that about 50% of these hospital readmissions may actually be preventable.7 Cardiac rehabilitation programs have been recognized as an effective intervention in improving not only short term, but also long term psychological and physiological functioning in patients with HF.9, 10In 1995, the Cardiac Rehabilitation clinical practice guideline from the U.S. Department of Health and Human Services, Agency for Healthcare Policy and Research (AHCPR) and the National Heart, Lung, and Blood Institute8 defined cardiac rehabilitation as “the provision of comprehensive long-term services involving medical evaluation, prescriptive exercise, cardiac risk factor modification, education, counselling, and behavioural interventions.” Today, this definition is still highly applicable and relevant. A study by Collins9 found that a 12-week cardiac rehabilitation program led to significant improvements in exercise tolerance and perceived physical function in HF patients. Similarly, a randomized controlled trial of cardiac rehabilitation in elderly patients with HF, found that patients in the intervention group who underwent a cardiac rehabilitation program for 8 weeks had significantly fewer hospital readmissions and had shorter hospital stays than the control group.10 These studies show that if patients adhere to their cardiac rehabilitation programs, these programs could reduce hospital readmissions and improve patients’ functional capacity. Adherence is defined as “the extent to which a persons’ behaviour (taking medication, following the recommended diet, and/or executing lifestyle changes) coincides with agreed recommendations from a health care provider.”11 Various methods can be used to measure a patient's level of adherence. Patient interviews and self-reported questionnaires are most commonly used though these may not necessarily be the most accurate methods. Other instruments include the Medication Event Monitoring System (MEMS), pill count, measurement of serum medication concentration or serum Angiotensin-Converting Enzyme (ACE) activity, interview of the healthcare provider, patient diaries and chart review.12 Non-adherence occurs when patients fail to adhere to the recommended medication, diet, and exercise regime in part or full, and is unfortunately a major problem in HF and chronic disease at present12. It can ultimately lead to higher morbidity and mortality rates in patients, a reduction in quality of life, and increased healthcare costs.13 As such, it is important to have a better understanding of the factors affecting adherence to cardiac rehabilitation programs in HF patients, in order that healthcare organizations and professionals may implement strategies to enhance patient adherence in the near future. WHO11 identified a multidimensional model of adherence in the management of chronic conditions. The model includes five dimensions that affect adherence: socioeconomic; healthcare setting and system related; condition related; treatment-related and patient-related factors. Patient-related factors, namely knowledge and beliefs, have been found in some studies, to have a significant impact on patient adherence.12, 14 On one hand, a knowledge deficit could lead to poor adherence when patients are unable to connect knowledge about their disease and symptoms to the medication uses and effectiveness17, for example, or when patients are simply unaware of the need to implement certain lifestyle changes and restrictions.14 However, while these evidences portray a close correlation of knowledge to adherence, on the other end of the spectrum, there may also be patients who choose not to adhere to the recommended guidelines despite possessing adequate knowledge.18 The same could be said about beliefs. While some studies have shown that beliefs can have a direct bearing on adherence14, 19, 20, there may also be patients who hold positive beliefs about their diet, medication or exercise, but yet demonstrate poor compliance, possibly due to other factors.14 The success of the HF rehabilitation program is largely dependent on a patient's ability and willingness to carry out the series of complex and multifaceted self-care activities.21 However, patients are often faced with the reality that many of these lifestyle changes are challenging and daunting to make. Nurses and healthcare professionals need to seize the opportunity to facilitate the coping of these HF patients and their families - from handling symptoms and complications of their condition, to following treatment plans, and eventually achieving better outcomes.21 It is therefore imperative that nurses and other healthcare professionals familiarize themselves with the latest evidence that supports best practice, as they strive toward the common goal of improving adherence and promoting self-care behaviors among HF patients. This systematic review aims to present the best available evidence in the last two decades, about knowledge, beliefs and adherence to cardiac rehabilitation programmes in HF patients, and determine the relationship between these factors. Patient adherence has long been linked to disease progression, patient outcomes and hospital readmission rates.13 With a better understanding of how patients' knowledge and beliefs can impact their