Patient education strategies for coronary heart disease in a cardiac rehabilitation setting: A scoping review

Varoon Chandramohan Jaiswal; Lata Parmar; Snehal Ghodey

doi:10.4103/jdmimsu.jdmimsu_93_21

REVIEW ARTICLE

Year : 2022 | Volume : 17 | Issue : 1 | Page : 152-165

Patient education strategies for coronary heart disease in a cardiac rehabilitation setting: A scoping review

Varoon Chandramohan Jaiswal¹, Lata Parmar², Snehal Ghodey³
¹ Sumandeep College of Physiotherapy, Sumandeep Vidyapeeth An Institution Deemed-to-be-University, Sumandeep Vidyapeeth, Vadodara, Gujarat; Cardiovascular and Respiratory Physiotherapy, MAEER'S Physiotherapy College, Talegaon Dabhade, Maharashtra, India
² Sumandeep College of Physiotherapy, Sumandeep Vidyapeeth An Institution Deemed-to-be-University, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
³ Deaprtment of Musculoskeletal Physiotherapy, MAEER'S Physiotherapy College, Talegaon Dabhade, Maharashtra, India

Date of Submission	28-Feb-2021
Date of Decision	10-Dec-2021
Date of Acceptance	29-Jan-2022
Date of Web Publication	25-Jul-2022

Correspondence Address:
Dr. Varoon Chandramohan Jaiswal
MAEER'S Physiotherapy College, Talegaon Dabhade, Taluka Maval District, Pune, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_93_21

Abstract

Coronary artery disease is the leading cause of death and disability globally. Comprehensive cardiac rehabilitation has been proved to be beneficial in reducing death and disability for patients with coronary artery disease. Patient education is an integral part of comprehensive cardiac rehabilitation and its benefits are well documented. The objective of the scoping review is to map the strategies of patient education in a cardiac rehabilitation setting. A total of 31 published scientific articles (24 research studies and 7 reviews) were included in the review based on the inclusion criteria. 23 varied patient education strategies for coronary heart disease patients were identified from the included studies and 20 different delivery formats of education have been reported in the literature. This scoping review provides a brief insight to various patient education strategies and delivery format used in a cardiac rehabilitation setting.

Keywords: Cardiac rehabilitation, coronary heart disease, death, disability, patient education

How to cite this article:
Jaiswal VC, Parmar L, Ghodey S. Patient education strategies for coronary heart disease in a cardiac rehabilitation setting: A scoping review. J Datta Meghe Inst Med Sci Univ 2022;17:152-65

How to cite this URL:
Jaiswal VC, Parmar L, Ghodey S. Patient education strategies for coronary heart disease in a cardiac rehabilitation setting: A scoping review. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Sep 25];17:152-65. Available from: https://journals.lww.com/dmms/pages/default.aspx/text.asp?2022/17/1/152/352253

Introduction

Cardiovascular disease (CVD) is a major reason for death and disability globally.^[1],[2] It also produces immense healthcare and social burden.^[3] Death due to CVDs in 2017 is estimated at around 17.8 million and 35.6 million years lived with disability.^[4] CVDs are responsible for 151,377 million disability-adjusted life years, of which 62,587 million are due to coronary heart disease (CHD).^[5] Death and disability predominantly come from low and medium-income countries in the world.^[6],[7] Disability due to CHD leads to reduced health-related quality of life (HRQOL) in the diseased people as compared to their healthy counterparts.^[8] Cardiac rehabilitation has been strongly recommended as part of essential care that should be available to cardiac patients to improve their clinical and functional status.^[9],[10] Initially, rehabilitation of cardiac patients involved only exercise training and psychological counseling to selective patients with anxiety and depression due to acute coronary events. Since 1960 cardiac rehabilitation has evolved in with focusing on various aspects of health and lifestyle modification, this modern cardiac rehabilitation is called comprehensive cardiac rehab with its core components comprises of exercise prescription, education about health and disease, advice, and lifestyle modification strategies to reduce risk factors for CHD.^[11] A Cochrane review published in 2010 which studied 7683 patients contributing to total mortality outcome concluded that cardiac rehabilitation is effective in reducing cardiac mortality.^[12] The American Heart Association and American College of Cardiology strongly recommend Cardiac rehabilitation for the patients with myocardial infarction, this recommendation is based on the strong evidence coming from results of the multiple meta-analyses have demonstrated a reduction in the mortality rates.^[13],[14] Studies have also proved that Cardiac Rehab reduces hospital admission in a 1-year duration, improves HRQOL, and reduction in the cost of health care resources in patients with CHD.^[15]

