Biomedical subjects
Alexander M Clark
Publications and source records attributed to Alexander M Clark.
Meta-analysis: secondary prevention programs for patients with coronary artery disease.
BACKGROUND: Although supervised exercise programs reduce mortality in survivors of myocardial infarction, the effects of other types of cardiac secondary prevention programs are unknown. PURPOSE: To determine the effectiveness of secondary cardiac prevention programs with and without exercise components. DATA SOURCES: The authors searched MEDLINE (1966-2004), the Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, SIGLE, and the Cochrane Effective Practice and Organization of Care Study Registry. They also contacted primary study authors and hand-searched bibliographies provided by the Centers for Medicare & Medicaid Services. STUDY SELECTION: Randomized clinical trials. DATA EXTRACTION: Two reviewers chose studies and extracted data independently; random-effects summary risk ratios were calculated. DATA SYNTHESIS: The authors identified 63 randomized trials (21 295 patients with coronary disease). The summary risk ratio was 0.85 (95% CI, 0.77 to 0.94) for all-cause mortality, but this result differed over time with a risk ratio of 0.97 (CI, 0.82 to 1.14) at 12 months and 0.53 (CI, 0.35 to 0.81) at 24 months. The summary risk ratio was 0.83 (CI, 0.74 to 0.94) for recurrent myocardial infarction over a median follow-up of 12 months. Effects were similar for programs that included risk factor education or counseling with a structured exercise component (risk ratio, 0.88 [CI, 0.74 to 1.04] for mortality and 0.62 [CI, 0.44 to 0.87] for myocardial infarction), for programs that included risk factor education or counseling without an exercise component (risk ratio, 0.87 [CI, 0.76 to 0.99] for mortality and 0.86 [CI, 0.72 to 1.03] for myocardial infarction), and for programs that were solely exercise-based (risk ratio, 0.72 [CI, 0.54 to 0.95] for mortality and 0.76 [CI, 0.57 to 1.01] for myocardial infarction). Most of these programs improved quality of life or functional status, but effect sizes were small. LIMITATIONS: Although these programs may reduce total health care costs, published data on the costs of the programs are inadequate to conclusively comment on their cost-effectiveness. CONCLUSIONS: A wide variety of secondary prevention programs improve health outcomes in patients with coronary disease.
Attaining adequate consent for the use of electronic patient records: an opt-out strategy to reconcile individuals' rights and public benefit.
Electronic patient records (EPRs) hold great promise for improving patient care and public health. However, governments in Europe and North America have recently adopted legislation for the processing of personal data. In the United Kingdom there is a consensus that the Data Protection Act (1998) and the Human Rights Act (1998) have significant implications for the consent required for health data to be processed or passed. However, interpretations of these implications have been wide-with considerable differences apparent between regulatory bodies, government, researchers and practitioners. These arguments centre on the form of consent generally required to pass electronic personal data to health care personnel for use in decisions about the health care of populations or the individual, the circumstances in which different methods of consent are appropriate and the sufficiency of the public interest needed to counter the need for direct informed consent. To assist those developing EPRs or similar systems, we present the 'opt-out' consent strategy used for the implementation of the Coronary Heart Disease (CHD) Register developed as part of the Scottish Executive National CHD Demonstration Project. This strategy balanced the individual's right to consent with the public interest by taking all reasonable steps to inform residents about the potential direct and indirect purposes of the register, storage arrangements and types of individuals likely to access personal and anonymised data on the register. Simultaneously, the population was provided with easy and equally available opportunities to opt-out of inclusion.
A qualitative study of the contribution of pharmacists to heart failure management in Scotland.
STUDY OBJECTIVES: (1) To identify the medication management needs of chronic heart failure (CHF) patients and their caregivers; (2) To examine the perceived support for medication management available to these people from health professionals; (3) To identify the actual and potential perceived contribution of pharmacists to medication management. SETTING: A mixed urban/ rural region in the west of Scotland. DESIGN: Semi-structured qualitative research interviews. PARTICIPANTS: A total of 50 people with CHF (NYHA Class II and III) due to left ventricular systolic dysfunction (33 males; mean age 67 years, 17 females; mean age 68 years) and 30 nominated caregivers recruited from the outpatient departments of two hospitals in the West of Scotland. Sampling was purposive to include patients from a range of CHF severity, ages and sexes. MAIN RESULTS: Managing medications was a responsibility shared by both the patients with CHF and caregivers. Treatment regimens were reported to be difficult to comply with. Health professionals were seen to provide little support for medication management. Pharmacists were viewed as being a good and accessible source of practical assistance who were also knowledgeable about the individual's heart health history. Participants reported valuing advice from pharmacists about the side effects of medications and for their assistance in reducing the complex logistics of medication management and in having medications delivered. CONCLUSIONS: Patients with CHF and caregivers voiced a willingness to try to manage their medication regimen accurately but had a limited capacity to do so. Pharmacists were viewed as providing valuable support to patients with CHF and their caregivers, in terms of medication management. The extended role of pharmacists in medication management of CHF should be encouraged.
A realist study of the mechanisms of cardiac rehabilitation.
