This post will be a repost of a research paper by myself and a graduate professor of mine. My research was on motivational interviewing, goal setting, and problem-solving interventions with patients in a rehabilitation center. Even though the study was in a “Special population” the conclusions can be applied to many people’s seeking to change their behaviors. I hope you enjoy the article, and if you have any questions about the study don’t hesitate to reach out to in the contact tab.

CONCORDIA UNIVERSITY, ST. PAUL

ST. PAUL, MINNESOTA

DEPARTMENT OF KINESIOLOGY AND HEALTH SCIENCES    

Goal setting and counseling intervention significantly improves attendance of a cardiac and pulmonary rehab program

John C. Cole, MS, Joseph D. Ostrem, PhD, any other individuals that have been integral in your paper generation.

Introduction

Cardiac and pulmonary rehabilitation (CR and PR) programs aim to improve physical, psychological and social health in patients with varying cardiovascular or pulmonary limitations. Interventions typically center around supervised exercise therapy, risk factor reduction, disease education and psychological services (USDHHS, 2019a; USDHHS, 2019b; AACVPR, 2019a; AACVPR, 2019b). Both CR and PR programs use a multi-disciplinary team comprised of nurses, exercise physiologist, respiratory therapists, dieticians, psychological professionals, administrators, physicians and physician assistants. CR and PR programs are often operated out of the same facility by the same staff due to their similarities in approach, principles and purposes. In addition, some clinics even treat CR and PR patients simultaneously (USDHHS, 2019a; USDHHS, 2019b; AACVPR, 2019a; AACVPR, 2019b).

CR has been shown to improve cardiovascular health through decreased mortality risk, decreased hospital readmissions, improved exercise capacity, risk factor reduction and improvements in quality of life (QOL) (Anderson et al., 2016). These benefits are mirrored in PR with patients witnessing increases in tidal volume, decreased respiratory rates, improved oxygen saturations, improvements in skeletal muscle function, positive body composition changes and increased cardiovascular function (Bianchi et al., 2004; Nici et al., 2006). Furthermore, PR patients report improvements in exercise capacity, ratings of dyspnea, QOL ratings and decreases in hospital readmission rates (Cheng et al., 2018; Nici, 2006; Rochester, Fairburn & Crouch, 2014; Ryrso et al., 2015). The benefits of CR and PR programs appear to be dose-dependent, with more sessions attended resulting in greater benefits received (Hammill, 2010; Martin, 2012). Despite this strong evidence for the effectiveness of these programs there is a lack of participation in both. According to Medicare and patient records from multiple CR programs, participation in CR programs are estimated to be approximately 20% (Ades et al., 2018). In addition, a systematic review by Keating, Lee & Holland (2011) illustrated that PR programs had varying attendance rates nationwide from 8.3-49.6%. Since CR and PR programs share similarities in purpose, principles, structure, staffing and effectiveness as well as deleterious statistics on attendance rates, the need for strategies to improve attendance in both CR and PR programs is apparent. While research exists investigating interventions to improve attendance to CR and PR a majority produce barriers to implementation such as time constraints, structure changes and increased cost, in addition to only investigating effectiveness in CR or PR (Benzo, 2013; Bertelsen, 2017; Gaalema, 2016; Lynggard, 2017; McPaul, 2007; McGrady, 2014; Ringbaek, 2016). In one such study by Pack et al (2016) investigating the effect of patient incentives on attendance to CR researchers noted, “there remain little effective strategies that improve attendance that are not costly to a clinic (Pack et al., 2016).”

Purpose

The current study sought to improve attendance in both a CR and PR program by utilizing a no cost, brief, goal setting intervention in conjunction with a problem-solving and motivational interviewing (MI) collaboration. Goal setting consisted of a patient centered SMART goal described by Wade et al. (2009) as specific, easily measurable, attainable, realistic and time bound, which was created during the first rehabilitation session. Multiple goal setting studies using similar goal construction methods have been assessed in the adult cardiovascular population and have shown effectiveness in behavior change (Artinian et al., 2010). With goal setting interventions, it is imperative to provide regular feedback to instill a sense of learning and providing mastery experiences for the patient (Strecher et al., 1995; Wade et al., 2009), thus a 1-3-minute weekly counseling session utilizing a problem-solving method in conjunction with a MI communication style was implemented where the patient was directly involved in development of strategies aimed at goal completion. Both problem solving and MI have shown promise in improving adherence to exercise and other rehabilitation components in settings such as CR and PR and the populations these programs serve (Benzo, 2013; Blair, 2011; Grave, 2011; Maxwell-Smith, 2017; McGrady, 2014; Moore, 2006; Shumaker, 2009; Steele, 2008; Zurilla, 1971). MI has four main tenets: 1) express empathy, 2) demonstrate understanding and straying from conflict with the patient, 3) supporting the patient’s self-efficacy, 4) when necessary illustrate to the patient that their current behavior is not parallel with their expressed goal (Shumaker, 2009). Problem-solving is centered around four main steps 1) collaborate with the patient to identify barriers to completion of their smart goal, 2) collaborate with the patient to develop a strategy to overcome identified barriers, 3) select a strategy in conjunction with the patient, 4) reassess the effectiveness of the strategy at a designated time with the patient.  However, this research study used a short goal setting and problem-solving intervention in both CR and PR populations. It was hypothesized that patients receiving the goal setting and counseling intervention would increase attendance compared to a retrospective control group (RCG). Additionally, it was hypothesized that patient’s perception of their progress toward completion of their goals would be associated with their performance improvements.

