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1.  Effects of educational intervention based on PRECEDE model on self care behaviors and control in patients with type 2 diabetes in 2012 
Background
Diabetes is a chronic disease and its control requires essential change in patients' life style. The aim of this study was survey of effects of educational intervention based on PRECEDE Model on self care behaviors and control in patients with type 2 diabetes.
Methods
This was a quasi-experimental study carried out in 78 patients with type 2 diabetes who have referred to Minoodasht clinic of diabetes. The educational program has been designed according to the PRECEDE Model. Prior to perform the educational intervention, the patients filled a questionnaire which was designed according to the structure of PRECEDE Model for type 2 diabetes patients. The diabetes education program was performed on three target groups (patients, their families and Health care personnel). After four weeks, the effects of the educational program have been evaluated through the same questionnaire. The findings were analyzed by SPSS version 16 and p-value less than 0.05 was taken as statistically significant.
Results
The mean age of participants was 49 years, 87.2% were married and 19.2% was illiterate. The rate of income of 44.9% was low. 66% had a family history of diabetes and 64% had been afflicted with diabetes more than 5 years. The Chi-square test showed a significant relationship between formation of a file in diabetes clinic and on-time presence to receive services and participation in the educational classes with the marital status variable. The results also showed that there is a significant relationship between observing food diet and job. The mean scores of knowledge, attitude, practice, reinforcing factors and enabling factors has increased after educational intervention. The Chi-square test shows a significant difference before and after of education intervention in stages of the model.
Conclusion
The obtained results based on PRECEDE Model would support the positive effect of the educational intervention and its major elements (predisposing, enabling and reinforcing factors) on diabetes self-care behaviors.
doi:10.1186/2251-6581-13-72
PMCID: PMC4114427  PMID: 25075380
Educational intervention; PRECEDE Model; Self-care; Type 2 diabetes
2.  The Impact of Pain and Depression on Post-CABG Recovery 
Psychosomatic medicine  2010;72(7):620-625.
Objective
To describe the relationship between pain and depression on recovery after coronary artery bypass grafting (CABG).
Methods
A secondary data analysis on 453 depressed and nondepressed post-CABG patients enrolled in a randomized, controlled, effectiveness trial of telephone-delivered collaborative care for depression. Outcome measures were collected from March 2004 to September 2007 and included pain, physical function, and mood symptoms.
Results
Depressed patients (baseline Patient Health Questionnaire-9 score ≥ 10) versus those without depression reported significantly worse pain scores on the SF-36 Bodily Pain Scale at baseline and up to 12-months post-CABG, p < 0.05. Among patients with depression, those who received collaborative care reported significantly better pain scores at each time point between 2 and 12-months post-CABG vs. depressed patients randomized to the usual care control group, p < 0.05. Regardless of intervention status, depressed participants with at least moderate pain at baseline reported significantly lower functional status (measured by the Duke Activity Status Index) at 8 and 12-months vs. depressed patients with none or mild pain, p < 0.05. Depressed patients with at least moderate pain at baseline were also significantly less likely to show improvement of depressive symptoms throughout the course of follow-up vs. depressed patients with little or no pain, p < 0.05. These findings controlled for age, gender, education, race, comorbid conditions and baseline pain diagnosis.
Conclusions
Depression and pain appear to influence functional recovery post-CABG. The relationship between these two conditions and 12-month outcomes should be considered by clinicians when planning treatment.
doi:10.1097/PSY.0b013e3181e6df90
PMCID: PMC2939235  PMID: 20562371
Depression; Pain; CABG; Collaborative Care
3.  The effectiveness of educational intervention based on PRECEDE model on the level of stress among the elderly at elderly clubs 
Introduction:
The elderly are vulnerable to negative effects of stress factors; so, the present study was conducted to determine the effect of educational intervention based on the PRECEDE model on stress level of the elderly and to control stress factors.
Materials and Methods:
In this quasi-experimental study, 94 elderly people from the clubs for the elderly in Tehran were randomly divided into case and control groups in 2008–2009. Planning for the educational program was done according to the PRECEDE model. Before implementing the program, valid and reliable depression, anxiety, and stress questionnaires (DASS 21) were completed for both groups. The experimental group received the educational intervention based on the PRECEDE model (eight sessions, one session per week), and both groups were followed up two months after the intervention (the previous questionnaires were filled again). DASS 21 Scoring and Interpretation Generator was used for calculating scores of the questionnaires. Finally, the data obtained were analyzed by the SPSS 15 software using t-test, paired t-test, and Mann-Whitney test at a significant level of P≤0.05.
Results:
The findings showed significant differences between the experimental group and control group in terms of predisposing factors of knowledge (P≤0.001) and attitude (P≤0.001), enabling factors (P≤0.001), reinforcing factors (P≤0.001), and functioning especially in deep breathing and relaxation techniques (P≤0.001). Mean scores and severity of stress were significant after the intervention (P≤0.001).
Conclusion:
The findings of the present study confirmed the effectiveness of the PRECEDE model-based educational program on preventing or reducing stress level in the elderly.
doi:10.4103/2277-9531.106641
PMCID: PMC3778573  PMID: 24083253
Educational intervention; elderly; PRECEDE model; stress
4.  The Effect of an Intervention Based on the PRECEDE- PROCEED Model on Preventive Behaviors of Domestic Violence Among Iranian High School Girls 
Background
Domestic violence is one of the major health problems among women. Promoting preventive behaviors of domestic violence among women and girls can play crucial role in reducing this health problem.
