Each year, the Preventive Cardiovascular Nurses Association (PCNA) invites healthcare professionals involved in original data-based research or innovative quality improvement projects related to cardiovascular risk reduction and disease management to submit an abstract to be presented at PCNA’s Annual Symposium. Abstracts are judged and the top oral and posters presentations at the Annual Symposium are selected for publication in the Journal of Cardiovascular Nursing. The winners are presented below.
Oral Presentation—Data-Based Research
Pitavastatin Lowers Plasma Levels of COQ10 Less Than Equipotent Doses of Rosuvastatin or Atorvastatin
Patrick M. Moriarty, MD; Jim Backes, PharmD; Janelle Ruisinger, PharmD; Jo A. Wick, PhD; Craig A. Sponseller, MD, Kansas University Medical Center, Kansas City, Kansas.
Background: Studies have demonstrated statins, through competitive inhibition of HMG-CoA reductase, equally decrease plasma levels of cholesterol and CoQ10. The reduction of CoQ10 following statin therapy is considered a possible mechanism for the drugs causing adverse effects, particularly myopathy.
Hypothesis: An equipotent dose of pitavastatin will lower CoQ10 levels less than rosuvastatin or atorvastatin.
Methods: Single site double blind study of 134 patients randomized to pitavastatin (4 mg/qd), rosuvastatin (5 mg/qd) and atorvastatin (20 mg/qd) for 12 weeks. The primary endpoint was to determine the difference in plasma levels of total CoQ10, ubiquinol and ubiquinone levels, before and after 12 weeks of therapy, between the three groups. Nine patients were excluded from the final analysis for not completing therapy. Non-parametric Kruskal Wallis tests were done to assess treatment differences in the change in CoQ10, ubiquinol, and ubiquinone from baseline.
Results: Comparable LDL-C reduction was noted among the 3 groups (p-value = 0.2626); however, pitavastatin decreased CoQ10 levels, in particular ubiquinol, significantly less than atorvastatin and rosuvastatin (p-value = 0.0401). No statistically significant treatment difference was observed in ubiquinone levels (p-value = 0.6988), however the significant change in ubiquinol (p-value < 0.0401) allowed total CoQ10 (p-value = 0.0697) to be marginally significant. No statistically significant treatment differences were observed in the metabolic or lipid measures. Among the lipoprotein particles and apolipoproteins, LDL-particle number showed a significant difference between treatment groups (p-value = 0.0087), as subjects in the rosuvastatin arm exhibited the smallest decrease in LDL-particle number, while those in the atorvastatin arm exhibited the largest decrease.
Conclusion: Pitavastatin may be preferred when considering statin therapy for patients with drug induced muscle symptoms. Additional trials are needed to corroborate the lesser reduction of CoQ10 levels with adverse effects from statin therapy.
Oral Presentation—Innovation in Patient Care
Improving Heart Failure Disease Management Through Post Discharge Home Visits
Jennifer Simon, BSN, RN Hendricks Regional Health, Danville, Indiana; Jan Hesler,BSN, RN-BC, CHFN Hendricks Regional Health, Danville, Indiana; Ruth Rudolf, RN, CHFN Hendricks Regional Health, Danville, Indiana.
Background: Heart failure (HF) readmissions remain a concern with greater than 50% of patients being readmitted within 6 months of discharge (Akshay 2012). Since 2000, cardiac rehabilitation nurses in a community hospital have provided support for discharged HF patients. The nurse performed face-to-face in-patient education, in addition to three subsequent tele-management calls over a one-month period; that method of education alone was determined to be less than ideal and prompted a redesign in 2014 to include a home visit.
Purpose: Knowledge and skill retention gaps were identified and seemed to be associated with education program limitations. Tele-management was limited to disease management, self-efficacy, and medication reconciliation. It was realized that an in-home approach would allow for individualized needs assessment and educational intervention.
