title: Secondary Prevention Risk Interventions Via Telemedicine and Tailored Patient Education (SPRITE): A Randomized Trial to Improve Postmyocardial Infarction Management An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial A mobile phone intervention increases physical activity in people with cardiovascular disease: Results from the HEART randomized controlled trial Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease Just-in-time evidence-based e-mail "reminders" in home health care: impact on patient outcomes. Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial The UPBEAT Nurse-Delivered Personalized Care Intervention for People with Coronary Heart Disease Who Report Current Chest Pain and Depression: A Randomised Controlled Pilot Study Increasing the medium-term clinical benefits of hospital-based cardiac rehabilitation by physical activity telemonitoring in coronary artery disease patients A Web-Based Program Improves Physical Activity Outcomes in a Primary Care Angina Population: Randomized Controlled Trial Depression-focused interpersonal counseling and the use of healthcare services after myocardial infarction. Technology Evaluation: A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease The effect of different cardiovascular risk presentation formats on intentions, understanding and emotional affect: a randomised controlled trial using a web-based risk formatter (protocol) A randomised controlled trial of a consumer-focused e-health strategy for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) study protocol Web-Based Targeted Nutrition Counselling and Social Support for Patients at Increased Cardiovascular Risk in General Practice: Randomized Controlled Trial Promoting fruit and vegetable consumption. Testing an intervention based on the theory of planned behaviour Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain. Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial Design and baseline characteristics of the 10 Small Steps Study: a randomised controlled trial of an intervention to promote healthy behaviour using a lifestyle score and personalised feedback The Know & Go! program improves knowledge for patients with coronary heart disease in pilot testing. A Web-Based Approach to Address Cardiovascular Risks in Managers: Results of a Randomized Trial The TeleGuard trial of additional telemedicine care in CAD patients. 2 Morbidity and mortality after 12 months Providing a Web-based Online Medical Record with Electronic Communication Capabilities to Patients With Congestive Heart Failure: Randomized Trial Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system. Impact of a telehealth intervention to augment home health care on functional and recovery outcomes of elderly patients undergoing coronary artery bypass grafting. The health impact of an online heart disease support group: a comparison of moderated versus unmoderated support. Randomized trial of a home recovery intervention following coronary artery bypass surgery. Web-based tailoring and its effect on self-efficacy: results from the MI-HEART randomized controlled trial Psychodynamic Motivation and Training program (PMT) for the secondary prevention in patients with stable coronary heart disease: study protocol for a randomized controlled trial of feasibility and effects Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol Computerized community cholesterol control (4C): meeting the challenge of secondary prevention. Designing a theory- and evidence-based tailored eHealth rehabilitation aftercare program in Germany and the Netherlands: study protocol A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial Randomized controlled trial of an informatics-based intervention to increase statin prescription for secondary prevention of coronary disease One-year follow-up of a therapeutic lifestyle intervention targeting cardiovascular disease risk Influence of an early recovery telehealth intervention on physical activity and functioning after coronary artery bypass surgery among older adults with high disease burden. An intervention to improve secondary prevention of coronary heart disease. Electronic prescribing via the internet for a coronary artery disease and hypertension megatrial Role of telecardiology in the assessment of angina in patients with recent acute coronary syndrome Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial. A pilot-study to identify the feasibility of an Internet-based coaching programme for changing the vascular risk profile of high-risk patients. A comparison of in-person home care, home care with telephone contact and home care with telemonitoring for disease management Cardiac rehabilitation after myocardial infarction: What influences patients’ intentions to attend? Utilization of the internet to deliver cardiac rehabilitation at a distance: a pilot study. The WHICH? trial: rationale and design of a pragmatic randomized, multicentre comparison of home- vs. clinic-based management of chronic heart failure patients. Impact of a home communication intervention for coronary artery bypass graft patients with ischemic heart failure on self-efficacy, coronary disease risk factor modification, and functioning. Therapeutic benefit of internet-based lifestyle counselling for hypertension. Just-in-time evidence-based e-mail "reminders" in home health care: impact on nurse practices. Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial. Randomized Comparison of Elective Stent Implantation and Coronary Balloon Angioplasty Guided by Online Quantitative Angiography and Intracoronary Doppler Web-based Internet telemedicine management of patients with heart failure. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. An Internet- and Mobile-Based Tailored Intervention to Enhance Maintenance of Physical Activity After Cardiac Rehabilitation: Short-Term Results of a Randomized Controlled Trial Telephonically-monitored home exercise early after coronary artery bypass surgery. A text messaging intervention to promote medication adherence for patients with coronary heart disease: a randomized controlled trial. Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. Clinical trial of an Internet-based case management system for secondary prevention of heart disease. Enhancing the quality of care for patients with coronary heart disease: the design and baseline results of the hastening the effective application of research through technology (HEART) trial. The TeleGuard trial of additional telemedicine care in CAD patients. 1 Utilization of the system A computer based telemedicine protocol to predict acute coronary syndrome in patients with chest pain at home. An Online Community Improves Adherence in an Internet-Mediated Walking Program. Part 1: Results of a Randomized Controlled Trial A randomized trial of computer-based communications using imagery and text information to alter representations of heart disease risk and motivate protective behaviour. Telehome monitoring in patients with cardiac disease who are at high risk of readmission. The effects of interpersonal counselling on health-related quality of life after myocardial infarction. Effect of Preventive Messages Tailored to Family History on Health Behaviors: The Family Healthware Impact Trial Effects of lifestyle modification on coronary artery calcium progression and prognostic factors in coronary patients--3-year results of the randomized SAFE-LIFE trial. Nurse and patient communication profiles in a home-based telehealth intervention for heart failure management. A computerized intervention to decrease the use of calcium channel blockers in hypertension Self-Study from Web-Based and Printed Guideline Materials [Efficacy of an educational preventive technology in patients with stable angina in ambulatory conditions]. Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial. Influence of a symptom management telehealth intervention on older adults' early recovery outcomes after coronary artery bypass surgery. A multifaceted intervention to narrow the evidence-based gap in the treatment of acute coronary syndromes: rationale and design of the Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes (BRIDGE-ACS) cluster-randomized trial. Evaluation of a Telemedicine Service for the Secondary Prevention of Coronary Artery Disease Effect of Adding a Values Clarification Exercise to a Decision Aid on Heart Disease Prevention: A Randomized Trial Enabling healthy choices: is ICT the highway to health improvement?
abstract: Background — Secondary prevention by risk factor modification improves patient outcomes , yet it is often not achieved in clinical practice . Reasons for failure stem from challenges of prioritizing risk factor reduction and engaging patients in changing their behaviors . We hypothesize that a novel telemedicine intervention with tailored patient education could improve cardiovascular risk factors . Methods — To evaluate this intervention , we propose enrolling 450 patients with a recent myocardial infa rct ion and hypertension into a 3-arm r and omized , controlled trial . The first arm ( n=150 ) will receive home blood pressure ( BP ) monitors plus a nurse-delivered , telephone-based tailored patient education intervention and will be enrolled into HealthVault , a Microsoft electronic health record platform . The second arm ( n=150 ) will also receive BP monitors plus a tailored patient education intervention and be enrolled in HeartVault . However , the patient education intervention will be delivered by a Web-based program and will cover topics identical to those in the nurse-delivered intervention . Both arms will be compared with a control group receiving st and ard care ( n=150 ) . All participants will have an in-person assessment at baseline and at completion of the study , including st and ardized measurements of BP , LDL cholesterol , and glycosylated hemoglobin ( in diabetic subjects ) . The study design will allow assessment of a telephone-based , nurse-administered disease management program versus st and ard care . The main outcome of interest is the reduction in systolic BP in each intervention group compared with the control group at 12 months . Secondary outcomes assessed will include reductions in LDL cholesterol , body weight , and glycosylated hemoglobin , as well as adherence to evidence -based therapies and improvement in health behaviors . Conclusion — If successful in optimizing BP control , managing other coronary heart disease risk factors , and demonstrating a lower cost , the Web-based disease management tool has the potential to enhance coronary artery disease management , quality of care , and ultimately , patient outcomes . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00901277 Of 22 r and omized trials of rehabilitation with exercise  after myocardial infa rct ion ( MI ) , one trial had results that achieved conventional statistical significance . To determine whether or not these studies , in the aggregate , show a significant benefit of rehabilitation after myocardial infa rct ion , we performed an overview of all r and omized trials , involving 4,554 patients ; we evaluated total and cardiovascular mortality , sudden death , and fatal and nonfatal reinfa rct ion . For each endpoint , we calculated an odds ratio ( OR ) and 95 % confidence interval ( 95 % CI ) for the trials combined . After an average of 3 years of follow-up , the ORs were significantly lower in the rehabilitation than in the comparison group : specifically , total mortality ( OR = 0.80 [ 0.66 , 0.96 ] ) , cardiovascular mortality ( OR = 0.78 [ 0.63 , 0.96 ] ) , and fatal reinfa rct ion ( OR = 0.75 [ 0.59 , 0.95 ] ) . The OR for sudden death was significantly lower in the rehabilitation than in the comparison group at 1 year ( OR = 0.63 [ 0.41 , 0.97 ] ) . The data were compatible with a benefit at 2 ( OR = 0.76 [ 0.54 , 1.06 ] ) and 3 years ( OR = 0.92 [ 0.69 , 1.23 ] ) , but these findings were not statistically significant . For nonfatal reinfa rct ion , there were no significant differences between the two groups after 1 ( OR = 1.09 [ 0.76 , 1.57 ] ) , 2 ( OR = 1.10 [ 0.82 , 1.47 ] ) , or 3 years ( OR = 1.09 [ 0.88 , 1.34 ] ) of follow-up . The observed 20 % reduction in overall mortality reflects a decreased risk of cardiovascular mortality and fatal reinfa rct ion throughout at least 3 years and a reduction in sudden death during the 1st year after infa rct ion and possibly for 2 - 3 years . With respect to the independent effects of the physical exercise component of cardiac rehabilitation , the relatively small number of " exercise only " trials , combined with the possibility that they may have had a formal or informal nonexercise component precludes the possibility of reaching any definitive conclusion . To do so would require a r and omized trial of sufficient size to distinguish between no effect and the most plausible effect based on the results of this overview Abstract Objective : To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care . Design : A before and after pragmatic cluster r and omised controlled trial utilising a two by two incomplete block design . Setting : 60 general practice s in north east Engl and . Participants : General practitioners and practice nurses in the study practice s and their patients aged 18 or over with angina or asthma . Main outcome measures : Adherence to the guidelines , based on review of case notes and patient reported generic and condition specific outcome measures . Results : The computerised decision support system had no significant effect on consultation rates , process of care measures ( including prescribing ) , or any patient reported outcomes for either condition . Levels of use of the software were low . Conclusions : No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care . This was probably due to low levels of use of the software , despite the system being optimised as far as was technically possible . Even if the technical problems of producing a system that fully supports the management of chronic disease were solved , there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex , multiple conditions Aim To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease ( IHD ) . Methods and results In this single-blind , parallel , two-arm , r and omized controlled trial adults ( n = 171 ) with IHD were r and omized to receive a mobile phone delivered intervention  ( HEART ; n = 85 ) plus usual care , or usual care alone ( n = 86 ) . Adult participants aged 18 years or more , with a diagnosis of IHD , were clinical ly stable as out patients , able to perform exercise , able to underst and and write English , and had access to the Internet . The HEART ( Heart Exercise And Remote Technologies ) intervention involved a personalized , automated package of text messages and a secure website with video messages aim ed at increasing exercise behaviour , delivered over 24 weeks . All participants were able to access usual community-based cardiac rehabilitation , which involves encouragement of physical activity and an offer to join a local cardiac support club . All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake ( PVO2 ; primary outcome ) , self-reported physical activity , health-related quality of life , self-efficacy and motivation ( secondary outcomes ) . Results showed no differences in PVO2 between the two groups ( difference −0.21 ml kg−1 min−1 , 95 % CI : −1.1 , 0.7 ; p = 0.65 ) at 24 weeks . However significant treatment effects were observed for selected secondary outcomes , including leisure time physical activity ( difference 110.2 min/week , 95 % CI : −0.8 , 221.3 ; p = 0.05 ) and walking ( difference 151.4 min/week , 95 % CI : 27.6 , 275.2 ; p = 0.02 ) . There were also significant improvements in self-efficacy to be active ( difference 6.2 % , 95 % CI : 0.2 , 12.2 ; p = 0.04 ) and the general health domain of the SF36 ( difference 2.1 , 95 % CI : 0.1 , 4.1 ; p = 0.03 ) at 24 weeks . The HEART programme was considered likely to be cost-effective for leisure time activity and walking . Conclusions A mobile phone intervention was not effective at increasing exercise capacity over and above usual care . The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services Background : The CardioFit internet-based expert system was design ed to promote physical activity in patients with coronary heart disease ( CHD ) who were not participating in cardiac rehabilitation . Design : This r and omized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes . Methods : A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and r and omly assigned to either  CardioFit  ( n = 115 ) or  usual care ( n = 108 ) . The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking . They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist . Usual care consisted of physical activity guidance from an attending cardiologist .  Physical activity was measured by pedometer and self-reported over a 7-day period , 6 and 12 months after r and omization . Results : The CardioFit internet-based physical activity expert system significantly increased objective ly measured ( p = 0.023 ) and self-reported physical activity ( p = 0.047 ) compared to usual care . Emotional ( p = 0.038 ) and physical ( p = 0.031 ) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care . Conclusions : Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care . Use of the CardioFit program could extend the reach of rehabilitation and secondary -prevention services OBJECTIVE To assess the impact and cost-effectiveness of two information-based provider reminder interventions design ed to improve self-care management and outcomes of heart failure ( HF ) patients . DATA SOURCES / STUDY SETTING Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF . STUDY DESIGN Patients were treated by nurses r and omly assigned to usual care or one of two intervention groups . The basic intervention was an e-mail to the patient 's nurse highlighting six HF-specific clinical recommendations . The augmented intervention supplemented the initial nurse reminder with additional clinician and patient re sources . DATA COLLECTION Patient interviews were conducted 45 days post admission to measure self-management behaviors , HF-specific outcomes ( Kansas City Cardiomyopathy Question naire-KCCQ ) , health-related quality of life ( EuroQoL ) , and service use . PRINCIPAL FINDINGS Both interventions improved the mean KCCQ summary score ( 15.3 and 12.9 percent , respectively ) relative to usual care ( p < or = .05 ) . The basic intervention also yielded a higher EuroQoL score relative to usual care ( p < or = .05 ) . In addition , the interventions had a positive impact on medication knowledge , diet , and weight monitoring . The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes . CONCLUSIONS This study demonstrates the positive impact of targeting evidence -based computer reminders to home health nurses to improve patient self-care behaviors , knowledge , and clinical outcomes . It also advances the field 's limited underst and ing of the cost-effectiveness of selected strategies for translating research into practice Objective To investigate whether an internet based , nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinical ly manifest vascular disease . Design Prospect i ve r and omised controlled trial . Setting Multicentre trial in secondary and tertiary healthcare setting . Participants 330 patients with a recent clinical manifestation of atherosclerosis in the coronary , cerebral , or peripheral arteries and with at least two treatable risk factors not at goal . Intervention Personalised website with an overview and actual status of patients ’ risk factors and mail communication via the website with a nurse practitioner for 12 months ; the intervention combined self management support , monitoring of disease control , and drug treatment . Main outcome measures The primary endpoint was the relative change in Framingham heart risk score after 1 year . Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor . Results Participants ’ mean age was 59.9 ( SD 8.4 ) years , and most patients ( n=246 ; 75 % ) were male . After 1 year , the relative change in Framingham heart risk score of the intervention group compared with the usual care group was −14 % ( 95 % confidence interval −25 % to −2 % ) . At baseline , the Framingham heart risk score was higher in the intervention group than in the usual care group ( 16.1 ( SD 10.6 ) v 14.0 ( 10.5 ) ) , so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score . This produced a relative change of −12 % ( −22 % to −3 % ) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and −8 % ( −18 % to 2 % ) adjusted for the baseline score . Of the individual risk factors , a difference between groups was observed in low density lipoprotein cholesterol ( −0.3 , −0.5 to −0.1 , mmol/L ) and smoking ( −7.7 % , −14.9 % to −0.4 % ) . Some other risk factors tended to improve ( body mass index , triglycerides , systolic blood pressure , renal function ) or tended to worsen ( glucose concentration , albuminuria ) . Conclusion An internet based , nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease . Trial registration Clinical trials NCT00785031 Background Depression is common in people with coronary heart disease ( CHD ) and associated with worse outcome . This study explored the acceptability and feasibility of procedures for a trial and for an intervention , including its potential costs , to inform a definitive r and omized controlled trial ( RCT ) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression . Methods Multi-centre , outcome assessor-blinded , r and omized parallel group study . CHD patients reporting chest pain and scoring 8 or more on the HADS were r and omized to personalized care ( PC ) or treatment as usual ( TAU ) for 6 months and followed for 1 year . Primary outcome was acceptability and feasibility of procedures ; secondary outcomes included mood , chest pain , functional status , well being and psychological process variables . Result 1001 people from 17 General Practice CHD registers in South London consented to be contacted ; out of 126 who were potentially eligible , 81 ( 35 % female , mean age = 65 SD11 years ) were r and omized .  PC  participants ( n = 41 ) identified wide ranging problems to work on with nurse-case managers . Good acceptability and feasibility was indicated by low attrition ( 9 % ) , high engagement and minimal nurse time used ( mean/SD = 78/19 mins assessment , 125/91 mins telephone follow up ) . Both groups improved on all outcomes . The largest between group difference was in the proportion no longer reporting chest pain  ( PC 37 % vs TAU 18 % ; mixed effects model OR 2.21 95 % CI 0.69 , 7.03 ) . Some evidence was seen that self efficacy ( mean scale increase of 2.5 vs 0.9 ) and illness perceptions ( mean scale increase of 7.8 vs 2.5 ) had improved in PC vs TAU participants at 1 year . PC appeared to be more cost effective up to a QALY threshold of approximately £ 3,000 . Conclusions Trial and intervention procedures appeared to be feasible and acceptable . PC allowed patients to work on unaddressed problems and appears cheaper than TAU . Trial Registration Controlled-Trials.com IS RCT Background The purpose of this study was to evaluate the effect of a physical activity telemonitoring program on daily physical activity level , oxygen uptake capacity ( VO2peak ) , and cardiovascular risk profile in coronary artery disease ( CAD ) patients who completed phase II cardiac rehabilitation ( CR ) . Methods Eighty CAD patients who completed phase II CR were r and omly assigned to an additional telemonitoring intervention or st and ard CR . The patients in the intervention group ( n = 40 ) wore a motion sensor continuously for 18 weeks . Each week these patients received a step count goal , with the aim to gradually increase the patients ’ physical activity level . In the control group ( n = 40 ) , the patients wore an unreadable motion sensor for seven days for measurement purpose s only ( at start of follow-up , and after six and 18 weeks ) . At start of follow-up and after 18 weeks blood lipid profile , glycemic control , waist circumference and body mass index was assessed . VO2peak was assessed at start of follow-up , and after six and 18 weeks . Re-hospitalisation rate was followed during this timeframe . Results In the intervention group , VO2peak increased significantly during follow-up ( P = 0.001 ) , in the control group it did not ( P = 0.273 ) . A significant correlation was found between daily aerobic step count and improvement in VO2peak ( P = 0.030 , r = 0.47 ) . Kaplan-Meier curve analysis showed a trend towards fewer re-hospitalisations for patients in the telemonitoring group ( P = 0.09 ) . Conclusions The study showed that , to maintain exercise tolerance and lower re-hospitalisation rate after hospital-based CR in CAD patients , a physical activity telemonitoring program might be an effective intervention Background Angina affects more than 50 million people worldwide . Secondary prevention interventions such as cardiac rehabilitation are not widely available for this population . An Internet-based version could offer a feasible alternative . Objective Our aim was to examine the effectiveness of a Web-based cardiac rehabilitation program for those with angina . Methods We conducted a r and omized controlled trial , recruiting those diagnosed with angina from general practitioners ( GPs ) in primary care to an intervention or control group . Intervention group participants were offered a 6-week Web-based rehabilitation program ( “ ActivateYourHeart ” ) . The program was introduced during a face-to-face appointment and then delivered via the Internet ( no further face-to-face contact ) . The program contained information about the secondary prevention of coronary heart disease ( CHD ) and set each user goals around physical activity , diet , managing emotions , and smoking . Performance against goals was review ed throughout the program and goals were then reset/modified . Participants completed an online  exercise diary and communicated with rehabilitation specialists through an email link/synchronized chat room . Participants in the control group continued with GP treatment as usual , which consisted of being placed on a CHD register and attending an annual review . Outcomes were measured at 6-week and 6-month follow-ups during face-to-face assessment s. The primary outcome measure was change in daily steps at 6 weeks , measured using an accelerometer . Secondary outcome measures were energy expenditure ( EE ) , duration of sedentary activity ( DSA ) , duration of moderate activity ( DMA ) , weight , diastolic/systolic blood pressure , and body fat percentage . Self-assessed question naire outcomes included fat/fiber intake , anxiety/depression , self-efficacy , and quality of life ( QOL ) . Results A total of 94 participants were recruited and r and omized to the intervention ( n=48 ) or the usual care  ( n=46 ) group ; 84 and 73 participants completed the 6-week and 6-month follow-ups , respectively . The mean number of log-ins to the program was 18.68 ( SD 13.13 , range 1 - 51 ) , an average of 3 log-ins per week per participant . Change in daily steps walked at the 6-week follow-up was + 497 ( SD 2171 ) in the intervention group and –861 ( SD 2534 ) in the control group ( 95 % CI 263 - 2451 , P=.02 ) . Significant intervention effects were observed at the 6-week follow-up in EE ( + 43.94 kcal , 95 % CI 43.93 - 309.98 , P=.01 ) , DSA ( –7.79 minutes , 95 % CI –55.01 to –7.01 , P=.01 ) , DMA ( + 6.31 minutes , 95 % CI 6.01 - 51.20 , P=.01 ) , weight ( –0.56 kg , 95 % CI –1.78 to –0.15 , P=.02 ) , self-efficacy ( 95 % CI 0.30 - 4.79 , P=.03 ) , emotional QOL score ( 95 % CI 0.01 - 0.54 , P=.04 ) , and angina frequency ( 95 % CI 8.57 - 35.05 , P=.002 ) . Significant benefits in angina frequency ( 95 % CI 1.89 - 29.41 , P=.02 ) and social QOL score ( 95 % CI 0.05 - 0.54 , P=.02 ) were also observed at the 6-month follow-up . Conclusions An Internet-based secondary prevention intervention could be offered to those with angina . A larger pragmatic trial is required to provide definitive evidence of effectiveness and cost-effectiveness . Trial Registration International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 90110503 ; http://www.controlled-trials.com/IS RCT N90110503/IS RCT N90110503 ( Archived by WebCite at http://www.webcitation.org/6RYVOQFKM ) PURPOSE The purpose for this study was to evaluate the association between depression-focused interpersonal counseling ( IPC ) and the use of healthcare services in Finl and after myocardial infa rct ion ( MI ) . DESIGN AND METHODS The measures were done at 6 and 18 months after MI in the r and omized intervention ( n= 51 ) and the control group ( n= 52 ) . FINDINGS There was less use of somatic specialized healthcare services in the intervention group from 6 to 18 months after hospital discharge , and with intervention patients who had no other long-term disease during 6 months . PRACTICE IMPLICATION S Confirmation of possible benefits of IPC for practice calls for more specific studies OBJECTIVE The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease ( CAD ) care and to assess physician attitudes toward this reminder system . DESIGN We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics . Clinics were r and omized so that physicians received either evidence -based electronic reminders within their patients ' electronic medical record or usual care . There were five reminders for diabetes care and four reminders for CAD care . MEASUREMENTS The primary outcome was receipt of recommended care for diabetes and CAD . We created a summary outcome to assess the odds of increased compliance with overall diabetes care ( based on five measures ) and overall CAD care ( based on four measures ) . We surveyed physicians to assess attitudes toward the reminder system . RESULTS Baseline adherence rates to all quality measures were low . While electronic reminders increased the odds of recommended diabetes care ( odds ratio [ OR ] 1.30 , 95 % confidence interval [ CI ] 1.01 - 1.67 ) and CAD ( OR 1.25 , 95 % CI 1.01 - 1.55 ) , the impact of individual reminders was variable . A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD . The majority of physicians ( 76 % ) thought that reminders improved quality of care . CONCLUSION An integrated electronic reminder system result ed in variable improvement in care for diabetes and CAD . These improvements were often limited and quality gaps persist Background The future risk of heart disease can be predicted with increasing precision . However , more research is needed into how this risk is conveyed and presented . The aim of this study is to compare the effects of presenting cardiovascular risk in different formats on individuals ' intention to change behaviour to reduce risk , underst and ing of risk information and emotional affect . Methods / design A r and omised controlled trial comprising four arms , with a between subjects design will be performed . There will be two intervention groups and two control groups . The first control comprises a pre-intervention question naire and presents risk in a bar graph format . The second control presents risk in a bar graph format without pre-intervention question naire . These two control groups are to account for the potential Hawthorne effect of thinking about cardiovascular risk before viewing actual risk . The two intervention groups comprise presenting risk in either a pictogram or metonym format ( image depicting seriousness of having a myocardial infa rct ion ) .  800 individuals ' aged between 45 and 64 years , who have not been previously diagnosed with heart disease and have access to a computer with internet , will be given a link to a website comprising a risk calculator and electronic question naires . 10-year risk of having a coronary heart disease event will be assessed and presented in one of the three formats . A post-intervention question naire will be completed after viewing the risk format . Main outcome measures are ( i ) intention to change behaviour , ( ii ) underst and ing of risk information , ( iii ) emotional affect and ( iv ) worry about future heart disease . Secondary outcomes are the sub-components of the theory of planned behaviour : attitudes , perceived behavioural control and subjective norms . Discussion Having review ed the literature , we are not aware of any other studies which have used the assessment of actual risk , in a trial to compare different graphical cardiovascular risk presentation formats . This trial will provide data about which graphical cardiovascular risk presentation format is most effective in encouraging behaviour change to reduce cardiovascular risk . Trial registration Current Controlled Trials IS RCT Introduction Fewer than half of all people at highest risk of a cardiovascular event are receiving and adhering to best practice recommendations to lower their risk . In this project , we examine the role of an e-health-assisted consumer-focused strategy as a means of overcoming these gaps between evidence and practice . Consumer Navigation of Electronic Cardiovascular Tools ( CONNECT ) aims to test whether a consumer-focused e-health strategy provided to Aboriginal and Torres Strait Isl and er and non-indigenous adults , recruited through primary care , at moderate-to-high risk of a cardiovascular disease event will improve risk factor control when compared with usual care . Methods and analysis R and omised controlled trial of 2000 participants with an average of 18 months of follow-up to evaluate the effectiveness of an integrated consumer-directed e-health portal on cardiovascular risk compared with usual care in patients with cardiovascular disease or who are at moderate-to-high cardiovascular disease risk . The trial will be augmented by formal economic and process evaluations to assess acceptability , equity and cost-effectiveness of the intervention . The intervention group will participate in a consumer-directed e-health strategy for cardiovascular risk management . The programme is electronically integrated with the primary care provider 's software and will include interactive smart phone and Internet platforms . The primary outcome is a composite endpoint of the proportion of people meeting the Australian guideline -recommended blood pressure ( BP ) and cholesterol targets . Secondary outcomes include change in mean BP and fasting cholesterol levels , proportion meeting BP and cholesterol targets separately , self-efficacy , health literacy , self-reported point prevalence abstinence in smoking , body mass index and waist circumference , self-reported physical activity and self-reported medication adherence . Ethics and dissemination Primary ethics approval was received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council . Results will be disseminated via the usual scientific forums including peer- review ed publications and presentations at international conferences Clinical Trials registration number ACTRN12613000715774 Background Using the Internet may prove useful in providing nutrition counselling and social support for patients with chronic diseases . Objective We evaluated the impact of Web-based nutrition counselling and social support on social support measures , anthropometry , blood pressure , and serum cholesterol in patients at increased cardiovascular risk . Methods We conducted a r and omized controlled trial among patients with increased cardiovascular risk in Canadian family practice s. During 8 months , patients in the intervention group and control groups received usual care . Patients in the intervention group also had access to a Web-based nutrition counselling and social support tool ( Heartweb ) . Site use during the study was monitored . We measured social support , body mass index , waist/hip ratio , blood pressure , and cholesterol levels at baseline and at 4 and 8 months to assess the effectiveness of the intervention . Results We r and omized 146 patients into the Web-based intervention ( n=73 ) or the control group ( n=73 ) . Within the Web-based intervention group , Heartweb was used by only 33 % ( 24/73 ) of patients , with users being significantly younger than nonusers ( P=.03 ) . There were no statistically significant differences between the intervention group and the control group in changes in social support , anthropometry , blood pressure , and serum cholesterol levels . Conclusions Uptake of the Web-based intervention was low . This study showed no favourable effects of a Web-based nutrition counselling and social support intervention on social support , anthropometry , blood pressure , and serum cholesterol . Improvements in reach and frequency of site use are needed to increase the effectiveness of Web-based interventions This study evaluated the efficacy of a theory of planned behaviour ( TPB ) based intervention to increase  fruit and vegetable consumption .  