Objectives
This study was conducted to evaluate the effect of an intervention based on PRECEDE-PROCEED Model on preventive behaviors of domestic violence among Iranian high school girls.
Patients and Methods
An interventional study was completed during 2010-2011 in 10 high schools in the district 17 of Tehran municipality with 510 female students. We used the components of the PRECEDE-PROCEED Model for planning, implementation and evaluation of the program. Based on the results of need assessment, an appropriate environmental and educational intervention was implemented in the intervention group. Changes in predisposing, reinforcing, enabling factors and especially preventive behaviors immediately and two months after the intervention activities were assessed by questionnaires based on PRECEDE-PROCEED Model.
Results
The intervention had significantly positive effect on predisposing, enabling and reinforcing factors immediately and two months after the intervention (P < 0.05). Repeated measures Analysis of variance showed a significant positive increase in preventive behaviors score in the intervention group from baseline to two months.
Conclusions
The PRECEDE-PROCEED Model can be applied as a conceptual framework for identifying the relevant behavioral and environmental risk factors associated with domestic violence. Development and implementation the skills-based education using this model can lead to the promotion of preventive behaviors of domestic violence and reduction in domestic violence cases.
doi:10.5812/ircmj.3517
PMCID: PMC3589774  PMID: 23486646
Domestic Violence; Health Education; Health Promotion; Iran
5.  Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting 
Critical care medicine  2002;30(2):330-337.
Objective
Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB.
Design
Retrospective, comparative survey.
Setting
University-affiliated tertiary care hospital.
Patients
Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository.
Interventions
None.
Measurements and Main Results
The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p = .0004), number of vessels bypassed (p = .013), vessel location (diagonal [p < .003] or posterior descending artery [p < .001]), and net fluid balance on the operative day (p = .015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p = .0004), more intensive care unit readmissions (p = .0004), and required more assistance at hospital discharge (p = .017).
Conclusions
Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.
PMCID: PMC3679531  PMID: 11889304
atrial fibrillation; resource utilization; coronary artery bypass grafting; minimally invasive direct vision coronary artery bypass grafting
6.  Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial 
Heart  2001;86(3):317-323.
OBJECTIVE—To evaluate the effectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting (CABG).
DESIGN—Randomised controlled trial.
SETTING—Community, January 1997 to March 1998.
STUDY GROUPS—98 (75 male) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust. Patients were randomly assigned to usual care (control; n = 49) or a nurse led intervention programme (n = 49).
INTERVENTION—A shared care programme consisting of health education and motivational interviews, according to individual need, was carried out monthly. Care was provided in the patients' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic.
OUTCOME MEASURES—Smoking status, obesity, physical activity, anxiety and depression, general health status, and proportion of patients exceeding target values for blood pressure, plasma cholesterol, and alcohol intake.
RESULTS—Compared with patients who received usual care, those participating in the nurse led programme were more likely to stop smoking (25% v 2%, p = 0.001) and to reduce obesity (body mass index > 30 kg/m2) (16.3% v 8.1%, p = 0.01). Target systolic blood pressure improved by 19.8% compared with a 10.7% decrease in the control group (p = 0.001) and target diastolic blood pressure improved by 21.5% compared with 10.2% in the control group (p = 0.000). However, there was no significant difference between groups in the proportion of patients with cholesterol concentrations exceeding target values. There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in difference in mean scores between the groups ranging from 8.1 (p = 0.005) to 36.1 (p < 0.000). Levels of anxiety and depression improved (p < 0.000) and there was improvement in time spent being physically active (p < 0.000).
CONCLUSIONS—This nurse led shared care intervention was shown to be effective for improving care for patients on the waiting list for CABG.


Keywords: coronary artery bypass grafting; coronary heart disease risk; nurse led shared care; risk reduction
doi:10.1136/heart.86.3.317
PMCID: PMC1729900  PMID: 11514487
7.  TELEPHONE-DELIVERED COLLABORATIVE-CARE FOR TREATING POST-CABG DEPRESSION: A RANDOMIZED CONTROLLED TRIAL 
Context
Depressive symptoms commonly follow coronary artery bypass (CABG) surgery and are associated with worse clinical outcomes.
Objective
To test the effectiveness of telephone-delivered collaborative care for post-CABG depression versus doctors’ usual care.
Design
Single-blind effectiveness trial.
Setting
Seven Pittsburgh-area university-based and community hospitals.
Participants
302 depressed post-CABG patients and a non-depressed comparison group of 151 randomly sampled post-CABG patients recruited between 3/2004 and 9/2007 and followed as outpatients.
Intervention
8-Months of telephone-delivered collaborative care provided by nurses working with patients’ primary care physicians and supervised by a study psychiatrist and study primary care physician.
Main Outcome Measures
Mental health-related quality of life (HRQoL) as measured by the SF-36 MCS at 8-months follow-up; secondary outcome measures included mood symptoms (Hamilton Rating Scale for Depression (HRS-D)), physical HRQoL (SF-36 PCS) and functioning (Duke Activity Status Index (DASI)); and hospital readmissions.