Design/Implementation: A pilot program was initiated; readmission data were monitored. The program focused on disease management and self-efficacy, with an added home visit at no cost to the patient. Program attributes include inpatient education, scheduling home visit, and two follow-up calls. Nurse visits include the patient and family. Visit goals include physical assessment, an accurate scale, medication education/reconciliation, and review of meal plan/pantry contents. A knowledge and behavior assessment utilizing the teach-back method occurs.
Evaluation/Outcomes: Over 12 months, 170 HF patients were discharged to home. Of the 106 patients who refused home visits, 7.7% were readmitted within less than 30 days. Of the 64 patients who accepted and received home visits, 1.5% were readmitted within less than 30 days. The data indicated a reduced 30 day re-admission rate among home visit patients; it was decided to adopt the pilot as routine practice.
Conclusions/Implications for Practice: Home visits seem to provide insight into management of complex chronic diseases, which is an advantage in transition to home. Interprofessional efforts are underway to increase patients who accept a home visit.
First Place—Innovation in Patient Care
A Patient-Centered Web-Based Program Improves Self-care Adherence for Patients With Heart Failure
Sara Black, MSN, CRNP, NP-C, Penn State Hershey Medical Center, Hershey, Pennsylvania; Andrew Foy, MD, Penn State Hershey Medical Center, Hershey, Pennsylvania; Tom Lloyd, PhD, Penn State Hershey College of Medicine, Hershey, Pennsylvania; Harleah Buck, PhD, Penn State University, State College, Pennsylvania
Category: Innovations in Patient Care
Background: Heart failure readmissions place a large economic burden on hospital systems. Many heart failure patient readmissions result from poor compliance with self-care practices after discharge.
Purpose: We assessed the feasibility and effectiveness of a patient-centered Web-based pilot intervention to enhance patients’ ability to provide heart failure self-care, particularly with respect to medication adherence, weight monitoring, and daily aerobic activity.
Design/Implementation: Patients used an individualized iPad with monitoring program each day for 30 days to record their weight, medication adherence, duration completing prescribed exercises, and to view short educational videos. Participants were provided an aerobic stepper and asked to time daily use. In addition to examining feasibility and acceptability, linear random coefficients models were fit to assess patterns of patient’s weight, activity, and medication adherence.
Evaluation/Outcomes: We enrolled 12 patients in our pilot. Group compliance in completing daily tasks for weight and exercise values was 84%. None of the subjects showed persistent weight gain over 30 days. The slope of weight vs time was negative (−0.17; p-value = 0.002). Subjects increased time spent on the aerobic stepper. The slope of stepper use vs time was positive (0.08; p-value = 0.04). The study group showed good adherence to taking prescribed medications, with two thirds taking 75% or more over the study period.
Implications for Practice: A patient centered Web-based program delivered via an iPad showed promise in improving self-care in this pilot study. Mobile technology offers new approaches to managing CHF patients under changing reimbursement policies.
Second Place—Innovation in Patient Care
Reducing Deep Vein Thrombosis in Acute Rehabilitation Using Education and Tool Automation
Elizabeth L. Levine, DNP, ANP-BC, RN-BC, Schenectady Pulmonary and Critical Care Associates, Schenectady, New York
Background: Deep vein thrombosis (DVT) is a leading cause of avoidable hospital deaths. Despite the known health risk, established DVT healthcare standards are often neglected by healthcare providers. The project focused on providers implementing established clinical guidelines to decrease the incidence rate of DVTs in a 115-bed acute rehabilitation hospital. The participants of the project were four nurse practitioners, two physicians and a physician assistant who were employees of a privately owned cardiopulmonary medical practice.
Purpose: The purpose of the evidence-based practice change project was to improve knowledge of DVT prophylaxis, improve provider adherence to standardized prophylaxis guidelines, and decrease the incident rate of DVTs.