The extent to which fruit and vegetable consumption and change in intake could be explained by the TPB was also examined . Participants were r and omly assigned to two levels of intervention frequency matched for intervention content ( low frequency n=92 , high frequency n=102 ) . Participants received TPB-based email messages design ed to increase fruit and vegetable consumption , messages targeted attitude , subjective norm and perceived behavioural control ( PBC ) . Baseline and post-intervention measures of  TPB variables and behaviour were collected . Across the entire study cohort , fruit and vegetable consumption increased by 0.83 servings/day between baseline and follow-up . Intention , attitude , subjective norm and PBC also increased ( p<.05 ) . The TPB successfully modelled fruit and vegetable consumption at both time points but not behaviour change . The increase of fruit and vegetable consumption is a promising preliminary finding for those primarily interested in increasing fruit and vegetable consumption . However , those interested in theory development may have concerns about the use of this model to explain behaviour change in this context . More high quality experimental tests of the theory are needed to confirm this result Cardiac pain arising from chronic stable angina ( CSA ) is a cardinal symptom of coronary artery disease and has a major negative impact on health-related quality of life ( HRQL ) , including pain , poor general health status , and inability to self-manage . Current secondary prevention approaches lack adequate scope to address CSA as a multidimensional ischemic and persistent pain problem . This trial evaluated the impact of a low-cost six-week angina psychoeducation program , entitled The Chronic Angina Self-Management Program ( CASMP ) , on HRQL , self-efficacy , and re source fulness to self-manage anginal pain . One hundred thirty participants were r and omized to the CASMP or three-month wait-list usual care ; 117 completed the study . Measures were taken at baseline and three months . General HRQL was measured using the Medical Outcomes Study 36-Item Short Form and the disease-specific Seattle Angina Question naire ( SAQ ) . Self-efficacy and re source fulness were measured using the Self-Efficacy Scale and the Self-Control Schedule , respectively . The mean age of participants was 68 years , 80 % were male . Analysis of variance of change scores yielded significant improvements in treatment group physical functioning [ F=11.75(1,114 ) , P<0.001 ] and general health [ F=10.94(1,114 ) , P=0.001 ] aspects of generic HRQL . Angina frequency [ F=5.57(1,115 ) , P=0.02 ] , angina stability [ F=7.37(1,115 ) , P=0.001 ] , and self-efficacy to manage disease [ F=8.45(1,115 ) , P=0.004 ] were also significantly improved at three months . The CASMP did not impact re source fulness . These data indicate that the CASMP was effective for improving physical functioning , general health , anginal pain symptoms , and self-efficacy to manage pain at three months and provide a basis for long-term evaluation of the program Objective Cardiac rehabilitation ( CR ) is pivotal in preventing recurring events of myocardial infa rct ion ( MI ) . This study aims to investigate the effect of a smartphone-based home service delivery ( Care Assessment Platform ) of CR ( CAP-CR ) on  CR  use and health outcomes compared with a traditional , centre-based programme ( TCR ) in post-MI patients . Methods In this unblinded r and omised controlled trial , post-MI patients were r and omised to TCR ( n=60 ; 55.7±10.4 years ) and CAP-CR ( n=60 ; 55.5±9.6 years ) for a 6-week CR and 6-month self-maintenance period . CAP-CR , delivered in participants ’ homes , included health and exercise monitoring , motivational and educational material delivery , and weekly mentoring consultations . CAP-CR uptake , adherence and completion rates were compared with TCR using intention-to-treat analyses . Changes in clinical outcomes ( modifiable lifestyle factors , biomedical risk factors and health-related quality of life ) across baseline , 6 weeks and 6 months were compared within , and between , groups using linear mixed model regression . Results CAP-CR had significantly higher uptake ( 80 % vs 62 % ) , adherence ( 94 % vs 68 % ) and completion ( 80 % vs 47 % ) rates than TCR ( p<0.05 ) . Both groups showed significant improvements in 6-minute walk test from baseline to 6 weeks ( TCR : 537±86–584±99 m ; CAP-CR : 510±77–570±80 m ) , which was maintained at 6 months . CAP-CR  showed slight weight reduction ( 89±20–88±21 kg ) and also demonstrated significant improvements in emotional state ( K10 : median ( IQR ) 14.6 ( 13.4–16.0 ) to 12.6 ( 11.5–13.8 ) ) , and quality of life ( EQ5D-Index : median ( IQR ) 0.84 ( 0.8–0.9 ) to 0.92 ( 0.9–1.0 ) ) at 6 weeks . Conclusions This smartphone-based home care CR programme improved post-MI CR uptake , adherence and completion . The home-based CR programme was as effective in improving physiological and psychological health outcomes  as traditional CR . CAP-CR is a viable option towards optimising use of CR services . Trial registration number ANZCTR12609000251224 Background Non-communicable diseases ( NCDs ) are the leading causes of death globally and are associated with a limited set of common , modifiable health behaviours : tobacco use , physical inactivity , harmful use of alcohol and unhealthy diet . General practice offers an ideal avenue for addressing such health behaviours on a population -wide basis . This paper describes the protocol of a multiple health behaviour change intervention design ed for implementation in general practice and summarises the baseline characteristics of its participants . Method / Design The 10 Small Steps ( 10SS ) study , a r and omised controlled trial , involved 4,678 adult general practice patients in Queensl and , Australia .  Self-reported data were collected to establish the proportion of participants meeting recommended guidelines for ten health behaviours : physical activity , body mass index , alcohol , smoking and six dietary behaviours . Participants were r and omised to four groups : contact at baseline only ( ' single intervention ' and corresponding control group ) and contact at baseline and 3 months ( ' dual intervention ' and corresponding control group ) . At each contact the participants received a computer-tailored feedback and one page information sheet according to their allocation to intervention or control groups . Change in the intervention group compared to the control group was assessed at 3 and 12 months after baseline data collection .Responses were summed to calculate an individual lifestyle score ( the Prudence Score ) , which ranged from 0 to 10 . The baseline response was 56.5 % ( 4678 of 8343 invited participants ) and the study sample was primarily female ( 68.7 % ) with an average age of 47 years . The mean Prudence Score was 5.8 ( 95%CI 5.75 - 5.85 ) . Discussion Baseline data from the 10SS study show that nearly all participants engage in some health behaviours but relatively few adhere simultaneously to a core set of dietary and lifestyle behaviours associated with risk of NCDs . Ample scope exists to improve health behaviour to reduce NCDs in the general practice setting and the 10SS study trial will provide data on the extent to which a minimal computer-tailored intervention can meet this objective . The protocol developed for the 10SS study has potential for translation into routine general practice as it has minimal impact on practice routine whilst contributing to primary prevention objectives .Trial Registration The Australian New Zeal and Clinical Trials Registry OBJECTIVE To determine if patients hospitalized for angioplasty could learn about symptoms , risk factors , and care-seeking behaviors before and after discharge and to assess patient acceptability of the intervention . METHODS Thirty-two women and 32 men were r and omly assigned to groups and completed an intervention pretest . The experimental group viewed the Know & Go ! slide presentation at baseline and 2 and 4 months after discharge . A satisfaction survey was mailed to patients in the experimental group . RESULTS There were no significant differences between groups in clinical or sociodemographic characteristics . The experimental group scored significantly higher on an intervention posttest at study completion ( F = 15.21 ; P < .001 ) . Patients were highly satisfied with the program and computer technology ( range 0 - 12 , M = 9.57 ± 1.83 ) . CONCLUSION The Know & Go ! intervention was safe , effective , and acceptable to patients in pilot testing . Results support refinement and further testing of the intervention for patients diagnosed with coronary heart disease Objectives : To examine whether a Web-based health and leadership development program— design ed specifically for managers — was associated with changes in self-reported and biometric indicators of cardiovascular disease within the context of a r and omized control trial . Methods : A total of 145 managers from 8 organizations participated in a 6-month Internet-based program or a control condition . They completed pre- and posttest assessment s that included both self-reported attitudes ( on diet , exercise , and mental health ) and biometric measures ( eg , body weight , waist circumference ) . Results : The intervention was associated with improvements in dietary attitudes , dietary self-efficacy , and exercise , and reductions in distress symptoms . Women in the program reduced their waist circumference significantly more than controls . Conclusions : The program showed promise for reducing cardiovascular disease risk factors . Similar results across diverse organizations suggest the program may be useful across industry types Summary In the TeleGuard trial , 1500 patients with established coronary artery disease ( CAD ) were recruited and r and omized to control or intervention groups . Patients in the intervention group were equipped with a 12-lead event recorder and could contact a call centre and transmit an ECG whenever they wished . In a 12-month study , the composite endpoint ( all-cause mortality , myocardial infa rct ion , re-hospitalization or re-vascularization ) was seen in 40 % of the intervention patients and in 38 % of the control patients . In both groups , approximately 40 % were re-hospitalized . In total , 73 patients experienced re-vascularization , 75 showed an infa rct ion and 33 died . Equipping CAD patients with a 12-lead ECG device and providing a telemedicine centre with 24-hour availability did not decrease risk for the composite endpoint ( re-hospitalization , re-vascularization , ( subsequent ) myocardial infa rct ion and /or death ) . It is likely that the clinical pathway used in the telemedicine centre led to an increased hospital admission rate in the intervention group Background It is possible to provide patients with secure access to their medical records using the Internet . Such access may assist patients in the self-management of chronic diseases such as heart failure . Objective To assess how a patient-accessible online medical record affects patient care and clinic operations . The SPPARO ( System Providing Access to Records Online ) software consisted of a web-based electronic medical record , an educational guide , and a messaging system enabling electronic communication between the patient and staff . Methods A r and omized controlled trial was conducted in a specialty practice for patients with heart failure . Surveys assessing doctor-patient communication , adherence , and health status were conducted at baseline , 6 months , and 1 year . Use of the system , message volume , utilization of clinical services , and mortality were monitored . Results One hundred and seven patients were enrolled ( 54 intervention and 53 controls ) . At 12 months , the intervention group was not found to be superior in self-efficacy ( KCCQ self-efficacy score 91 vs. 85 , p=0.08 ) , but was superior in general adherence ( MOS compliance score 85 vs. 78 , p=0.01 ) . A trend was observed for better satisfaction with doctor-patient communication . The intervention group had more emergency department visits ( 20 vs. 8 , p=0.03 ) , but these visits were not temporally related to use of the online medical record . There were no adverse effects from use of the system . Conclusions Providing patients with congestive heart failure access to an online medical record was feasible and improved adherence . An effect on health status could not be demonstrated in this pilot study OBJECTIVE To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system ( CDSS ) and a specific implementation strategy . Evaluation of patient outcome . DESIGN R and omised study with health centres as units . The intervention group had the CDSS installed and made ready for use , doctors and assistants were trained and received a user-manual , the doctors were offered telephone repetitions , a seminar in risk intervention and , at the same seminar , further demonstration of the CDSS . The doctors received baseline registration s with information of how they treated their own hypertensive patients , and use of the CDSS was checked repeatedly . SETTING General practice in Sør- and Nord-Trøndelag counties in Norway , 380,000 inhabitants . PARTICIPANTS Seventeen health centres with 24 doctors and 984 patients in the intervention group . Data from 879 patients used in the final analyses . Twelve health centres with 29 doctors and 1255 patients in the control group . Data from 1119 patients used in the final analyses . MAIN OUTCOME MEASURES After an intervention period of 18 months , group differences in level of systolic and diastolic blood pressure , serum cholesterol , body mass index , and risk score for myocardial infa rct ion were calculated , as well as group differences in fractions of smokers . RESULTS Significant group difference in favour of intervention group : diastolic blood pressure 1 mmHg ( 95 % CI -1.89 , -0.17 ) . However , a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg ( 95 % CI 1.0 , 4.5 ) had been reduced to 1.2 mmHg ( 95 % CI -0.6 , 3.0 ) after intervention . CONCLUSION Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinical ly significant way OBJECTIVE This pilot study examined the effect of a home communication intervention ( HCI ) to augment home health care ( HHC ) on functioning and recovery outcomes of elderly patients undergoing coronary artery bypass graft . DESIGN A r and omized , experimental two-group ( N = 50 ) repeated- measures design was used . Both HCI and control subjects received HHC , and the HCI group also received the 12-week HCI delivered by a telehealth device , the Health Buddy ( Health Hero Network ) . The Medical Outcome Study Short Form-36 measured physiologic and psychosocial functioning at baseline , 6 weeks , and 3 months after surgery . Follow-up subject interviews ascertained self-report of postoperative problems and health care use . SAMPLE Subjects had an average age of 75.3 years and included males ( 56 % ) and females ( 44 % ) . RESULTS By using repeated- measures analyses of covariance , covariating for the total number of HHC visits , HCI subjects , compared with the HHC group only , had a significantly higher adjusted mean general health functioning score ( F = 8.41 [ 1 , 36 ] , P < .01 ) . There were significant time effects on physical , role-physical , and mental health functioning , indicating that both groups improved over time . The groups reported similar postoperative problems ; however , the control group had more emergency department visits than the HCI group . CONCLUSIONS Findings demonstrate the potential benefit of using an HCI to further augment outcomes of high-risk patients undergoing coronary artery bypass graft surgery referred to HHC after hospitalization The aim of this study was to assess whether our online closed community heart care support group and information re source could sustain changes in health behaviour after the moderators withdrew their support . Heart patients ( n = 108 ) living in a deprived area of Greater Manchester were recruited from general practitioners ' coronary heart disease registries . The sample for this r and omized controlled trial was divided in half at r and om where half of the participants received password-protected access to our health portal and the other half did not . At 6 months follow-up ( based on the moderated phase ) , there was a significant difference between the experimental group and the controls in terms of self-reported diet ( eating bad foods less often ) . This change in behaviour was not sustained during the 3-month unmoderated phase . During this unmoderated phase of the intervention , the experimental group had significantly more health care visits compared with the controls . There was no significant difference between the two phases for either group in terms of exercise , smoking or social support . This study offers insight into the potential implication s for health changes of moderating arrangements for online health communities For this study a r and omized clinical trial was design ed to test the effects of an early home recovery information intervention on physical functioning , psychological distress , and symptom frequency 1 month following coronary artery bypass graft surgery ( CABG ) . Recovery outcomes were compared between two groups : those receiving an audiotape of information on expected physical sensations and their management ( Cardiac Home Information Program [ CHIP ] ) in addition to the usual care , and those receiving the usual cardiac discharge information protocol .  A nonprobability sample of 180 patients ( 84 women and 96 men ; mean age = 62 years ) was equally distributed between the two study groups . When controlling for age , comorbidity , and cardiac functional status , the results showed positive effects on physical functioning in women and psychological distress , vigor and fatigue in men . Consistent with other studies , women had worse physical functioning and more symptom frequency than men . These findings indicate that the CHIP intervention is an effective method to prepare CABG patients for home recovery This paper reports the effects of a tailored Web-based delivery system on self-efficacy as it relates to a patients ' response to acute myocardial information ( AMI ) symptoms . The data reported are from MI-HEART , a r and omized trial examining ways in which a clinical information system can favorably influence the appropriateness and rapidity of decision-making in patients suffering from symptoms of acute myocardial infa rct ion . Participants were r and omized into one of three groups : tailored Web-based , non-tailored Web-based and non-tailored paper based .  A theoretically based behavioral-cognitive model was used to identify key variables upon which to tailor education material . A key variable in the model is self-efficacy , operationalized with a three-dimensional scaling . Results show trends in improved self-efficacy scores for all groups at 1-month follow up , with sustained significant increases in baseline to 3-month scores only in the tailored Web-based group . One possible explanation could be related to " hit-count " , which was significantly higher in the tailored group . This study is a first step in quantifying the contribution of Web-based tailoring over non-tailoring in changing key determinants of patient delay to AMI symptoms Background Nonpharmacological secondary prevention of coronary heart disease is considered a safe and effective measure to substantially reduce mortality . Despite the effectiveness of lifestyle changes , the compliance rate of patients is very low mainly due to psychosocial barriers . Psychotherapeutic approaches that address how persons think about themselves and their behaviors appear to have a significant potential for improving health behavior . Methods / design Against this background , our study aims to examine the feasibility and effects of a Psychodynamic Motivation and Training program ( PMT ) as compared to one session of advice in exercise training ( EX ) and treatment as usual ( TAU ) . For that purpose , 90 patients with stable coronary heart disease and a physically inactive lifestyle will be r and omly assigned to the three groups ( each with n = 30 ) . The primary outcome is the change in the individual anaerobic threshold as determined by spiroergometry from baseline to six month follow-up . Secondary endpoints include change in endothelial function , biomarkers of inflammation and oxidative stress , quality of life , symptoms of fatigue , illness perception and feasibility of the treatment approach . We hypothesize that physical fitness will improve more in PMT than in EX and TAU , with PMT and EX more than TAU , and that the effects will be more pronounced for participants with current mental or psychosocial distress . Discussion The results of the study will help to determine the effectiveness of a psychodynamic lifestyle change approach and to identify measures for design ing specifically tailored interventions to improve compliance with cardiovascular prevention . Trial registration Clinical Trials.gov Identifier : The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease ( CHD ) remains unclear . This systematic review aim ed to determine their effectiveness and included r and omized controlled trials of lifestyle interventions , in primary care or community setting s , with a minimum follow-up of three months , published since 1990 . 