Using exercise to improve quality of life for people with heart failure Abstract
In the current economic climate within the NHS, behavioural-change interventions in chronic disease such as exercise programmes will be time-limited within acute hospital facilities. The challenge is to deliver cost-effective, participatory, population-specific health interventions that result in measurable benefits. Methodology: A mixed-methods study was undertaken to assess the benefits of participation in a structured exercise programme for patients with heart failure. Primary outcomes were improvements in functional capacity and quality of life. Secondary outcome measures related to patient satisfaction and sustainability of the intervention post study. Results: Overall significant improvements were not found in quality of life or functional capacity; some participants demonstrated significant improvements with others showing minor improvement or no improvement in one or both domains. Conclusions: Anecdotal evidence of perceived benefit was expressed in participant satisfaction responses. Secondary outcomes were met in relation to sustainability with commissioning of hospitaland community-based programmes on completion of the study. Key words: Heart failure ■ Quality of life ■ Exercise ■ Sustainability
M
anagement strategies of heart failure have moved from the prescriptive medical model to a more holistic model with an emphasis on lifestyle modifications and psychosocial support. (National Institute for Health and Care Excellence (NICE), 2010). Included in recommendations is the value of exercise with increasing evidence of efficacy and safety of exercise programmes. There is a substantial body of empirical evidence that identifies benefits of exercise in patients with heart failure; a meta-analysis of clinical benefits suggests that reversal of left ventricular remodelling occurs secondary to aerobic exercise training (Haykowsky et al, 2007). In the ExTraMatch study, a randomised multicentre trial undertaken by The Royal Brompton Hospital with adjustment of prognostic predictors of primary endpoints, exercise training in heart failure patients was associated with a reduction in all cause and cardiovascular morbidity (ExTraMatch, 2004). The benefits of exercise in heart failure include reduction in mortality and morbidity
Fiona Milligan is Senior Educator for Evidence-based Practice, HMC Organisation, Qatar Accepted for publication: November 2013
1242
statistics as well as improved quality of life. However, what was also evident was the lack of representation of older population groups; the mean age in the majority of the studies was less than 65 years and comorbidities common to an older population were included in the exclusion criteria (EuroQol Group, 1990). There is a dearth of studies that address issues of sustainability (of the benefits of exercise and participation in exercise programmes) and the older cohort with significant and multiple comorbidities.This would suggest that outcome data in a large number of studies are not representative of current population demographics (Lloyd-Williams et al, 2002). There are significant cost implications in the delivery of exercise programmes that are not time-limited in people living with chronic disease or long-term conditions, which may have resulted in a lack of provision both in hospital and within the community (Milligan, 2012). Following ethical approval, a study was undertaken to evaluate the benefits of participating in a structured exercise programme for patients with chronic heart failure (HF). The aim was to provide a sustainable intervention, inclusive and representative of the general population, which provided evidence of benefit in relation to improved functional capacity and quality of life (QOL). A mixed methodology design was used to evaluate functional capacity and QOL before and after each stage of the programme, beginning in hospital and progressing into the community. The programme was designed to meet the needs of a wide age range of patients and those with multiple comorbidities, a group of people often excluded from HF exercise studies as they are deemed high risk for exercise. The design of the exercise programme proposed to address this risk. Three levels of exercise—low, medium and high intensity— were provided with adaptations such as chair-based exercises forming part of the circuit that incorporated both equipment and floor exercise. The inclusion criteria included a documented diagnosis of heart failure on echocardiogram with a management plan in place incorporating evidence-based pharmacology strategies. There was no restriction on aetiology of heart failure or age. However, participants were required to demonstrate a minimal functional capacity of three metabolic equivalents (METS), the ability to undertake basic activities of living (Woolf-May and Ferrett, 2008). The exclusion criteria were: ■■ Unstable heart failure ■■ Uncontrolled atrial fibrillation
© 2013 MA Healthcare Ltd
Fiona Milligan
British Journal of Nursing, 2013, Vol 22, No 21
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.238.007.043 on November 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
cardiology ■■ Hypertension ■■ Symptomatic
hypotension exacerbation of chronic disease ■■ Inability to provide informed consent. The final sample size of 48 was representative of total numbers on a HF clinical nurse specialist’s caseload. Pre- and post-functional capacity and QOL were measured at each stage of the exercise programme. Patient satisfaction was measured through anonymous questionnaires on completion of the programme. All participants attended the initial in-hospital programme. On completion they were stratified into one of three arms (home exercise programme, group exercise class and GP exercise scheme; Figure 1) in order to continue the programme due to time-limited intervention within the hospitals. They were stratified according to functional capacity (greater capacity to GP scheme for more independent exercise) and patient choice was also a factor. The GP exercise referral scheme was already in existence, but there was poor uptake in a number of leisure centres and heart failure patients were in general