Implementation: A literature review and established guidelines for antithrombotic therapies yielded an automated tool which assigned risk values to patients and prophylaxis prescription guidance. After a one-hour education session, provider’s use of an electronic DVT risk assessment tool to assess new patients and guide prescription decision making was evaluated. Pre and post education tests measured provider knowledge and education effectiveness. Descriptive statistics and t-test evaluated test results and tool usage, as well as DVT benchmark and project comparison incidence rates from hospital electronic medical records diagnostic data.
Evaluation and Outcomes: Three outcomes were attained. Provider knowledge mean score increased 43% (t = 2.364: p = 0.003). The compliance rate of providers using the assessment tool was 97.6%. The DVT incidence rate during the project was 1.6%, which was 23.4% below the benchmark rate of 25%.
Conclusion and Implication for Practice: Assessment aided by automation enabled appropriate DVT prophylaxes. The DVT risk assessment tool remains in place for other providers to utilize, as practice workflow was improved by saving time with streamlined admissions processing. Automated DVT risk management has the potential to result in shorter hospital stays, improve patient outcomes, and increase quality of life years.
Third Place—Innovation in Patient Care
Healthy Heart Program to Decrease 30-Day Hospital Readmissions in Vulnerable Populations
Elizabeth F. Buselli, ANP-BC, FNP-BC, PhD; Adriene Clark-Wilkerson, RN, MSN, TNCC, CEN, Sutter Delta Medical Center, Antioch, California.
Background and Purpose: Reducing 30-day hospital readmissions for patients with chronic disease is a rising concern. Vulnerable populations bear a higher burden of complex cardiovascular disease (CVD), and a higher risk of readmissions due to noncompliance, chronic disease state, low health literacy, multiple comorbidities and decreased access to care. One community hospital in Northern California developed an innovative program to decrease 30-day preventable CVD hospital readmissions.
Program Design and Implementation: The Healthy Heart Program (HHP) is a free Nurse Practitioner (NP)–led multifactorial out-patient risk reduction program (education, lifestyle change and surveillance) to decrease readmissions. Inpatients with CVD, CHF, COPD and pneumonia are identified via computer and visited by the NP. A program brochure is provided and a STOPLIGHT handout about self-monitoring and managing symptoms is reviewed. Patients schedule one follow-up session which includes focused health assessment and physical examination; weight and edema measurement; medication reconciliation; discharge physician appointments; education on nutrition, symptom management and self-assessment geared toward the patient’s literacy level; discussion about behavior changes; and stress management. Written materials are provided.
Evaluation and Outcomes: Eighty-five patients with congestive heart failure, myocardial infarction, CVD, COPD and pneumonia, multiple co-morbidities, low socioeconomic status and low healthy literacy attended at least one session over a 20-month period. Only 5 patients were readmitted within 30 days of hospital discharge which is a 6% readmission rate. Overall hospital readmission rate for CVD during the same time period was 20.1%.
Conclusions and Implications for Practice: For those patients who attended the HHP, rate of preventable 30-day readmission was low. Next steps will increase the proportion of eligible patients who participate. The HHP is effective in reducing hospital readmissions for patients with chronic diseases. Increasing referrals and obtaining funds for transportation vouchers and other materials to better serve a broader group is indicated.
First Place—Data-Based Research
Hypoglycemic Fear: Influence on Glucose Variability and Self-management Behavior in Type 1 Diabetes
Pamela Martyn-Nemeth, PhD, RN; Laurie Quinn, PhD, RN; Chang Park, PhD; Sue Penckofer, PhD, RN, University of Illinois at Chicago; Loyola University Chicago.
Background: Persons with type 1 diabetes (T1DM) have two to four times the risk for cardiovascular disease (CVD). Glycemic variability (GV), the minute-to-minute fluctuation in glucose levels, is a potential CVD risk factor but is not reflected in A1C. Many people with T1DM develop fear of hypoglycemia (FOH), which can lead to avoidance behaviors (e.g., excess food intake, restriction of insulin, avoidance of physical activity) that may result in greater GV, which may be associated with increased CVD. Young adults may be at particular risk because they report greater FOH.