Patient education is an important component of the comprehensive cardiac rehabilitation program offered to patients with CHD.^[16],[17] Patient education focuses mainly on behavioral and self-management strategies of risk factors to enhance the HRQOL of the patients.^[18] The cardiac rehabilitation program is ideal to impart the patient education program to CHD patients and has also been proved more effective than an individual or telephone-based approach. Content of the patient education in CHD patients is focused on nutrition, physical activity, cessation of smoking, prescribed medications, knowledge of the disorders, sexuality, and social adaptation of the disorder.^[19] A Cochrane review conducted in 2017 concluded that participants received patient education as part of the cardiac rehabilitation program showed no reduction in overall mortality as compared to those who have not received any education. It was also concluded that there is some evidence that patient education does reduce fatal or non-fatal cardiovascular events and may improve HRQOL the utilization rates of a cardiac rehabilitation facility as underutilization of cardiac rehab program by the patients is well documented.^[20] With all these proven benefits of patient education on coronary artery disease patients, the review of various strategies to the delivery of patient's education is the need of the hour.

Given the dearth in the literature in the current state of knowledge on various strategies available on patient education of CHD patients in a cardiac rehabilitation setting the authors have conducted a scoping review. Scoping reviews prove useful when the goal is to plot the current state of knowledge in a specific research area. A preliminary search was conducted on 3 June 3, 2020, in the PubMed and Cochrane database for systematic reviews, and no current or ongoing reviews were found to examine the patient education strategies for CHD in a cardiac rehabilitation setting.

Materials and Methods

Scoping review questions:

What patient education strategies exist for CHD patients in a cardiac rehabilitation setting?

Objectives

To identify the existing strategies of patient education for coronary heart disease in a cardiac rehabilitation setting
To summarize the patient education strategies used in the cardiac rehab program
To make recommendations for the areas of future research on patient education for coronary heart disease.

Inclusion criteria

Participants: The scoping review will include worldwide studies that include Coronary heart disease patients receiving any type of education for health
Concept: The core concept of the review is to study the strategies of patient education and only the studies on the same will be included
Context: The context of the review is to study patient education strategies in a cardiac rehab program
Types of evidence sources: The scoping review is open for all types of studies this will include,

Quantitative: Experimental, quasi experimental, prospective and retrospective cohort, case-control and cross-sectional studies
Observational: Case series, individual case reports, descriptive cross-sectional studies
Qualitative: Phenomenology, ethnography, qualitative description
Mixed method studies
Systematic reviews, narrative reviews, and opinion letters will be included along with the grey literature
Research published in the English language only will be included and no date restrictions shall be implemented in the search [Figure 1].

Figure 1: PRISMA Scr flow diagram

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Search strategy

A search strategy was formulated to locate both published and unpublished primary types of research done on patient education in a cardiac rehabilitation setting. An initial search of PubMed was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the Mesh terms used to describe the articles, were used to develop a full search strategy detailed in [Appendix 1]. The final step of the search strategy was done by reviewing the reference lists of articles included in the review to identify additional papers.

Information sources

PubMed, Cochrane Database and registry of clinical trial, Pedro (Physical therapy Evidence Database).

Grey literature search

Was done by searching Clinical trial registries example: ClinicalTrails. gov, Google Scholar.

Study selection process

Two hundred and seventy-six records were identified by using the search strategy and the above mentions sources. Records were downloaded and were compiled in the reference management software (Mendeley Version 1803) and all the articles were processed for duplicity and 9 duplicate records were removed. Two hundred and sixty-seven articles titles and abstract was screened for the inclusion criteria by two independent reviewers for including the articles in the review in which 235 records were excluded. The remaining 32 records were included for full-text screening and 1 record was excluded as the full text was not available in the English language. As described in [Figure 1] thirty-one records were included for the review, data charting was done.

Data Charting

Results extracted from the source of evidence (according to the concept of the scoping review) [Table 1].

Table 1: Data Charting

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Results

Results are described and analysed in [Table 2].