Design

CR patients were instructed to attend three days per week with each session lasting from 60-75 minutes. A daily session consisted of a 5-10 minute very light-light dynamic warmup, 10-40 minutes of cardiovascular exercise prescribed between 30-90%HRR determined at initial evaluation and dependent on patient’s capacity, 15-20 minutes of resistance training using multiple modalities including free weights, machines and elastic bands followed by a 5-10-minute cooldown consisting of stretching and relaxation. All necessary precautions were taken to ensure patients were safe during their exercise session. CR program patients also received a wide range of education covering topics such as smoking cessation, nutrition, exercise safety and progression, psychology, among others. This CR program has been in effect at the rehabilitation center since 2016 which allows for historical comparison to occur.

PR patients were instructed to attend two days per week with each session lasting from 60-75 minutes. The difference in CR and PR required days is due to regulatory requirements in CR, structure of the clinic in which both the CR and PR programs were operated out of and clinic administration. A daily PR session consisted of a 5-10 minute very light-light dynamic warmup focusing on core tenets of warming up (increasing core temperature, slightly increasing HR and BP, etc.) while also focusing on stretching secondary respiratory musculature and proper breathing techniques in hopes of optimizing performance. This was followed by 10-30 minutes of cardiovascular exercise prescribed at an intensity pre-determined at initial evaluation and dependent on patient’s capacity (30-90%HRR and/or 2-6 Rate of perceived dyspnea (RPD)), 15-20 minutes of resistance training using multiple modalities including free weights, machines and elastic bands followed by a 5-10-minute cooldown consisting of stretching, relaxation and group diaphragmatic exercises. All necessary precautions were taken to ensure patients were safe during their exercise session. PR program patients received similar education opportunities as the CR patients. This PR program has been in effect at the rehabilitation center since 2016 which allows for historical comparison to occur.

A total of 32 patients were recruited for the intervention group (IVG) (7 PR and 25 CR), with one patient choosing not to participate in the study. The study length was 12-weeks. Patients were all admitted as either intensive Phase 2 CR patients or PR patients. The CR population included a myriad of diagnoses: myocardial infarction (MI) (STEMI and non-STEMI), congestive heart failure (CHF) (diastolic and systolic), coronary bypass surgery (CABG), percutaneous intervention (PCI), valvular disease/surgery, or left ventricular assistive device (LVAD) placement. The PR population consisted of the following diagnoses: chronic obstructive pulmonary disease (COPD), pulmonary hypertension, pulmonary fibrosis, interstitial lung disease (ILD) and/or any other condition deemed appropriate by the patient’s medical doctor for cardiopulmonary rehabilitation services. Exclusionary criteria included any ailment that would impede the patient’s ability to properly comprehend the intervention such as mental or hearing impairments, in addition to any barriers that would cause deviations from the standard CR or PR program schedule. One patient was excluded from the study due to their PR referral requesting more sessions per week than standard. RCG data was gathered via a Quinton telemetry monitoring system (QTMS) and clinic records from previous years (2016, 2017, 2018). The RCG were matched against the IVG based on age (±2), gender, principle diagnosis and selected using random sampling software as to remove any selection bias.

