Rivka HermanRivka Herman11** ,RN.,RN. M.ScM.Sc Michal LibergalMichal Libergal11*, PhD; David Rott*, PhD; David Rott22, MD, MD

11Henrietta Szold Hadassah-Hebrew University School of Nursing, in the Faculty of Henrietta Szold Hadassah-Hebrew University School of Nursing, in the Faculty of Medicine, Jerusalem, Israel. Medicine, Jerusalem, Israel. 22 Department of Medicine, Hadassah-Hebrew Department of Medicine, Hadassah-Hebrew

University Medical Center, Mt. Scopus, Jerusalem, IsraelUniversity Medical Center, Mt. Scopus, Jerusalem, Israel

Coronary Heart DiseaseCoronary Heart Disease• In the USA affects 200 men and women out In the USA affects 200 men and women out

of every 100,000of every 100,000• In Israel 25,000 hospitalizations every yearIn Israel 25,000 hospitalizations every year• CHD is a chronic disease that affects CHD is a chronic disease that affects

patients and their caregivers in terms of patients and their caregivers in terms of physical, psychological and social conditions.physical, psychological and social conditions.

(Acsis, 2008 ; American Heart Association (2006)(Acsis, 2008 ; American Heart Association (2006)

Cardiac rehabilitationCardiac rehabilitation• Decrease both morbidity and mortality of Decrease both morbidity and mortality of

patients with CHDpatients with CHD• Therefore its application is a class I Therefore its application is a class I

recommendation in most contemporary recommendation in most contemporary cardiovascular clinical practice guidelinescardiovascular clinical practice guidelines

• The participation rate in such programs,The participation rate in such programs, in the in the central region of Israel, is only between 14-20%central region of Israel, is only between 14-20%

(Wenger 2008; Acsis 2008 ; Williams et al. 2006)(Wenger 2008; Acsis 2008 ; Williams et al. 2006)

Cardiac RehabilitationCardiac Rehabilitation&&

Quality of LifeQuality of Life

Quality of lifeQuality of life • QOL is a broad concept, influenced by QOL is a broad concept, influenced by

personal perceptions, coping mechanisms, personal perceptions, coping mechanisms, and environmental constraints. and environmental constraints.

• Improving QOL is a major goal in the Improving QOL is a major goal in the context of preventive and therapeutic context of preventive and therapeutic cardiology and in cardiac rehabilitation in cardiology and in cardiac rehabilitation in particular .particular .

WHOQOL Group (1997)WHOQOL Group (1997)

The impetus for conducting The impetus for conducting this researchthis research

• To evaluate the correlation between To evaluate the correlation between participation in a CR program and QOL.participation in a CR program and QOL.

• Evaluate the association of demographic Evaluate the association of demographic parameters and cardiac risk factors on parameters and cardiac risk factors on QOL. QOL.

• A prospectiveA prospective study. study. • The target population included patients The target population included patients

with CHD who attended the cardiac with CHD who attended the cardiac rehabilitation center at our institution.rehabilitation center at our institution.

• Inclusion criteria were: stable CHD; post Inclusion criteria were: stable CHD; post MI ; age between 30-80 years; ability to MI ; age between 30-80 years; ability to answer questionnaires in Hebrew and answer questionnaires in Hebrew and independence in ADL. independence in ADL.

Three different tools were Three different tools were utilized in this researchutilized in this research

• General demographic questionnaire. General demographic questionnaire. • Cardiac assessment, utilized for Cardiac assessment, utilized for

admission into the rehabilitation program. admission into the rehabilitation program. • The Mec-New Heart Disease Health-The Mec-New Heart Disease Health-

related Quality of Life Questionnaire.related Quality of Life Questionnaire.

(Hofer et al. 2004). (Hofer et al. 2004).

Mec-New Health Related Mec-New Health Related Quality of LifeQuality of Life questionnairequestionnaire

• The questionnaire was comprised of 27 The questionnaire was comprised of 27 questions with a Likert scale in three domains: questions with a Likert scale in three domains: physical, emotional, and social.physical, emotional, and social.

• The questionnaire has a Cronbach's α of 0.93-The questionnaire has a Cronbach's α of 0.93-0.95 in English. 0.95 in English.

• The Hebrew version was validated by Dankner The Hebrew version was validated by Dankner et al. (2008) and accepted with a Cronbach's α et al. (2008) and accepted with a Cronbach's α of 0.93of 0.93..

Informed consentInformed consent• The study was approved by the The study was approved by the

institutional ethics board of the Hadassah-institutional ethics board of the Hadassah-Hebrew University Medical Center and all Hebrew University Medical Center and all participants provided written informed participants provided written informed consent after having received explanations consent after having received explanations regarding the study.regarding the study.

InterventionIntervention• Assessment by a cardiologist to determine Assessment by a cardiologist to determine

cardiac risk level.cardiac risk level.• Assessment by a physiologist.Assessment by a physiologist.• Admission by a nurse prior to physical Admission by a nurse prior to physical

activity. The program included variety of activity. The program included variety of lectures presented by the multidisciplinary lectures presented by the multidisciplinary cardiac rehabilitation team.cardiac rehabilitation team.