Objectives: Determine (1) whether FOH is associated with increased GV in young adults with T1DM and (2) if FOH impacts self-management of diabetes.
Methods: In 31 young adults (18–35 years), we used a prospective, repeated measures design, to examine (1) associations of FOH with GV; (2) other factors that influence FOH (prior hypoglycemic experiences, anxiety, mood); and (3) self-management behaviors (diet, physical activity). Data were collected using questionnaires; a daily diary (for FOH); continuous glucose monitoring (for GV); and actigraphy (for physical activity). Correlation techniques were used to examine the daily measures of FOH and GV, associated factors, and temporal relationships between FOH and GV.
Results: Most participants (78%) reported FOH. FOH was associated with GV (r = .263, p < .001). Prior day FOH was associated with next-day GV (r = .194, p = .014). FOH was also associated with poorer self-management behaviors, more sedentary activity (r = .204, p =.019); less vigorous physical activity (r = −.181, p = .038); and greater stress-induced eating (r = .219, p = .003).
Conclusions: FOH is a critical deterrent to diabetes self-management in young adults withT1DM. The significant association of FOH with GV, physical activity, and eating behavior provides preliminary evidence for FOH’s role in self-management and CVD risk.
Second Place—Data-Based Research
Health Beliefs Related to Physical Activity in Patients Living With Implantable Cardioverter Defibrillators
Rebecca Susan Crawford, PhD, RN; Kathleen C. Insel, PhD, RN-Professor, Biobehavioral Health Science Division, College of Nursing, The University of Arizona, Tucson; Anne G. Rosenfeld, PhD, RN, FAAN, FAHA-Associate Dean for Research, Biobehavioral Health Science Division, College of Nursing, The University of Arizona, Tucson; Pamela G. Reed, PhD, RN, FAAN-Professor, Community & Systems Health Science Division, College of Nursing, The University of Arizona, Tucson.
Background: Low levels of physical activity (PA) are a significant predictor of early death among recipients of implantable cardioverter defibrillators (ICDs). Regular, moderate PA is associated with improved quality of life (QOL), reduced arrhythmia burden, and improved health outcomes in ICD recipients yet many do not engage in PA and reasons for lack of engagement are unclear.
Objective: The purpose of this study was to examine health beliefs related to PA and QOL in adults with ICDs.
Methods: A descriptive, cross-sectional design was used to measure the concepts, perceived benefits, perceived barriers and self-efficacy from the Health Belief Model as a theoretical framework.
Results: The sample (n = 81) was primarily male (71.6%) and white (77.8%), with a mean age of 70.23 years. Most were insured by Medicare (79%) and live in rural areas (75.3%). Most had heart failure (HF) (98.2%) and almost 40% reported decreased PA levels since ICD implant. There were no differences in health beliefs and QOL scores between subjects who had an ICD as a primary or secondary prevention of sudden cardiac death. Almost 33 percent of variance in total PA participation can be explained by Self-Efficacy for Exercise (SEE) (β = .390, p < .01); Self-efficacy after ICD (SEICD) (β = .215, p < .05); age (β = −.234, p < .01); New York Heart Association (NYHA) Classification (β = −.198, p <.05); and ICD type (β = .014, p > 05). SEE alone accounted for almost 23% of variance. Perceived barriers (β = −.310, p < .01) accounted for 9.3% of variance in planned PA.
Conclusion: Findings indicate the strength of self-efficacy in predicting PA participation in adult ICD recipients. Findings highlight the low levels of PA in ICD recipients thus further validates the need for more research to increase PA in the ICD population.