unable to access the programme. GP exercise programmes often have poor uptake because of restrictions on when patients can access this programme i.e. time programme. Instructors should be level 4 when exercising heart failure or high-risk patients, or hold a specialised cardiac rehabilitation training qualification. It is hard to find instructors with this level of expertise. In addition, leisure centres often exclude HF patients because they are at a high risk, which has litigation and insurance implications. It was proposed that the community group exercise programme would be delivered by the British Association of Cardiac Rehabilitation (BACR) instructors, initially funded through the research grant. In order to meet secondary outcomes of sustainability, the programme was designed to build on existing resources and engagement of key stakeholders in the process. These were identified as GPs, local leisure services and voluntary agencies such as Age Concern Kensington and Chelsea. A random sample of 50 local GPs was sent a questionnaire with five questions relating to exercise in heart failure patients. An explanation of the exercise research study was included with the questionnaire. Eleven replies were received (response rate of 22%). Five questions reflected their views on a number of statements (Table 1). ■■ Acute
© 2013 MA Healthcare Ltd
Methods and study design A total of 48 participants meeting the inclusion criteria were recruited into five rolling exercise programmes beginning in hospital and progressing to appropriate community or home programmes. Clinical investigations included baseline physiological measurements of blood pressure, heart rate and an electrocardiogram (ECG). Haemoglobin (HB) and brain natriuretic peptide (BNP) was also collected before the programme as routine investigations. Participants’ functional capacity, exercise ability and heart rate response were assessed before and after each stage of the exercise programme using the Six Minute Walk Test (SMWT). This method of evaluating functional capacity is widely used in older population groups and in cardiac
British Journal of Nursing, 2013, Vol 22, No 21
Hospital exercise programme
GP exercise referral programme local leisure centres
Group exercise supervised by BACR instructor
Home exercise bespoke booklet and supported by volunteers from Age Concern (60+)
Figure 1. Exercise pathway
Table 1: GP questionnaire responses Responses were graded: Strongly agree (1), Agree (2), Neither agree nor disagree (3), Disagree (4) Q1 I am happy for my patients to participate in the exercise research programme
91% either strongly agreed or agreed
Q2 I am aware of current exercise opportunities available for heart failure patients to access in the community
45% disagreed, 18% neither agreed nor disagreed
Q3 I would be happy to refer patients with heart failure to current GP exercise referral schemes without detailed information on functional capacity in relation to exercise
36% disagreed, 18% neither agreed nor disagreed
Q4 I would be happy to write a letter of endorsement for exercise for heart failure patients to local leisure services without detailed information on functional capacity in relation to exercise
63% disagreed, 9% neither agreed nor disagreed
Q5 I am satisfied that local leisure centres are currently able to deliver exercise programmes for patients with heart failure
45% disagreed, 27% neither agreed nor disagreed
Table 2: Recruitment process Total number on heart failure clinical nurse specialist caseload
158
Passed away (pre-recruitment)
10
Not suitable
59
Invited to participate in programme
89
Declined/not interested
41
Recruited
48
Table 3: Study sample characteristics Sample size
Gender
Mean age Median age
Ethnic group
Diagnosis
Potential 158
M=32 F=16
Mean: 66.9 yrs Median: 69 yrs
23 White/British 4 Caribbean 3 White/Irish 7 Any other white group 1 Indian 2 Any other ethnic group 3 Any other Asian group 2 Pakistani 2 Any other black group 1 White/Asian
LVSD=20 Cardiomyopathy =19 HFPEF=9
Actual 48
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Table 4: Summary of data analysis Pre-trial heart rates, diastolic blood pressure, SMWT and both quality of life scores
No statistically significant difference between the mean values of any of the parameters tested for any of the five groups, before each exercise stage was commenced. p=0.05
Mean scores for SMWT and both components of quality of life measurement Groups 1, 3 and 4
No statistical difference
Mean SMWT values for Groups 2 and 5
Statistically significant difference at 0.1
Group 5
Statistically significant difference between the means of the pre-trial and the 24-week SMWT values, p=0.05
QOL tests for groups 2–5
An overall improvement in scores which were not statistically significant
500 400 300 200 100 0
1
Sample Time n Pre
2 n 12 weeks
3 Group n 24 weeks
4
5
Data analysis
Figure 2: Mean values for SMWT before and during exercise period
6
SPSS PASW Statistics version 18 was used to analyse outcome data (Table 3). The following descriptive statistics were calculated for the pre-exercise trial values for the pre-, 12- and 24-week values for the SMWT and QOL indices for each of the study groups: mean, standard deviation (SD), maximal and minimal values.
4
Results
Mean EQ-5D Descriptive
10 8
2 0
1
Sample Time n Pre
2 n 12 weeks
3 Group
4
5
4
5
n 24 weeks
Figure 3: Quality of life: EQ–5D descriptive score
Mean EQ-5D VAS
80
60
40
20
0
1
Sample Time n Pre
2 n 12 weeks
Figure 4: Quality of life: EQ–5D VAS score
1244
populations.There is minimal equipment or expense involved in conducting the test and it can be replicated outside clinical environments (American Thoracic Society, 2002). QOL was evaluated using the EQ-5D, which consists of two components: a descriptive system and visual analogue scale (VAS).The tool is a validated generic QOL measurement chosen by the Heart Support patient group for its easy use and short format (EuroQol Group, 1990). Heart failure aetiology was a combination of cardiomyopathy, left ventricular systolic dysfunction (LVSD) and heart failure with preserved ejection fraction (HFPEF). The sample was predominantly male; the age range was 24 to 80 years with a median age of 69 (Table 2).