21 trials with 10,799 patients were included ; the interventions were multifactorial ( 10 ) , educational ( 4 ) , psychological ( 3 ) , dietary ( 1 ) , organisational ( 2 ) , and exercise ( 1 ) . The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes . In trials that examined mortality and morbidity , significant benefits were reported for total mortality ( in 4 of 6 trials ; overall risk ratio ( RR ) 0.75 ( 95 % confidence intervals ( CI ) 0.65 , 0.87 ) ) , cardiovascular mortality ( 3 of 8 trials ; overall RR 0.63 ( 95 % CI 0.47 , 0.84 ) ) , and nonfatal cardiac events ( 5 of 9 trials ; overall RR 0.68 ( 95 % CI 0.55 , 0.84 ) ) . The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult . However , the beneficial effects observed in this review are encouraging and should stimulate further research Background Efficacious strategies for the primary prevention of coronary heart disease ( CHD ) are underused , and , when used , have low adherence . Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice . Methods We conducted a r and omized trial of a CHD prevention intervention ( including a computerized decision aid and automated tailored adherence messages ) at one university general internal medicine practice . After obtaining informed consent and collecting baseline data , we r and omized patients ( men and women age 40 - 79 with no prior history of cardiovascular disease ) to either the intervention or usual care . We then saw them for two additional study visits over 3 months . For intervention participants , we administered the decision aid at the primary study visit ( 1 week after baseline visit ) and then mailed 3 tailored adherence reminders at 2 , 4 , and 6 weeks . We assessed our outcomes ( including the predicted likelihood of angina , myocardial infa rct ion , and CHD death over 10 years ( CHD risk ) and self-reported adherence ) between groups at 3 month follow-up . Data collection occurred from June 2007 through December 2009 . All study procedures were IRB approved . Results We r and omized 160 eligible patients ( 81 intervention ; 79 control ) and followed 96 % to study conclusion . Mean predicted CHD risk at baseline was 11.3 % . The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points ( 95 % CI 8 % to 42 % ) , with the biggest effect for aspirin . It also changed predicted CHD risk by -1.1 % ( 95 % CI -0.16 % to -2 % ) , with a larger effect in a pre-specified subgroup of high risk patients . Conclusion A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk . Clinical trials registration number Clinical Trials.gov : Background Cardiac rehabilitation ( CR ) is a secondary prevention program that offers education and support to assist patients with coronary heart disease ( CHD ) make lifestyle changes . Despite the benefits of CR , attendance at centre-based sessions remains low . Mobile technology ( mHealth ) has potential to reach more patients by delivering CR directly to mobile phones , thus providing an alternative to centre-based CR . The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours ( for example , physically active , fruit and vegetable intake , not smoking , low alcohol consumption ) over and above usual CR services in New Zeal and adults diagnosed with CHD . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted at two Auckl and hospitals in New Zeal and . One hundred twenty participants will be r and omised to receive a 24-week evidence - and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone ( control ) . The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months , measured using a composite health behaviour score . Secondary outcomes include overall cardiovascular disease risk , body composition , illness perceptions , self-efficacy , hospital anxiety/depression and medication adherence . Discussion This study is one of the first to examine an mHealth-delivered comprehensive CR program . Strengths of the trial include quality research design and in-depth description of the intervention to aid replication . If effective , the trial has potential to augment st and ard CR practice s and to be used as a model for other disease prevention or self-management programs . Trial registryAustralian New Zeal and Clinical Trials Registry : BACKGROUND Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease . The Computer-based Clinical Decision Support System provides an opportunity t close these gaps . OBJECTIVES To study the impact of computerized intervention on secondary prevention of CAD . METHODS The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an up date d  lipoprotein profile  and treatment with lipid-lowering drugs . The program produced automatic computer-generated monitoring and treatment recommendations . Adjusted primary clinics were r and omly assigned to intervention ( n=56 ) or st and ard care arms ( n=56 ) . Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment . Compliance and lipid levels were monitored . The study group comprised all patients with CAD who were alive at least 3 months after hospitalization . RESULTS Follow-up was available for 7448 patients ( median 19.8 months , range 6 - 36 months ) . Overall , 51.7 % of patients were adequately screened , and 55.7 % of patients were compliant with treatment to lower lipid level . In patients with initial low density lipoprotein  > 120 mg/dl , a significant decrease in LDL levels was observed in both arms , but was more pronounced in the intervention arm : 121.9 + /- 34.2 vs. 124.3 + /- 34.6 mg/dl ( P < 0.02 ) . A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs , 37 % vs. 40.9 % ( P < 0.001 ) . CONCLUSIONS This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines , presenting a major obstacle to implementing effective secondary prevention . Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation Background Cardiac rehabilitation programs aim to improve health status and to decrease the risk of further cardiac events .  Persons undergoing rehabilitation often have difficulties transferring the learned health behaviors into their daily routine after returning home and maybe to work . This includes physical activity as well as fruit and vegetable consumption . Computer-based tailored interventions have been shown to be effective in increasing physical activity as well as fruit and vegetable consumption . The aim of this study is , to support people in transferring these two learned behavior changes and their antecedents into their daily life after cardiac rehabilitation . Methods The study will have a r and omized controlled design and will be conducted among German and Dutch people who participated in cardiac rehabilitation . The study will consist of one intervention group which will be compared to a waiting list control group . During the eight week duration of the intervention , participants will be invited to participate in the online after-care program once per week . The intervention encourages participants to define individual health behavior goals as well as action , and coping plans to reach these self-determined goals . The effectiveness of the program will be compared between the intervention condition and the control group in terms of behavior change , antecedents of behavior change ( e.g. , self-efficacy ) , ability to return to work and increased well-being . Further , subgroup-differences will be assessed including differences between the two countries , socioeconomic inequalities and across age groups . Discussion The present study will make a contribution to underst and ing how such an online-based tailored interventions enables study participants to adopt and maintain a healthy lifestyle . Implication s can include how such an online program could enrich cardiac rehabilitation aftercare further . Trial registration NTR 3706 , Background Coronary heart disease ( CHD ) and depression are leading causes of disease burden globally and the two often co-exist . Depression is common after Myocardial Infa rct ion ( MI ) and it has been estimated that 15 - 35 % of patients experience depressive symptoms . Co-morbid depression can impair health related quality of life ( HRQOL ) , decrease medication adherence and appropriate utilisation of health services , lead to increased morbidity and suicide risk , and is associated with poorer CHD risk factor profiles and reduced survival . We aim to determine the feasibility of conducting a r and omised , multi-centre trial design ed to compare a tele-health program ( MoodCare ) for depression and CHD secondary prevention , with Usual Care ( UC ) . Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome ( ACS ) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensl and . Consenting participants are then contacted at two weeks post-discharge for baseline assessment . One hundred eligible participants are to be r and omised to an intervention or a usual medical care control group ( 50 per group ) . The intervention consists of up to 10 × 30 - 40 minute structured telephone sessions , delivered by registered psychologists , commencing within two weeks of baseline screening . The intervention focuses on depression management , lifestyle factors ( physical activity , healthy eating , smoking cessation , alcohol intake ) , medication adherence and managing co-morbidities . Data collection occurs at baseline ( Time 1 ) , 6 months ( post-intervention ) ( Time 2 ) , 12 months ( Time 3 ) and 24 months follow-up for longer term effects ( Time 4 ) . We are comparing depression ( Cardiac Depression Scale [ CDS ] ) and HRQOL ( Short Form-12 [ SF-12 ] ) scores between treatment and UC groups , assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects . A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government . Discussion This manuscript presents the protocol for a r and omised , multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients . The results of this trial will provide valuable new information about potential psychological and wellbeing benefits , cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression . Trial Registration NumberAustralia and New Zeal and Clinical Trials Register ( ANZCTR ) : Background : Nurse-led interventions have proven beneficial to reduce estimated cardiovascular risk . Aim : The purpose of this study was to evaluate the effect of systematic , nurse-led individual lifestyle counseling sessions on the reduction of 10-year cardiovascular risk scores in patients with coronary artery disease ( CAD ) . Methods : This was a r and omized clinical trial of CAD patients treated at a tertiary referral hospital . The intervention group received nurse-led guidance by means of five face-to-face sessions and telephone contact over the course of one year , starting three months after hospital discharge . Exercise and dietary goals were set for each patient and monitored at each session . The control group received st and ard medical advice . Patients were stratified by Framingham risk score and compared at the end of the follow-up period . Results : The final sample comprised 74 patients , 38 in the intervention group and 36 in the control group . Mean age was 58±9 years ; 74 % of patients were male . A 1.7 point ( −13.6 % ) reduction in risk score was recorded in the intervention group , vs a 1.2 point increase in risk score ( + 11 % ) in the control group ( p=0.011 ) . Significant between-group differences were detected for weight ( intervention , 78±14 kg at baseline vs 77±14 kg at study end ; control , 78±15 kg vs 79±15 kg ; p=0.04 ) , systolic blood pressure ( intervention , 136±22 mm Hg vs 124±15 mm Hg ; control , 126±15 mm Hg vs 129±16 mm Hg ; p=0.005 ) , and diastolic blood pressure ( intervention , 82±10 mm Hg vs 77±09 mm Hg ; control , 79±09 mm Hg vs 80±10 mm Hg ; p=0.02 ) . Conclusion : Structured and systematic nurse-led lifestyle counseling effectively reduced cardiovascular risk score OBJECTIVE : Suboptimal treatment of hyperlipidemia in patients with coronary artery disease ( CAD ) is well documented . We report the impact of a computer-assisted physician-directed intervention to improve secondary prevention of hyperlipidemia . DESIGN AND SETTING : Two hundred thirty-five patients under the care of 14 primary care physicians in an academically affiliated practice with an electronic health record were enrolled in this proof-of-concept physician-blinded r and omized , controlled trial . Each patient with CAD or risk equivalent above National Cholesterol Education Program-recommended low-density lipoprotein ( LDL ) treatment goal for greater than 6 months was r and omized , stratified by physician and baseline LDL . Physicians received a single e-mail per intervention patient . E-mails were visit independent , provided decision support , and facilitated “ one-click ” order writing . MEASUREMENTS : The primary outcomes were changes in hyperlipidemia prescriptions , time to prescription change , and changes in LDL levels . The time spent using the system was assessed among intervention patients . RESULTS : A greater proportion of intervention patients had prescription changes at 1 month ( 15.3 % vs 2 % , P=.001 ) and 1 year ( 24.6 % vs 17.1 % , P=.14 ) . The median interval to first medication adjustment occurred earlier among intervention patients ( 0 vs 7.1 months , P=.005 ) . Among patients with baseline LDLs > 130 mg/dL , the first postintervention LDLs were substantially lower in the intervention group ( 119.0 vs 138.0 mg/dL , P=.04 ) . Physician processing time was under 60 seconds per e-mail . CONCLUSION : A visit-independent disease management tool result ed in significant improvement in secondary prevention of hyperlipidemia at 1-month postintervention and showed a trend toward improvement at 1 year Background : In this study , we tested the efficacy of a low-intensity lifestyle intervention aim ed at reducing the risk of cardiovascular disease among mid-life individuals . Methods : We conducted a r and omized controlled trial in which participants were r and omly assigned either to receive a health report card with counselling ( from a Telehealth nurse ) on smoking , exercise , nutrition and stress or to receive usual care . The patients were divided into 2 groups on the basis of risk : the primary prevention group , with a Framingham risk score of 10 % or higher ( intervention , n = 157 ; control , n = 158 ) , and the secondary prevention group , who had a diagnosis of coronary artery disease ( intervention , n = 153 ; control , n = 143 ) . The primary outcome was a change in the Framingham global risk score between baseline and 1-year follow-up . Data were analyzed separately for the 2 prevention groups using an intention-to-treat analysis controlling for covariates . Results : Within the primary prevention group , there were statistically significant changes for the treatment group relative to the controls , from baseline to year 1 , in Framingham score ( intervention , –3.10 [ 95 % confidence interval ( CI ) –3.98 to –2.22 ] ; control , –1.30 [ 95 % CI –2.18 to –0.42 ] ; p < 0.01 ) and scores for total cholesterol ( intervention , –0.41 [ 95 % CI –0.59 to –0.23 ] ; control , –0.14 [ 95 % CI –0.32 to 0.04 ] ; p < 0.05 ) , systolic blood pressure ( intervention , –7.49 [ 95 % CI –9.97 to –5.01 ] ; control , –3.58 [ 95 % CI –6.08 to –1.08 ] ; p < 0.05 ) , nutrition level ( intervention , 0.30 [ 95 % CI 0.13 to 0.47 ] ; control , –0.05 [ 95 % CI –0.22 to 0.12 ] ; p < 0.01 ) , and health confidence ( intervention , 0.20 [ 95 % CI 0.09 to 0.31 ] ; control , 0.04 [ 95 % CI –0.07 to 0.15 ] ; p < 0.05 ) , with adjustment for covariates . No significant changes in outcome variables were found for the secondary prevention group . Interpretation : We found evidence for the efficacy of an intervention addressing multiple risk factors for primary prevention at 1 year using Framingham risk score report cards and telephone counselling . ( Requirement for clinical trial registration waived [ enrolment completed before requirement became applicable ] . OBJECTIVE Older adults with poor functioning preoperatively are at risk for delayed recovery and more impaired outcomes after coronary artery bypass surgery ( CABS ) . The study objective was to determine whether a 6-week early recovery telehealth intervention , design ed to improve self-efficacy and management related to symptoms after CABS , was effective in improving outcomes ( physical activity , physiologic , and psychologic functioning ) for older adults ( aged > 65 years ) with higher disease burden . METHODS A descriptive , repeated- measures experimental design was used . Follow-up data were collected at 3 and 6 weeks and 3 months after CABS . Subjects were drawn from a larger r and omized clinical trial . Parent study subjects who had high disease burden preoperatively ( physical component score of < 50 on the Medical Outcome Study Short Form-36 and RISKO score of > 6 ) were included ( N = 55 ) , with 23 subjects in the early recovery intervention group and 31 subjects in the usual care group ( n = 31 ) . Subjects ranged in age from 65 to 85 years ( M = 71.6 + 5.1 years ) . RESULTS There was a significant main effect by group ( F[1,209 ] = 4.66 , P < .05 ) . The intervention group had a least square means of 27.9 kcal/kg/d of energy expenditure compared with the usual care group of 26.6 kcal/kg/d per the RT3 accelerometer ( Stayhealthy , Inc , Monrovia , CA ) . Both groups had significantly improved physical ( F[2,171 ] = 3.26 , P < .05 ) and role-physical ( F[2,171 ] = 6.64 , P < .005 ) functioning over time . CONCLUSION The subgroup of subjects undergoing CABS with high disease burden were responsive to an early recovery telehealth intervention . Improving patients '  physical activity and functioning can reduce morbidity and mortality associated with poor functioning after cardiac events BACKGROUND Translating guidelines into clinical practice has proved to be quite difficult , even when the guidelines are well accepted and noncontroversial . Both computerized reminders and academic detailing have been effective in changing physician prescribing behavior . In this study , we sought to use these methods , mediated by clinical pharmacists , to improve adherence to the secondary prevention guidelines in hospitalized patients with myocardial infa rct ion . METHODS A r and omized , prospect i ve study was performed in which computerized alerts identifying hospitalized patients with elevated troponin I levels were routed to clinical pharmacists . The pharmacists then conducted academic detailing for physicians caring for patients with acute myocardial infa rct ion who were r and omized to the intervention group . Patients in the control group received st and ard care . The main outcome measure was the proportion of patients discharged on a regimen of aspirin , beta-blockers , angiotensin-converting enzyme inhibitors , and statins .  