Table 2: Results

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Discussion

We identified 31 research articles as per the specified inclusion criteria out of which 16 researches were published in last 5 years (2015-2020). Twenty-three different patient education strategies are identified by the authors. Researches included in this review can be broadly arranged in 6 different categories based on their outcomes.

Supporting patient education as part of cardiac rehab program
Increasing utilization and adherence of the emergency and rehab services
Improving risk factor profile and reducing mortality
increased knowledge about the disease, improved self-care behavior and quality of life
Return to work
Development of educational program and framework.

Supporting patient education as part of cardiac rehab program

We found 3 systematic reviews suggesting a strong role of patient education in management of coronary heart disease. Patient education is the integral component of cardiac rehab and secondary prevention programs.^[19] Patient education sessions are conducted by health-care professionals in both inpatient and outpatient settings in group and face to face format during clinic visit with or without spouse in a structured or an unstructured format.^[21]

Increasing utilization and adherence of the emergency and rehab services

A systematic review published in 2019 concluded that patient education is a prime intervention in promoting the utilization of cardiac rehab services.^[20] Primary patient education strategy influencing the utilization and adherence of rehab services included in the review is telephonic counseling with or without spouse and informative mails.^[22],[23] Patient participation in decision making (CHOICE program), learning and coping strategies (LC rehab) and motivational interviewing were the strategies reported to be effective in increasing the utilization and adherence to the rehab services.^{[22],[24],[25]} Face to face personalized education did not reduce pre hospital delay and no increase in emergency department use was reported.^[26]

Improving risk factor profile and reducing mortality

Patient education has a significant role in reducing mortality and improving the risk factor profile in patients with coronary artery disease. Systematic reviews and meta-analysis of randomized controlled trial (RCT) and quasi-experimental studies have concluded that the psychoeducational patient educational strategy has reduced cardiac mortality by 34%, recurrence of MI, and has improved risk factor profile.^{[27],[28],[29]} Patient education strategies such as PEGASE educational program, CHOICE program, face to face sessions, structured flipchart, and teach-back strategies reported being effective in reducing mortality and improving risk factor profile.^{[22],[29],[30]} However other strategies such as LC rehab and personalized patient education by providing ultrasonography reports were reported to have no effect on mortality and readmissions.^[31],[32]

Increased knowledge about the disease and improved self-care behavior and quality of life

The effect of patient education has been extensively studied by researchers for improving disease-specific knowledge, self-care behavior change, and quality of life. A systematic review of 42 studies reported that patient education has a positive effect on patients' disease-specific knowledge and behavior change.^[33] Another systematic review and network meta-analysis, which included 148 RCTs, reported patient education lead to improvements in the quality of life.^[34] Patient education strategies such as CHOICE program, providing disease-specific information in the form of booklet and videos, curriculum-based education on coronary heart disease, the cardiac college which is part of an E-health university to improve the health literacy of patients, inpatient psychoeducation, audience response system, and LC-rehab were reported to be effective in improving the knowledge of disease in coronary heart disease patients.^{[22],[25],[35],[36],[37],[38],[39],[40]} Improvements in self-care and Quality of life were the other two outcomes that were reported to have positively impacted by patient education. Strategies involved in improving self-care and Quality of life are “Cardiac home educational trail” (CHEST) a peer support intervention, innovative psychological intervention, face-to-face educational sessions using flipcharts, and teach-back focusing on self-care, M-health program, and self-management educational group program.^{[29],[41],[43],[44]}

Return to work

A Cochrane review published in 2019 which included 39 RCTs in total has a sub-category of 15 studies comparing the effect of psychological intervention (including health education) versus usual care on return to work, concluded that there is little or no effect of psychological intervention which includes health education on return to work status at 6 months after acute myocardial event.^[45] LC rehab patient education strategy also had no effect on return to work after 1 year of follow-up.^[46]

Development of educational program and framework

We found only one patient education program framework tool published as per our search criteria. French I care project, it provides framework to health-care educators to develop the therapeutic education specific to congestive cardiac failure.^[47]

Conclusions

Patient education program in cardiac rehab setting is well supported in the literature. Patient education plays a vital role in increasing utilization and adherence of the emergency services, improving risk factor profile and reducing mortality, increasing knowledge about the disease, and improving self-care behavior and quality of life. Patient education has little or no role in return to work after myocardial event according to the studies included in the review.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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