3 Group n 24 weeks
There were no statistically significant differences between the five groups in the mean values of initial exercise programmes of heart rate, blood pressure, SMWT or QOL. The analysis shows that there was a statically significant difference in SMWT between some of the groups as they progressed through the different stages of the exercise programme. This would suggest that there is evidence of benefit in increased physical activity or functional capacity over a sustained period of exercise. This would imply that although some benefits may be conferred during participation in shorter or time-limited programmes, longer, more sustainable interventions have the potential to deliver greater improvements. However, the outcome data for improvements in QOL were not significant, although there were improvements in scores in some of the groups (Table 4). Group variances were equal for the pre-trial SMWT and both QOL scores. The F statistic indicated that there was no statistically significant difference between the mean values of any of the parameters tested for any of the five groups, before each exercise stage was commenced (Figure 2). The SNK test placed all groups in a single subset for each parameter, indicating that the values were statistically not significantly different at the p=0.05 level. It can therefore be assumed there is no bias in allocation within the five groups for these parameters.
© 2013 MA Healthcare Ltd
Mean Six Minute Walk Test (metres)
600
British Journal of Nursing, 2013, Vol 22, No 21
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cardiology The Levene statistic indicated that the group variances were equal when comparing pre-, 12- and 24-week stage measurements for each group. The F value indicated that the mean scores for SMWT and both the components of QOL measurement were not statistically different for Groups 1, 3 and 4 (Figure 3). There was a statistically significant difference at 0.1 between the mean SMWT values for Groups 2 and 5. The Tamhane test showed that only Group 5 showed a statistically significant difference between the means of the pre- and the 24-week SMWT values, p=0.05. Group 3 was excluded from the SNK test as no participant from this cohort progressed to 24-week exercise programme stage. There was no statistically significant difference between the pre-, 12- and 24-week results for either QOL test in any of the four groups. Groups 1 and 4 showed no statistically significant difference between the SMWT values for all three samples. In Group 5, there was a statistically significant difference, p = 0.05, between the mean pre- and 24week SMWT value, while in Group 2 there was a statistically significant difference between the 24-week SMWT and the pre- and 12-week mean values. In both groups the mean 24-week sample was greater than the first two mean values. This suggests the possibility of an improvement in the SMWT value by 24 weeks for Groups 2 and 5. In QOL tests for groups 2–5, although there appeared to be an overall improvement in scores, this was not statistically significant (Figure 4).
Discussion Data are variable in relation to improvements in functional capacity and QOL. Some participants exhibited substantial improvements in SMWT with others showing little or no improvement. There was no significant variance in QOL scoring pre- and post-intervention. It has been hypothesised that QOL tools commonly used in chronic HF are not reliable or valid means of measuring quality of life in this cohort group. More relevant assessment may be gained from assessing the individuals’ experience of chronic heart failure including treatment and care pathway (Calvert et al, 2005).
© 2013 MA Healthcare Ltd
Conclusions The lack of significant improvements in identified primary outcome measures may have resulted from the chronic progressive nature of heart failure disease process or multiple comorbidities often found in this group. Significant sample attrition rate has affected the generalisability of the findings in addition to sample size. Experiential satisfaction and benefits from participation and improvement relative to previous ability is suggestive of benefit gained from intervention, which is not reflected in data obtained through formal or structured information collection. The success of the intervention can be seen in participant satisfaction, the commissioning of a hospital-based class and pathways in place linking to a supported community programme (Table 5). Despite inconclusive outcome data from the study, the anecdotal evidence and high levels of patient satisfaction have led to a HF exercise programme being commissioned at Chelsea and Westminster Hospital.