During the first session, the IVG received an initial consultation where they were informed of the study, all questions were answered regarding the study, informed consent was acquired. All HIPAA guidelines and necessary precautions to protect patient’s privacy and health information were taken per clinic policies and procedures. One individual chose to not take part in the study. The initial consultation was conducted by the rehabilitation staff (Registered Nurse (RN), Respiratory Therapist (RT) and Exercise Physiologist (EP)) where they acquired insurance information, a detailed medical history, identified barriers to rehabilitation program, obtained a current medication list and orientated the patient to the clinic and procedures. Next, pre-exercise vital signs were taken including heart rate (HR), blood pressure (BP), oxygen saturation (02), mean arterial pressure (MAP), resting EKG, and anthropometric measures (weight, height and body mass index (BMI)). The patients then performed a 6-minute walk test and an 8-foot sit and go test in which exercise data was gathered (exercising BP, HR, EKG and 02). The patient rested for at least 5 minutes before resting vitals were assessed. Then, the patient’s individualized exercise prescription and care plan was discussed, and a start date was set for their first full session of rehab. All patients in the RCG received the same consultation process. There had been no changes to the structure of the CR or PR programs from the time the RCG were assessed to the time of the present study. During the evaluation process, patients were asked to create a SMART goal with assistance from the rehab staff if necessary. Once the goal was set it was displayed on the patient’s daily exercise prescription sheet created by the QTMS. Once a week research staff approached the IVG while on the exercise floor and conducted the problem solving and MI collaborative counseling intervention. Staff were instructed to keep all counseling sessions ❤ minutes, no interaction went over this time restriction. During each intervention the IVG were asked to rate their perceived progress toward their goal completion on a 1-5 Likert scale where 1-5 represented “no closer to goal completion”, “slightly closer to goal completion”, “half-way to goal completion”, “almost to goal completion”, “goal completed”, respectively. This rating was then recorded by the researcher. All patient exercise data such as HR, BP, exercise duration, 02, METs and weight were recorded in the QTMS.

Methods

Exercise equipment and a QTMS were used to provide exercise therapy and track exercise and patient data. Exercise equipment used in the rehabilitation programs included Sports Art Fitness (Mukilteo, WA, USA) treadmills (MODEL: T655), stationary bicycles (C575U), recumbent bicycles (C575R), ellipticals (MODEL: E875), arm ergometers (MODEL: UB521M), and Sci-Fit Systems, Inc.(Tulsa, OK, USA) recumbent steppers (MODEL: REX7000; MODEL: REX7000; MODEL: REX7000,). The average Metabolic Equivalent (MET) achieved and duration completed on each modality completed by the patient each session was taken from these exercise modalities and logged into the QTMS by the researcher.

Attendance was assessed in both groups by summing all sessions attended and dividing by all session opportunities. Sessions attended excluded the evaluation day, as an aspect of this day is setting a start day which may not be consecutive depending on clinic availability and individual patient factors. There were no exemptions for sessions missed for both the IV and RCG. All patients in both the IV and RCG were offered the opportunity to make up missed sessions on a non-scheduled day (Tuesday and Thursday for CR patients and Monday, Wednesday or Friday for PR patients) as to offer the patient more flexibility and improve adherence.

Patient performance was identified as the change in METs across the 12-week period. The MET’s achieved by each patient was estimated by the various modalities at the clinic via an internally programmed metabolic equation. METs were not calculated according to metabolic parameters and anthropometric measures. This is was due to lack of equipment such as a metabolic cart. The same parameters (age, gender, etc.) were constant across all machines and patients. Therefore, changes in METs overtime likely represented true changes in capacity as factors that would change the outcome of these metabolic equations, such as significant weight changes, did not occur in the IV (average weight loss 0.315lb). Change in MET’s was calculated by taking the average maximal MET’s achieved across the first and last 5 sessions the patient attended. This methodology was chosen for two reasons. One, patients who did not complete the program did not complete a post 6MWT. Two, an average of multiple sessions would likely illustrate a patient’s submaximal capacity. If a patient attended less than 10 sessions, the same methodology was used for however many sessions were available. If a patient only attended the consultation their performance change was calculated as zero.

All data was assessed using SPSS statistical software. The mean attendance rate of the IV and RCG were analyzed using an independent t-test assuming equal variance. This same method was also used to analyze mean attendance rates of subgroups within the IV and RCG groups: CR and PR of IV against CR and PR of RCG. In addition, a linear regression analysis was conducted assessing correlation between average change in performance and each patient’s Likert scale ratings of perceived goal completion.

Results

Independent t-test analysis revealed there to be a statistically significant difference between the mean attendance rates of the IV and RCG groups (p .034). Subgroup analysis revealed there to be a significant difference between the IV CR subgroup and RCG CR subgroup (p .019). Analysis of IV PR subgroup and RCG PR subgroup revealed a non-significant difference in mean attendance rates (p .220). Analysis of correlations between patient’s change in performance and each patient’s Likert scale ratings of goal completion revealed a strong correlation (r = .786).