Results
Depressed intervention patients (N=150) reported greater improvements (all P ≤ 0.02) in mental HRQoL (SF-36 MCS: Δ 3.2 points; 95% CI: 0.5–6.0), physical functioning (DASI: Δ 4.6 points; 1.9–7.3), and mood symptoms (HRS-D: Δ3.1 points (1.3–4.9); and were more likely to report a ≥ 50% decline in HRS-D score from baseline (50.0% vs. 29.6%; NNT 4.9 (3.2–10.4)) than depressed patients randomized to their physicians’ usual care (N=152) (P<0.001). Depressed men were particularly likely to benefit from the intervention (SF-36 MCS: Δ 5.7 points (2.2–9.2); P=0.001) and tended to have a lower incidence of rehospitalization for cardiovascular causes than depressed men receiving usual care (13% vs. 23%; P=0.07) or depressed women (19% vs. 11%; P=0.22). However, the mean HRQoL and physical functioning of depressed intervention patients did not reach that of our non-depressed comparison group.
Conclusions
Compared to usual care, telephone-delivered collaborative care for post-CABG depression resulted in improved HRQoL, physical functioning, and mood symptoms at 8-months follow-up.
doi:10.1001/jama.2009.1670
PMCID: PMC3010227  PMID: 19918088
Depression; coronary artery bypass surgery; randomized clinical trial; collaborative care; coronary artery disease
8.  Optimism, Response to Treatment of Depression, and Rehospitalization After Coronary Artery Bypass Graft Surgery 
Psychosomatic medicine  2012;74(2):200-207.
Objective
Optimism has been associated with a lower risk of rehospitalization after coronary artery bypass graft (CABG) surgery, but little is known about how optimism affects treatment of depression in post-CABG patients.
Methods
Using data from a collaborative care intervention trial for post-CABG depression, we conducted exploratory post hoc analyses of 284 depressed post-CABG patients (2-week posthospitalization score in the 9-item Patient Health Questionnaire ≥10) and 146 controls without depression who completed the Life Orientation Test – Revised (full scale and subscale) to assess dispositional optimism. We classified patients as optimists and pessimists based on the sample-specific Life Orientation Test – Revised distributions in each cohort (full sample, depressed, nondepressed). For 8 months, we assessed health-related quality of life (using the 36-item Short-Form Health Survey) and mood symptoms (using the Hamilton Rating Scale for Depression [HRS-D]) and adjudicated all-cause rehospitalization. We defined treatment response as a 50% or higher decline in HRS-D score from baseline.
Results
Compared with pessimists, optimists had lower baseline mean HRS-D scores (8 versus 15, p = .001). Among depressed patients, optimists were more likely to respond to treatment at 8 months (58% versus 27%, odds ratio = 3.02, 95% confidence interval = 1.28–7.13, p = .01), a finding that was not sustained in the intervention group. The optimism subscale, but not the pessimism subscale, predicted treatment response. By 8 months, optimists were less likely to be rehospitalized (odds ratio = 0.54, 95% confidence interval = 0.32–0.93, p = .03).
Conclusions
Among depressed post-CABG patients, optimists responded to depression treatment at higher rates. Independent of depression, optimists were less likely to be rehospitalized by 8 months after CABG. Further research should explore the impact of optimism on these and other important long-term post-CABG outcomes.
doi:10.1097/PSY.0b013e318244903f
PMCID: PMC4056336  PMID: 22286847
optimism; pessimism; depression; coronary artery bypass graft; collaborative care; randomized controlled trial
9.  Effectiveness of PRECEDE model for health education on changes and level of control of HbA1c, blood pressure, lipids, and body mass index in patients with type 2 diabetes mellitus 
BMC Public Health  2011;11:267.
Background
Individual health education is considered to be essential in the overall care of patients with type 2 diabetes (DM2), although there is some uncertainty regarding its metabolic control benefits. There have been very few randomized studies on the effects of individual education on normal care in DM2 patients with a control group, and none of these have assessed the long-term results. Therefore, this study aims to use this design to assess the effectiveness of the PRECEDE (Predisposing, Reinforcing, Enabling, Causes in Educational Diagnosis, and Evaluation) education model in the metabolic control and the reduction of cardiovascular risk factors, in patients with type 2 diabetes.
Methods
An open community effectiveness study was carried out in 8 urban community health centers in the North-East Madrid Urban Area (Spain). Six hundred patients with DM2 were randomized in two groups: PRECEDE or conventional model for health promotion education. The main outcome measures were glycated hemoglobin A1c, body mass index (BMI), blood pressure, lipids and control criteria during the 2-year follow-up period.
Results
Glycated hemoglobin A1c and systolic blood pressure (SBP) levels decreased significantly in the PRECEDE group (multivariate analysis of covariance, with baseline glycated hemoglobin A1c, SBP, and variables showing statistically significant differences between groups at baseline visits). The decrease levels in diastolic blood pressure (DBP), triglycerides and LDL cholesterol were nonsignificant. PRECEDE increased compliance in all control criteria, except for LDL cholesterol. BMI did not change during the study in either of the two models analyzed.
Conclusions
PRECEDE health education model is a useful method in the overall treatment in patients with type 2 diabetes, which contributes to decrease glycated hemoglobin A1c and SBP levels and increase the compliance in all the control criteria, except for LDL cholesterol.
Trial registration number
ClinicalTrials.gov NCT01316367
doi:10.1186/1471-2458-11-267
PMCID: PMC3098792  PMID: 21524316
10.  Dementia and Depression with Ischemic Heart Disease: A Population-Based Longitudinal Study Comparing Interventional Approaches to Medical Management 
PLoS ONE  2011;6(2):e17457.
Background
We compared the proportion of ischemic heart disease (IHD) patients newly diagnosed with dementia and depression across three treatment groups: percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical management alone (IHD-medical).