British Journal of Nursing, 2013, Vol 22, No 21
Table 5: Patient satisfaction questionnaire Q1 I was happy with the initial recruitment process to the exercise study
92% agreed with this statement
Q2 The written information provided prior to starting the programme was sufficient
84% agreed with this statement
Q3 I was happy with the type of exercise undertaken on the programme
96% agreed with this statement
Q4 The exercise was adapted to suit my needs and ability
92% agreed with this statement
Q5 I knew whom and how to contact the team delivering the exercise
100% agreed with this statement
Q6 I was happy with how the programme was delivered and staff involved in the delivery
96% agreed with this statement
Q7 I was happy with the transition period to the community class and the information provided
92% agreed with this statement
Q8 I felt I was involved with decisions made regarding the exercise programme in the hospital
88% agreed with this statement
Q9 I would be able in the future to undertake exercise safely without supervision as a result of participating in the programme
84% agreed with this statement
Q10 I feel that participating in the programme has increased my exercise ability and improved my confidence and self-esteem
92% agreed with this statement
Kensington and Chelsea leisure services have agreed to subsidise a pilot for a long-term conditions exercise class in a local leisure centre. Already recruited to participate in the programme are individuals living with COPD, heart failure and rheumatoid arthritis, with discussions under way for exit strategies into existing exercise or leisure activities provided within the borough. A total of 47 volunteers working with Kensington and Chelsea Age Concern in association with 60Plus were trained to deliver a home exercise programme initially within the north of the borough. The home exercise training programme was adapted for delivery to those classified as the elderly or frail who may benefit from supported exercise at home. Twenty of the volunteers trained are now delivering home exercise. This suggests secondary outcome measures of sustainability of the intervention have been achieved despite inconclusive primary outcome data. Living with long-term conditions or chronic disease can impact on QOL with physical limitations secondary to symptoms or disease processes resulting in social isolation and depression (Department of Health, 2005). Participation in inclusive structured exercise programmes within community environments may in part address these factors. Further studies that are longitudinal in nature may provide more substantive evidence of benefit from the intervention, which BJN would support future allocation of resources. Acknowledgements: The author would like to thank the following for their support: National Institute Health Research (NIHR), Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for North West London; Pam Copeland, Clinical Nurse Specialist, Heart Failure; Project Lead IP ICP Arm, Chelsea and Westminster Hospital Foundation Trust; Katie Baxter, Cardiac Rehabilitation Physiotherapist, Hounslow and Richmond Community Healthcare; Steve Whitmore, British
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Key points n The
key to sustainability of beneficial exercise lies in identification and engagement of key stakeholders such as voluntary agencies and leisure services in the process
n Interventions
that are longitudinal and target chronic disease population groups in order to be sustainable in the current climate of cost constraints need to build on existing resources and find alternative delivery methods
n Patient
involvement and inclusion, rather than traditional paternalistic design and delivery models, may be more successful in delivering beneficial interventions in chronic disease
n In
the absence of conclusive statistical data, anecdotal evidence of benefit can support quality of life interventions
Association of Cardiac Rehabilitation (BACR) Exercise Instructor; Tina Albrecht, (BACR) Exercise Instructor; Vicky Cruz, Research Nurse, Chelsea and Westminster Hospital Foundation Trust; Madeleine Wilson, Level 4/Phase 1V Specialist Exercise Instructor, Cardiac Disease/Studio Coordinator; Sylvia Chalkley, Research Coordinator, Division of Medicine, Imperial College Faculty of Medicine, Chelsea & Westminster Campus Leisure Services Royal Borough of Kensington and Chelsea Sports Development Team.
Conflict of interest: This article presents independent research commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. American Thoracic Society Statement (2002) Guidelines for the Six Minute Walk Test. American Journal Critical Care Medicine 166: 111-7. http://tinyurl.com/ nnp524z (accessed 1 November 2013) Calvert MJ Freemantle N, Cleland JGF (2005) The impact of chronic heart failure on health-related quality of life data acquired in the baseline phase of the CARE-HF study. Eur J Heart Fail 7(2): 243-51 Department of Health (2005) Supporting People with long term conditions: An NHS and social care model to support local innovation and integration. Department of Health, London. http://tinyurl.com/oothn5a (accessed 18 November 2013) EuroQol Group (1990) EuroQol-a new facility for the measurement of health –related quality of life. Health Policy 16(3): 199-208 ExTraMatch; exercise training (2004) Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ 328: 189 Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM (2007) A meta-analysis of the effect of exercise training on left ventricular modelling in heart failure patient: the benefit depends of the type of training performed. J Am Coll Cardiol 49(24): 2329-36 Lloyd-Williams F, Mair FS, Leitner M (2002) Exercise training and heart failure: a systematic review. Br J Gen Pract 52(474): 47-55 Milligan F (2012) The Exercise Debate. Br J Cardiol 19: 53-4 National Institute for Health and Clinical Excellence (2010) Chronic Heart Failure. Management of chronic heart failure in adults in primary and secondary care. www.nice.org.uk/guidence/CG108 (Accessed 18 November 2013) Woolf-May K, Ferrett D (2008) ISWT METS Cardiac patients. British Journal of Sports Medicine 42: 36-41
Research Skills for Nurses and Midwives This book aims to provide nurses and midwives with a sound theoretical knowledge base for understanding, critically appraising and undertaking research in all areas of health service provision. A comprehensive insight is provided into philosophies, methodologies and methods relevant to health care, using examples from both professions. This new edition is expanded, more detailed and includes a new chapter which offers a ‘how to do’ section, which nurses and midwives, beginning to engage with research for the first time, will enjoy and find useful. The book covers the main sources of research and evidence which nurses and midwives use to develop their practice. The two main headings explore qualitative and quantitative research in depth, avoiding jargon, but building in many examples to illustrate the topics. In addition, the application of other forms of evidence is addressed, as is the role of mixed methods designs. Not only does the book encourage nurses and midwives to develop their research and evidence skills, by the time the reader has completed it, they will have the knowledge and skills to conduct their own small scale research projects.