RESULTS The intervention had a significant impact on the proportion of patients discharged on a regimen of angiotensin-converting enzyme inhibitors  ( 328/365 [ 89.9 % ] vs 409/488 [ 83.8 % ] , intervention vs control , respectively , P = .02 ) , and statins ( 344/365 [ 94.2 % ] vs 436/488 [ 89.3 % ] , P = .02 ) . There was no statistical impact on beta-blocker ( 350/365 [ 95.9 % ] vs 448/488 [ 91.8 % ] , P = .10 ) or aspirin use ( 352/365 [ 96.4 % ] vs 471/488 [ 96.5 % ] , P = .87 ) . When all 4 classes were considered together , 305 ( 83.6 % ) of 365 patients vs 343 ( 70.3 % ) of 488 patients were discharged on a regimen of all secondary prevention medications to which they did not have a contraindication ( P<.001 ) . CONCLUSION A computerized alert with pharmacist-mediated academic detailing is an effective means to increase adherence to secondary prevention guidelines for coronary heart disease A unique feature of the International Verapamil SR/Tr and olapril Study ( INVEST ) is the Internet‐based , electronic data capture system developed at the University of Florida for this trial . This system allows for direct collection of patient enrollment data , r and omization , study drug prescribing , and real‐time monitoring of patient data online . In this trial , immediate transmission of patient‐specific data occurs using online data collection forms . Investigators only need a personal computer with access to the Internet ; no complicated hardware , software systems , or paper storage files are necessary . INVEST is the first large r and omized clinical trial to use electronic prescribing systems in the research setting . Electronic prescribing eliminates errors associated with illegible h and writing , inappropriate dosing , and inappropriate medication choice . Because the INVEST protocol allows flexibility of medication choice and dosage range within r and omly assigned treatment strategies based on patient tolerance and blood pressure response , physician investigators may use individual practice patterns and preferences . The electronic system provides guidance to physicians relative to the addition of medication or dosage adjustments within the protocol . Electronic tracking and reporting mechanisms have enabled investigators in this complex megatrial to enroll , r and omize , and manage patients in real time with great accuracy We compared two models of assistance ( telecardiology versus usual care ) for patients discharged after acute coronary syndrome ( ACS ) , in the assessment of angina .  Two hundred patients were r and omized into two groups at discharge for ACS : Group A to telecardiology and Group B to usual care .  Early hospital readmission ( in the first month ) occurred in 16 patients ( seven in Group A and nine in Group B ) . Six of Group A were readmitted for a cardiac cause ( non-cardiac in one ) . Angina was the only cardiac cause . Five of the Group B patients were readmitted for a cardiac cause ( non-cardiac in four ) . The results of the present study emphasize that patients with ACS suffer from a definite rate of cardiac symptoms within the first month ( 63 % ) . Angina occurs more frequently within the first two weeks ( 68 % of cases ) . Telecardiology slightly reduces hospital readmissions  ( telecardiology 44 % versus usual care 56 % ) , but better identifies true angina BACKGROUND Cardiovascular risk reduction in ambulatory patients who survive myocardial infa rct ion ( MI ) is effective but underused . We sought to evaluate a provider-directed , Internet-delivered intervention to improve cardiovascular management for post-MI out patients . METHODS The Department of Veterans Affairs ( VA ) MI-Plus study was a cluster-r and omized trial involving 168 community-based primary care clinics and 847 providers in 26 states , the Virgin Isl and s , and Puerto Rico , from January 1 , 2002 , through December 31 , 2008 , with the clinic as the r and omization unit . We collected administrative data for 15,847 post-MI patients and medical record data for 10,452 of these . A multicomponent , Internet-delivered intervention included quarterly educational modules , practice guidelines , monthly literature summaries , and automated e-mail reminders delivered to providers for 27 months . Main outcome measures included percentage of patients who achieved each of 7 clinical indicators , a composite score of the 7 clinical indicators , and mean low-density lipoprotein cholesterol and hemoglobin A(1c ) levels . RESULTS Clinics had a median of 3 providers ( interquartile range , 2 - 6 ) , with a median of 50.0 % of providers ( 33.3%-66.7 % ) participating in the study . Patients in intervention clinics had greater improvements ( from 70.0 % to 85.5 % ) in the percentages prescribed β-blockers than patients in control clinics ( 71.9 % to 84.0 % ; adjusted improvement gain for intervention vs control , 2.6 % ; 95 % CI , 0.1%-4.1 % ) . We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A(1c ) . CONCLUSION A longitudinal , Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients OBJECTIVE To evaluate the feasibility of a web-based coaching programme for vascular risk factor treatment , to describe the patterns of use and to measure changes in risk factors . METHODS Patients with a clinical manifestation of arterial disease and Internet access were asked to participate in the nurse-led Internet-based risk factor management programme . At the first clinic visit , a personalized action plan was made for the treatment of risk factors . Patients were instructed on communication with a specialized nurse through Internet and encouraged to enter self-measured risk factor levels at their personalized website . The nurse practitioner replied on working days and gave feedback , support , and recommendations on lifestyle and medical treatment . After 6 months , risk factors were re-measured . RESULTS Fifty patients participated , 70 % were overweight , 64 % had hypertension , 42 % hyperlipidemia , and 24 % smoked at baseline . During 6 months , the log-in average at the individual website was 35 times per patient ( 1.3 log-ins/week ) ; while the nurse practitioner logged-in at the overall website 23 times/week . The website was hardly used by five patients . Most e-mail messages were sent by patients for hypertension ( 211 times ) and obesity ( 203 times ) , whereas the nurse practitioner sent nearly twice as many e-mail messages for hypertension ( 400 times ) and obesity ( 455 times ) . The level of most risk factors decreased and the fraction of achieved treatment goals increased ( blood pressure from 36 to 58 % , LDL-cholesterol from 58 to 64 % , glucose from 64 to 82 % ) . CONCLUSIONS A web-based vascular risk factor intervention programme is feasible ; it is frequently used by patients and suitable to decrease the level of several risk factors . It has the promise of being an efficacious intervention for risk factor sanitation in patients with symptomatic vascular disease . PRACTICE IMPLICATION S An Internet-based individualised risk management programme could make patients aware of their self-management capability and may contribute to risk factor reduction We compared the effects of evidence -based disease management guidelines delivered to patients with heart failure and diabetes using three different modalities : in-person visits alone ( Control ) , in-person visits and a telephone intervention ( Telephone ) , and in-person visits and telemonitoring ( Telemonitoring ) .  Patients were r and omized to the three groups . There were 112 patients in the Control group , 93 in the Telephone group and 98 in the Telemonitoring group . During the first 60 days , 10 % of the Control group were rehospitalized , 17 % of the Telephone group and 16 % of the Telemonitoring group . Having heart failure and receiving more in-person visits were significantly related to readmission and time to readmission . However , after adjusting for diagnosis and visits , the differences between the three groups were non-significant . There was a trend for increased risk of readmission for the Telephone group compared to Control alone ( P = 0.07 , risk ratio 2.2 , 95 % CI : 0.9 to 5.2 ) and for readmission sooner ( P = 0.02 , risk ratio 2.3 , 95 % CI : 1.2 to 4.6 ) . Patient rehospitalization and emergency department visit rates were lower than the national average , making it difficult to detect a difference between groups . Previous rehospitalization was a consistent predictor of those who were rehospitalized , suggesting that it may be a useful indicator for identifying patients likely to need additional attention Background : Cardiac rehabilitation ( CR ) programmes have increased their availability and exp and ed their eligibility criteria . This study sought to identify current predictors and reasons influencing myocardial infa rct ion patients ’ pre-discharge intentions to attend CR .  Methods : Patients in this longitudinal , prospect i ve , five site study completed question naires that surveyed their intentions to attend , attendance and main reasons for non-attendance at CR . Results : 84 % of the 1172 patients indicated that they intended to attend CR . Multivariate analyses revealed that age , employment and earlier history of myocardial infa rct ion were significant predictors of intention to attend CR , yet contributed to only a small proportion of the variance . The main reasons given for not intending to attend CR were lack of interest and perception that the programme would not be beneficial . Other obstacles included work , transport or time . A total of 708 ( 60 % ) patients responded at 12 months , and of these , 44 % who did not intend to attend CR had attended . Conclusion : Patient sociodemographic and clinical profile , although significant , are not major predictors of intention to attend CR . Lack of interest and misconceptions regarding CR are cited as key barriers . Some of these seem to have been addressed post discharge as a good proportion of patients who had not intended to attend CR did change their minds and attended . Motivation of patients to participate in CR , including the identification of barriers and the provision of comprehensive information about the purpose and varied formats of CR programmes , could be used to help further address barriers to attendance Less than 25 % of eligible patients attend cardiac rehabilitation programs ( CRP )  , with geographical proximity being a predominant barrier . Therefore , we undertook a pilot study to assess the feasibility and safety of using the Internet as a medium for delivery of an interactive " virtual " CRP ( vCRP ) to patients at a distance . Fifteen patients on the waiting list for a local hospital-based CRP were r and omized to either an Internet-based vCRP or observational control . The vCRP consisted of on-line intake forms , one-on-one chat sessions with a nurse , dietitian , and exercise specialist , downloadable exercise heart rate monitoring , education and data monitoring of blood pressure , weight , and glucose . Participants were assessed for exercise capacity , risk factors , and lifestyle behaviors at baseline and at 12 weeks . Those in the vCRP logged onto the Internet-based CRP an average of 4.2 times per week . There were no adverse events in the vCRP participants . The vCRP group significantly improved their HDL-C , triglycerides , total cholesterol : HDL-C ratio , exercise capacity as assessed in metabolic equivalents , weekly physical activity , and exercise specific self-efficacy ( p < 0.05 ) . There were no significant improvements in the control group . Improvements in the vCRP group were similar to historical controls in a st and ard CRP . Feedback from exit interviews of the vCRP participants was unanimously positive . This Internet-based CRP result ed in clinical ly significant improvements in risk factors and exercise capacity similar to that of a st and ard CRP . The high user acceptance indicated that this program may have the potential to effectively manage patients who do not have access to traditional hospital-based CRP AIMS To describe the rationale and design of the Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care ( WHICH ? ) trial . METHODS WHICH ? is a pragmatic , multicentre , r and omized controlled trial that seeks to determine if multidisciplinary management of chronic heart failure ( CHF ) patients post-acute hospitalization delivered in a patient 's own home is superior to care delivered via a specialist CHF outpatient clinic . The composite primary endpoint is all-cause , unplanned recurrent hospitalization or death during 12 - 18 months of follow-up . Of 688 eligible patients , 280 patients ( 73 % male and 66 % principal diagnosis of CHF ) with a mean age of 71 ± 14 years have been r and omized to home- ( n = 143 ) or clinic-based ( n = 137 ) post-discharge management . This will provide 80 % power ( two-sided alpha of 0.05 ) to detect a 15 % absolute difference in both the primary end-point and rate of all-cause hospital stay . Preliminary data suggest that the two groups are well matched in nearly all baseline socio-economic and clinical parameters . The majority of patients have significant co-morbidity , including hypertension ( 63 % ) , coronary artery disease ( 55 % ) , and atrial fibrillation ( 53 % ) with an accordingly high Charlson Index of Comorbidity Score ( 6.1 ± 2.4 ) . PERSPECTIVE Despite its relatively small size , the WHICH ? trial is well placed to examine the relative impact of two of the most commonly applied forms of face-to-face management design ed to reduce recurrent hospitalization and prolong survival in CHF patients OBJECTIVE The purpose of this study is to determine the impact of a home communication intervention ( HCI ) for ischemic heart failure Coronary Artery Bypass Graft ( CABG ) patients > /= 65 years of age on self-efficacy , coronary artery disease risk factor modification and functioning posthospitalization . DESIGN A r and omized clinical trial with repeated measures was used . SAMPLE A sub sample of ischemic heart failure CABG surgery patients ( n = 35 ) was drawn from the parent study of 180 CABG patients . RESULTS HCI participants ( n = 18 ) had significantly higher adjusted mean self-efficacy scores [ F(1 , 29 ) = 6.40 , P < .05 ] and adjusted mean levels of functioning ( physical , general health , mental , and vitality functioning ) compared with the routine care group ( n = 17 ) , using repeated measures analysis of covariance with baseline scores as covariates . There were also significant effects of time on bodily pain and role emotional functioning . Significantly higher exercise adherence ( t = 3.09 , P < .01 ) and lower reported stress ( t = 3.77 , P < .01 ) at 3 months after surgery was reported by HCI subjects . CONCLUSIONS Data from this pilot study can be used to strengthen the HCI intervention with more tailored strategies for vulnerable subgroups of CABG patients BACKGROUND Preventive electronic (e)-counselling has been shown to reduce cardiovascular risk factors . However , heterogeneity in outcomes is commonly reported due to differences in e- protocol s. We incorporated key features of an established behavioural therapy , motivational interviewing , to help st and ardize e-counselling in order to reduce blood pressure in patients with hypertension . METHODS Subjects ( n = 387 , mean age = 56 years , 59 % female , 72 % taking ≥ 1 antihypertensive drug ) were diagnosed with stage 1 or 2 hypertension . Subjects were r and omized to a 4-month protocol of e-counselling ( beta version of the " Blood Pressure Action Plan " , Heart and Stroke Foundation of Canada ) vs waitlist control ( general e-information on heart-healthy living ) . Outcomes were systolic , diastolic , and pulse pressures , and total lipoprotein cholesterol after treatment . RESULTS Intention to treat analysis did not find a significant group difference in outcomes due to contamination across the 2 arms of this trial . However , per protocol analysis indicated that subjects receiving ≥ 8 e-counselling messages ( a priori therapeutic dose ) vs 0 e-counselling messages ( control ) demonstrated greater reduction in systolic blood pressure ( mean , -8.9 mm Hg ; 95 % confidence interval [ CI ] , -11.5 to -6.4 vs -5.0 mm Hg ; 95 % CI , -6.7 to -3.3 , P = 0.03 ) , pulse pressure ( -6.1 mm Hg ; 95 % CI , -8.1 to -4.1 vs -3.1 mm Hg ; 95 % CI , -4.3 to -1.8 , P = 0.02 ) and total cholesterol ( -0.24 mmol/L ; 95 % CI , -0.43 to -0.06 vs 0.05 mmol/L ; 95 % CI , -0.06 to 0.16 , P = 0.03 ) , but not diastolic blood pressure . CONCLUSIONS These findings support the merit of evaluating whether e-counselling can improve blood pressure control and reduce cardiovascular risk over the long-term OBJECTIVE To test the effectiveness of two interventions design ed to improve the adoption of evidence -based practice s by home health nurses caring for heart failure ( HF ) patients . DATA SOURCES / STUDY SETTING Information on nurse practice s was abstract ed from the clinical records of patients admitted between June 2000 and November 2001 to the care of 354 study nurses at a large , urban , nonprofit home care agency . STUDY DESIGN The study employed a r and omized design with nurses assigned to usual care or one of two intervention groups upon identification of an eligible patient . The basic intervention was a one-time e-mail reminder highlighting six HF-specific clinical recommendations . The augmented intervention consisted of the initial e-mail reminder supplemented by provider prompts , patient education material , and clinical nurse specialist outreach . DATA COLLECTION At each home health visit provided by a study nurse to an eligible HF patient during the 45-day follow-up period , a structured chart abstract ion tool was used to collect information on whether the nurse provided the care practice s highlighted in the e-mail reminder . PRINCIPAL FINDINGS Both the basic and the augmented interventions greatly increased the practice of evidence -based care , according to patient records , in the areas of patient assessment and instructions about HF disease management . While not all results were statistically significant at conventional levels , intervention effects were positive in virtually all cases and effect magnitudes frequently were large . CONCLUSIONS The results of this r and omized trial strongly support the efficacy of just-in-time evidence -based reminders as a means of changing clinical practice among home health nurses who are geographically dispersed and spend much of their time in the field We evaluated whether telehealth counseling augments lifestyle change and risk factor decrease in subjects at high risk for primary or secondary cardiovascular events compared to a recommended guideline for brief preventive counseling . Subjects at high risk or with coronary heart disease ( 35 to 74 years of age , n = 680 ) were r and omized to active control ( risk factor feedback , brief advice , h and outs ) or telehealth lifestyle counseling ( active control plus 6 weekly 1-hour teleconferenced sessions to groups of 4 to 8 subjects ) . Primary outcome was question naire assessment of adherence to daily exercise/physical activity and diet ( daily vegetable and fruit intake and restriction of fat and salt ) after treatment and at 6-month follow-up . Secondary outcomes were systolic and diastolic blood pressures , ratio of total to high-density lipoprotein cholesterol , and 10-year absolute risk for coronary disease . After treatment and at 6-month follow-up , adherence increased for telehealth versus control in exercise ( 29.3 % and 18.4 % vs 2.5 % and 9.3 % , respectively , odds ratio 1.60 , 95 % confidence interval 1.2 to 2.1 ) and diet ( 37.1 % and 38.1 % vs 16.7 % and 33.3 % , respectively , odds ratio 1.41 , 95 % confidence interval 1.1 to 1.9 ) . Telehealth versus control had greater 6-month decreases in blood pressure ( mean ± SE , systolic -4.8 ± 0.8 vs -2.8 ± 0.9 mm Hg , p = 0.04 ; diastolic -2.7 ± 0.5 vs -1.5 ± 0.6 mm Hg , p = 0.04 ) . Decreases in cholesterol ratio and 10-year absolute risk were significant for the 2 groups . In conclusion , telehealth counseling augments therapeutic lifestyle change in subjects at high risk for cardiovascular events compared to a recommended guideline for brief preventive counseling Background —The purpose of this study was to compare long-term outcomes of coronary stenting in all lesions  ( elective stenting ) or only in lesions with inadequate morphological and functional results after balloon angioplasty ( guided PTCA ) .  