level of adherence to cardiac rehabilitation programmes, healthcare professionals will then be able to implement appropriate strategies in addressing the dearth in patient adherence. Hopefully, this would lead to slower disease progression, better patient outcomes and lower hospital readmission rates in the near future. Prior to the commencement of this systematic review, the Cochrane Library, Joanna Briggs Institute (JBI) Library of Systematic Reviews and CINAHL database, were searched to ensure that no previous systematic reviews on this specific topic were identified. Through the searches, no systematic review on this topic was identified. Review Question/Objective Review Question: What is the impact of knowledge and beliefs of Heart Failure patients on their adherence to a cardiac rehabilitation program? The objective is to examine the relationship among knowledge, beliefs and adherence to a cardiac rehabilitation program in patients with Heart Failure (HF). More specifically, the objectives are to identify: The impact of knowledge and beliefs of HF patients on adherence to their: medication regime low sodium diet exercise recommendations other lifestyle recommendations, such as daily weighing and symptom management Criteria for considering studies for this review Inclusion Criteria Types of studies This review will consider any randomised controlled trials that examine the relationship between patient knowledge or beliefs and adherence to a treatment program. In the absence of RCTs other research designs, such as non-randomised controlled trials, cohort studies, case control studies, descriptive studies, and before and after studies, will be considered for inclusion to enable the identification of current best evidence regarding HF patients' knowledge and beliefs about their disease, medication, diet, exercise and other lifestyle change recommendations, and how these factors affect their adherence to cardiac rehabilitation programs. The review will exclude the following: Unpublished studies and other text such as reports, expert opinion papers, narratives, commentaries and grey literature Studies written in any other languages other than English due to a lack of translational resources Conference proceedings and grey literature Types of participants The review will consider studies that include patients, 18 years and older, who have a clinical diagnosis of Heart Failure, irregardless of the type of HF, and have been admitted to a cardiac rehabilitation program in inpatient or outpatient settings, irregardless of gender, ethnicity and the presence of co-morbidities. Types of interventions (Phenomena of Interest) This review will consider studies that evaluate the impact of HF patients' knowledge and beliefs of their disease, medication, diet, exercise and other lifestyle change recommendations, on their adherence to cardiac rehabilitation programs. Types of outcome measures This review will consider studies that include the following outcome measures: The adherence to cardiac rehabilitation programs in patients with HF. As cardiac rehabilitation programs are made up of many different components, the specific outcomes of interest in this study will include the following: The adherence to medication regimes in patients with HF The adherence to low-sodium diet recommendations in patients with HF The adherence to exercise recommendation in patients with HF The adherence to other lifestyle recommendations, such as daily weighing and symptom management, in patients with HF ?? Search strategy for identification of studies The search strategy aims to find only published studies in the English language. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: CINAHL PubMed (MEDLINE) SCOPUS Web of science OvidSP MDConsult ScienceDirect Sociological Abstracts Mosby's Nursing Consult Mednar TRIP Initial keywords to be used will be: Knowledge Belief Perception Adherence Concordance Compliance Heart failure Cardiac Failure Congestive heart failure Medication Diet Exercise Cardiac rehabilitation Cardiac Rehabilitation Program(me) Disease management Self care Self-management During the conduct of the search, consideration will be given to the diverse terminology used and the spelling of keywords as it might influence the identification of relevant studies. The search strategy can be found in Appendix I. All studies and documents identified during the database search will be assessed for relevance to the review based on the information provided in the title, abstract, and descriptor/MeSH terms. Studies identified from reference list searches of identified studies will be assessed for relevance based on the study title and abstract (if available). A full report will be retrieved for all studies that meet the inclusion criteria. If there is uncertainty about the degree to which an article meets the inclusion criteria, the full text of the article will be retrieved. The study will then be assessed for relevance once again using the inclusion criteria. Methods of the review Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data extraction Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix III).The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Potential conflict of interest There are no conflicts of interest.