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Although mortality from cardiovascular (CV) disease has fallen in the past decade, the burden of CV disease and related conditions remains high, with rates of hospitalization and disability and cost on the rise. Prevention and treatment of CV conditions often involve a complex regimen of lifestyle modification, medications, and/or symptom monitoring and management. Cardiovascular health professionals spend a great deal of time promoting awareness of and adherence to national guidelines for the prevention and management of CV conditions. In addition, patient education for hospitalized patients is becoming increasingly regulated by national organizations and payors. However, it is unclear which educational intervention elements or strategies are most effective for educating hospitalized CV patients and their families. The purpose of this systematic review of experimental and quasi-experimental studies was to identify and examine the characteristics and outcomes of CV health education interventions for hospitalized CV patients.
Although the prevalence and mortality rates of cardiovascular disease (CVD) have decreased over the past decade, cardiovascular (CV) conditions remain the most common diagnoses among all hospital discharges.1 An estimated 81 million Americans have CVDs, including hypertension, stroke, coronary heart disease (CHD), myocardial infarction (MI), heart failure (HF), and congenital heart disease, and 1 of every 3 deaths in the United States is attributable to CVD.1 Total CVD-related hospital costs for inpatient, outpatient, and emergency department (ED) care in the United States for the year 2010 are estimated at $155.7 billion.1 The staggering economic burden of CVD in the United States, including healthcare expenditures and lost productivity from deaths and disability, is evident and has warranted the current American Heart Association goal of improving the CV health of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%.2
As CV health professionals, we spend a great deal of time promoting awareness of and adherence to national guidelines for the prevention and management of CV conditions. We diligently educate and encourage individuals to adhere to their treatment regimen(s) and reduce CVD risk by modifying their lifestyle. However, the adoption and maintenance of new CVD risk-reducing behaviors pose seemingly insurmountable challenges for many individuals. For the hospitalized CV patient and their family, patient education often covers the continuum of primordial, primary, secondary, and tertiary disease prevention as well acute to chronic phases of disease management.2 Hence, the hospitalization can serve as a critical "tipping point," an ideal moment at which patients and their families are susceptible to patient education.
There are numerous challenges associated with providing education and counseling to CV patients in the hospital setting. Patients and families are often physically and psychologically unprepared for learning during hospitalization. Patients' level of illness acuity, anxiety, fatigue, cognitive function, and health literacy may influence their ability to actively engage in and benefit from patient education activities. Health professionals may have insufficient time to devote to ongoing and individualized patient education, thus resorting to distribution of standardized materials at discharge. Often, patient education is documented by a single statement or check mark indicating that information was provided, without including any details on the content or elements provided.3 In addition, health professionals often lack adequate skills for effective patient education and lifestyle modification counseling. Despite the challenges, patients and their families require education in preparation for CV health-promoting activities after hospital discharge.
The importance of family and caregiver involvement in education during hospitalization for an acute or chronic cardiac event may be critical. When a serious cardiac event occurs, a patient's family may be affected as well and often must assume caregiving responsibilities. In a study to determine the needs of hospitalized patients and their spouses after an acute cardiac event, Moser et al4 discovered that although both parties identified the need for information as being most important, there were significant discrepancies between patients and their spouses in priorities. Identified information needs for both patients and spouses were reportedly unmet by healthcare providers in 40% to 70% of cases.4 Similarly, the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) study reported that only 54% of US hospitalized HF patients received all mandated discharge education components.5 The information needs of hospitalized CV patients and their families commonly remain inadequately addressed at discharge.
Patient education is a combination of learning experiences influencing behavior change, producing change in knowledge, attitudes, and skills needed to maintain and improve CV health status and outcomes.6 Goals of education for CV patients include increased participation in decision making and in continuing care, increased potential to follow agreed-upon treatment regimen, maximization of patient and family CV care skills, improvement of patient and family coping skills, and promotion of a healthy lifestyle.2,6,7 The elements of patient education interventions include the following:
1. Approach to education. The approach involves the general strategy for communication information to patients. Approaches may be standardized or individualized. With standardized approaches, all individuals receive the same educational content. Individualized interventions may be tailored to specific individual characteristics. Standardized or individualized interventions may target specific populations (eg, older persons, those with low education).