Methods and Results —Treatment of multivessel disease , with any lesion length and vessel size , was allowed provided that all lesions were suitable for stent implantation .  Patients were r and omized to elective stent implantation ( n=370 ) or guided PTCA ( n=365 ) . An optimal PTCA result ( residual diameter stenosis ≤35 % , coronary flow reserve measured with a Doppler guidewire > 2.0 , absence of threatening dissections ) was achieved in 166 lesions ( 43 % ) . The remaining 218 lesions underwent stent implantation ( provisional stenting )  . Final residual diameter stenosis was lower in the elective and provisional stent groups ( 9.3 % and 10.2 % ) than in the optimal PTCA group ( 24.8 % , P < 0.00001 ) . On an intention-to-treat analysis , the probability of ≥1 major adverse cardiac event at 12 months was 17.8 % in the elective stenting group and 18.9 % in the guided PTCA group ( 20.1 % for optimal PTCA and 18.0 % for the provisional stenting subgroup , P = NS ) . The incidence of repeat target lesion revascularization at 1 year was 14.9 % in the elective stent group and 15.6 % in the guided PTCA group ( 17.6 % for optimal PTCA and 14.1 % for the provisional stenting subgroup , P = NS ) . Conclusions —When balloon angioplasty is guided by online quantitative angiography and Doppler-derived coronary flow reserve , with provisional stenting reserved for suboptimal results , early and late clinical outcomes are comparable to those achieved by elective stenting of all patients An Internet-based store- and -retrieval telemedicine system to communicate between patients and their healthcare provider was tested . The system requires no specialized equipment , is Web-based , and allows frequent surveillance of the health status of the patients with heart failure ( HF ) . Thirty six patients were recruited to evaluate a Web-based telemedicine system for reducing care encounters . Eighteen patients were r and omized to the telemedicine arm ( group T ) , and 18 were given usual clinical care ( group C ) in our HF center . Patients in group T reported three times weekly via a secure Internet site for telemedicine intervention . We studied patients with HF with New York Heart Association ( NYHA ) class 2 to 4 with hospitalization within past 6 months . Mean age was 56.1 + /- 12.6 years ( 66.7 % male ; 66.7 % Caucasian , 27.8 % African American , and 5.6 % Hispanic ) .  Mean ejection fraction ( EF ) was 23.9 % + /- 17.6 % in group T and 26.6 % + /- 16.4 % in group C. Over an 8-month period , unscheduled ( group T-3 ; group C-5 ) , and scheduled clinic visits ( group T-11 , group C-7 ) were similar ( p = NS ) ; one group T patient was transplanted , one group C patient died . Total hospital days were lower with group T ( 44 days ) compared to group C ( 133 days ) , p < 0.05 . An Internet-based telemedicine system was able to closely monitor patients with HF . Surveillance through Internet-based telemedicine result ed in less hospitalization compared to control patients . This system may be helpful in reducing the cost of HF patient care R and omized clinical trials of cardiac rehabilitation following myocardial infa rct ion have typically demonstrated a lower mortality in treated patients , but with a statistically significant reduction in only one trial . To overcome the problem of not being able to detect small but clinical ly important benefits in mortality in r and omized clinical trials of exercise and risk factor rehabilitation after myocardial infa rct ion with small numbers of patients , we carried out a meta- analysis on the combined results of ten r and omized clinical trials that included 4347 patients ( control , 2145 patients ; rehabilitation , 2202 patients ) . The pooled odds ratios of 0.76 ( 95 % confidence intervals , 0.63 to 0.92 ) for all-cause death and of 0.75 ( 95 % confidence intervals , 0.62 to 0.93 ) for cardiovascular death were significantly lower in the rehabilitation group than in the control group , with no significant difference for nonfatal recurrent myocardial infa rct ion . These results suggest that , for appropriately selected patients , comprehensive cardiac rehabilitation has a beneficial effect on mortality but not on nonfatal recurrent myocardial infa rct ion Background An increase in physical activity for secondary prevention of cardiovascular disease and cardiac rehabilitation has multiple therapeutic benefits , including decreased mortality . Internet- and mobile-based interventions for physical activity have shown promising results in helping users increase or maintain their level of physical activity in general and specifically in secondary prevention of cardiovascular diseases and cardiac rehabilitation . One component related to the efficacy of these interventions is tailoring of the content to the individual . Objective Our trial assessed the effect of a longitudinally tailored Internet- and mobile-based intervention for physical activity as an extension of a face-to-face cardiac rehabilitation stay . We hypothesized that users of the tailored intervention would maintain their physical activity level better than users of the nontailored version . Methods The study population included adult participants of a cardiac rehabilitation program in Norway with home Internet access and a mobile phone . The participants were r and omized in monthly clusters to a tailored or nontailored ( control ) intervention group . All participants had access to a website with information regarding cardiac rehabilitation , an online discussion forum , and an online activity calendar . Those using the tailored intervention received tailored content based on models of health behavior via the website and mobile fully automated text messages . The main outcome was self-reported level of physical activity , which was obtained using an online international physical activity question naire at baseline , at discharge , and at 1 month and 3 months after discharge from the cardiac rehabilitation program . Results Included in the study were 69 participants . One month after discharge , the tailored intervention group ( n=10 ) had a higher median level of overall physical activity ( median 2737.5 , IQR 4200.2 ) than the control group ( n=14 , median 1650.0 , IQR 2443.5 ) , but the difference was not significant ( Kolmogorov-Smirnov Z=0.823 , P=.38 , r=.17 ) . At 3 months after discharge , the tailored intervention group ( n=7 ) had a significantly higher median level of overall physical activity ( median 5613.0 , IQR 2828.0 ) than the control group ( n=12 , median 1356.0 , IQR 2937.0 ; Kolmogorov-Smirnov Z=1.397 , P=.02 , r=.33 ) . The median adherence was 45.0 ( 95 % CI 0.0 - 169.8 ) days for the tailored group and 111.0 ( 95 % CI 45.1 - 176.9 ) days for the control group ; however , the difference was not significant ( P=.39 ) . There were no statistically significant differences between the 2 groups in stage of change , self-efficacy , social support , perceived tailoring , anxiety , or depression . Conclusions Because of the small sample size and the high attrition rate at the follow-up visits , we can not make conclusions regarding the efficacy of our approach , but the results indicate that the tailored version of the intervention may have contributed to the long-term higher physical activity maintained after cardiac rehabilitation by participants receiving the tailored intervention compared with those receiving the nontailored intervention . Trial Registration Clinical Trials.gov : NCT01223170 ; http:// clinical trials.gov/show/NCT01223170 ( Archived by WebCite at http://www.webcitation.org/6Nch4ldcL ) To evaluate the usefulness of telephonically-monitored home exercise in patients within two weeks postcoronary bypass surgery , we r and omly enrolled 46 male patients in a 12-week home program of either short walks or bicycle ergometry . Home exercise was done five times weekly and monitored both before and immediately after three times weekly . New arrhythmias or conduction disturbances were detected in 18 of 23 ( 78 percent ) of the bicycle group and in 20 of 23 ( 87 percent ) of the short walk patients . New symptoms developed in three patients , two from the short walk group and one from the bicycle group . Two bikers and one walker developed elevated blood pressure ; all were referred to physicians and were successfully managed . Electrocardiographic abnormalities led directly to diagnostic and therapeutic intervention in nine of the 46 patients -four bikers and five walkers . There were no complications such as ventricular tachycardia or ventricular fibrillation . Technically clear telephone rhythm strips were obtained from patients calling both locally and long distance OBJECTIVE Pharmacologic treatment for secondary prevention of coronary heart disease ( CHD ) is critical to prevent adverse clinical outcomes . In a r and omized controlled trial , we compared antiplatelet and statin adherence among patients with CHD who received : ( 1 ) text messages ( TM ) for medication reminders and education , ( 2 ) educational TM only , or ( 3 ) No TM .  METHODS A mobile health intervention delivered customized TM for 30 days . We assessed and analyzed medication adherence with electronic monitoring devices [ Medication Event Monitoring System ( MEMS ) ] by one-way ANOVA and Welch tests , two-way TM response rates by t-tests , and self-reported adherence ( Morisky Medication Adherence Scale ) by Repeated Measures ANOVA . RESULTS Among 90 patients ( 76 % male , mean age 59.2 years ) , MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken ( p=0.02 ) , percentage number of doses taken ( p=0.01 ) , and percentage of prescribed doses taken on schedule ( p=0.01 ) .  TM response rates were higher for antiplatelets than statins ( p=0.005 ) . Self-reported adherence revealed no significant differences among groups . CONCLUSION TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses . PRACTICE IMPLICATION S Feasibility and high satisfaction were established . Mobile health interventions show promise in promoting medication adherence BACKGROUND Secondary prevention is not adequately implemented after myocardial infa rct ion ( MI ) . We assessed the effect on quality of care and prognosis of a long-term , relatively intensive rehabilitation strategy after MI . METHODS We conducted a multicenter , r and omized controlled trial in patients following st and ard post-MI cardiac rehabilitation  , comparing a long-term , reinforced , multifactorial educational and behavioral intervention with usual care . A total of 3241 patients with recent MI were r and omized to a 3-year multifactorial continued educational and behavioral program ( intervention group ; n = 1620 ) or usual care ( control group ; n = 1621 ) . The combination of cardiovascular ( CV ) mortality , nonfatal MI , nonfatal stroke , and hospitalization for angina pectoris , heart failure , or urgent revascularization procedure was the primary end point . Other end points were major CV events , major cardiac and cerebrovascular events , lifestyle habits , and drug prescriptions . RESULTS End point events occurred in 556 patients ( 17.2 % ) . Compared with usual care , the intensive intervention did not decrease the primary end point significantly ( 16.1 % vs 18.2 % ; hazard ratio [ HR ] , 0.88 ; 95 % confidence interval [ CI ] , 0.74 - 1.04 ) . However , the intensive intervention decreased several secondary end points : CV mortality plus nonfatal MI and stroke ( 3.2 % vs 4.8 % ; HR , 0.67 ; 95 % CI , 0.47 - 0.95 ) , cardiac death plus nonfatal myocardial infa rct ion ( 2.5 % vs 4.0 % ; HR , 0.64 ; 95 % CI , 0.43 - 0.94 ) , and nonfatal MI ( 1.4 % vs 2.7 % ; HR , 0.52 ; 95 % CI , 0.31 - 0.86 ) . A marked improvement in lifestyle habits ( ie , exercise , diet , psychosocial stress , less deterioration of body weight control ) and in prescription of drugs for secondary prevention was seen in the intervention group . CONCLUSION The GOSPEL Study is the first trial to our knowledge to demonstrate that a multifactorial , continued reinforced intervention up to 3 years after rehabilitation following MI is effective in decreasing the risk of several important CV outcomes , particularly nonfatal MI , although the overall effect is small . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00421876 PURPOSE Despite demonstrated benefits of cardiac rehabilitation and risk factor reduction , only 11 % to 38 % of eligible patients with cardiovascular disease ( CVD ) participate in cardiac rehabilitation programs .  Women and older adults are particularly less likely to participate in cardiac rehabilitation . In an effort to broaden access to cardiac rehabilitation , the authors developed an alternative Internet-based program that allows nurse case managers to provide risk factor management training , risk factor education , and monitoring services to patients with CVD . METHODS The evaluation consisted of a r and omized , clinical trial involving 104 patients with CVD , 53 of whom used the program as a special intervention ( SI ) for 6 months and 51 of whom received usual care ( UC ) .  RESULTS The results indicate that fewer cardiovascular events occurred among the SI subjects ( 15.7 % ) than among the UC subjects ( 4.1 % ) ( P = .053 ) , result ing in a gross cost savings of $ 1418 US dollars per patient . With a projected program cost of $ 453 USD per patient , the return on investment is estimated at 213 % . More weight loss occurred in the SI group ( -3.68 pounds ) than in the UC group ( + .47 pounds ) ( P = .003 ) . The differences between the two groups in terms of blood pressure , lipid levels , depression scores , minutes of exercise , and dietary habits were not statistically significant . CONCLUSION An Internet-based case management system could be used as a cost-effective intervention for patients with CVD , either independently or in conjunction with traditional cardiac rehabilitation BACKGROUND Effective therapies exist for reducing mortality in persons with coronary heart disease ( CHD ) , but they remain underused . OBJECTIVE To report the design and baseline results of a quality improvement project design ed to increase the use of hydroxymethyl glutaryl coenzyme A ( HMG-CoA ) reductase inhibitors , beta-adrenergic blocking agents , and angiotensin-converting enzyme ( ACE ) inhibitors in patients with CHD in a network-model managed care setting . METHODS Patients with CHD were identified by search ing a cl aims data base . Use of therapies was assessed by linkage with a pharmacy benefits data base . A survey was mailed to primary care physicians to collect information related to attitudes and behavioral intentions regarding aggressive management of CHD . An intervention , consisting of a guideline summary , performance feedback , and medical chart reminders , was evaluated in a r and omized , practice -based trial . RESULTS Among 1189 patients with CHD , the median prevalence of receipt of  HMG-CoA reductase inhibitors , beta-adrenergic blocking agents , and ACE inhibitors across practice s at baseline ( the first 3 months of 1999 ) was 50.0 % , 35.0 % , and 18.8 % , respectively . Reported barriers included a perception that aggressive management of CHD is thought to be unimportant by support staff yet to require significant staff time . Aggressive management of CHD was perceived to incur non-reimbursable costs , to be unimportant in their patient population , to require a great deal of patient education and self-management , and to be limited because many patients do not adhere to therapy . CONCLUSIONS Opportunities exist for enhancing the quality of care provided to patients with CHD . Our experience to date supports the logistical feasibility of implementing network-level quality enhancement efforts in managed care networks Summary Patients with established coronary artery disease ( CAD ) were recruited in 11 hospitals and r and omized to an intervention ( telemedicine system ; n = 752 ) or a control group ( usual medical care ; n = 748 ) . On the day before discharge , patients in the intervention group were equipped with a 12-lead event recorder and trained to use the device . Whenever they had symptoms , they could contact the call centre , transmit an ECG ( without redialling ) and consult a physician . During a 12-month study , 171 patients ( 23 % ) in the intervention group contacted the call centre , a total of 269 times . The main reasons for calling were chest pain and radiating pain . Pathological changes were seen in 24 % of the transmitted ECGs . Only 23 % of the calls were made in the first hour after onset of symptoms and a further 12 % in the subsequent hour , suggesting that patients should be encouraged to use ECG transmission at an earlier stage . At follow-up , 157 patients ( 21 % ) had had at least one recurrent cardiac event ( myocardial infa rct ion , cardiac hospital stay , re-vascularization ) . The proportion was significantly higher in telemedicine users ( 35 % ) than in non-users ( 17 % ) , P < 0.001 . Regardless of utilization , the majority of the intervention patients considered that the telemedicine system was helpful ( users = 93 % , non-users = 89 % ; P = 0.095 ) The decision to admit a patient to a coronary care unit for acute coronary syndrome ( ACS ) has serious medical and financial consequences . In this study , we aim ed to develop a computer program to predict the existence of ACS in patients with chest pain at home ; it is intended that patients will be able to access the program via the website to test its validity . This study proceeded in two phases . In the first phase , a computer-based decision protocol was developed using recursive-partitioning analysis to predict ACS in 250 patients with chest pain on the basis of their historical data . In the second phase , this protocol was tested in 115 patients for diagnosis of ACS prospect ively . Thirty-two of the