Methods and Findings
De-identified, individual-level administrative records of health service use for the population of Manitoba, Canada (approximately 1.1 million) were examined. From April 1, 1993 to March 31, 1998, patients were identified with a diagnosis of IHD (ICD-9-CM codes). Index events of CABG or PCI were identified from April 1, 1998 to March 31, 2003. Outcomes were depression or dementia after the index event. Patients were followed forward to March 31, 2006 or until censored. Proportional hazards regression analysis was undertaken. Independent variables examined were age, sex, diabetes, hypertension and income quintile, medical management alone for IHD, or intervention by PCI or CABG. Age, sex, diabetes, and presence of hypertension were all strongly associated with the diagnosis of depression and dementia. There was no association with income quintile. Dementia was less frequent with PCI compared to medical management; (HR = 0.65; p = 0.017). CABG did not provide the same protective effect compared to medical management (HR = 0.90; p = 0.372). New diagnosis depression was more frequent with interventional approaches: PCI (n = 626; hazard ratio = 1.25; p = 0.028) and CABG (n = 1124, HR = 1.32; p = 0.0001) than non-interventional patients (n = 34,508). Subsequent CABG was nearly 16-fold higher (p<0.0001) and subsequent PCI was 22-fold higher (p<0.0001) for PCI-managed than CABG-managed patients.
Conclusions
Patients managed with PCI had the lowest likelihood of dementia—only 65% of the risk for medical management alone. Both interventional approaches were associated with a higher risk of new diagnosed depression compared to medical management. Long-term myocardial revascularization was superior with CABG. These findings suggest that PCI may confer a long-term protective effect from dementia. The mechanism(s) of dementia protection requires elucidation.
doi:10.1371/journal.pone.0017457
PMCID: PMC3046165  PMID: 21387018
11.  Autonomic cardiovascular dysregulation as a potential mechanism underlying depression and coronary artery bypass grafting surgery outcomes 
Background
Coronary artery bypass grafting (CABG) is often used to treat patients with significant coronary heart disease (CHD). To date, multiple longitudinal and cross-sectional studies have examined the association between depression and CABG outcomes. Although this relationship is well established, the mechanism underlying this relationship remains unclear. The purpose of this study was twofold. First, we compared three markers of autonomic nervous system (ANS) function in four groups of patients: 1) Patients with coronary heart disease and depression (CHD/Dep), 2) Patients without CHD but with depression (NonCHD/Dep), 3) Patients with CHD but without depression (CHD/NonDep), and 4) Patients without CHD and depression (NonCHD/NonDep). Second, we investigated the impact of depression and autonomic nervous system activity on CABG outcomes.
Methods
Patients were screened to determine whether they met some of the study's inclusion or exclusion criteria. ANS function (i.e., heart rate, heart rate variability, and plasma norepinephrine levels) were measured. Chi-square and one-way analysis of variance were performed to evaluate group differences across demographic, medical variables, and indicators of ANS function. Logistic regression and multiple regression analyses were used to assess impact of depression and autonomic nervous system activity on CABG outcomes.
Results
The results of the study provide some support to suggest that depressed patients with CHD have greater ANS dysregulation compared to those with only CHD or depression. Furthermore, independent predictors of in-hospital length of stay and non-routine discharge included having a diagnosis of depression and CHD, elevated heart rate, and low heart rate variability.
Conclusions
The current study presents evidence to support the hypothesis that ANS dysregulation might be one of the underlying mechanisms that links depression to cardiovascular CABG surgery outcomes. Thus, future studies should focus on developing and testing interventions that targets modifying ANS dysregulation, which may lead to improved patient outcomes.
doi:10.1186/1749-8090-5-36
PMCID: PMC2882369  PMID: 20465820
12.  A case study of hospital closure and centralization of coronary revascularization procedures 
Background
Despite nation-wide efforts to reduce health care costs through hospital closures and centralization of services, little is known about the impact of such actions. We conducted this study to determine the effect of a hospital closure in Calgary and the resultant centralization of coronary revascularization procedures from 2 facilities to a single location.
Methods
Administrative data were used to identify patients who underwent coronary artery bypass grafting (CABG), including those who had combined CABG and valve procedures, and patients who underwent percutaneous transluminal angioplasty (PTCA) in the Calgary Regional Health Authority from July 1994 to March 1998. This period represents the 21 months preceding and the 24 months following the March 1996 hospital closure. Measures, including mean number of discharges, length of hospital stay, burden of comorbidity and in-hospital death rates, were compared before and after the hospital closure for CABG and PTCA patients. Multivariate analyses were used to derive risk-adjustment models to control for sociodemographic variables and comorbidity.
Results
The number of patients undergoing CABG was higher in the year following than in the year preceding the hospital closure (51.6 per 100 000 before v. 67.3 per 100 000 after the closure); the same was true for the number of patients undergoing PTCA (129.8 v. 143.6 per 100 000). The burden of comorbidity was significantly higher after than before the closure, both for CABG patients (comorbidity index 1.3 before v. 1.5 after closure, p < 0.001) and for PTCA patients (comorbidity index 1.0 before v. 1.1 after, p = 0.04). After adjustment for comorbidity, the mean length of hospital stay was significantly lower after than before the closure for CABG patients (by 1.3 days) and for PTCA patients (by 1.0 days). The adjusted rates of death were slightly lower after than before the closure in the CABG group. The adjusted rates of death or CABG in the PTCA group did not differ significantly between the 2 periods.
Interpretation
Hospital closure and the centralization of coronary revascularization procedures in Calgary was associated with increased population rates of procedures being performed, on sicker patients, with shorter hospital stays, and, for CABG patients, a trend toward more favourable short-term outcomes. Our findings indicate that controversial changes to the structure of the health care system can occur without loss of efficiency and reduction in quality of care.