2. Mode of delivery. The mode of delivery encompasses the medium or format for information delivery. Medium is the process through which education is delivered and may include face-to-face or telephone contact, written resources, or audiovisual materials. Format refers to how the education is offered and may include 1-on-1 or group interaction.
3. Dose. Dose is the level at which an intervention is delivered and may be described as the number and length of educational sessions.6,8
Patient education for hospitalized patients is becoming increasingly regulated by national organizations and payors. The Joint Commission's general requirements on patient education include documentation of the creation, implementation, and effectiveness of overall patient education programs as well as specific documentation of education provided to hospitalized patients and families.7 Similarly, the National Quality Forum has specified that all patient education must include detailed, documented, written discharge instructions for the patient or caregiver.9 Hospital staff are devoting significant resources to meeting these requirements. However, it is unclear which educational intervention elements or strategies are most effective for educating hospitalized CV patients and their families. The purpose of this systematic review of experimental and quasi-experimental studies was to identify and examine the characteristics and outcomes of CV health education interventions for hospitalized CV patients.
A systematic review of PubMed and Cumulative Index to Nursing and Allied Health Literature databases was conducted using the following keywords: cardiac patient education, cardiovascular patient education, and descriptors such as hospital, hospital* and inpatients, myocardial infarction, coronary heart disease, heart failure, and cardiac surgery. Reference lists of studies retrieved were also examined for additional studies that reported testing an educational intervention for hospitalized CV patients. Inclusion criteria were as follows: (1) included used experimental or quasi-experimental study design, (2) included a sample of adults (>=18 years of age) with or at risk for CVD, (3) tested an educational intervention that was provided or initiated during hospitalization, and (4) published in English between January 2000 and June 2010. Outcomes of educational intervention were not prespecified because of the heterogeneity of the hospitalized CV patient population and goals of intervention.
A total of 2136 citations were identified from electronic databases and reviewed, with 25 studies meeting inclusion criteria for this review. Of the 25 studies reviewed, 80% (n = 20) were randomized controlled trials (RCTs) and 20% (n = 5) were quasi-experimental studies. Table 1 summarizes the study population, intervention elements, outcomes, and results for each study. Table 2 provides a brief synopsis of the characteristics of the educational interventions, including approach, type of tailoring, mode, dose, guiding theoretical framework/educational principles, and effects on outcomes. The studies were conducted in the United States (n = 12), United Kingdom (n = 4), Italy (n = 2), Australia (n = 2), Canada (n = 1), Germany (n = 1), the Netherlands (n = 1), Norway (n = 1), and Sweden (n = 1). Patient populations included adults admitted for a broad range of CV conditions and procedures: acute chest pain/cardiac ischemia, acute coronary syndrome, CVD, congenital heart disease, HF, MI, stroke, coronary angiography/angioplasty, cardiac catheterization, and coronary artery bypass surgery. One study targeted nonacute patients in an ED waiting room. Two trials15,20,23 had fewer than 100 participants.
Only 2 studies,14,21 both RCTs, explicitly included caregivers and family members in the intervention. Significant improvements in knowledge21 and caregiver burden, anxiety, depression, and healthcare costs17 were reported. Fourteen (56%) trials tested an individualized approach, whereas 11 (44%) tested standardized education approaches. Mode of intervention was highly variable across studies, with most studies combining 1 or more mode of intervention delivery. Educational intervention modes included written materials, visual cue card, wallet card, verbal advice, 1-on-1 counseling in person or via telephone, group counseling, home care after discharge, biofeedback, hands-on instruction, as well as video/DVD, computer-based, and multimedia formats. Whereas all studies tested interventions that provided patient and/or caregiver education, 3 studies also included interventions at the healthcare professional level, such as reminder stickers in medical charts17 and education, decision support, and feedback.27,28 The majority (60%) of interventions was delivered entirely during hospitalization, and among 40%, some aspect of the intervention was delivered after discharge. The number of intervention sessions ranged from 1 to 13 across studies, with the majority (60%) of study interventions involving only 1 educational session. Although several studies did not report the duration of educational sessions, reported sessions were from 7 minutes to 2.5 hours in length.