patients answered the algorithm questions on the website . All of the patients who visited the website of this study were advised to go to the emergency department . Although the algorithm showed the presence of ACS in 82 of 115 patients , 60 of 115 patients were diagnosed as having ACS in the emergency department ( n = 55 ) or at follow-up . The agreement between the diagnosis of the algorithm and the true diagnosis was moderate and statistically significant ( Kappa coefficient 0.61 , P < 0.001 ) . The sensitivity of the algorithm was 100 % , although its specificity was 60 % . The accuracy of the algorithm in diagnosing ACS was 81 % . The algorithm diagnoses patients with ACS at a high ratio and decreases the number of patients being unnecessarily admitted to the emergency with non-ACS Background Approximately half of American adults do not meet recommended physical activity guidelines . Face-to-face lifestyle interventions improve health outcomes but are unlikely to yield population -level improvements because they can be difficult to disseminate , expensive to maintain , and inconvenient for the recipient . In contrast , Internet-based behavior change interventions can be disseminated widely at a lower cost . However , the impact of some Internet-mediated programs is limited by high attrition rates . Online communities that allow participants to communicate with each other by posting and reading messages may decrease participant attrition . Objective Our objective was to measure the impact of adding online community features to an Internet-mediated walking program on participant attrition and average daily step counts . Methods This r and omized controlled trial included sedentary , ambulatory adults who used email regularly and had at least 1 of the following : overweight ( body mass index [ BMI ] ≥ 25 ) , type 2 diabetes , or coronary artery disease . All participants ( n = 324 ) wore enhanced pedometers throughout the 16-week intervention and uploaded step-count data to the study server . Participants could log in to the study website to view graphs of their walking progress , individually-tailored motivational messages , and weekly calculated goals . Participants were r and omized to 1 of 2 versions of a Web-based walking program . Those r and omized to the “ online community ” arm could post and read messages with other participants while those r and omized to the “ no online community " arm could not read or post messages . The main outcome measures were participant attrition and average daily step counts over 16 weeks . Multiple regression analyses assessed the effect of the online community access controlling for age , sex , disease status , BMI , and baseline step counts . Results Both arms significantly increased their average daily steps between baseline and the end of the intervention period , but there were no significant differences in increase in step counts between arms using either intention-to-treat or completers analysis . In the intention-to-treat analysis , the average step count increase across both arms was 1888 ± 2400 steps . The percentage of completers was 13 % higher in the online community arm than the no online community arm ( online community arm , 79 % , no online community arm , 66 % , P = .02 ) . In addition , online community arm participants remained engaged in the program longer than no online community arm participants ( hazard ratio = 0.47 , 95 % CI = 0.25 - 0.90 , P = .02 ) . Participants with lower baseline social support posted more messages to the online community ( P < .001 ) and viewed more posts ( P < .001 ) than participants with higher baseline social support . Conclusion Adding online community features to an Internet-mediated walking program did not increase average daily step counts but did reduce participant attrition . Participants with low baseline social support used the online community features more than those with high baseline social support . Thus , online communities may be a promising approach to reducing attrition from online health behavior change interventions , particularly in population s with low social support . Trial Registration NCT00729040 ; http:// clinical trials.gov/ct2/show/NCT00729040 ( Archived by WebCite at http://www.webcitation.org/5v1VH3n0A OBJECTIVE Advances in web-based animation technologies provide new opportunities to develop graphic health communications for dissemination throughout communities . We developed imagery and text contents of brief , computer-based programmes about heart disease risk , with both imagery and text contents guided by the common-sense model ( CSM ) of self-regulation . The imagery depicts a three-dimensional , beating heart tailored to user-specific information . DESIGN A 2 × 2 × 4 factorial design was used to manipulate concrete imagery ( imagery vs. no imagery ) and conceptual information ( text vs. no text ) about heart disease risk in prevention-oriented programmes and assess changes in representations and behavioural motivations from baseline to 2 days , 2 weeks , and 4 weeks post-intervention . METHODS Sedentary young adults ( N= 80 ) were r and omized to view one of four programmes : imagery plus text , imagery only , text only , or control .  Participants completed measures of risk representations , worry , and physical activity and healthy diet intentions and behaviours at baseline , 2 days post-intervention ( except behaviours ) , and 2 weeks ( intentions and behaviours only ) and 4 weeks later . RESULTS The imagery contents  increased representational beliefs and mental imagery relating to heart disease , worry , and intentions at post-intervention . Increases in sense of coherence ( underst and ing of heart disease ) and worry were sustained after 1 month . The imagery contents also increased healthy diet efforts after 2 weeks . The text contents increased beliefs about causal factors , mental images of clogged arteries , and worry at post-intervention , and increased physical activity 2 weeks later and sense of coherence 1 month later . CONCLUSION The CSM-based programmes induced short-term changes in risk representations and behaviour motivation . The combination of CSM-based text and imagery appears to be most effective in instilling risk representations that motivate protective behaviour Patients with chronic conditions are heavy users of the health care system . There are opportunities for significant savings and improvements to patient care if patients can be maintained in their homes . A r and omized control trial tested the impact of 3 months of telehome monitoring on hospital readmission , quality of life , and functional status in patients with heart failure or angina . The intervention consisted of video conferencing and phone line transmission of weight , blood pressure , and electrocardiograms . Telehome monitoring significantly reduced the number of hospital readmissions and days spent in the hospital for patients with angina and improved quality of life and functional status in patients with heart failure or angina . Patients found the technology easy to use and expressed high levels of satisfaction .  Telehealth technologies are a viable means of providing home monitoring to patients with heart disease at high risk of hospital readmission to improve their self-care abilities AIM To evaluate the effects of interpersonal counselling on health-related quality of life after myocardial infa rct ion . BACKGROUND Depression is a risk factor for poor health-related quality of life after myocardial infa rct ion . Interpersonal counselling seems to reduce depressive symptoms and distress after myocardial infa rct ion . METHODS Myocardial infa rct ion patients ( n=103 ) were r and omised into an intervention group ( n=51 ) with 1 - 6 ( mean 4·6 ) interpersonal counselling-sessions focusing on managing depressive symptoms and a control group ( n=52 ) . Health-related quality of life after myocardial infa rct ion was measured with EuroQol-5D ( EQ-5D ) in hospital , at six and 18 months after discharge . RESULTS No differences in the changes of health-related quality of life were found between the groups during follow-up . However , health-related quality of life improved significantly in the intervention group . In the group of patients under 60 years , the effect of interpersonal counselling was significant in the intervention group compared with the control group . CONCLUSIONS Interpersonal counselling does not seem to improve health-related quality of life better than st and ard care after myocardial infa rct ion in general , but it does seem to be beneficial with younger myocardial infa rct ion patients . RELEVANCE TO CLINICAL PRACTICE There is a need to study the effects of interpersonal counselling further with younger myocardial infa rct ion patients and to develop the intervention further , before using it systematic ally as part of nursing practice PURPOSE We wanted to determine the impact of automated family history assessment and tailored messages for coronary heart disease , stroke , diabetes , colorectal , breast , and ovarian cancer on preventive behaviors compared with a st and ard preventive message . METHODS The study was a cluster-r and omized clinical trial that included 41 primary care practice s , the majority in the Midwest , using Family Healthware  , a self-administered , Web-based tool that assesses familial risk for the diseases and provides personalized risk-tailored messages . Patients in the control group received an age- and sex-specific health message related to lifestyle and screening . Smoking cessation , fruit and vegetable intake , physical activity , aspirin use , blood pressure , and cholesterol and blood glucose screening  were assessed at baseline and 6 months after the intervention . RESULTS Of 4,248 participants , 3,344 ( 78 % ) completed the study . Participants were white ( 91 % ) , female ( 70 % ) , and insured ( 97 % ) , and had a mean age of 50.6 years ( range 35–65 years ) . Intervention participants were more likely to increase daily fruit and vegetable consumption  from 5 or fewer servings a day to 5 or more servings a day ( OR = 1.29 ; 95 % confidence interval [ CI ] , 1.05–1.58 ) and to  increase physical activity ( OR = 1.47 ; 95 % CI , 1.08–1.98 ) to 5 to 6 times a week for 30 minutes or more a week . The absolute differences in proportion were 3 % and 4 % , respectively . Intervention participants were less likely to move from not having cholesterol screening in the last 5 years to having their cholesterol measured within 5 years ( OR = 0.34 ; 95 % CI , 0.17–0.67 ) , with an absolute difference of 15 % . CONCLUSIONS Messages tailored to an individual ’s familial risk for 6 common diseases modestly increased self-reported physical activity and fruit and vegetable intake but reduced the likelihood of receiving cholesterol screening OBJECTIVE Given the multimodal medical and interventional treatment options in coronary artery disease ( CAD ) , the current value of intensified lifestyle modification remains unclear . No r and omized studies have so far assessed the impact of lifestyle modification on coronary artery calcium ( CAC ) . We examined the long-term effects of a one-year comprehensive lifestyle modification on risk factors and CAC by means of a r and omized clinical trial . METHODS 96 participants ( age range 35 - 75 years , 22 women ) of the SAFE-LIFE r and omized trial in patients with established CAD completed 3-year follow-up . The active treatment was a one-year lifestyle modification and stress reduction intervention ( LG ) , while the control group received written advice only ( AG ) .  CAC ( derived from electron beam tomography ) , blood lipids , heart rate , blood pressure , anginal symptoms and quality -of-life were assessed on entry and at 3-year follow-up . RESULTS Lifestyle modification had no impact on change of CAC after three years ( median progression factor [ 25th,75th percentile ] 1.46 [ 1.16,2.19 ] in LG and 1.41 [ 1.20,1.79 ] in AG ; p=0.68 ) , but led to reductions of blood pressure , heart rate and to dose-reductions in anti-ischemic medications as compared to AG . Multiple regression analysis indicated that in the pooled study population increase of CAC was related to psychosocial factors and heart rate . CONCLUSION In the presence of modern treatments , complementary prescription of comprehensive lifestyle modification has no impact on CAC progression but sustainable benefit for blood pressure , heart rate and the need of anti-ischemic medication is demonstrated . A possible influence of stress reduction measures on CAC progression should be further evaluated OBJECTIVE This study compared differences in  nurse and patient communication profiles between two telehealth modes : telephone and videophone , and evaluated longitudinal changes in communication , nurse perceptions , and patient satisfaction . METHODS Subjects were enrolled in a r and omized controlled clinical trial evaluating a 90-day home-based intervention for heart failure . Telephone ( n=14 ) and videophone ( n=14 ) interactions were audio taped and analyzed using the  Roter Interaction Analysis System .  RESULTS Nurses were more likely to use open-ended questions , back-channel responses , friendly jokes , and checks for underst and ing on the telephone compared to videophone .  Compliments given and partnership were more common on the videophone .  Patients were more likely to give lifestyle information and approval comments on the telephone , and used more closed-ended questions on the videophone .  Nurses perceptions of the interactions were not different between the telephone and videophone , nor did their perceptions change significantly over the course of the intervention . There were no significant differences in patient satisfaction between the telephone and videophone . CONCLUSIONS The results of this study did not support use of a videophone over the telephone . PRACTICE IMPLICATION S It is critical to match technologies to patient needs and use the least complex technology possible . When considering use a videophone , health care providers should critically examine the trade-offs between additional complexities with the added value of the visual interaction Objective To determine whether a computer-assisted reminder would alter prescribing habits for the treatment of hypertension in accordance with current clinical guidelines in a general internal medicine clinic . Design A r and omized trial . Setting The General Internal Medicine Clinic of the Veterans Affairs Puget Sound Health Care System , Seattle Division . Patients / Participants Clinic providers were r and omized to a control group ( n=35 ) or intervention group ( n=36 ) . We targeted the providers of patients being treated for hypertension with calcium channel blockers , a class of drug not recommended for initial therapy . InterventionAn automated computer query identified eligible patients and their providers . A guideline reminder was placed in the charts of patients of intervention providers ; the charts of patients of control providers received no reminder . Measurements and main results During the 5-month study period , 346 patients were seen by the 36 primary care providers ( staff physicians , nurse practitioners , residents , and fellows ) in the intervention group , and 373 patients were seen by the 35 providers in the control group . Intervention providers changed 39 patients ( 11.3 % ) to other medications during the study period , compared with 1 patient ( < 1.0 % ) of control providers ( p<.0001 ) . For patients whose therapy was unchanged , providers noted angina in 23.1 % , indications other than those for hypertension in 9.5 % , intolerable adverse effects with first-line therapy in 13.9 % , and inadequte control with first-line therapy in 13.9 % . Of those patients without provider-indicated contraindications , 23.6 % were switched from calcium channel blockers to first-line agents during the intervention period . Conclusions The use of a computerized , clinic-based intervention increased compliance with guidelines in the treatment of primary hypertension in general , and decreased the use of calcium channel blockers for the treatment of hypertension in particular Many primary care physicians have not learned about key advances in caring for patients after acute myocardial infa rct ion , including the use of -blockers ( 1 ) and angiotensin-converting enzyme inhibitors ( 2 ) . Although professional organizations have disseminated guidelines for the care of acute myocardial infa rct ion ( 3 , 4 ) , important therapies continue to be underused ( 5 ) . Physicians read guidelines to stay up-to- date ( 6 ) , but reading without additional interaction is relatively ineffective for learning ( 7 ) and has little effect on practice ( 8) . Physicians therefore need better methods for learning from guidelines .  