Tie for Third Place—Data-Based Research
Priority and Importance of Intervention Content to Improve Medication Adherence: Perspectives of Patients at Risk for Metabolic Syndrome and Health Care Providers
Chun-Ja Kim, PhD, RN; Elizabeth A. Schlenk, PhD, RN; Moonsun Kim, MSN, RN; Dae Jung Kim, MD.
Background: As the prevalence of metabolic syndrome has increased, the rate of prescription medications has grown. Patients with chronic diseases take 50% of prescribed doses and 25% of patients take less than what is prescribed. Medication nonadherence contributes to poor outcomes. Little is known about priority and importance of intervention content to improve medication adherence from patients’ and health care providers’ perspectives.
Objectives: To examine priority and importance of intervention content to improve medication adherence among patients at risk for metabolic syndrome and providers.
Methods: This study was part of an ongoing longitudinal, prospective clinical trial on diabetic adults at risk for metabolic syndrome in a university hospital. To determine priority and importance of content to improve medication adherence, 30 patients and 42 providers (physicians and nurses) responded to 21 items derived from the WHO adherence model and literature reviews: drug name, purpose, dose, time, directions, side effects, managing side effects, efficacy, actions, interactions, duration, knowledge, physical activity, diet, stress management, treatment-related factors, environmental factors, patient-related factors, socioeconomic factors, system-related factors, and communication with providers.
Results: The average age was 53 years and 61.5% were women. Types of medications included hypoglycemic (100.0%), antihypertensive (46.2%), anti-dyslipidemic (38.5%), and cardiac/antiplatelet agents (15.4%). Two-thirds followed a physical activity or diet regimen, and 30% reported performing stress management. Patients and providers perceived “medication purpose” as top priority. Next, patients perceived “disease knowledge” and “physical activity”, whereas providers perceived “directions (5 rights).” Patients perceived “managing side effects,” “drug-drug or drug-food interactions,” and “stress management” as top importance, whereas providers perceived “purpose,” “dose,” and “efficacy” of medications.
Conclusions: Patients and providers agreed that “medication purpose” was top priority. However, they differed on other priorities and importance. During interventions, providers need to assess and include patients’ perspectives on priority and importance of content to improve medication adherence.
This research was support by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (grant number: 2013R1A1A2059806).
Tie for Third Place—Data-Based Research
Automated Versus Manual Blood Pressure in Patients With Atrial Fibrillation and/or Hypertension
Jo Anne Pouliot, MSN; Jennie Moravec, MSN,CNS-BC, Advocate Good Samaritan Hospital, Downers Grove, Illinois.
Background: On the telemetry unit nurses have noted discrepancies in blood pressure (BP) measurement among patients with atrial fibrillation (AF) and/or hypertension (HTN). Current practice has included the use of both manual and automatic BP measurements, but it is imperative that BP measurements be accurate as treatment decisions are made based on these readings.
Objectives: The purpose of this descriptive, comparative study was to determine whether there is a significant difference in BP measurement between automated and manual techniques in AF and/or patients with HTN.
Methods: Subjects were adults who had HTN and/or AF admitted to telemetry units at a community hospital. BP was measured in both the sitting and lying position. Between group differences were assessed with Repeated-Measures ANOVA or independent samples t-tests, and Pearson’s correlation was used to examine the relationship between BP reading discrepancies and heart rate.
Results: Mean discrepancies between the automatic and manual BP readings ranged from 8.6 ± 6.9 for sitting systolic BP to 7.2 ± 5.8 for lying diastolic BP. Discrepancies did not differ statistically between HTN or AF groups, and the relationship between HR and BP discrepancy was supported for lying diastolic BP readings only.
Conclusion: Our findings revealed no difference between automatic and manual BP readings. Change in position also revealed no difference.
Implications: Although there were some numerical discrepancies, the findings revealed no significant clinical differences. The inclusion criteria ensured that only subjects who fit the standard cuff were included in the study. Should the question have been around proper cuff size rather than position and type of device?