Of the studies reviewed, 2 reported targeting of educational content beyond the focus on a particular CV condition. Interventions were targeted to those with limited education,13 those with limited health literacy,20 and to older persons with use of a touch screen and large, clear illustrations and buttons.32 Individual tailoring of interventions was reported in 8 (32%) studies: tailoring approaches to included diagnosis-based information12; lifestyle, knowledge, and medical therapy specific information16; preferences for topics, amount of information, and font size18; postdischarge care plan20; CV risk factor values and personalized goals23; individual achievements and goals25; individual needs and communication style30; and caregiver training tailored to patient's needs.21 Only 5 studies reported the theoretical framework or educational principle that guided the intervention. Guiding frameworks included self-care,9 self-care agency,19 self-regulation,30 self-efficacy,18 and general educational principles.10,15,18
Outcomes measured in the reviewed studies included knowledge, psychosocial (ie, anxiety, depression, satisfaction), behavioral (ie, diet, physical activity, adherence, self-care, smoking cessation), clinical (ie, lipid profile, blood pressure, mortality), and healthcare utilization (ie, ED visits, hospitalization, cost). All but 3 studies13,17,27 reported statistically significant results in at least 1 outcome. Of the 10 studies that included a postdischarge intervention component, 9 reported statistically significant effects on at least 1 of the study outcomes. The educational interventions had a positive effect on knowledge in 9 of 10 studies, psychosocial aspects in 7 of 11 studies, behavior in 7 of 12 studies, clinical outcomes in 4 of 7 studies, and healthcare utilization in 5 of 8 studies that measured these categories of outcomes. Of the 3 studies that found no significant intervention effect on outcomes, 1 was a prospective time series study that tested a provider- and patient-level intervention delivered during and after hospitalization27 and 2 RCTs13,27 tested brief interventions delivered in 1 session during hospitalization.
Patient education interventions for hospitalized patients have been tested in a broad range of CV conditions including HF, CABG surgery, MI, CHD, stroke, and percutaneous coronary intervention and in hospitalized smokers with CVD. Most studies in this review used multifaceted approaches such as 1-on-1 counseling, video education, written material, and computer-based teaching. Interventions ranged from brief single sessions to 13 educational sessions, and noteworthy is the fact that only a few studies had multiple educational sessions. Compared with single-session interventions, evidence suggests that programs that incorporate scheduled follow-up sessions as a core component are generally more effective.35
Overall, education of CV patients and family in the hospital setting had a significant effect on the individual's knowledge and psychosocial, behavioral, clinical, and healthcare utilization outcomes, but in varying degrees. Most studies (9/10) that measured intervention effect on knowledge showed a significant improvement in knowledge. However, fewer interventions improved behavioral and/or clinical outcomes. Surprisingly, of the 4 studies16,18,24,32 measuring knowledge and behavioral and/or clinical outcomes, none showed a significant effect on both knowledge and behavioral or clinical outcomes. This may be because knowledge is necessary but insufficient to impact behavior and clinical outcomes.8,36 Interventions designed to build self-care, communication, and problem-solving skills may be more effective in improving behavioral and clinical outcomes.37,38 It may be important to note that of the 4 studies22,23,26,29 that tested interventions that resulted in improved clinical outcomes, all used multiple modes of intervention delivery and education was individualized in 2 of the 4 studies. The strategies applied across studies varied, which limits our ability to make meaningful generalizations. Additional research is need in the area of behavioral and clinical outcomes to determine which patient education methods are most effective in improving CV health behavior and related outcomes.
With a focus on reducing the nation's healthcare expenditure and improving the quality of healthcare, examination of the effect of patient education strategies on healthcare utilization outcomes and cost is increasingly important. Of the 5 studies11,20-22,26 that demonstrated improved healthcare utilization outcomes, the majority (80%) delivered individualized education in multiple sessions, and all interventions were delivered through multiple modes. Anderson et al11 reported on an inpatient education program combined with discharge planning and outpatient support for elderly HF patients which cost approximately $158 per subject to implement and translated into a $1541 cost saving per subject over 6 months compared with control. This cost savings was the result of reduced readmission and utilization of home health and skilled nursing services after discharge. In this study, 6-month readmission rates were significantly lower in the intervention compared with the control group (11.4% vs 44.2%), which the authors indicated was similar to results obtained by comprehensive trials with medical management.11 This study exemplifies that effective education strategies can be implemented during and after hospitalization to improve healthcare utilization outcomes and ultimately reduce costs. Unfortunately, demonstrating the cost-effectiveness of patient education strategies can be challenging given that in our current healthcare environment, hospital system, provider, and payor incentives often are not aligned. Further research to demonstrate the most effective educational strategies is needed along with policy changes to align incentives to ensure reimbursement for delivery of effective patient education activities.
