The Effect of Discharge Planning on Adherence to Treatment in Patients with Ischemic Heart Disease

Introduction

Nowadays, cardiovascular diseases are the most significant cause of death worldwide (1). According to the World Health Organization, 1.7 million deaths occur due to this disease annually, and it is predicted that by 2030, this rate reach to more than 23 million deaths (2, 3). In Iran, cardiovascular disease is the most important cause of death, so that it includes 46% of all deaths in the country (4). Ischemic heart disease (IHD) is a common cardiovascular disease (CVD) (2) in which sufficient oxygen does not reach to a part of the myocardium. The most common cause of IHD is atherosclerotic disease of one or more coronary arteries, which leads to decreased blood circulation to an area of the myocardium resulting in inadequate perfusion of the myocardium coronary artery (5). Regarding the abundance of evidence that indicates the relationship between lifestyle and cardiovascular disease, the need to emphasize lifestyle modification, as an important factor in determining the prognosis and complications of this disease is quite prominent and justifiable (6, 7). IHD patients are at risk of recurrent heart attack and are always struggling with the disease; for this reason, they should be treated long-term to reduce the risk of heart attack recurrence (8). In this regard, one of the major health system employees’ concerns is the lack of patients' adherence to treatment after discharging from the hospital (9).

The World Health Organization defines adherence to treatment as the amount to which a patient's behavior conforms, including how he or she receives medication and follows medication regimen, food diet, lifestyle changes, comply with the recommendations of health care providers (10, 11). There are many barriers that prevent patients following the treatment plan. These factors include low levels of knowledge and awareness, difficulty in commuting, financial costs, embarrassment and reduced access to health care services (12, 13). Adherence to treatment is often considered as a crucial remedy option in chronic diseases because it is cheaper than other therapeutic interventions (6). Undoubtedly, teaching health-related behaviors is a method by which one can take a big step in promoting society’s health and improving the quality of lifestyle. Educating the patient and following up after discharge plays a vital role in the patient's rehabilitation. One of the methods of education and follow-up is designing and implementation of discharge program for patients (14). A review of previous studies shows that the discharge program has always been considered by researchers. The study of Salmani et al. et al. (2017), which measured the impact of the discharge planning on the quality of patients’ life suffered from breast cancer indicated that the discharge planning can be considered as an influential method to improve the quantity of life in patients with breast cancer after surgery (15). Also,  Tavşanlı et al. (2013) in their research in Turkey reported that videophone technology is useful in the post-discharge planning  to control the blood sugar of diabetic patients (16). In the study of Paryad and colleagues with aim to assess the status of following the care instructions in patients undergoing coronary artery bypass graft surgery, the results revealed that only 11.5 % of the surveyed units had a good adherence to the diet (17); it is obvious that the effectiveness of these services is highly related to the conditions of each country. Considering that post-discharge care for ischemic heart patients is less studied in the country and there are limited internal studies in this area, and since providing educational manuals to patients alone cannot reduce the consequences of chronic diseases and also allocating studies to the post-surgery stages, rehabilitation and advanced stages of the disease; more comprehensive studies are needed in these patients in order to prevent advanced stages of the disease. Therefore, the present study was conducted with aim to determine the effect of discharge planning on adherence to treatment in patients with IHD in Farshchian Cardiovascular Hospital of Hamadan.

Methods

This quasi-experimental study was performed on 70 patients with IHD hospitalized in Hamadan Farshchian Cardiovascular Hospital in 2018. The subjects were divided into experimental (n = 35) and control (n = 35) groups according to the inclusion criteria and using random permutation blocks (CONSORT flow diagram, Figure 1).

Inclusion criteria were full consciousness and lack of cognitive problems, diagnosis of IHD by a specialist and approved by the relevant physician, at least passing 6 months since the diagnosis of the disease, having a mobile phone and the ability to use it. Exclusion criteria were the need for re-admission or emergency interventions during the study, the patient's death, the use of other formal training classes, rehabilitation during the research, and the patient's refusal to continue participating at any stage of the study. In this way, a permuted block randomization method with blocks of size 4 was used to randomly allocate the participants into two groups of control and intervention. This was conducted using R software version 3.5.2.

The sample size was conducted according to the Cochrane sample size formula for comparing two means by considering the 95% confidence level of the test , the test power equal to 80% and and colleagues and its validity and reliability was confirmed (19). In this study, in order to determine the reliability of the treatment adherence tool, the method of determining the internal correlation of the questionnaire items was used by measuring Cronbach's alpha and its reliability was calculated based on Cronbach's alpha coefficient in three areas of food diet adherence, physical activity and medication regimen as0.96, 0.94, 0.89, respectively. Diet questions involve two sections which address dietary habits and types of consumed foods. The first part contains 10 questions related to the patient's dietary habits on a Likert scale (never, rarely, sometimes, often and always) which is scored from 0 to 4 based on the patient's response, and the second part consists 20 questions including the type of food consumed based
on the number of times (daily, 3-4 times a week, 1-2 times a week, 1-2 times a month and never) which is scored from 4-0 (4 means the most desirable answer and 0 means the least desirable answer), and the total points were 0- 120.

