Original Article
Psychosocial Screening and Assessment Practice within Cardiac Rehabilitation: A Survey of Cardiac Rehabilitation Coordinators in Australia

https://doi.org/10.1016/j.hlc.2016.04.018Get rights and content

Background

Many cardiac rehabilitation (CR) guidelines and position statements recommend screening for psychosocial risk factors, although there is wide variation in the recommended factors and recommended screening tools. Little is known about screening in CR in Australia.

Methods

Cardiac rehabilitation coordinators at the 314 CR programs operating across Australia, drawn from the 2014 Australian Directory of Cardiac Rehabilitation Services were invited to participate in an online survey.

Results

Of 165 complete responses, 157 (95%) CR coordinators indicated that they screened at entry with 132 (80%) screening on exit. At CR entry, programs screened for – depression (83%), anxiety (75%), stress (75%), and sleep disturbance (57%). The use of standardised instruments by those screening at entry varied from 89% for depression to only 9% for sleep disturbance. Organisational, resource and personal barriers inhibited the routine screening for many psychosocial factors.

Conclusions

Surveys such as this are useful for monitoring the rate of adoption of guideline recommendations and identifying barriers to implementation. Findings can also inform discussions about what should be included in minimum data sets for CR programs, and the identification of brief screening tools that have been validated not just in the general population but in cardiac patients.

Introduction

Coronary Heart Disease (CHD) is the leading cause of death in Australia [1]. Patients who have had a cardiac event are at increased risk of a subsequent event and death [2] and are, therefore, a priority for preventive cardiology [3]. As such, in Australia [4] and worldwide [5], it is recommended that cardiac rehabilitation (CR) be offered to all patients after an acute event. Cardiac rehabilitation is a multidisciplinary intervention, which improves functional capacity, recovery and psychological well-being [5], [6], [7]. Cardiac rehabilitation has been shown to reduce the risk of further heart attack or death by 25-30% [8], [9]. In addition, models of care that incorporate psychosocial and education-based CR [10], [11] may improve the health-related quality of life [12]. As the European Association of Cardiovascular Prevention and Rehabilitation notes [13] CR is recommended (with the highest level of scientific evidence-class I) by the European Society of Cardiology, the American Heart Association and the American College of Cardiology in the treatment of patients with coronary artery disease (CAD) [14], [15], [16].

Centre-based group programs are the major systematic approach to CR currently available in Australia. Group CR typically comprises low or moderate intensity physical activity; and education and discussion, with programs usually running for six to eight weeks [4], [6]. Cardiac rehabilitation aims to restore individuals to their optimal level of physical, psychological, social and vocational wellbeing and is considered ‘an essential part of the contemporary care of heart disease’ [17].

Section snippets

Current Guidelines for Psychosocial Screening in CR

According to the recently published core components of cardiac disease secondary prevention and rehabilitation [18], [19] it is recommended that patients be formally assessed at entry to the program and a mutually agreed treatment plan devised, and assessed again at exit and at 6- and 12-month follow-up. It is recommended that the entry assessment include medical history; current medications; physical and functional status; risk factor profiles; health behaviours including, for example,

Participants

Eligible participants were coordinators of CR programs currently operating in Australia. Based on a 5% margin of error and 95% confidence intervals, a sample of 174 CR coordinators was required [40]. This represented a 50% response rate (of the full population of 314 CR programs).

Measures

An online survey was developed which asked about screening activities across a range of traditional and emerging CVD risk factors and included an assessment of who undertakes the screening, how it is done, and the

Screening

Of the 314 CR programs invited to participate, 180 responses were received. Of these, four declined to complete the survey after reading the plain language statement, leaving 176, the required target sample size. Just over 50% (52.5%) of program coordinators were included although 11 surveys were incomplete, resulting in 165 complete responses (49%). Of these complete responses 157 (95%) respondents indicated that they screened at entry while 132 (80%) indicated that they screened on exit.

Discussion

Most programs undertake some form of psychosocial screening or assessment of patients at program entry (95%) and exit (82%), with depression being the psychosocial factor screened for most commonly. The take-up rate of screening for depression, of over 80%, is higher than the rates identified in a recent survey of depression screening in North America [73] where the highest screening rate identified was under 70%. Depression screening using the validated screening tool recommended for

Conclusion

Surveys such as this national survey of screening and assessment practice in CR are useful for monitoring the use of guideline recommendations and identification of barriers to implementation, particularly of recommendations on screening. The findings from this study should also contribute to discussions about what to include in a minimum data set for CR programs, and the identification of brief screening tools that have been validated not just in the general population but in cardiac patients,

Conflict of Interest

None declared.

Acknowledgement

We thank the Australian Cardiovascular Health and Rehabilitation Association (ACRA) for their endorsement in this project.

References (76)

  • AIHW

    Australia's health 2012. Australia's health no. 13. Cat. no. AUS 156

    (2012)
  • M.R. Law et al.

