"In the tube" following sternotomy: A quasi-experimental study.

BACKGROUND: Traditionally, physical movement has been limited for cardiac surgery patients, up to 12-weeks post-operatively. Patients are asked to use "standard sternal precautions," restricting their arm movement, and thereby limiting stress on the healing sternum. AIM: To compare return to function, pain/discomfort, wound healing, use of pain medication and antibiotics, and post-operative length of hospital stay in cardiac surgery patients having median sternotomy who used standard sternal precautions or Keep Your Move in the Tube movement protocols post-operatively. METHODS: A quasi-experimental design was used (100 standard sternal precautions and 100 Keep Your Move in the Tube patients). Patients were followed in person or by telephone over a period of 12-weeks postoperatively. Outcomes were measured at day 7, as well as weeks 4, 8, and 12 weeks. RESULTS: The majority of participants (77% in each group) were male and had coronary artery bypass graft surgery (66% standard sternal precautions and 72% Keep Your Move in the Tube). Univariate analysis revealed the standard sternal precautions group had lesser ability to return to functional activities than the Keep Your Move in the Tube group (p<0.0001) over time. This difference was minimized however, by week 12. Multivariate analysis revealed that increasing age, body mass index, and female sex were associated with greater functional impairment over time, but no difference between standard sternal precautions and Keep Your Move in the Tube groups. CONCLUSIONS: Keep Your Move in the Tube, a novel patient-oriented movement protocol, has potential for cardiac surgery patients to be more confident and comfortable in their recovery.

Ethno-Cultural Considerations in Cardiac Patients' Medication Adherence.

We aimed to develop an in-depth understanding about factors that influence cardiac medication adherence among South Asian, Chinese, and European White cardiac patients. Sixty-four patients were purposively sampled from an ongoing study cohort. Interviews were audio-recorded and transcribed for analyses. Physicians' culturally sensitive communication and patients' motivation to live a symptom-free and longer life enhanced adherence. European Whites were motivated to enhance personal well-being and enjoy family life. South Asians' medication adherence was influenced by the desire to fulfill the will of God and family responsibilities. The Chinese were motivated to avoid pain, illness, and death, and to obey a health care provider. The South Asians and Chinese wanted to ultimately reduce medication use. Previous positive experiences, family support, and establishing a routine also influenced medication adherence. Deterrents to adherence were essentially the reverse of the motivators/facilitators. This analysis represents an essential first step forward in developing ethno-culturally tailored interventions to optimize adherence.

Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with type 2 diabetes mellitus: a population-based cohort study.

AIM: To determine the prescribing of and adherence to oral hypoglycaemic agents, insulin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statin therapy among South-Asian, Chinese and white people with newly diagnosed diabetes. METHODS: The present study was a population-based cohort study using administrative and pharmacy databases to include all South-Asian, Chinese and white people aged ≥ 35 years with diabetes living in British Columbia, Canada (1997-2006). Adherence to each class of medication was measured using proportion of days covered over 1 year with optimum adherence defined as ≥ 80%. RESULTS: The study population included 9529 South-Asian, 14 084 Chinese and 143 630 white people with diabetes. The proportion of people who were prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statin or oral hypoglycaemic agents was ≤ 50% for all groups. South-Asian and Chinese people had significantly lower adherence for all medications than white people, with the lowest adherence to angiotensin-converting enzyme inhibitor treatment (South-Asian people: adjusted odds ratio 0.37, 95% CI 0.34-0.39; P<0.0001; Chinese people: adjusted odds ratio 0.50, 95% CI 0.47-0.54; P<0.0001) and statin therapy (South-Asian people: adjusted odds ratio 0.47, 95% CI 0.41 - 0.53, P < 0.0001; Chinese people: adjusted odds ratio 0.72, 95% CI 0.67 - 0.77; P<0.0001) compared with white people. CONCLUSION: Adherence to evidence-based pharmacotherapy was substantially worse among the South-Asian and Chinese populations. Care providers need to be alerted to the high levels of non-adherence in these groups and the underlying causes need to be investigated.

Factors influencing medication adherence in South Asian people with cardiac disorders: an ethnographic study.