Figure 1. CONSORT flowchart of the study

In the field of exercise / physical activity, the test includes 10 questions related to the pattern of exercise / physical activity, which was scored based on the person's response to the questions with a score of 4-0 (4 means the most desirable answer and 0 means the least desirable answer), and the total score in the field of physical activity was 0-40.

The range of medication regimen consisted of 5 questions related to the patient's medication consumption pattern, which was scored based on the individual's answers to the questions with a score of 0-4, and the total score in this area was 0-20. Then, based on the total scores obtained by patients from the questions in each area, the patients' adherence to treatment was calculated, so the highest possibility in each area indicated the desired adherence to treatment.

The aim and process of the research was explained to all the participants. Patients had given informed consent to the anonymous use of their information for educational and research purposes. Then, discharge planning was performed based on the stages of the nursing process in two stages in four sessions (30minutes) of face-to-face training before discharge and 8 follow-up cases through telephone conversation 10-15 minutes after discharge in the experimental group. The control group only received the usual care of the hospital.

The first stage was the first 24 hours after admission. At this level, the discharge program process began based on the stages of the nursing process (19). In the implementation phase, the training was provided according to the care needs extracted from the latest references in the field of educational needs of IHD patients and previous research in this field, which was arranged based on three areas of food diet, medication regimen, exercise and physical activity implemented by question and answer methods as a care plan in four sessions until the patients were discharged. It should be noted that in all sessions, one of the patient's family members who lived with him/her, or was involved in the patient's care plan was present and the training items were stated in a very simple and comprehensible method. Then in the second phase (post-discharge phase), the follow-up period was divided into two sections of 2 months. In the first two months after discharge, the patients were followed up using a phone call once a week (a total of eight telephone conversations). Telephone follow-ups include: review of the taught content, emphasizing and reminding regular consumption of medicines according to the prescribed time and dosage and the prescribed method of consumption, healthy diet, including: compliance with the restriction of salt consumption and reduction of fat consumption, more fruit consumption, vegetables and fiber, gradual start of physical activity, not consuming alcohol and quitting smoking, as well as measuring blood pressure on a daily basis and informing the doctor about headache, dizziness, abnormally  breathing during exercise, chest pain and epistaxis, etc. In the second two months after discharge, the patients contacted the researcher only if there was a problem or went to the hospital in-person. Finally, two months after the end of telephone conversations, the questionnaire of treatment adherence in IHD patients was again completed by the participants in both groups (Figure 2).

Figure 2. discharge planning based on nursing process diagram

Data analysis was performed by SPSS software (version 22) and using descriptive and inferential statistics test. Paired t-test, Independent t-test, chi-square and Fisher's exact test were used to analyze the data. P<0.05 was considered statistically significant.

Results

In this study, the majority of participants in both intervention and control groups were in the age range of 45 to 65 years. Mean age of patients in the intervention group was (57.49 ± 11.495) year and in the control group was (60.17 ± 11.813) year.

Also, 51.4% of the patients in the intervention group and 48.6% in the control group were male and the rest were female. In addition, most patients in the intervention (77.1%) and control (85.7%) groups were married. In the intervention group, the highest number of patients were illiterate (54.3%) and only 11.4% had university education. Moreover, 48.6% of patients in the control group had no university education and only 5.7% had university education. In the intervention group (71.4%) and in the control group (68.6%) of patients had high blood pressure. In the intervention group (74.3%) of patients and in the control group (42.9%) did not have information about the disease. Therefore, the results of Chi-square test showed no significant difference between the intervention and control groups in terms of demographic variables (except information about the disease) (p> 0.05). Further details on the demographic information of the research samples were shown in Table 1.

Table 1. Demographic Information of Participants

*Chi-square test/ ** Fisher's exact test

Table 2. Comparison of patients' adherence to treatment plan in experimental and control groups before and after intervention based on discharge plan

*Paired t-test                        **Independent t-test

Before the intervention, there was no statistically significant difference between the control and experimental groups in terms of adherence to treatment (p> 0.05); however, after the discharge planning, patient’s adherence to  treatment in all areas significantly increased in the experimental group (P <0.001). In the control group after the intervention, there was a statistically significant increase in the field of food diet and adherence to treatment (p = 0.001); while changes in following the medication regimen, physical activity and exercise program were not statistically significant (p> 0.05) (Table 2).

It should be noted that some areas were significant in the control group, even though this difference was insignificant compared to the experimental group, which can be attributed to the hospital's education and patient's education unit (Table 2).

Discussion

The results of the present study indicated that the use of discharge planning significantly affected adherence to treatment in IHD patients. These results were in line with the findings of the study by Kobe et al. (2014), which in their review article examined the degree of adherence to the treatment in patients with coronary artery disease. Their results indicated that telephone follow-up increased the patient’s adherence to treatment and consequently led to less re-admission of patients in the hospital (20). Also, Dale et al. (2015) and Kamrani et al. (2015) in their studies showed that following-up of patients' status by nurses can boost following the treatment plan in chronic patients (21, 22) .

