Person-centred, nurse-led follow-up programme after surgical treatment for intermittent claudication

Abstract

Intermittent Claudication (IC) is a common symptom of peripheral arterial disease with a prevalence of 5-10% among people 70 years of age or older. The symptoms of IC are discomfort or pain in the lower extremities, which is induced by exercise and relieved by short rest. Individuals with IC are burdened with chronic pain, fatigue, impaired walking ability and restricted mobility, and thereby negatively affected health related quality of life (HRQoL). Moreover, individuals with IC have high risk for cardiovascular events and mortality. Treatment of IC includes smoking secession, increased physical activity, medical treatment with lipid-modifying agents and antiplatelet agents, and surgical treatment when appropriate. Patients’ adherence to recommended lifestyle changes and medical treatment is a challenge, and 50% of all those with long-term medical therapy have poor adherence. It has been shown that health literacy as well as self-efficacy are associated with adherence. Intensified and person-centred care has been suggested to increase patients’ adherence. Person-centred care means involving the patient in their care as partners. The patient and the healthcare provider work together using the patients’ expertise in themselves as well as their life situation, and the healthcare providers’ expertise in the disease and treatment, to then develop a health plan for the patient jointly.

The aim of this thesis was to evaluate if a person-centred, nurse-led follow-up programme, when compared to standard follow-up programme had an effect on: 1) Improving the patient’s adherence to medication (primary outcome) and reducing risk factors for cardiovascular disease (Paper II); 2) improving patients’ health related quality of life, health literacy and general self-efficacy (Paper III) and 3) Patients’ experience of receiving either of the programmes (Paper I and IV).

The methods used were both qualitative and quantitative. Paper I was a qualitative interview study and the other three papers (II, III and IV) were quantitative studies evaluating a randomised controlled clinical trial (RCT), the FASTIC study, in which patients with IC were randomised to either person-centred, nurse-led follow-up or standard follow-up programme. The participants were scheduled for surgery at either of the two vascular surgery units in Stockholm and had given their written consent to participate. Data was then collected at baseline and 1 year after surgery on medication refills, risk factors for cardiovascular disease, HRQoL, health literacy, self-efficacy and patients’ perception of the quality of care provided using qualitative semi-structured interview (Paper I) registry for prescribed medication (Paper II) and self-reported questionnaires (Paper II, III and IV).

A total of 318 patients were eligible, of those 214 were randomised and 204 analysed according to intention-to-treat. Results from Paper II showed that there was no difference in adherence to lipid-modifying agents or antiplatelet and/or anticoagulant agents between the groups receiving person-centred, nurse-led follow-up or standard follow-up programme at 1 year after surgery. Adherence was significantly overestimated when self-reported in comparison to registry data. The groups did not differ regarding predicted 10-year risk of cardiocerebrovascular events at 1 year after surgery. One risk factor, HbA1c, was significantly higher in the intervention group, however there was no difference in the change overtime. Those in the intervention group were more likely to quit smoking than in the control group but with no significance. Paper III showed that there were no significant differences between the groups regarding HRQoL, health literacy and self-efficacy. Inadequate health literacy was shown to be significantly associated with low HRQoL. In Paper I, the patients in both groups described that participation in follow-up programmes after surgery was a positive experience leading to increased awareness of their own health. The intervention group described that the person-centred care was important for maintaining healthy lifestyle changes. Paper IV showed that the patients in the intervention group tended to perceive the quality of care more satisfactory than the control group, with significant differences in some aspects such as information about self-care.

In conclusion, person-centred, nurse-led follow-up programme did not improve adherence to medication; had similar effect on HRQoL, health literacy and self-efficacy, and was more likely perceived as satisfactory in some aspects of quality of care when compared with standard follow-up programme.