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ISBN-13: 978-1-85642-503-2; paperback; publication: 2013; 150 pages; RRP £19.99
British Journal of Nursing, 2013, Vol 22, No 21
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In the current economic climate within the NHS, behavioural-change interventions in chronic disease such as exercise programmes will be time-limited within acute hospital facilities. The challenge is to deliver cost-effective, participatory, population-specific health interventions that result in measurable benefits. Methodology: A mixed-methods study was undertaken to assess the benefits of participation in a structured exercise programme for patients with heart failure. Primary outcomes were improvements in functional capacity and quality of life. Secondary outcome measures related to patient satisfaction and sustainability of the intervention post study. Results: Overall significant improvements were not found in quality of life or functional capacity; some participants demonstrated significant improvements with others showing minor improvement or no improvement in one or both domains. Conclusions: Anecdotal evidence of perceived benefit was expressed in participant satisfaction responses. Secondary outcomes were met in relation to sustainability with commissioning of hospitaland community-based programmes on completion of the study. Key words: Heart failure ■ Quality of life ■ Exercise ■ Sustainability
M
anagement strategies of heart failure have moved from the prescriptive medical model to a more holistic model with an emphasis on lifestyle modifications and psychosocial support. (National Institute for Health and Care Excellence (NICE), 2010). Included in recommendations is the value of exercise with increasing evidence of efficacy and safety of exercise programmes. There is a substantial body of empirical evidence that identifies benefits of exercise in patients with heart failure; a meta-analysis of clinical benefits suggests that reversal of left ventricular remodelling occurs secondary to aerobic exercise training (Haykowsky et al, 2007). In the ExTraMatch study, a randomised multicentre trial undertaken by The Royal Brompton Hospital with adjustment of prognostic predictors of primary endpoints, exercise training in heart failure patients was associated with a reduction in all cause and cardiovascular morbidity (ExTraMatch, 2004). The benefits of exercise in heart failure include reduction in mortality and morbidity
Fiona Milligan is Senior Educator for Evidence-based Practice, HMC Organisation, Qatar Accepted for publication: November 2013
1242
statistics as well as improved quality of life. However, what was also evident was the lack of representation of older population groups; the mean age in the majority of the studies was less than 65 years and comorbidities common to an older population were included in the exclusion criteria (EuroQol Group, 1990). There is a dearth of studies that address issues of sustainability (of the benefits of exercise and participation in exercise programmes) and the older cohort with significant and multiple comorbidities.This would suggest that outcome data in a large number of studies are not representative of current population demographics (Lloyd-Williams et al, 2002). There are significant cost implications in the delivery of exercise programmes that are not time-limited in people living with chronic disease or long-term conditions, which may have resulted in a lack of provision both in hospital and within the community (Milligan, 2012). Following ethical approval, a study was undertaken to evaluate the benefits of participating in a structured exercise programme for patients with chronic heart failure (HF). The aim was to provide a sustainable intervention, inclusive and representative of the general population, which provided evidence of benefit in relation to improved functional capacity and quality of life (QOL). A mixed methodology design was used to evaluate functional capacity and QOL before and after each stage of the programme, beginning in hospital and progressing into the community. The programme was designed to meet the needs of a wide age range of patients and those with multiple comorbidities, a group of people often excluded from HF exercise studies as they are deemed high risk for exercise. The design of the exercise programme proposed to address this risk. Three levels of exercise—low, medium and high intensity— were provided with adaptations such as chair-based exercises forming part of the circuit that incorporated both equipment and floor exercise. The inclusion criteria included a documented diagnosis of heart failure on echocardiogram with a management plan in place incorporating evidence-based pharmacology strategies. There was no restriction on aetiology of heart failure or age. However, participants were required to demonstrate a minimal functional capacity of three metabolic equivalents (METS), the ability to undertake basic activities of living (Woolf-May and Ferrett, 2008). The exclusion criteria were: ■■ Unstable heart failure ■■ Uncontrolled atrial fibrillation
© 2013 MA Healthcare Ltd
Fiona Milligan
British Journal of Nursing, 2013, Vol 22, No 21
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.238.007.043 on November 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
cardiology ■■ Hypertension ■■ Symptomatic