Furthermore, Damush et al. (2015) in a study on patients suffering from stroke showed that adherence to the treatment plan can be significantly improved by using training in their programs (23). The results of the studies by Dizavandi (2021) et al. and Shojaee et al. (2013), which examined the effect of patient’s education and telephone follow-up by the nurse on  self-efficacy and re-admission  of patients with heart failure and covid-19, are also consistent with the results of the present study (24, 25). Therefore, following the treatment programs via continuous training and follow-up, which is the leading pillar of the discharge planning is vital and economical for patients, especially chronic diseases patients, to achieve improvement and promotion of health care. On the other hand, the results of a study conducted by Beaver et al. on patients suffer from breast cancer did not confirm the results of the present research. Their study showed that patients’ follow-up did not have much effect on following the treatment in patients with breast cancer (26). The reason for the lack of follow-up in breast cancer patients can be the nature of cancer and its impacts on the patient's ability to accept treatment. A study by Wang et al. (2013) which examined the effect of home visits and telephone follow-up on post-discharge training and re-admission of patient also showed that telephone follow-up alone may not be effective in reducing patients' re-admission. Different methods were utilized for post-discharge training, and in order to have more influential training, an educational pamphlet was also used in addition to telephone follow-up (27).

One area of following treatment is keeping diet plan. In line with the effect of using the discharge planning on diet adherence, the results of the present study represented a significant increase in patients' diet adherence. In this regard, the study of Zakeri Moghaddam et al.(2016), which was conducted to evaluate the effect of self-management program on therapeutic adherence in patient with ischemic heart disease, showed that the implementation of self-management program  leads to better adherence of therapy in these patients (18). The findings of the current research were also consistent with the study by Kamrani et al., which investigated the impact of telephone training and follow-up by a nurse on adherence to treatment in patients with acute coronary syndrome (22). The results of the present study are similar to the findings of Hung et al., who gave telephone counseling to patients after bone marrow transplantation about their nutritional status and physical activity (29), as well as the results of Joekes’s study aimed to improve diet adherence in patients with myocardial infarction, and also some other studies which measured the effect of telephone follow-up and discharge planning on the adherence to the diabetic patients (20, 31, 32). However, in the studies by Nahapetyan et al. and Paryad et al., only a small percentage of participants followed the dietary instructions; several factors can influence this outcome (17, 28). Obviously, achieving a proper diet requires a deep understanding of the disease and also having a good economic status of the family, given that most of the patients in the present study did not have a good economic status, it cannot be expected that they have a perfectly appropriate diet and eating habits.

Another area of following the treatment is continuing exercise program and physical activity. The present research indicated that the discharge program increased patients' adherence to the recommended exercise program and physical activity after discharge from the hospital. This finding is consistent with the study of Bikmoradi and colleagues (29). Also, the Lao’s study showed that telemedicine can increase continuing the exercise program and  exercise ability in patients suffering from chronic obstructive pulmonary disease (30). However, the disease studied in the current research was different from the disease in the Lao's study; also several educational methods such as training sessions, booklets and telephone follow-up were used, which strengthens the trainings provided to the patients.

Another area of treatment adherence is following the medication regimen. The outcomes of this study showed that the implementation of the discharge planning increases adherence to the medication regimen. This finding was consistent with the results of a study by Rinfert et al. (31) which showed increase in the rate of following the use of antiplatelet drugs in patients with stents. This finding was also consistent with the results of other studies which aimed to follow patients through SMS reminder system leading to increased drug adherence in patients suffered from acute coronary syndrome (32-34). The results of the present study were also consistent with the results of the study by Yadegary et al. with the aim of applying an educational program on drug self-management of patients with epilepsy (35). Also, Tang et al. reported the results similar to the results of the present study; they concluded that follow-up improves the patients’ drug adherence (36). Therefore, according to the present study, the implementation of discharge planning based on the stages of the nursing process can be introduced as a basic method to increase following the medication regimen. One of the limitations of this study was individual differences of the participants, which may affect the results. Consequently, the researcher's lack of confidence in the accuracy of the answers given by participants was another limitation of the study. Furthermore, individual beliefs and differences affect a person's learning and application of training, which can affect outcomes that cannot be controlled. The strengths of this study included saving the patient's time and money. Blinding method was not used in this study.

Implications for practice

The results of this study indicated that a discharge planning along with treatment plan for IHD patients lead to positive results in terms of following the diet food, exercise and activity plan, medication regimen and in general following the patient’s adherence to treatment plan. In this regard, the existence of a comprehensive educational plan based on the patients’ needs can reduce health care costs and increase patient’s independence. In addition to education, it is necessary to follow-up with aim to establish and create a continuous and dynamic care relationship to increase awareness and strengthen the performance of an effective care process that improves the quality of patient’s life and reduces the complications of the disease. For this purpose, it is suggested that a separate unit called the discharge planning unit be considered in hospitals and medical centers, using the nurses’ experiences, in order to design and implement a discharge plan for patients.

Acknowledgments

This research is the result of a master's thesis in Community Health Nursing that was approved by the ethics committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1397.487). The authors would like to thank all the patients and their family who participated in the study.

Conflicts of interest

The authors declared no conflict of interests.