PMCID: PMC81069  PMID: 11387915
13.  Short and Long Term Mortality after Coronary Artery Bypass Grafting (CABG) Is Influenced by Socioeconomic Position but Not by Migration Status in Sweden, 1995–2007 
PLoS ONE  2013;8(5):e63877.
Background
There are no nationwide studies on mortality after coronary artery bypass grafting (CABG) among foreign-born populations that include detailed information about country of birth and information about socioeconomic position. The objective was to investigate the risk of mortality after CABG considering socioeconomic position, sex and country of birth.
Material and Methods
We included all 72 333 patients undergoing a first isolated CABG in Sweden, during 1995 - 2007 of whom 12.7% were foreign-born. The patients were classified according to educational level, sex, and country of birth and were followed up to December 2007. We estimated the risk of short and long term mortality after CABG in a multivariable model adjusted for age, calendar year of surgery, diabetes, educational level, and waiting time for surgery. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated based on the Cox proportional hazard model.
Findings
There were 15,284 deaths during the follow-up, 10.4% of whom were foreign-born. The foreign-born patients were 3 to 4 years younger than Sweden-born patients at the time of CABG surgery. There were no significant differences in overall early or late mortality between foreign-born and Sweden-born men and women after CABG. All-cause mortality differed in between regions and was highest in foreign-born men from Eastern Africa (HR 3.80, 95% CI 1.58–9.17), China (HR 3.61, 95% CI 1.50–8.69), and in Chile (HR 2.12, 95% CI 1.01–4.47). Patients with low level of education had worse survival compared to those with longer than 12 years of education irrespective of sex and country of birth. This difference was more pronounced among foreign-born women (HR 1.50, 95% CI 1.00–2.33).
Conclusion
This national study showed higher CABG mortality in patients from lower socioeconomic position. Early and late mortality did not differ after isolated CABG in foreign-born and Sweden-born patients.
doi:10.1371/journal.pone.0063877
PMCID: PMC3661557  PMID: 23717501
14.  Prevalence and correlates of complicated grief in adults who have undergone a coronary artery bypass graft 
Journal of affective disorders  2011;136(3):381-385.
Background
Complicated Grief (CG) is a recently described mental health condition that follows bereavement. CG is often comorbid with depression and may also be associated with poor health outcomes. However, CG has not been studied in depressed medically ill populations. This study examined the prevalence, correlates, and impact of CG in depressed post-coronary artery bypass graft surgery (CABG) patients.
Methods
A 5-item CG screen was administered to 302 depressed post-CABG patients participating in a comparative effectiveness intervention trial at 7 Pittsburgh-area hospitals from March 2004 to September 2007. Eligible patients were randomly assigned to either a telephone-delivered collaborative care intervention for depression or their primary care physicians’ usual care. Measures examined depression, physical and mental health-related quality of life, and physical functioning over 8 months.
Results
Compared to CG screen-negative patients, CG screen-positive patients were younger, more likely to: be female, non-White, have lost a partner or child, and to have used tobacco or antidepressants. At baseline, they had significantly higher depression and lower mental health scores. At 8 months, screen-positives had poorer physical functioning and marginally higher depression scores.
Limitations
The study lacked a definitive measure of CG. Moreover, the CG-positive group was relatively small, reducing the power to detect differences between groups or control for the possible influence of other variables on identified results.
Conclusions
CG in depressed post-CABG patients is associated with negative health and mental health outcomes. These results underscore the importance of identifying and treating CG in depressed medically ill populations.
doi:10.1016/j.jad.2011.11.018
PMCID: PMC3428012  PMID: 22209126
complicated grief; coronary artery bypass graft; depression; screening; care management
15.  Cardiac rehabilitation outcomes following a 6-week program of PCI and CABG Patients 
Coronary artery events requiring intervention are associated with depressed cardiac autonomic function. Whether a 6-week cardiac rehabilitation (CR) differs in effectiveness in improving exercise capacity (6MWT), cardiorespiratory function (peakVO2), and autonomic function (HRV) following either cardiac bypass surgery (CABG) or percutaneous coronary revascularization (PCI) is unknown. The current study therefore compared the change in 6MWT and peak VO2 to HRV variables following a 6-week CR program and with patients having either PCI or CABG. Thirty-eight patients, (PCI, n = 22 and CABG, n = 16) participated in the CR program and results for pre and post 6 min walk test (6MWT), peakVO2, and heart rate variability (HRV) were obtained. Our study has shown that a 6 weeks program following either PCI or CABG improves function. However, the effect on post-CABG differs to that of post-PCI patients. The change in distance walked (6MWT, metres) was higher in the CABG (Δ6MWT: 61, p < 0.001) compared to the PCI group (Δ6MWT: 41, p < 0.001). Maximum exercise capacity (peak VO2, ml/kg.min) also changed significantly with a greater change in the CABG group (ΔPCI: 0.7, p < 0.001; ΔCABG: 1.0, p < 0.001) but did not reach normal population values. Although an improvement in HRV parameters was noted for the PCI group, a statistically significant improvement in HRV was observed only in the CABG group for the following; SDNN (ms) (baseline vs. post-rehabilitation (median ± IQR): 31.2 ± 25.6 vs. 51.8 ± 23.1, p < 0.01), RMSSD (19.32 ± 19.9 vs. 42.1 ± 34.2, p < 0.01); LF (ms2) (191 ± 216 vs. 631 ± 693, p < 0.01) and HF (107 ± 201 vs. 449 ± 795.0, p < 0.05). A significant interaction in the PCI group but not in the CABG group was observed using correlation analysis between the 6MWT and peak VO2 with HRV parameters indicating that being healthier that is, a better 6MWT and peak VO2 led to better HRV results but no significant effect of CR in the PCI group. When the results were investigated for baseline 6MWT and peak VO2 effect using a covariate analysis, a significant influence of CR on HRV parameters was retained in the CABG group (p = 0.0072). Our study indicates that a 6-weeks CR program benefits both patient groups in terms of exercise capacity, cardiorespiratory function and autonomic nervous system modulation of heart rate, with CABG patients showing the most improvement. HRV can be a useful additional variable to gauge cardiac function following CR.