Although a number of studies that used standardized intervention approaches improved outcomes, greater benefit is generally attributed to individualized approaches. Standardization of educational tools ensures that all patients receive equivalent, evidence-based information and, importantly, may be more feasible to deliver in a busy, inpatient setting. However, strategies that fit with the patient's learning styles, cognitive level, and motivation by using tailored interventions offer a more directed way to enhance compliance among patients. Individualization should therefore begin with evaluating patients' learning needs,39 learning styles,40 and health literacy41 to effectively educate and improve CV health outcomes. Although health literacy has been identified as a barrier to effective education in several populations, in this review, only 1 study tailored their intervention to patients with limited health literacy.20
Because 75% of all information absorbed comes visually, 13% comes from hearing, and the rest comes from the other senses, it seems appropriate that most studies included visuals such as illustrated booklets and video animations.42 Most studies tested multifaceted interventions, so it is not clear which aspects of interventions may be more effective. However, interventions using a combination of intervention modes, for example, written, audiovisual, and pictorial, have been suggested to be most effective in improving knowledge and behavioral outcomes.39
Surprisingly, only 5 studies identified which theoretical framework or educational principles were used as the guiding framework for their interventions. Effective patient education requires knowledge of theoretical frameworks and educational principles to achieve optimal health outcomes.43 The most commonly tested theories and models include the Health Belief Model, Self-efficacy Theory, Health Promotion Model, Stages of Change Model, and PRECEDE-PROCEED Model.44 However, learning and behavior change are a complex process that may not be completely explained by a single theory or model. These theories are helpful in understanding patient motivation for behavior change and developing effective health promotion strategies.
As this review has shown, there are various patient education strategies that can be implemented for the hospitalized CV patient and family. However, interventions need to be feasible as well as cost-effective. Barriers at the institutional, provider, and patient level that encumber the adoption and effectiveness of patient education strategies also need to be addressed. Nursing shortages, faster discharge processes,45 and lack of reimbursement for time spent in additional patient outreach/education46 are but a few institutional-level barriers to effective patient education. Healthcare professional-level barriers identified in the literature include paternalistic teaching style, lack of motivation, lack of self-efficacy, lack of outcome expectancy, lack of counseling skills, and knowledge deficit on education principles.47-49 Patient-level barriers include knowledge, attitude and beliefs about CV health,35,50-53 and health literacy.54,55 Failure to address the above barriers may result in suboptimal outcomes despite the potential effectiveness of a particular patient education strategy.
A multilevel, interdisciplinary approach is needed to improve patient education for hospitalized CV patients and their families. Evaluation methods for teaching in the inpatient setting must improve and move beyond single-statement documentation that teaching was provided to include the approach, mode, and dose of delivery as well as feedback from patients on the effectiveness of teaching. Additional translational research is needed in the area of CV health education to determine the most effective patient education strategies in the hospital setting. Although interventions focused on patient education strategies are beneficial, patient education is rarely delivered in isolation from other primordial, primary, and secondary prevention strategies. Although education alone may be insufficient to improve CV health outcomes, we believe that this review is a significant addition to the body of research on CV patient education and highlights the need for a greater emphasis on education strategies that improve behavioral, clinical, and healthcare utilization.
* Systematic review of experimental and quasi-experimental studies identified the characteristics and outcomes of CV health education interventions for hospitalized CV patients.
* Important implications include those for the design of educational interventions to improve knowledge, behavioral, and clinical outcomes among hospitalized CV patients.
* Evidence suggests that, compared with single-session interventions, programs that incorporate scheduled follow-up sessions as a core component are generally more effective.
* Interventions designed to build self-care, communication, and problem-solving skills may be more effective in improving behavioral and clinical outcomes than those focused solely on increasing knowledge.
* Patient education strategies that fit with the patient's learning styles, cognitive level, and motivation by using tailored interventions offer a more directed way to enhance compliance among patients.
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