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QUESTION: For patients who have had a myocardial infarction (MI) and their partners, is an inpatient cardiac education and counselling programme more effective than usual care and as effective as extended care after discharge for improving knowledge, mood (anxiety and depression), function, and satisfaction?
Randomised (unclear allocation concealment), blinded (outcome assessors) controlled trial with follow up at discharge and 2, 6, and 12 months.
6 medical wards of a hospital in Dundee, Scotland.
117 patients were enrolled and 100 patients (mean age 56 y, 65% men) who were discharged from the coronary care unit after a first MI and their partners completed the study. Inclusion criteria were confirmed MI (World Health Organisation criteria), age ≤70 years, fluency in English, and ability to consent.
Wards were randomised. 38 patients and their partners received the inpatient cardiac education and counselling programme, 29 received the extended programme, and 33 received usual care. The inpatient and extended groups were offered up to 5 sessions of education and counselling starting within 3 days of ward admission. The nurse led sessions addressed issues as they became relevant and included information, guided action plans, advice, leaflets, and videos. Patients in the extended group were offered up to 8 additional sessions in the 6 weeks after hospital discharge. Usual care patients received no specific intervention.
Main outcome measures
Knowledge, mood (Hospital Anxiety and Depression Scale), disability and resumption of normal activities (Functional Limitations Profile), and satisfaction with care.
At 2 months, patients and partners in both counselling groups had higher knowledge scores than patients in the usual care group (p<0.01); patients in the extended group had higher knowledge scores than patients in the inpatient group (p=0.02). Patients and partners in both counselling groups had lower depression scores at 2, 6, and 12 months and lower anxiety scores at 2 (p<0.02) and 6 months than the usual care group. Both counselling groups had less functional limitation at 6 and 12 months (p<0.01); the counselling groups did not differ at either time point. Both counselling groups were more satisfied with care at discharge and 2 months than the usual care group (p<0.001); the extended counselling group was more satisfied than the inpatient group.
Nurse led inpatient education and counselling after a myocardial infarction, with or without education and counselling after discharge, was more effective than usual care for improving knowledge, mood, and satisfaction for patients and their partners, and for decreasing functional limitations.
Cardiac rehabilitation is a multifaceted, multidisciplinary approach typically involving the identification of high risk patients and targeted risk factor reduction. This is achieved through various interventions including exercise programmes, diet, weight management, smoking cessation, stress management, and patient education and counselling.
The study by Johnston et al focuses on 1 important aspect of rehabilitation, patient education, and counselling. Studies that have examined the role of patient education and counselling support the positive findings of this study.1 The findings differ about the appropriate timing of education and counselling.
Participants were from 1 facility in Scotland and therefore the findings may differ for other populations. Because education and counselling programmes may vary across facilities, the findings should be limited to facilities that implement a programme with similar content. In addition, counsellor skill, training, and ability will also influence outcomes at other facilities.
The outcomes assessed were common psychosocial outcomes in cardiac rehabilitation. Of equal interest and importance, however, are measures of change in risk factors such as smoking, cholesterol concentrations, hypertension, and exercise because they have a known effect on mortality. Any interventions separate from the study intervention, such as reading of additional materials or repeat admission to hospital during the follow up phase, would affect the results and are important issues for nurses to consider when applying these findings to their clinical settings.
This study adds to existing research, which supports the need for hospital based cardiac education and counselling for patients after MI. The results are important to staff nurses who care for cardiac patients in hospital, nurse counsellors, patient educators, and staff involved in rehabilitative care. These findings are particularly helpful for nurses wishing to start a cardiac education and counselling programme or those who primarily serve rural or geographically distant populations where travel to a programme after discharge is not feasible.
Source of funding: Chief Scientist Office, the Scottish Home and Health Department.
For correspondence: Dr M Johnston, School of Psychology, University of St Andrews, St Andrews, Fife KY16 9JU, UK.
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