doi:10.3389/fphys.2013.00302
PMCID: PMC3812547  PMID: 24198786
cardiac rehabilitation; exercise; percutaneous coronary angioplasty; coronary artery bypass drafting; heart rate variability
16.  Cluster randomized controlled trial of a psycho-educational intervention for people with a family history of depression for use in general practice 
BMC Psychiatry  2013;13:325.
Background
The strongest risk factor for depression is having a family history of the condition. Many individuals with a family history of depression are concerned about their personal risk for depression and report unmet educational and psychological support needs. No supportive and/or educational interventions are currently available that target this group of individuals. In this study we will develop and evaluate the first online psycho-educational intervention targeted to individuals with a family history of depression. Genetic risk information and evidence-rated information on preventive strategies for depression will be provided to such individuals in a general practice setting. The intervention will also incorporate a risk assessment tool. The content and delivery of the intervention will be pilot-tested.
Methods/design
The proposed intervention will be evaluated in the general practitioner (GPs) setting, using a cluster randomized controlled trial. GP practices will be randomized to provide either access to the online, targeted psycho-educational intervention or brief generic information about depression (control) to eligible patients. Eligibility criteria include having at least one first-degree relative with either major depressive disorder (MDD) or bipolar disorder (BD). The primary outcome measure is 'intention to adopt, or actual adoption of, risk-reducing strategies’. Secondary outcome measures include: depression symptoms, perceived stigma of depression, knowledge of risk factors for development of depression and risk-reducing strategies, and perceived risk of developing depression or having a recurrence of family history. Over the course of the study, participants will complete online questionnaires at three time points: at baseline, and two weeks and six months after receiving the intervention or control condition.
Discussion
This novel psycho-educational intervention will provide individuals with a family history of depression with information on evidence-based strategies for the prevention of depression, thus, we hypothesize, enabling them to make appropriate lifestyle choices and implement behaviors designed to reduce their risk for depression. The online psycho-educational intervention will also provide a model for similar interventions aimed at individuals at increased familial risk for other psychiatric disorders.
Trial registration
The study is registered with the Australian and New Zealand Clinical Trials Group (Registration no: ACTRN12613000402741).
doi:10.1186/1471-244X-13-325
PMCID: PMC3897985  PMID: 24289740
Family history; Major depressive disorder; Bipolar disorder; Online intervention; Psycho-education; Prevention
17.  Applying an Educational-participatory Program based on the PRECEDE Model for Promoting Self-esteem and Mental Health of Students in Iran 
Background:
The students’ vulnerability to different problems can have an impact on their mental health. Regarding the lack of evidence on the effectiveness of interventional programs based on health education planning models in this area in developing countries, an educational-participatory program based on the PRECEDE model was used, to promote the medical science students’ self-esteem and mental health status, in Iran.
Methods:
In this experimental study, 154 students from the universities of medical sciences in the north east of Iran were selected by stratified random sampling method. Then, they were randomly assigned to two groups of case and control. The questionnaires, including the enabling, reinforcing, and predisposing factors, the Rosenberg self-esteem scale, and the GHQ-28 were used for data collection. Then, an intervention plan, including focus group discussions and training of selected life skills, based on the PRECEDE model, was conducted for the case group.
Results:
The predisposing, reinforcing, and enabling factors, and the self-esteem and mental health of the students showed a significant difference between the case and control groups. The Pearson correlation coefficient showed that there was a correlation between mental health and knowledge (P =0.008), between self-esteem and knowledge (P =0.02), self-esteem and attitude (P =0.01), and mental health and attitude (P = 0.03).
Conclusion:
Health promotion planning by using life skills training based on the PRECEDE model can result in participation and empowerment, in order to promote the self-esteem and mental health of the students.
PMCID: PMC3354393  PMID: 22624080
Mental health; PRECEDE model; self-esteem; students
18.  Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review 
Research to date indicates that the number of coronary artery bypass graft (CABG) surgery patients affected by depression (i.e., major, minor, dysthymia) approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsychological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.
doi:10.3724/SP.J.1263.2011.12221
PMCID: PMC3418911  PMID: 22916068
Depression; Depressive disorder; Coronary artery bypass; Coronary artery disease; Antidepressive agents; Anxiety
19.  Can Collaborative Depression Care Management Reduce Disparities in Depression Treatment and Outcomes? 
Archives of general psychiatry  2011;68(6):627-636.
Context
Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes.
Objective
To examine the effect of DCM on treatment disparities by education and ethnicity among older depressed primary care patients.
Design, Setting and Participants
Analysis of data from a randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). This analysis included patients from 20 primary care practices, 60 or older, and with major depression (n=396). We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by ethnicity (and vice versa).
Intervention
Algorithm-based recommendations to physicians and care management by depression care managers.