Conclusions

This study sought to examine the effect of the goal setting intervention in conjunction with a short counseling intervention on attendance in a CR and PR program. The results of the study illustrated that the IV group experienced a significant increase in their mean attendance compared to the RCG. This finding corresponds with other goal setting studies that demonstrate its effectiveness at improving outcomes in the rehabilitation setting. Furthermore, this study illustrates that the dosage of interventions such as goal setting and MI can be minimal and still effective. Both these interventions have generally been longer in duration in previous CR and PR research, likely due to the dose-response relationship witnessed in counseling such as MI (Santiago de Araújo Pio, 2019). However, with barriers such cross-training staff, job rotation, financial limitations, and time constraints in CR and PR programs interventions that are quick and effective are indispensable (Kraus, 2007). Furthermore, subgroup analysis revealed IV CR subgroup witnessed a significant attendance improvement (p .019) compared to the IV PR subgroup (p .22). This may illustrate that these two population respond differently to behavioral interventions such as goal setting, problem solving and motivational interviewing communication styles. In addition, goal setting and MI’s effect on CR outcomes is well established, however, this level of efficacy does not appear to be established within the PR research. However, this researcher feels that though statistical significance was not found with the IV PR subgroup analysis, this group witnessing a 17.2% improvement in attendance is significant clinically.

Postulating, perhaps the difference between the groups deals with their perception of disease control. This factor has already been associated with negative outcomes among different chronic disease population, including COPD, and could lend reasoning behind why cognitive behavioral strategies (CBT) effect these populations differently (Kaptein, 2008; Karamanidou et al., 2008; Welch & Thomas-Hawkins, 2005). A respiratory patient’s prognosis is likely to be grimmer due to the irreversible and deteriorating nature of their disease, opposed to that of a CR patient post-CABG or PCI. This same concept would then also hold true for other prevalent respiratory diagnoses seen in the PR setting such as IPF or ILD. If this inference is true, it demonstrates the importance of determining a PR patient’s perception of disease control as standard practice as to stratify those patients who may experience a diminished positive effect from CBT. In addition, PR patients may require a larger dose of CBT type interventions due to their stage of change and the behavior they are trying to change. Similar to optimal feedback frequency being dependent upon individual stage of learning and skill complexity (Sidaway, et al., 2008; Sidaway et al. 2012). Perhaps the 1-3-minute problem-solving and MI counseling intervention seen within this study was of too low of a dosage for some PR patients, or CR patients, due to these factors. More research should be conducted to identify if this hypothesis is true, what methods could be used to identify the appropriate dosage of counseling needed for an individual as to optimize efficiency of counseling interventions.

Additionally, when assessing for correlations between patient’s Likert scale ratings and performance improvements a trend arose denoting higher rating associated with greater performance improvements (r .7868 – table 4). In addition, an individual with a Likert rating of 4 or 5 was more likely to attend CR and PR compared to those individuals whose maximal rating was a 1,2 or 3 by 83%, 45% and 13%, respectively. This could be interpreted as a correlation between an individual’s perception of progress toward their goal and their performance in CR and PR. This implies that one’s perception of their progress plays a principal role in factors such as adherence and performance. This theme has been witnessed in previous research where an individual’s perception of control or capability, referred to as one’s self-efficacy, is linked to performance improvements (Feltz, 1988). This finding illustrates that interventions aimed at increasing one’s self-efficacy, such as goal setting and motivational interviewing, has a positive impact on individual’s performance and should be implemented in programs such as CR and PR.

Limitations of this study included small samples, a short study length, use of only a single researcher/clinician and conduction at a single clinic location. A larger sample would have better illustrated the impact of the intervention on the larger CR and PR populations. Small sample size was due to clinic procedures such as patient scheduling, while the study period was dictated by deadlines specific to the researcher. In addition, the fact that a single researcher carried out the interventions and patients came from a single clinic is a limitation. Past research with similar interventions has also identified this limitation (Santiago de Araújo Pio, 2019).

Continued research into goal setting interventions in CR and PR programs with techniques, such as the one used in this study, which decrease barriers to start up and are easy to implement are needed. Past designs have presented barriers to implementation in the form of time constraints, cost and structure changes. Future research should attempt to look at interventions with minimal startup and their effect on attendance to CR and PR. Future research designs should attempt to establish a large effect size by ensuring a large sample size. In addition, longer study durations need to be used. Furthermore, more studies need to assess the effect of such interventions using different clinicians and in different clinics in differing communities with diverse populations.

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