AIM: The aim of this paper is to report patients' experiences of cardiac rehabilitation and perceptions of the mechanisms and contexts influencing its long-term effectiveness. BACKGROUND: Cardiac rehabilitation programmes for the secondary prevention of coronary heart disease are common. The effects of these programmes, however, can be inconsistent and little is known of the personal and contextual factors that influence service effectiveness. METHOD: Forty-seven participants with a formal diagnosis of coronary heart disease who had attended a programme of cardiac rehabilitation in Scotland 3 years previously were included in focus groups to discuss their perceptions and experiences (30 males and 17 females). The data were generated in 2002 and analysed using the realist approach of Pawson and Tilley (1997). RESULTS: Participants' accounts indicated that the didactic content of cardiac rehabilitation was not strongly linked to longer-term health behaviour change. The main positive effects of cardiac rehabilitation were related to the effect of participation on mediating social and body-focused mechanisms that were triggered when the rehabilitation setting was perceived to be safe. Social mechanisms identified included social comparisons, camaraderie, and social capital. Body-focused mechanisms included greater knowledge of personal physical boundaries and a greater trust in the heart-diseased body. Collectively, these mechanisms had a positive effect on confidence that was perceived as being imperative to maintain health behaviour change. CONCLUSIONS: More support is required to promote health behaviour change after the completion of cardiac rehabilitation. Use of community-based exercise services and conventional or web-based support groups for coronary heart disease patients should be encouraged, as these appear to extend the positive health effects of the mechanisms that promote behaviour change. At the completion of cardiac rehabilitation programmes, patients should be referred to safe and appropriate community-based exercise services. Further research is needed to examine the effects on health outcomes of mechanisms and contexts related to cardiac rehabilitation.
Registries and informed consent.
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Promoting participation in cardiac rehabilitation: patient choices and experiences.
BACKGROUND: Cardiac rehabilitation can be an effective means for the secondary prevention of coronary heart disease, but a majority of eligible individuals fail to attend or drop out prematurely. Little research has examined patients' decisions about attendance. AIMS: This paper reports a study examining patients' beliefs and decision-making about cardiac rehabilitation attendance. METHODS: A purposive sample of patients from a mixed urban-rural region of Scotland was studied in 2001 using focus groups. Those who were eligible for a standardized 12-week cardiac rehabilitation programme were compared, with separate focus groups held for individuals with high attendance (>60% attendance; n = 27), high rates of attrition (<60% attendance; n = 9) and non-attendance (0% attendance; n = 8). A total of 44 patients (33 men; 11 women) took part in eight focus groups. RESULTS: Participants from all groups held sophisticated and cohesive frameworks of beliefs that influenced their attendance decisions. These beliefs related to the self, coronary heart disease, cardiac rehabilitation, other attending patients, and health professionals' knowledge base. An enduring embarrassment about group or public exercise also influenced attendance. Those who attended reported increased faith in their bodies, a heightened sense of fitness and a willingness to support new patients who attended. CONCLUSIONS: Reassurance to ease exercise embarrassment should be given before and during the early stages of programmes, and this could be provided by existing patients. Strategies to promote inclusion should address the inhibiting factors identified in the study, and should present cardiac rehabilitation as a comprehensive programme of activities likely to be of benefit to the individual irrespective of personal characteristics, such as age, sex or exercise capacity.
The American Cancer Society, American Diabetes Association, and American Heart Association joint statement on preventing cancer, cardiovascular disease, and diabetes: where are the social determinants?
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Preparing for change in the secondary prevention of coronary heart disease: a qualitative evaluation of cardiac rehabilitation within a region of Scotland.
BACKGROUND: Secondary prevention of Coronary Heart Disease (CHD) is often poorly managed and its benefits attained in only a minority of those with CHD. Guidelines developed in the United Kingdom and North America suggest that in future cardiac rehabilitation programmes should provide services through individualized programmes that cater for a wide range of conditions associated with CHD. This will involve substantial and costly changes to current programmes that are mostly standardized and for postmyocardial infarction patients. Based on change theory, this study examined the dynamics, strengths and weaknesses of an existing programme in a Scottish region which was due to undergo the changes suggested by guidelines. AIM: To examine the perceived provision of secondary prevention services for CHD from the perspectives of health professionals within one region in the West of Scotland. METHODS: A purposive sample of 14 health professionals (eight primary and six secondary care health professionals) was selected to cover a range of professional roles including both specialists and generalists. Separate focus group discussions (2) were held with primary care and secondary care professionals. FINDINGS: Whilst the health professionals were enthusiastic about CHD prevention and their involvement, they perceived barriers to the success of the existing service as being complex and multifactorial, including patient, social and service-related factors. Although both groups identified motivation as the most influential personal factor, secondary care staff tended to focus on the importance of patient factors in influencing motivation to change, whereas the primary care staff referred more to the cumulative effects of social and cultural factors. Professionals highlighted weaknesses in the transition between hospital and community-based services with regard to the information flow between primary and secondary care. CONCLUSIONS: Although the study has immediate relevance for the local area, it highlighted issues of more general relevance to cardiac rehabilitation programme development and intersectoral working, such as communications and role perceptions in multi-professional working and the need to adapt services to local socio-economic conditions.