Main Outcome Measures
Antidepressant use, depressive symptoms and intensity of DCM over 2 years
Results
The PROSPECT intervention had a larger and more lasting effect among less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) [95% confidence interval (CI): 1.7, 26.4] among the no-college group, compared with a null effect among the college-educated (−9.2 pps [95% CI: −25.0, 2.7]); at month 24, the intervention reduced depressive symptoms by 2.6 points on the Hamilton Depression Rating Scale [95% CI: −4.6, −0.4] among no-college patients, 3.8 points [95% CI: −6.8, −0.4] more than among the college group. The intervention benefitted non-Hispanic whites more than minority patients. Intensity of DCM received by minorities was 60-70% of that by whites after the initial phase, but did not differ by education.
Conclusions
The PROSPECT intervention substantially reduced disparities by patient education, but failed to mitigate racial/ethnic disparities, in depression treatment and outcomes. Incorporation of culturally-tailored strategies in DCM models may be needed in order to extend their benefits to minorities.
doi:10.1001/archgenpsychiatry.2011.55
PMCID: PMC3522183  PMID: 21646579
20.  Health related quality of life trajectories and predictors following coronary artery bypass surgery 
Background
Many studies have demonstrated that health related quality of life (HRQoL) improves, on average, after coronary artery bypass graft surgery (CABGS). However, this average improvement may not be realized for all patients, and it is possible that there are two or more distinctive groups with different, possibly non-linear, trajectories of change over time. Furthermore, little is known about the predictors that are associated with these possible HRQoL trajectories after CABGS.
Methods
182 patients listed for elective CABGS at The Royal Melbourne Hospital completed a postal battery of questionnaires which included the Short-Form-36 (SF-36), Profile of Mood States (POMS) and the Everyday Functioning Questionnaire (EFQ). These data were collected on average a month before surgery, and at two months and six months after surgery. Socio-demographic and medical characteristics prior to surgery, as well as surgical and post-surgical complications and symptoms were also assessed. Growth curve and growth mixture modelling were used to identify trajectories of HRQoL.
Results
For both the physical component summary scale (PCS) and the mental component summary scale (MCS) of the SF-36, two groups of patients with distinct trajectories of HRQoL following surgery could be identified (improvers and non-improvers). A series of logistic regression analyses identified different predictors of group membership for PCS and MCS trajectories. For the PCS the most significant predictors of non-improver membership were lower scores on POMS vigor-activity and higher New York Heart Association dyspnoea class; for the MCS the most significant predictors of non-improver membership were higher scores on POMS depression-dejection and manual occupation.
Conclusion
It is incorrect to assume that HRQoL will improve in a linear fashion for all patients following CABGS. Nor was there support for a single response trajectory. It is important to identify characteristics of each patient, and those post-operative symptoms that could be possible targets for intervention to improve HRQoL outcomes.
doi:10.1186/1477-7525-4-49
PMCID: PMC1560373  PMID: 16904010
21.  Prevalence and Outcome of Upper Gastrointestinal Bleeding Post-coronary Artery Bypass Graft 
Background:
Upper gastrointestinal bleeding (UGIB), a potentially fatal occurrence, can sometimes follow coronary artery bypass graft (CABG) surgery. However, little has been published about its prevalence, risk factors, and outcomes.
Aim:
This study aimed to determine the rate, etiologies, predisposing factors, and outcomes of UGIB following CABG.
Method:
The authors conducted a retrospective chart review of all UGIBs which followed CABGs performed at the University of Alberta Hospital from January 1, 1998 to December 31, 2002.
Results:
During the study period, 4,502 CABGs were performed at the UAH. Eighteen patients (0.4%) had a documented major UGIB (defined as evidence of melena, red or coffee-grounds emesis, blood per NG tube, or a decrease of Hgb by > 20 g/l and requiring a confirmation by endoscopy or radiological study). Two of these 18 patients (11%) had a past history of peptic ulcer disease, and one of these patients had had previous UGIB. Three patients (17%) had been taking proton pump inhibitors (PPI) before the UGIB occurred. At the time of UGIB, PPIs were prescribed for 16 patients (89%), and the PPIs achieved effective hemostasis as a single agent for 10 (62.5%). Of the 18 patients, 16 (89%) underwent upper GI endoscopy. Bleeding was found to be due to duodenal ulceration in 9 (56%), esophagitis in 4 (22%) and gastritis in 6 cases (33%); fifty percent of these patients had multiple sites of bleeding. Endoscopic therapeutic intervention was needed by 6 patients (37.5%), and successful hemostasis was achieved for 5 of these patients (83%). One patient had a recurrence of bleeding and required surgery. One patient underwent surgery as the primary hemostatic therapy after a diagnostic endoscopy. The overall surgical rate was 11.1% for this patient cohort. In this cohort, three patients died, two from multi-organ failure, and the third, a surgically managed patient, had a cardiac arrest 72 hours post-surgery. The number of complication increased as both cardiopulmonary bypass and cross clamp time increased. There were no endoscopy-related complications.
Conclusions:
UGI bleeding following CABGs is relatively infrequent, occurring at a rate of 0.4% in this study. Upper gastrointestinal bleeding post-CABG is most frequently related to a duodenal ulcer, though 50% of the patients had multiple bleeding sites. prolonged bypass and cross clamp time associated with more complications.
PMCID: PMC3068711  PMID: 21475474
Upper gastrointestinal bleeding; Coronary artery bypass surgery; Post-operative complications
22.  Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention 
Annals of internal medicine  2013;158(10):727-734.
Background
Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.
Objective
To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.