hypotension exacerbation of chronic disease ■■ Inability to provide informed consent. The final sample size of 48 was representative of total numbers on a HF clinical nurse specialist’s caseload. Pre- and post-functional capacity and QOL were measured at each stage of the exercise programme. Patient satisfaction was measured through anonymous questionnaires on completion of the programme. All participants attended the initial in-hospital programme. On completion they were stratified into one of three arms (home exercise programme, group exercise class and GP exercise scheme; Figure 1) in order to continue the programme due to time-limited intervention within the hospitals. They were stratified according to functional capacity (greater capacity to GP scheme for more independent exercise) and patient choice was also a factor. The GP exercise referral scheme was already in existence, but there was poor uptake in a number of leisure centres and heart failure patients were in general unable to access the programme. GP exercise programmes often have poor uptake because of restrictions on when patients can access this programme i.e. time programme. Instructors should be level 4 when exercising heart failure or high-risk patients, or hold a specialised cardiac rehabilitation training qualification. It is hard to find instructors with this level of expertise. In addition, leisure centres often exclude HF patients because they are at a high risk, which has litigation and insurance implications. It was proposed that the community group exercise programme would be delivered by the British Association of Cardiac Rehabilitation (BACR) instructors, initially funded through the research grant. In order to meet secondary outcomes of sustainability, the programme was designed to build on existing resources and engagement of key stakeholders in the process. These were identified as GPs, local leisure services and voluntary agencies such as Age Concern Kensington and Chelsea. A random sample of 50 local GPs was sent a questionnaire with five questions relating to exercise in heart failure patients. An explanation of the exercise research study was included with the questionnaire. Eleven replies were received (response rate of 22%). Five questions reflected their views on a number of statements (Table 1). ■■ Acute
© 2013 MA Healthcare Ltd
Methods and study design A total of 48 participants meeting the inclusion criteria were recruited into five rolling exercise programmes beginning in hospital and progressing to appropriate community or home programmes. Clinical investigations included baseline physiological measurements of blood pressure, heart rate and an electrocardiogram (ECG). Haemoglobin (HB) and brain natriuretic peptide (BNP) was also collected before the programme as routine investigations. Participants’ functional capacity, exercise ability and heart rate response were assessed before and after each stage of the exercise programme using the Six Minute Walk Test (SMWT). This method of evaluating functional capacity is widely used in older population groups and in cardiac
British Journal of Nursing, 2013, Vol 22, No 21
Hospital exercise programme
GP exercise referral programme local leisure centres
Group exercise supervised by BACR instructor
Home exercise bespoke booklet and supported by volunteers from Age Concern (60+)
Figure 1. Exercise pathway
Table 1: GP questionnaire responses Responses were graded: Strongly agree (1), Agree (2), Neither agree nor disagree (3), Disagree (4) Q1 I am happy for my patients to participate in the exercise research programme
91% either strongly agreed or agreed
Q2 I am aware of current exercise opportunities available for heart failure patients to access in the community
45% disagreed, 18% neither agreed nor disagreed
Q3 I would be happy to refer patients with heart failure to current GP exercise referral schemes without detailed information on functional capacity in relation to exercise
36% disagreed, 18% neither agreed nor disagreed
Q4 I would be happy to write a letter of endorsement for exercise for heart failure patients to local leisure services without detailed information on functional capacity in relation to exercise
63% disagreed, 9% neither agreed nor disagreed
Q5 I am satisfied that local leisure centres are currently able to deliver exercise programmes for patients with heart failure
45% disagreed, 27% neither agreed nor disagreed
Table 2: Recruitment process Total number on heart failure clinical nurse specialist caseload
158
Passed away (pre-recruitment)
10
Not suitable
59
Invited to participate in programme
89
Declined/not interested
41
Recruited
48
Table 3: Study sample characteristics Sample size
Gender
Mean age Median age
Ethnic group
Diagnosis
Potential 158
M=32 F=16
Mean: 66.9 yrs Median: 69 yrs
23 White/British 4 Caribbean 3 White/Irish 7 Any other white group 1 Indian 2 Any other ethnic group 3 Any other Asian group 2 Pakistani 2 Any other black group 1 White/Asian
LVSD=20 Cardiomyopathy =19 HFPEF=9
Actual 48
1243
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Table 4: Summary of data analysis Pre-trial heart rates, diastolic blood pressure, SMWT and both quality of life scores
No statistically significant difference between the mean values of any of the parameters tested for any of the five groups, before each exercise stage was commenced. p=0.05
Mean scores for SMWT and both components of quality of life measurement Groups 1, 3 and 4
No statistical difference
Mean SMWT values for Groups 2 and 5
Statistically significant difference at 0.1
Group 5
Statistically significant difference between the means of the pre-trial and the 24-week SMWT values, p=0.05
QOL tests for groups 2–5
An overall improvement in scores which were not statistically significant
500 400 300 200 100 0
1
Sample Time n Pre
2 n 12 weeks
3 Group n 24 weeks
4
5
Data analysis
Figure 2: Mean values for SMWT before and during exercise period
6
SPSS PASW Statistics version 18 was used to analyse outcome data (Table 3). The following descriptive statistics were calculated for the pre-exercise trial values for the pre-, 12- and 24-week values for the SMWT and QOL indices for each of the study groups: mean, standard deviation (SD), maximal and minimal values.
4
Results
Mean EQ-5D Descriptive
10 8
2 0
1
Sample Time n Pre
2 n 12 weeks
3 Group
4
5
4
5
n 24 weeks
Figure 3: Quality of life: EQ–5D descriptive score
Mean EQ-5D VAS
80
60
40
20
0
1
Sample Time n Pre
2 n 12 weeks
Figure 4: Quality of life: EQ–5D VAS score
1244
populations.There is minimal equipment or expense involved in conducting the test and it can be replicated outside clinical environments (American Thoracic Society, 2002). QOL was evaluated using the EQ-5D, which consists of two components: a descriptive system and visual analogue scale (VAS).The tool is a validated generic QOL measurement chosen by the Heart Support patient group for its easy use and short format (EuroQol Group, 1990). Heart failure aetiology was a combination of cardiomyopathy, left ventricular systolic dysfunction (LVSD) and heart failure with preserved ejection fraction (HFPEF). The sample was predominantly male; the age range was 24 to 80 years with a median age of 69 (Table 2).