    The underlying risk of death after myocardial infarction in the absence of treatment

    Arch Intern Med.

    (2002)
  • Euroaspire II Study Group

    Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme

    Eur Heart J.

    (2001)
  • NHF & ACRA. National Heart Foundation of Australia and Australian Cardiac Rehabilitation Association

    Recommended framework for cardiac rehabilitation ‘04

    (2004)
  • WHO

    Rehabilitation after cardiovascular disease with special emphasis on developing countries

    (1993)
  • A.J. Goble et al.

    Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention

    (1999)
  • A. Beauchamp et al.

    Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up

    Heart.

    (2013)
  • T.G. Briffa et al.

    An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia

    The Medical journal of Australia.

    (2009)
  • N. Pogosova et al.

    Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

    European Journal of Preventive Cardiology

    (2015)
  • R.S. Taylor et al.

    Cochrane corner: cardiac rehabilitation for people with heart disease

    Heart.

    (2015)
  • M.F. Piepoli et al.

    Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

    Eur J Cardiovasc Prev Rehabil.

    (2010)
  • E. Braunwald et al.

    ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)

    Circulation.

    (2002)
  • R.J. Gibbons et al.

    ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)

    Circulation.

    (2003)
  • J.A. Jolliffe et al.

    Exercise-based rehabilitation for coronary heart disease

    Cochrane Database Syst Rev.

    (2001)
  • R.S. Taylor et al.

    Home-based versus centre-based cardiac rehabilitation

    Cochrane Database Syst Rev.

    (2010)
  • National Heart Foundation of Australia

    Secondary prevention of cardiovascular disease

    (2010)
  • D.M. Colquhoun et al.

    Screening, referral and treatment for depression in patients with coronary heart disease

    The Medical Journal of Australia.

    (2013)
  • J.H. Lichtman et al.

    Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association

    Circulation

    (2008)
  • D. Anderson et al.

    Social support, social networks and coronary artery disease rehabilitation: a review

    Can J Cardiol.

    (1996)
  • J. Barth et al.

    Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis

    Psychosom Med.

    (2010)
  • H.S. Lett et al.

    Social support and coronary heart disease: epidemiologic evidence and implications for treatment

    Psychosom Med.

    (2005)
  • F. Mookadam et al.

    Social support and its relationship to morbidity and mortality after acute myocardial infarction: systematic overview

    Arch Intern Med

    (2004)
  • N. Frasure-Smith et al.

    Social support, depression, and mortality during the first year after myocardial infarction

    Circulation

    (2000)
  • J. Gallagher et al.

    Psychological Aspects of Cardiac Care and Rehabilitation: Time to Wake Up to Sleep?

    Curr Cardiol Rep.

    (2015)
  • M.P. Hoevenaar-Blom et al.

    Sufficient sleep duration contributes to lower cardiovascular disease risk in addition to four traditional lifestyle factors: the MORGEN study

    European Journal of Preventive Cardiology

    (2014)
  • M. Azevedo Da Silva et al.

    Sleep duration and sleep disturbances partly explain the association between depressive symptoms and cardiovascular mortality: the Whitehall II cohort study

    J Sleep Res.

    (2014)
  • J.E. Ferrie et al.

    A prospective study of change in sleep duration: associations with mortality in the Whitehall II cohort

    Sleep

    (2007)
  • H.R. Banack et al.

    The association between sleep disturbance, depressive symptoms, and health-related quality of life among cardiac rehabilitation participants

    J Cardiopulm Rehabil Prev.

    (2014)
  • Cited by (14)

    • Implementation of systematic screening for anxiety and depression in cardiac rehabilitation: Real world lessons from a longitudinal study

      2022, Journal of Psychosomatic Research
      Citation Excerpt :

      Screening for anxiety and depression as part of CR is no exception. One review found that only 29–68% of CR programmes comply with recommendations [16], whereas higher proportions were seen in a survey of Australian CR programmes, where 83% reported screening for depression and 75% for anxiety [17]. A mixed picture was reported in a Danish study, where the proportion of hospitals screening for anxiety and depression increased from 67% to 97% in the first two years following launch of the national clinical guidelines [18], whereas it remained stable at approximately 20% of municipalities.

    • Cardiac Rehabilitation in Australia: A Brief Survey of Program Characteristics

      2018, Heart Lung and Circulation
      Citation Excerpt :

      The annual audits undertaken by the National Audit of Cardiac Rehabilitation team in the UK, shows the utility of having systematically collected comprehensive benchmark data on program characteristics since 2005 [22], allowing comparison of CR programs at national, regional and local levels, and very importantly, comparison of program structures and performance against CR guidelines [23]. The primary aim of this study was to assess pre and post CR psychosocial screening practices [24], while a secondary aim was to conduct a brief snapshot survey of CR program characteristics on a national scale, as no such profile had been conducted in Australia previously. Eligible participants were coordinators of 314 CR programs currently operating in Australia.

    View all citing articles on Scopus
    View full text