Heart and mind: The use of screening and digital health innovations

The overall scope of the three studies in this PhD was to investigate different aspects of assessment and management of psychological health in the cardiac rehabilitation (CR) setting.

More than 108 million people are living with a cardiovascular disease in Europe, placing a substantial burden on both the individual person as well as society. Comorbid anxiety and depression are prevalent in approximately 20% of cardiac patients, and are associated with poor health outcomes, including increased risk of recurrent cardiac events, morbidity, and mortality. It is therefore crucial to identify and treat this vulnerable subgroup of patients.

Screening for anxiety and depression in cardiac patients is recommended in national and international guidelines to identify patients with need for psychological support. The screening procedure is reported to be suboptimal in CR, but it is unknown whether there are any patient- or provider level characteristics associated with the likelihood of being screened.

Despite guideline recommendations for evidence-based management of anxiety and depression in CR, patients are undertreated. However, new person-centred web-based solutions, including internet-delivered cognitive behavioural therapy, may show efficacy and cost-effectiveness for cardiac patients, although more research on this topic is warranted.

Telerehabilitation is found beneficial for cardiac patients, but little is known about cardiac nurses’ experiences with delivery of web-based care. Their experiences could potentially influence the delivery of web-based care, as transition from in-person care to web-based care requires different competencies.

The aim of the first study was to investigate if the likelihood that patients with acute coronary syndrome were screened for anxiety and depression - as part of routine CR - was associated with patient characteristics and quality of provider level. For this observational retrospective study, data from the National Audit of Cardiac Rehabilitation (NACR) in the United Kingdom were used. A multivariate logistic regression analysis was performed to identify predictors for being screened for anxiety and depression. Based on the statistical analysis, we found that 60% of the CR population had been screened. We found inconsistencies in routine screening in CR, with identification of a range of patient- and provider level characteristics determining the likelihood of being screened. From this study, we concluded there was inconsistency in systematic screening for anxiety and depression. We recommend that CR centres should reflect on screening procedures, but also that decision makers should ensure support and resources for screening, for the benefit of patients participating in CR.

The aim of the second study was to examine the feasibility of a web-based intervention targeting anxiety and depression in patients with ischemic heart disease that is integrated in routine CR. For this interventional prospective feasibility study, we used a mixed-method approach. Patients (n=29) were recruited consecutively from routine CR settings in nine Danish CR centres. Regarding quantitative methods, descriptive statistics were used for assessing drop-out rate, changes in anxiety and depression scores, and usage and utility of the intervention. Regarding qualitative methods, thematic analysis was used for analysing evaluations of the experiences of patients and CR nurses with the intervention and the procedures. We found a drop-out rate<25%, positive changes in anxiety and depression scores, and acceptable use and utility of the intervention. Patients (n=14) and CR nurses (n=14) were in general positive towards the intervention. The conclusion of this study was that a randomized controlled trial on web-based treatment of anxiety and depression in CR seems feasible, and that this will be the next step to assess the efficacy and cost-effectiveness of the intervention.

In the third study, we explored the experience of cardiac nurses with respect to using a web-based intervention for patients with an implantable cardioverter defibrillator. This prospective qualitative study was interview-based using qualitative content analysis. We interviewed nine cardiac nurses across the five Danish university hospitals implanting ICDs, who delivered the web-based intervention. The results showed that cardiac nurses were positive towards the web-based intervention and believe it holds a large potential. However, they felt challenged by not having in-person and face-to-face contact with patients, which they found valuable for assessing patients’ wellbeing and especially psychological distress. From this study we concluded that as web-based communication entails a shift in the nursing role, it requires specific training to obtain adequate competences.

The overall conclusion of this PhD is that screening for anxiety and depression in CR should be optimised, and that the use of digital health solutions in CR holds great potential for management of psychological health. However, further research is needed to identify the most effective solutions for delivery of holistic web-based care to cardiac patients and what works for whom.