BACKGROUND: Within 1 year after percutaneous coronary intervention, more than 20% of patients experience new adverse events. Physical activity confers a 25% reduction in mortality; however, physical activity is widely underused. Thus, there is a need for more powerful behavioral interventions to promote physical activity. Our objective was to motivate patients to achieve an increase in expenditure of 336 kcal/wk or more at 12 months as assessed by the Paffenbarger Physical Activity and Exercise Index. METHODS: Two hundred forty-two patients were recruited immediately after percutaneous coronary intervention between October 2004 and October 2006. Patients were randomized to 1 of 2 groups. The patient education (PE) control group (n = 118) (1) received an educational workbook, (2) received a pedometer, and (3) set a behavioral contract for a physical activity goal. The positive affect/self-affirmation (PA) intervention group (n = 124) received the 3 PE control components plus (1) a PA workbook chapter, (2) bimonthly induction of PA by telephone, and (3) small mailed gifts. All patients were contacted with standardized bimonthly telephone follow-up for 12 months. RESULTS: Attrition was 4.5%, and 2.1% of patients died. Significantly more patients in the PA intervention group increased expenditure by 336 kcal/wk or more at 12 months, our main outcome, compared with the PE control group (54.9% vs 37.4%, P = .007). The PA intervention patients were 1.7 times more likely to reach the goal of a 336-kcal/wk or more increase by 12 months, controlling for demographic and psychosocial measures. In multivariate analysis, the PA intervention patients had nearly double the improvement in kilocalories per week at 12 months compared with the PE control patients (602 vs 328, P = .03). CONCLUSION: Patients who receive PA intervention after percutaneous coronary intervention are able to achieve a sustained and clinically significant increase in physical activity by 12 months. Trial Registration clinicaltrials.gov Identifier: NCT00248846.
PMID: 22269589 [PubMed - as supplied by publisher]
Impact of Carotid Plaque Screening on Smoking Cessation and Other Cardiovascular Risk Factors: A Randomized Controlled Trial.
Arch Intern Med. 2012 Jan 23;
Authors: Rodondi N, Collet TH, Nanchen D, Locatelli I, Depairon M, Aujesky D, Bovet P, Cornuz J
Abstract
BACKGROUND: Screening of peripheral atherosclerosis is increasingly used, but few trials have examined its clinical impact. We aimed to assess whether carotid plaque screening helps smokers to improve their health behaviors and cardiovascular risk factors. METHODS: We randomly assigned 536 smokers aged 40 to 70 years to carotid plaque ultrasonographic screening (US group) vs no screening (control group) in addition to individual counseling and nicotine replacement therapy for all participants. Smokers with at least 1 plaque received pictures of their plaques with a 7-minute structured explanation. The outcomes included biochemically validated smoking cessation at 12 months (primary outcome) and changes in cardiovascular risk factor levels and Framingham risk score. RESULTS: At baseline, participants (mean age, 51.1 years; 45.0% women) smoked an average of 20 cigarettes per day with a median duration of 32 years. The US group had a high prevalence of carotid plaques (57.9%). At 12 months, smoking cessation rates were high, but did not differ between the US and control groups (24.9% vs 22.1%; P = .45). In the US group, cessation rates did not differ according to the presence or absence of plaques. Control of cardiovascular risk factors (ie, blood pressure and low-density lipoprotein cholesterol and hemoglobin A(1c) levels in diabetic patients) and mean absolute risk change in Framingham risk score did not differ between the groups. The mean absolute risk change in Framingham risk score was +0.6 in the US group vs +0.3 in the control group (P = .56). CONCLUSION: In smokers, carotid plaque screening performed in addition to thorough smoking cessation counseling is not associated with increased rates of smoking cessation or control of cardiovascular risk factors. Trial Registration clinicaltrials.gov Identifier: NCT00548665.
PMID: 22269590 [PubMed - as supplied by publisher]
BACKGROUND: Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes. METHODS: This randomized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation (PA) was more effective than patient education (PE) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practices. Patients in both groups received a culturally tailored hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls designed to help them overcome barriers to medication adherence. Also, patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation. The main outcome measures were medication adherence (assessed with electronic pill monitors) and within-patient change in BP from baseline to 12 months. RESULTS: The baseline characteristics were similar in both groups: the mean BP was 137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had chronic kidney disease. Based on the intention-to-treat principle, medication adherence at 12 months was higher in the PA group than in the PE group (42% vs 36%, respectively; P = .049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .45) for the PA group and PE group, respectively, was not significant. CONCLUSIONS: A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans. Future studies should assess the cost-effectiveness of integrating such interventions into primary care. Trial Registration clinicaltrials.gov Identifier: NCT00227175.