Design
Observational treatment comparison using propensity score matching and Cox proportional hazards models.
Setting
United States, 1992 to 2008.
Patients
Medicare beneficiaries aged 66 years or older.
Intervention
Multivessel CABG or multivessel PCI.
Measurements
The CABG–PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.
Results
Among 105 156 propensity score–matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, −0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.
Limitation
Treatments were chosen by patients and physicians rather than being randomly assigned.
Conclusion
Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.
Primary Funding Source
National Heart, Lung, and Blood Institute.
doi:10.7326/0003-4819-158-10-201305210-00639
PMCID: PMC4117804  PMID: 23609014
23.  Relation of Depression, Natural Killer Cell Function, and Infections after Coronary Artery Bypass in Women 
Background
After hospital discharge for coronary artery bypass grafting (CABG), infection is a common cause of morbidity. Although depression has been associated with immune dysfunction, its role in post-CABG infection is unknown.
Aims
The purpose of this study was to: 1) compare natural killer cell cytotoxicity (NKCC) and post-hospitalization infections in depressed and non-depressed women after CABG; and 2) test whether NKCC mediated the relationship between post-discharge depression and infections.
Methods
Sixty-seven women recovering from CABG were assessed for depression prior to hospital discharge and followed for six months. Major depression was identified by a structured clinical interview. Infections were identified by patient report using the Modified Health Review and by medical chart audit.
Results
Compared to non-depressed women after CABG, women with major depression had reduced NKCC, more all-cause infections, and more self-reported illnesses. Although NKCC did not mediate the relationship between depression and wound (i.e. incisional) infections after CABG, it did mediate the relationship between depression and non-wound infections, including pneumonias and upper respiratory infections.
Conclusions
For the first six months after CABG, women with major depression are at increased risk for infections. Natural killer cell cytotoxicity may be related to this phenomenon, particularly to non-wound infections.
doi:10.1016/j.ejcnurse.2007.07.004
PMCID: PMC2292641  PMID: 17716947
depression; coronary artery bypass; infection; women
24.  Depressive Symptoms After CABG Surgery: A Meta-analysis 
Harvard review of psychiatry  2013;21(2):59-69.
Objective
Depression is highly comorbid with coronary artery disease. Clinicians face the question of whether patients’ depressive symptoms will improve after coronary artery bypass graft surgery (CABG). The objective of this meta-analysis is to determine the course of depressive symptoms after CABG.
Methods
EMBASE, PubMed, and PsycINFO were searched for studies assessing depression before and after CABG. Meta-analyses were performed for depression at early (1–2 weeks), recovery (>2 weeks to 2 months), mid (>2 months to 6 months), and late (>6 months) postoperative time points. Heterogeneity and publication bias were analyzed.
Results
Thirty-nine studies were included in the meta-analysis. Twelve reported dichotomous outcomes; 18 reported continuous outcomes; and 9 reported both. Risk of depression was increased early (relative risk [RR] = 1.27; 95% confidence interval [CI], 1.01–1.61). There was a significantly decreased risk of depression at recovery (RR = 0.78; 95% CI, 0.67–0.90), mid (RR = 0.64; 95% CI, 0.58–0.70), and late (RR = 0.68; 95% CI, 0.58–0.79) time points without heterogeneity. All studies reporting continuous depression scales had significant heterogeneity.
Conclusions
The risk of depression decreased post-CABG when depression was measured dichotomously. While depression improves overall and remits for some patients after CABG, the majority of patients will not experience remission of depression. Preoperative and postoperative depression monitoring is important.
doi:10.1097/HRP.0b013e31828a3612
PMCID: PMC3652273  PMID: 23656830
cardiac surgery; coronary artery bypass graft surgery; depression
25.  “Prehabilitation” prior to CABG surgery improves physical functioning and depression☆ 
Background
Many patients demonstrate psychological distress and reduced physical activity before coronary artery bypass graft surgery (CABG). Here we evaluated the addition of a brief, cognitive-behavioural intervention (the HeartOp Programme) to routine nurse counselling for people waiting for CABG surgery.
Methods
Randomised controlled trial comparing nurse counselling with the HeartOp programme to routine nurse counselling in 204 patients awaiting first time elective CABG. Primary outcome measures were: anxiety and length of hospital stay; secondary outcome measures were: depression, physical functioning, cardiac misconceptions and cost utility. Measures were collected prior to randomisation and after 8 weeks of their intervention prior to surgery, excepting length of hospital stay which was collected after discharge following surgery.
Results
100 patients were randomised to intervention, 104 to control. At follow-up there were no differences in anxiety or length of hospital stay. There were significant differences in depression (difference = 7.79, p = 0.008, 95% CI = 2.04–13.54), physical functioning (difference = 0.82, p = 0.001, 95%CI = 0.34–1.3) and cardiac misconceptions (difference = 2.56, p < 0.001, 95%CI = 1.64–3.48) in favour of the HeartOp Programme. The only difference to be maintained following surgery was in cardiac misconceptions. The HeartOp Programme was found to have an Incremental Cost Effectiveness Ratio (ICER) of £288.83 per Quality-Adjusted Life Year.
Conclusions
Nurse counselling with the HeartOp Programme reduces depression and cardiac misconceptions and improves physical functioning before bypass surgery significantly more than nurse counselling alone and meets the accepted criteria for cost efficacy.
doi:10.1016/j.ijcard.2008.06.001
PMCID: PMC2643012  PMID: 18703241
Pre-operative care; Coronary artery bypass; Self-care; Cognitive-behavioural treatment

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