BACKGROUND: South Asians experience higher rates of cardiovascular disease than any other ethnic group. Some evidence suggests that South Asians may be less adherent to cardiac medication regimens than Whites residing in Canada. Identification of the key factors contributing to adherence may assist this growing population to optimize their cardiac health. AIM: To explore key factors associated with adherence to cardiac medications among South Asian people with cardiac disease. METHODS: Ethnography was used to highlight population specific themes and domains related to medication adherence. Ethnographic observations were undertaken of patients, as well as their family (primary care) physicians and pharmacists (including their staff), while in physician offices and pharmacies. A purposive sample of patients (n=8), as well as physicians (n=3) and pharmacists (n=2) underwent in-depth interviews. Field note and interview data were transcribed verbatim and analyzed using ethnographic domain and thematic analysis. RESULTS: The patients relied on family members for instrumental support in remaining adherent with their medications. Relationships with healthcare professionals who demonstrated clear communication and cultural awareness was associated with enhanced medication adherence. Memory mechanisms needed to be individualized and were generally 'low technology'. While prepackaging of medications enhanced adherence, patients who used them were less knowledgeable about their medications. CONCLUSIONS: Healthcare providers should understand the importance of including family members in the care of South Asian people with heart disease. They also need to appreciate that the quality of provider-patient relationships are important to South Asian patients and will influence adherence to healthcare regimens. Expanding the role of nurse in the primary healthcare team could provide a cost-effective means of enhancing medication adherence.

Understanding the influence of urban- or rural-living on cardiac patients' decisions about diet and physical activity: descriptive decision modeling.

BACKGROUND: It is challenging to assist people to attend to risk factors for coronary artery disease (CAD). There is potential for cultural elements associated with place of residence (i.e., urban- or rural-living) to have an effect on peoples' decision-making about managing CAD risk. AIM: To better understand patient's decision-making processes regarding having a heart-healthy diet and engaging in regular physical activity (major CAD risk factors), and the potential influence of urban- or rural-living. METHODS: Based on a previous series of qualitative interviews with 42 cardiac patients (21 urban-living, 21 rural-living), hierarchical decision-models regarding eating a heart-healthy diet and engaging in regular physical activity were developed, and a survey based on the decision-models generated. The models were then tested for 'fit' with another group of 42 cardiac patients, and were revised to make them more parsimonious. The final models were tested with a novel group of 647 CAD patients from Alberta, Canada (327 urban-living, 320 rural-living). The primary analysis was focused on determining the extent to which patients completing the survey fell in the correct behavioral group. Thereafter individual nodes were examined to determine decision-making constructs that were different between urban- and rural-living patients. RESULTS: When tested, the models had overall accuracy of 93.5% for diet and 97.5% for physical activity. The most salient model nodes that led to differing behavioral outcomes reflected these constructs: perception of control over health; time, effort, or competing priorities; receipt of appropriate information; and appeal of the activity. CONCLUSIONS: This information is potentially useful to assist healthcare providers to: (1) understand patients' decisions regarding their cardiac risk factor modification behavior, and (2) better direct conversations about risk factor modification and educational activities.

Understanding coronary artery disease patients' decisions regarding the use of chelation therapy for coronary artery disease: descriptive decision modeling.

BACKGROUND: A considerable number of patients receive chelation therapy to treat their coronary artery disease. However, there is no current empirical evidence to support its use. AIM: To better understand patient's decision-making processes regarding the use of chelation therapy as a treatment for coronary artery disease. METHODS: Based on qualitative interviews with 32 coronary artery disease patients, a taxonomy of decision-related issues, hierarchical decision-model, and survey based on the model were developed. The model was then pilot tested with another group of 30 patients and revised accordingly. The final model was tested with another group of 167 patients (27 current users, 72 previous users, and 68 never users of chelation therapy). The primary examination of the model was to determine the degree to which it successfully identified people who fell within each behavioral group. This was done by dividing the total number of successes by the total number of cases on all paths (or questions in the questionnaire). RESULTS: The most important elements in the decision to use or not use chelation therapy were: previous experience with or learning about chelation therapy, openness to alternative treatments, satisfaction with current level of (traditional) care, physician opinion regarding chelation therapy, costs associated with chelation therapy, perceived access to chelation therapy provider, current state of health (good or bad), and wanting to do 'all one can' for heart health. When tested, the ability of the model to predict the appropriate outcome was nearly 93%. The most salient junctures in the model that led participants to different behavioral outcomes were: considering using non-traditional treatments; perceptions regarding potential risks and benefits; cost; and believing that using chelation therapy was 'doing all that they can' to help their heart health. CONCLUSIONS: Descriptive decision-modeling is a useful method to depict cardiac patients' decision-making concerning the use of chelation therapy. It can also assist healthcare providers and policy makers in directing interventions and policy aimed at enhancing the use of evidence-based therapies for cardiac patients.