Self- assessment tests  are often used to enhance self- study of printed material s ( 9 , 10 ) , but physicians can now choose from a growing number of World Wide Web sites that offer on-line self- study ( 11 ) . Since the 1960s , computer-assisted instruction has been explored as a method for medical education ( 12 - 15 ) . In theory , computer-assisted instruction can enhance self- study by tailoring presentations to learners ' individual needs and by including interactive simulations ( 16 ) . Two previous studies comparing computer-assisted instruction systems with carefully constructed self- study controls found mixed results ( 17 , 18 ) . In both of these studies , the systems were developed for and tested among medical students before the advent of the Web . Therefore , physicians have little direct evidence to inform their choices among currently available self- study methods . We conducted a r and omized trial to compare the educational outcomes produced by a Web-based tutorial on myocardial infa rct ion guidelines with those produced by self- assessment based and study from print versions of the same guidelines . We hypothesized that print-based self- study would result in substantial learning but Web-based self- study would produce incrementally greater knowledge gains , retention , learning efficiency , and satisfaction . We conducted this trial among residents rather than community physicians because residents frequently use self- study material s and because we anticipated that they would be more feasible to recruit . Methods Design of Self- Study Alternatives Guidelines and Learning Objectives The American College of Cardiology ( ACC ) , the American Heart Association ( AHA ) , and the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) allowed us to use their guidelines for this trial . We wrote 20 cognitive learning objectives ( 19 ) , covering knowledge from one or both guidelines that would be important for physicians who provide primary care to patients after myocardial infa rct ion . One of the authors , an expert in evidence -based cardiology , edited the objectives for content validity and importance . The final set of learning objectives is shown in the Appendix Table . Knowledge Tests We wrote multiple-choice questions that had one correct response demonstrating the knowledge in a single learning objective . Thirty attending physicians and fellows in internal medicine , family medicine , and cardiology critiqued the clarity and difficulty of prospect i ve questions by using an electronic mail quiz system that tracked each question 's average score ( 20 ) . These data were used to assemble a 20- question pretest and a different 20- question post-test . The tests included one question per learning objective and were approximately equivalent in overall difficulty . Expected scores on the final pretest and post-test differed by less than 6 % . For each question on the final test forms , participants could place a check mark next to the statement , I would like to review available evidence or recommendations on this topic . We referred to this feature as the review flag . For both of the self- study alternatives in this trial , learners initially completed the pretest on paper . Web-Based Self- Study Material s We constructed a Web-based learning system called SAGE ( Self- Study Acceleration with Graphic Evidence ) . Participants who used SAGE  copied their pretest answers into the system and were then taken to the main tutorial page , which presents an overview of the user 's pretest results for each learning objective . By clicking on hyperlinks , users could view a sequence of learning re sources for each objective . The first re source for each objective was the relevant pretest answer . From there , users could click on hyperlinks to view the relevant guideline passages ( highlighted segments of text in an on-line version of the complete guideline document ) . When guidelines referred to l and mark clinical trials , users could click on a link to open a graphic evidence browser ( Figure 1 ) . Complete instructions for using SAGE were provided in the system . The program was intended to combine two strategies of computer-assisted instruction : a tutorial strategy , which focuses the learner on deficits in previous knowledge , and a simulation strategy , which reinforces knowledge through interaction with graphic models of r and omized trial evidence . We wrote software for SAGE in Server-side JavaScript , using the Netscape Enterprise Server ( Mountain View , California ) running on a Sun Ultrasparc2 workstation ( Mountain View , California ) . For animated statistical graphics , we wrote a Java applet . Figure 1 . The SAGE ( Self- Study Acceleration with Graphic Evidence ) r and omized trial viewer . Printed Self- Study Material s Printed material s for the control group included the same self- assessment test and guidelines as the Web-based material s. The printed material s included 1 ) a booklet showing the correct answer for each pretest question and the learning objective each question was intended to evaluate and 2 ) complete reprints of the ACPASIM and ACC/AHA guidelines . Learners were instructed to compare their pretest answers with the correct answers and look up the evidence or guideline recommendations for each learning objective that they may not have met by using the outline structure of the ACPASIM guidelines and the index of the ACC/AHA guidelines . Material s in the control group were intended to provide learning through self- assessment and study from the actual guideline documents as distributed by the specialty societies . The control material s contained the same pretest answers and guideline content as SAGE but lacked the hypermedia navigation features and the detailed , interactive , graphic presentations of l and mark trial evidence . Of note , however , the guideline material s for both self- study groups contained all of the information that learners would need to meet each learning objective , including narrative descriptions of the key trial results that were available graphically in SAGE . Study Sample We recruited residency programs in family and internal medicine at four universities . Approval for research involving humans was obtained from each university 's institutional review board . A total of 5 family medicine and 7 internal medicine programs agreed to participate . We recorded the name , sex , and training year of every resident across all 12 programs in a confidential recruitment data base . Letters were placed in residents ' mailboxes inviting them to attend a 1.25-hour learning session in which they would be r and omly assigned to study from computer or printed material s on the care of myocardial infa rct ion . An honorarium of $ 30 was offered for completing the trial . The trial was also announced at resident conferences . All residents who attended a session and gave consent became eligible participants .  Self- Study Sessions Participants used the self- study material s in a single session that began with the pretest and ended with an immediate post-test . After completing the pretest , participants kept carbon copies of their answers , returned their originals , and received their r and omly generated study group assignment . Those assigned to the control group were given the printed material s , and those assigned to SAGE went to an adjacent computer classroom , where they logged on and entered their pretest answers . Participants in both groups were asked to study until they felt that they had met the learning objectives , at which point the self- study material s were removed and they immediately took the post-test on paper . Each session was proctored to ensure that all learning was attributable to self- study from the assigned material without use of extraneous material s or discussion with colleagues . No irregularities occurred . Participants could not attend more than one session and were not allowed to keep the printed self- study material s or to access SAGE after completing their session . Study Group Assignment Individual participants were r and omly assigned to study groups by a computer program that generated blocked r and omization stratified by the participants ' sex and residency year . As each resident arrived at a session , he or she was registered on a laptop computer that contained coded records from the recruitment data base . As the first participants finished the pretest , a r and omization program run on the laptop generated a balanced pool of assignments for each sexresidency year category ( using a block size of 2 [ 21 ] ) . For each registered participant , the program chose an assignment at r and om from the appropriate pool . As participants turned in their pretests , they and the investigators looked up their assignments on the laptop screen . Study group assignment was therefore simultaneously revealed to the participants and to the investigators . Outcome Measures Knowledge scores from multiple-choice tests were calculated by assigning 1 point per correct answer ; unanswered items were considered incorrect . This created scores that could range from 0 to 20 points . The primary outcome of the trial was knowledge on the immediate post-test . The time spent study ing was measured by using a time-stamp machine for participants in the control group and the server log for participants in the SAGE group . Learning efficiency was calculated as the point gain from pretest to immediate post-test divided by the Aim of the study was to assess efficacy of educational technology -- School for patients with stable angina -- in conditions of practical health care . We r and omized 100 patients with ischemic heart disease ( IHD ) and stable FC I-III angina into 2 groups one of which went through learning in a School for patients with IHD  ( 6 90 min sessions 2 times a week ) . Patients of both main and control groups were followed up for 12 months . During the whole term of the investigation in both groups observation and treatment of patients was conducted by physicians of city polyclinic in accordance with generally accepted method of care of patients with diagnosis " IHD , stable angina pectoris " . Results of the investigation evidence that study ing in the School for patients with stable angina significantly elevates level of medical information adopted by patients , ensures positive dynamics of the whole row of clinical and psychological parameters as well as integral parameters of quality of life of patients with IHD CONTEXT Depressive symptoms commonly follow coronary artery bypass graft ( CABG ) surgery and are associated with less positive clinical outcomes . OBJECTIVE To test the effectiveness of telephone-delivered collaborative care for post-CABG depression  vs usual physician care . DESIGN , SETTING , AND PARTICIPANTS Single-blind effectiveness trial at 7 university-based and community hospitals in or near Pittsburgh , Pennsylvania . Participants were 302 post-CABG patients with depression ( 150 , intervention ; 152 , usual care ) and a comparison group of 151 r and omly sample d post-CABG patients without depression recruited between March 2004 and September 2007 and observed as out patients until June 2008 . INTERVENTION Eight months of telephone-delivered collaborative care provided by nurses working with patients ' primary care physicians and supervised by a psychiatrist and primary care physician from this study . MAIN OUTCOME MEASURES Mental health-related quality of life ( HRQL ) measured by the Short Form-36 Mental Component Summary ( SF-36 MCS ) at 8-month follow-up ; secondary outcome measures included assessment of mood symptoms ( Hamilton Rating Scale for Depression [ HRS-D ] ) , physical HRQL ( SF-36 PCS ) , and functional status ( Duke Activity Status Index [ DASI ] ) ; and hospital readmissions . RESULTS The intervention patients reported greater improvements in mental HRQL ( all P < or = .02 ) ( SF-36 MCS : Delta , 3.2 points ; 95 % confidence interval [ CI ] , 0.5 - 6.0 ) , physical functioning ( DASI : Delta , 4.6 points ; 95 % CI , 1.9 - 7.3 ) , and mood symptoms ( HRS-D : Delta , 3.1 points ; 95 % CI , 1.3 - 4.9 ) ; and were more likely to report a 50 % or greater decline in HRS-D score from baseline ( 50.0 % vs 29.6 % ; number needed to treat , 4.9 [ 95 % CI , 3.2 - 10.4 ] ) than usual care patients ( P < .001 ) . Men with depression were particularly likely to benefit from the intervention ( SF-36 MCS : Delta , 5.7 points ; 95 % CI , 2.2 - 9.2 ; P = .001 ) . However , the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group . CONCLUSION Compared with usual care , telephone-delivered collaborative care for treatment of post-CABG depression result ed in improved HRQL , physical functioning , and mood symptoms at 8-month follow-up . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00091962 OBJECTIVE The study objective was to examine the effect of a symptom management ( SM ) telehealth intervention on physical activity and functioning and to describe the health care use of older adult patients ( aged > 65 years ) after coronary artery bypass surgery ( CABS ) by group ( SM intervention group and usual care group ) . METHODS A r and omized clinical trial design was used . The study was conducted in 4 Midwestern tertiary hospitals . The 6-week SM telehealth intervention was delivered by the Health Buddy ( Health Hero Network , Palo Alto , CA ) . Measures included Modified  7-Day Activity Interview , RT3 accelerometer  ( Stayhealthy , Inc , Monrovia , CA ) , physical activity and exercise diary , Medical Outcomes Study Short-Form 36 , and subjects ' self-report and provider records of health care use . Follow-up times were 3 and 6 weeks and 3 and 6 months after CABS . RESULTS Subjects ( N = 232 ) had a mean age of 71.2 ( + 4.7 ) years . There were no significant interactions using repeated- measures analyses of covariance . There was a significant group effect for average kilocalories/kilogram/day of estimated energy expenditure as measured by the RT3 accelerometer , with the usual care group having a higher estimated energy expenditure . Both groups had significant improvements over time for role-physical , vitality , and mental functioning . Both groups had similar health care use . CONCLUSION Subjects were able to return to preoperative levels of functioning between 3 and 6 months after CABS and to increase their physical activity over reported preoperative levels of activity . Further study of those patients undergoing CABS who could derive the most benefit from the SM intervention is warranted Translating evidence into clinical practice in the management of acute coronary syndromes ( ACS ) is challenging . Few ACS quality improvement interventions have been rigorously evaluated to determine their impact on patient care and clinical outcomes . We design ed a pragmatic , 2-arm , cluster-r and omized trial involving 34 clusters ( Brazilian public hospitals ) . Clusters were r and omized to receive a multifaceted quality improvement intervention ( experimental group ) or routine practice ( control group ) . The 6-month educational intervention included reminders , care algorithms , a case manager , and distribution of educational material s to health care providers . The primary end point was a composite of evidence -based post-ACS therapies within 24 hours of admission , with the secondary measure of major cardiovascular clinical events ( death , nonfatal myocardial infa rct ion , nonfatal cardiac arrest , and nonfatal stroke ) . Prescription of evidence -based therapies at hospital discharge were also evaluated as part of the secondary outcomes . All analyses were performed by the intention-to-treat principle and took the cluster design into account using individual-level regression modeling ( generalized estimating equations ) . If proven effective , this multifaceted intervention would have wide use as a means of promoting optimal use of evidence -based interventions for the management of ACS PURPOSE : Efficient ways are needed to implement the secondary prevention ( SP ) of coronary heart disease . Because few studies have investigated Web-based SP programs , our aim was to determine the usefulness of a new Web-based telemonitoring system , connecting patients provided with self-measurement devices and care managers via mobile phone text messages , as a tool for SP . METHODS : A single-blind , r and omized controlled , clinical trial of 203 acute coronary syndrome ( ACS ) survivors , was conducted at a hospital in Madrid , Spain . All patients received lifestyle counseling and usual-care treatment . Patients in the telemonitoring group ( TMG ) sent , through mobile phones , weight , heart rate , and blood pressure ( BP ) weekly , and capillary plasma lipid profile and glucose monthly . A cardiologist accessed these data through a Web interface and sent recommendations via short message service . Main outcome measures were BP , body mass index ( BMI ) , smoking status , low-density lipoprotein-cholesterol ( LDL-c ) , and glycated hemoglobin A1c ( HbA1c ) . RESULTS : At 12-month followup , TMG patients were more likely ( RR = 1.4 ; 95 % CI = 1.1−1.7 ) to experience improvement in cardiovascular risk factors profile than control patients ( 69.6 % vs 50.5 % , P = .010 ) . More TMG patients achieved treatment goals for BP ( 62.1 % vs 42.9 % , P = .012 ) and HbA1c ( 86.4 % vs 54.2 % , P = .018 ) , with no differences in smoking cessation or LDL-c . Body mass index was significantly lower in TMG ( −0.77 kg/m2 vs + 0.29 kg/m2 , P = .005 ) . CONCLUSIONS : A telemonitoring program , via mobile phone messages , appears to be useful for improving the risk profile in ACS survivors and can be an effective tool for secondary prevention , especially for overweight patients Background . Experts have called for the inclusion of values clarification ( VC ) exercises in decision aids ( DAs ) as a means of improving their effectiveness , but little research has examined the effects of such exercises . Objective . To determine whether adding a VC exercise to a DA on heart disease prevention improves decision-making outcomes . Design . R and omized trial . Setting . UNC Decision Support Laboratory . Patients . Adults ages 40 to 80 with no history of cardiovascular disease . Intervention . A Web-based heart disease prevention DA with or without a VC exercise . Measurements . Pre- and postintervention decisional conflict and intent to reduce coronary heart disease ( CHD ) risk and postintervention self-efficacy and perceived values concordance . Results . The authors enrolled 137 participants ( 62 in DA ; 75 in DA + VC with moderate decisional conflict ( DA 2.4 ; DA + VC 2.5 ) and no baseline differences among groups . After the interventions , they found no clinical ly or statistically significant differences between groups in decisional conflict ( DA 1.8 ; DA + VC 1.9 ; absolute difference VC — DA 0.1 , 95 % confidence interval [ CI ] : —0.1 to 0.3 ) , intent to reduce CHD risk ( DA 98 % ; DA + VC 100 % ; absolute difference VC — DA : 2 % , 95 % CI : —0.02 % to 5 % ) , perceived values concordance ( DA 95 % ; DA + VC 92 % ; absolute difference VC — DA —3 % , 95 % CI : —11 % to + 5 % ) , or self-efficacy for risk reduction ( DA 97 % ; DA + VC 92 % ; absolute difference VC — DA —5 % , 95 % CI : —13 % to + 3 % ) . However , DA + VC tended to change some decisions about risk reduction strategies . Limitations . Use of a hypothetical scenario ; ceiling effects for some outcomes . Conclusions . Adding a VC intervention to a DA did not further improve decision-making outcomes in a population of highly educated and motivated adults responding to scenario-based questions . Work is needed to determine the effects of VC on more diverse population s and more distal outcomes The White Paper Choosing health acknowledges that there is no lack of information in the system about healthy lifestyles , but the manner of communication of risk and the level of support for lifestyle change need improvement . Action also has to be taken to address inequalities in health and to focus on securing better access to healthier choices for people in disadvantaged groups or areas . Accordingly , this r and omized controlled trial examined whether access to a purpose -built health portal for heart disease could enable patients to manage better their heart conditions . We recruited 108 men and women aged 50—74 from coronary heart disease registries from a deprived area of Greater Manchester . Every participant received a new computer and one-year broadb and subscription ; however , only the experimental group received access to the Hearts of Salford health portal . Our results indicate that the experimental group changed their diet significantly . Specifically , they reported eating ` bad foods ' ( such as chips , sweets , crisps , fried foods , ready meals and cakes/biscuits ) significantly less often compared to the controls
target: Similarly , there was no clear evidence of effect for cardiovascular risk factors , although again the number of studies reporting these was small .
  There was some evidence for beneficial effects on HRQOL , dietary outcomes , and physical activity , although firm conclusions can not yet be made .
  The effects on healthcare utilisation and cost-effectiveness are also inconclusive , and trials are yet to measure the impact of  Internet interventions on compliance with medication .
background: BACKGROUND The Internet could provide a means of delivering secondary prevention programmes to people with coronary heart disease ( CHD ) .
  OBJECTIVES To determine the effectiveness of Internet-based interventions targeting lifestyle changes and medicines management for the secondary prevention of CHD .