3 Group n 24 weeks
There were no statistically significant differences between the five groups in the mean values of initial exercise programmes of heart rate, blood pressure, SMWT or QOL. The analysis shows that there was a statically significant difference in SMWT between some of the groups as they progressed through the different stages of the exercise programme. This would suggest that there is evidence of benefit in increased physical activity or functional capacity over a sustained period of exercise. This would imply that although some benefits may be conferred during participation in shorter or time-limited programmes, longer, more sustainable interventions have the potential to deliver greater improvements. However, the outcome data for improvements in QOL were not significant, although there were improvements in scores in some of the groups (Table 4). Group variances were equal for the pre-trial SMWT and both QOL scores. The F statistic indicated that there was no statistically significant difference between the mean values of any of the parameters tested for any of the five groups, before each exercise stage was commenced (Figure 2). The SNK test placed all groups in a single subset for each parameter, indicating that the values were statistically not significantly different at the p=0.05 level. It can therefore be assumed there is no bias in allocation within the five groups for these parameters.
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Mean Six Minute Walk Test (metres)
600
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cardiology The Levene statistic indicated that the group variances were equal when comparing pre-, 12- and 24-week stage measurements for each group. The F value indicated that the mean scores for SMWT and both the components of QOL measurement were not statistically different for Groups 1, 3 and 4 (Figure 3). There was a statistically significant difference at 0.1 between the mean SMWT values for Groups 2 and 5. The Tamhane test showed that only Group 5 showed a statistically significant difference between the means of the pre- and the 24-week SMWT values, p=0.05. Group 3 was excluded from the SNK test as no participant from this cohort progressed to 24-week exercise programme stage. There was no statistically significant difference between the pre-, 12- and 24-week results for either QOL test in any of the four groups. Groups 1 and 4 showed no statistically significant difference between the SMWT values for all three samples. In Group 5, there was a statistically significant difference, p = 0.05, between the mean pre- and 24week SMWT value, while in Group 2 there was a statistically significant difference between the 24-week SMWT and the pre- and 12-week mean values. In both groups the mean 24-week sample was greater than the first two mean values. This suggests the possibility of an improvement in the SMWT value by 24 weeks for Groups 2 and 5. In QOL tests for groups 2–5, although there appeared to be an overall improvement in scores, this was not statistically significant (Figure 4).
Discussion Data are variable in relation to improvements in functional capacity and QOL. Some participants exhibited substantial improvements in SMWT with others showing little or no improvement. There was no significant variance in QOL scoring pre- and post-intervention. It has been hypothesised that QOL tools commonly used in chronic HF are not reliable or valid means of measuring quality of life in this cohort group. More relevant assessment may be gained from assessing the individuals’ experience of chronic heart failure including treatment and care pathway (Calvert et al, 2005).
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Conclusions The lack of significant improvements in identified primary outcome measures may have resulted from the chronic progressive nature of heart failure disease process or multiple comorbidities often found in this group. Significant sample attrition rate has affected the generalisability of the findings in addition to sample size. Experiential satisfaction and benefits from participation and improvement relative to previous ability is suggestive of benefit gained from intervention, which is not reflected in data obtained through formal or structured information collection. The success of the intervention can be seen in participant satisfaction, the commissioning of a hospital-based class and pathways in place linking to a supported community programme (Table 5). Despite inconclusive outcome data from the study, the anecdotal evidence and high levels of patient satisfaction have led to a HF exercise programme being commissioned at Chelsea and Westminster Hospital.