PMID: 22269592 [PubMed - as supplied by publisher]
BACKGROUND: Patients with asthma engage in less physical activity than peers without asthma. Protocols are needed to prudently increase physical activity in asthma patients. We evaluated whether an educational intervention enhanced with positive affect induction and self-affirmation was more effective than the educational protocol alone in increasing physical activity in asthma patients. METHODS: We conducted a randomized trial in New York City from September 28, 2004, through July 5, 2007; of 258 asthma patients, 252 completed the trial. At enrollment, control subjects completed a survey measuring energy expenditure, made a contract to increase physical activity, received a pedometer and an asthma workbook, and then underwent bimonthly follow-up telephone calls. Intervention patients received this protocol plus small gifts and instructions in fostering positive affect and self-affirmation. The main outcome was the within-patient change in energy expenditure in kilocalories per week from enrollment to 12 months with an intent-to-treat analysis. RESULTS: Mean (SD) energy expenditure at enrollment was 1767 (1686) kcal/wk among controls and 1860 (1633) kcal/wk among intervention patients (P = .65) and increased by 415 (95% CI, 76-754; P = .02) and 398 (95% CI, 145-652; P = .002) kcal/wk, respectively, with no difference between groups (P = .94). For both groups, energy expenditure was sustained through 12 months. No adverse events were attributed to the trial. In multivariate analysis, increased energy expenditure was associated with less social support, decreased depressive symptoms, more follow-up calls, use of the pedometer, fulfillment of the contract, and the intervention among patients who required urgent asthma care (all P < .10, 2-sided test). CONCLUSIONS: A multiple-component protocol was effective in increasing physical activity in asthma patients, but an intervention to increase positive affect and self-affirmation was not effective within this protocol. The intervention may have had some benefit, however, in the subgroup of patients who required urgent asthma care during the trial. Trial Registration clinicaltrials.gov Identifier: NCT00195117.
PMID: 22269593 [PubMed - as supplied by publisher]
Positive Affect and Self-affirmation Are Beneficial, but Do They Facilitate Maintenance of Health-Behavior Change?: Comment on “A Randomized Controlled Trial of Positive-Affect Intervention and Medication Adherence in Hypertensive African Americans”
Arch Intern Med. 2012 Jan 23;
Authors: Williams GC, Niemiec CP
PMID: 22269594 [PubMed - as supplied by publisher]
Effect of Exercise Training on Depressive Symptoms Among Patients With a Chronic Illness: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
BACKGROUND: Physical inactivity and comorbid depressive symptoms are prevalent among patients with a chronic illness. To our knowledge, randomized controlled trials of the effects of exercise training on depressive symptoms among patients with a chronic illness have not been systematically reviewed. We estimated the population effect of exercise training on depressive symptoms and determined whether the effect varied according to patient characteristics and modifiable features of exercise exposure and clinical settings.
METHODS: Articles published before June 1, 2011, were located using the Physical Activity Guidelines for Americans Scientific Database, Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. Ninety articles involving 10 534 sedentary patients with a chronic illness were selected. Included articles required (1) randomized allocation to an exercise intervention or nonexercise comparison condition and (2) a depression outcome assessed at baseline and at mid- and/or postintervention. Hedges d effect sizes were computed, study quality was evaluated, and random effects models were used to estimate sampling error and population variance of the observed effects.
RESULTS: Exercise training significantly reduced depressive symptoms by a heterogeneous mean effect size delta (Δ) of 0.30 (95% CI, 0.25-0.36). Larger antidepressant effects were obtained when (1) baseline depressive symptoms were higher, (2) patients met recommended physical activity levels, and (3) the trial primary outcome, predominantly function related, was significantly improved among patients having baseline depressive symptoms indicative of mild-to-moderate depression.
CONCLUSIONS: Exercise reduces depressive symptoms among patients with a chronic illness. Patients with depressive symptoms indicative of mild-to-moderate depression and for whom exercise training improves function-related outcomes achieve the largest antidepressant effects.
Tests and expenditures in the initial evaluation of peripheral neuropathy.
Arch Intern Med. 2012 Jan 23;172(2):127-32
Authors: Callaghan B, McCammon R, Kerber K, Xu X, Langa KM, Feldman E
Abstract
BACKGROUND: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing.
METHODS: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods.
RESULTS: Of the 12 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14 362 vs $8067, P < .001).
CONCLUSIONS: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.