Statistical methodsStatistical methods• The correlation in reported QOL between The correlation in reported QOL between

pre- and post- participation in the CR pre- and post- participation in the CR program were assessed by a program were assessed by a paired t-testpaired t-test..

• Spearman’s CoefficientSpearman’s Coefficient was used to test was used to test the correlation between risk factors, risk the correlation between risk factors, risk level and education level.level and education level.

• Pearson’s CorrelationPearson’s Correlation was used to test the was used to test the relationship between age and QOL. relationship between age and QOL.

Rate of complianceRate of compliance• 8787 patients responded to questionnaires patients responded to questionnaires

prior to starting a cardiac rehabilitation prior to starting a cardiac rehabilitation program. program.

• After 3 months of rehabilitation, After 3 months of rehabilitation, 55 55 (63.2%) (63.2%) patients completed the same patients completed the same questionnaires. questionnaires.

Risk Factor and Demographic Risk Factor and Demographic DataData

• Most of the patients were Most of the patients were 55-6155-61 years of years of age, married, and underwent at least one age, married, and underwent at least one event of MI. event of MI.

• 40 participants 40 participants (53%) had a low risk factor (53%) had a low risk factor for CHD; for CHD; 2626 (33.8%) had a moderate risk (33.8%) had a moderate risk factor; and factor; and 1010 (13%) had a high risk factor (13%) had a high risk factor for CHD. for CHD.

Results (N-55)Results (N-55)

The QOL was significantly improved as The QOL was significantly improved as noted by their general score in the Mec-noted by their general score in the Mec-New Questionnaire and within each New Questionnaire and within each domain: emotional, physical limitations, domain: emotional, physical limitations, and social functionand social function

(t (54) = -3.59, (t (54) = -3.59, pp = 0.001) = 0.001)

Correlation between risk factors, risk Correlation between risk factors, risk level, age and education level level, age and education level

N-87N-87((((

AGE EDUCATION

NUMBER OF RISK

FACTORS

CARDIAC RISK

LAVEL   

0.0880.088 0.1840.184(*)(*) 0.2750.275(*)-(*)- 0.0870.087--HRQLGENERAL

0.1740.174 0.1270.127 0.2700.270(*)-(*)- 0.1260.126-- EMOTIONAL

0.0210.021-- 0.1370.137 0.2480.248(*)-(*)- 0.0810.081-- PHYSICAL

0.1200.120 0.2020.202(*)(*) 0.2580.258(*)-(*)- 0.1250.125-- SOCIAL

LimitationsLimitations• The study did not include a control group. The study did not include a control group. • A convenience sample was comprised of a A convenience sample was comprised of a

homogenous sample which may limit homogenous sample which may limit generalization.generalization.

• Other illnesses, than CHD, can influence Other illnesses, than CHD, can influence QOL. QOL.

• There was a loss to follow-up.There was a loss to follow-up.

Summary and relevance to Summary and relevance to clinical practiceclinical practice

• Nurses awareness as Coordinators of Nurses awareness as Coordinators of multidisciplinary team to QOL and for multidisciplinary team to QOL and for secondary prevention of, CHD is secondary prevention of, CHD is significantly important.significantly important.

• Use the HRQOL Questionnaire. Use the HRQOL Questionnaire. • Encourage the participation rate in such Encourage the participation rate in such

programs.programs.

ReferencesReferences• Hofer, S., Lim, L., Guyatt, G.,Oldridge, N. (2004). The MacNew Heart Disease Health- Hofer, S., Lim, L., Guyatt, G.,Oldridge, N. (2004). The MacNew Heart Disease Health-

related quality of life instrument: A summery International Journal of behavioral related quality of life instrument: A summery International Journal of behavioral Nutrition and physical Activity , 10, 1477-7525. Nutrition and physical Activity , 10, 1477-7525.

• Williams MA, Ades PA, Hamm LF, et al. Williams MA, Ades PA, Hamm LF, et al. Clinical evidence for a health benefit from Clinical evidence for a health benefit from cardiac rehabilitation: an update. Am Heart J. 2006;152(5):835-841cardiac rehabilitation: an update. Am Heart J. 2006;152(5):835-841

• Lloyd-Jones D, Adams R, Carnethon M, et al. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics -- Heart disease and stroke statistics -- 2009 update: a report from the American Heart Association Statistics Committee and 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Stroke Statistics Subcommittee. Circulation. 2009; 119(3):e21-181.Circulation. 2009; 119(3):e21-181.

• Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics -- 2008 Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics -- 2008 update: a report from the American Heart Association Statistics Committee and Stroke update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008; 117(4):e25-146.Statistics Subcommittee. Circulation. 2008; 117(4):e25-146.

• Skevington SM. Qualities of life, educational level and human development: an Skevington SM. Qualities of life, educational level and human development: an international investigation of health. Soc Psychiatry Psychiatr Epidemiol. 2010; international investigation of health. Soc Psychiatry Psychiatr Epidemiol. 2010; 45(10):999-100945(10):999-1009

• WHOQOL Group (1997). Measuring quality of life: Geneva Switzerland. (2009, June 10) WHOQOL Group (1997). Measuring quality of life: Geneva Switzerland. (2009, June 10) Retrieved from: http://www.who.int/mental_health/media/68.pdfRetrieved from: http://www.who.int/mental_health/media/68.pdf