British Journal of Nursing, 2013, Vol 22, No 21
Table 5: Patient satisfaction questionnaire Q1 I was happy with the initial recruitment process to the exercise study
92% agreed with this statement
Q2 The written information provided prior to starting the programme was sufficient
84% agreed with this statement
Q3 I was happy with the type of exercise undertaken on the programme
96% agreed with this statement
Q4 The exercise was adapted to suit my needs and ability
92% agreed with this statement
Q5 I knew whom and how to contact the team delivering the exercise
100% agreed with this statement
Q6 I was happy with how the programme was delivered and staff involved in the delivery
96% agreed with this statement
Q7 I was happy with the transition period to the community class and the information provided
92% agreed with this statement
Q8 I felt I was involved with decisions made regarding the exercise programme in the hospital
88% agreed with this statement
Q9 I would be able in the future to undertake exercise safely without supervision as a result of participating in the programme
84% agreed with this statement
Q10 I feel that participating in the programme has increased my exercise ability and improved my confidence and self-esteem
92% agreed with this statement
Kensington and Chelsea leisure services have agreed to subsidise a pilot for a long-term conditions exercise class in a local leisure centre. Already recruited to participate in the programme are individuals living with COPD, heart failure and rheumatoid arthritis, with discussions under way for exit strategies into existing exercise or leisure activities provided within the borough. A total of 47 volunteers working with Kensington and Chelsea Age Concern in association with 60Plus were trained to deliver a home exercise programme initially within the north of the borough. The home exercise training programme was adapted for delivery to those classified as the elderly or frail who may benefit from supported exercise at home. Twenty of the volunteers trained are now delivering home exercise. This suggests secondary outcome measures of sustainability of the intervention have been achieved despite inconclusive primary outcome data. Living with long-term conditions or chronic disease can impact on QOL with physical limitations secondary to symptoms or disease processes resulting in social isolation and depression (Department of Health, 2005). Participation in inclusive structured exercise programmes within community environments may in part address these factors. Further studies that are longitudinal in nature may provide more substantive evidence of benefit from the intervention, which BJN would support future allocation of resources. Acknowledgements: The author would like to thank the following for their support: National Institute Health Research (NIHR), Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for North West London; Pam Copeland, Clinical Nurse Specialist, Heart Failure; Project Lead IP ICP Arm, Chelsea and Westminster Hospital Foundation Trust; Katie Baxter, Cardiac Rehabilitation Physiotherapist, Hounslow and Richmond Community Healthcare; Steve Whitmore, British
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Key points n The
key to sustainability of beneficial exercise lies in identification and engagement of key stakeholders such as voluntary agencies and leisure services in the process
n Interventions
that are longitudinal and target chronic disease population groups in order to be sustainable in the current climate of cost constraints need to build on existing resources and find alternative delivery methods
n Patient
involvement and inclusion, rather than traditional paternalistic design and delivery models, may be more successful in delivering beneficial interventions in chronic disease
n In
the absence of conclusive statistical data, anecdotal evidence of benefit can support quality of life interventions
Association of Cardiac Rehabilitation (BACR) Exercise Instructor; Tina Albrecht, (BACR) Exercise Instructor; Vicky Cruz, Research Nurse, Chelsea and Westminster Hospital Foundation Trust; Madeleine Wilson, Level 4/Phase 1V Specialist Exercise Instructor, Cardiac Disease/Studio Coordinator; Sylvia Chalkley, Research Coordinator, Division of Medicine, Imperial College Faculty of Medicine, Chelsea & Westminster Campus Leisure Services Royal Borough of Kensington and Chelsea Sports Development Team.
Conflict of interest: This article presents independent research commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. American Thoracic Society Statement (2002) Guidelines for the Six Minute Walk Test. American Journal Critical Care Medicine 166: 111-7. http://tinyurl.com/ nnp524z (accessed 1 November 2013) Calvert MJ Freemantle N, Cleland JGF (2005) The impact of chronic heart failure on health-related quality of life data acquired in the baseline phase of the CARE-HF study. Eur J Heart Fail 7(2): 243-51 Department of Health (2005) Supporting People with long term conditions: An NHS and social care model to support local innovation and integration. Department of Health, London. http://tinyurl.com/oothn5a (accessed 18 November 2013) EuroQol Group (1990) EuroQol-a new facility for the measurement of health –related quality of life. Health Policy 16(3): 199-208 ExTraMatch; exercise training (2004) Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ 328: 189 Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM (2007) A meta-analysis of the effect of exercise training on left ventricular modelling in heart failure patient: the benefit depends of the type of training performed. J Am Coll Cardiol 49(24): 2329-36 Lloyd-Williams F, Mair FS, Leitner M (2002) Exercise training and heart failure: a systematic review. Br J Gen Pract 52(474): 47-55 Milligan F (2012) The Exercise Debate. Br J Cardiol 19: 53-4 National Institute for Health and Clinical Excellence (2010) Chronic Heart Failure. Management of chronic heart failure in adults in primary and secondary care. www.nice.org.uk/guidence/CG108 (Accessed 18 November 2013) Woolf-May K, Ferrett D (2008) ISWT METS Cardiac patients. British Journal of Sports Medicine 42: 36-41
Research Skills for Nurses and Midwives This book aims to provide nurses and midwives with a sound theoretical knowledge base for understanding, critically appraising and undertaking research in all areas of health service provision. A comprehensive insight is provided into philosophies, methodologies and methods relevant to health care, using examples from both professions. This new edition is expanded, more detailed and includes a new chapter which offers a ‘how to do’ section, which nurses and midwives, beginning to engage with research for the first time, will enjoy and find useful. The book covers the main sources of research and evidence which nurses and midwives use to develop their practice. The two main headings explore qualitative and quantitative research in depth, avoiding jargon, but building in many examples to illustrate the topics. In addition, the application of other forms of evidence is addressed, as is the role of mixed methods designs. Not only does the book encourage nurses and midwives to develop their research and evidence skills, by the time the reader has completed it, they will have the knowledge and skills to conduct their own small scale research projects.
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