ee

Heart, Lung and Circulation (2019) 28, 761–770

1443-9506/04/$36.00

https://doi.org/10.1016/j.hlc.2018.03.013

ORIGINAL ARTICLE

Evaluating the Effectiv

eness of an Online

Cardiac Rehabilitation Resource (www. svhhearthealth.com.au) in Improving Knowledge and Confidence for Patients With Newly Diagnosed Cardiac Conditions: A Pre-Experimental Pilot Study

Nikki Molan, [51_TD$DIFF]MDa,b, Sam Emmanuel, MBBS a [52_TD$DIFF], Tamra Langley, [51_TD$DIFF]BN a, Cameron J. Holloway, MBBS, MRCP a [53_TD$DIFF],b,c,d*

aSt Vincent’s Hospital, Sydney, NSW, Australia bUniversity of Notre Dame, Sydney, NSW, Australia cSt Vincent’s Clinical School, University of New South Wales, Sydney, NSW, Australia dVictor Chang Cardiac Research Institute, Sydney, NSW, Australia

Received 16 May 2017; received in revised form 10 March 2018; accepted 12 March

2018; online published-ahead-of-print 27 March 2018

Background Cardiac rehabilitation (CR) is an important tool for the secondary prevention of cardiac disease. Despite its

proven effectiveness, CR remains vastly under-utilised especially amongst the most disadvantaged

patients. As an adjunct to CR, the St Vincent’s Heart Health website (SVHHH) was created by the St

Vincent’s Hospital CR team to provide information via simplified medical text, videos and animations.

We evaluated the effectiveness of the website in educating patients about their heart condition.

Methods Patientswith a newly diagnosed cardiac conditionwere recruited fromSt Vincent’s Hospital inpatientwards

and outpatient clinics (n = 67, age 63+/�11) and given 30 minutes to interact with our online resource. Using

a pre-test post-test design we evaluated the success of the website in improving patients’ knowledge of their

condition using a modified Brief Illness Perception Questionnaire and Patient Activation Questionnaire.

Results After interacting with the website, participants rated a 50% improvement in the control they felt over their

heart condition (p < 0.01). Understanding of investigations, medications and management improved by

38%, 31% and 38%, respectively (all p < 0.01). Subjects’ understanding of their heart condition improved by

34% and confidence improved by more than 18% (p < 0.01). These improvements were seen irrespective of

age and primary place of residence. While older subjects had the lowest confidence using the internet, they

demonstrated the greatest self-reported improvement in knowledge. There was no improvement in

patients’ perceived concern about their illness.

© 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).

Published by Elsevier B.V. All rights reserved.

Abbreviations: CR, Cardiac Rehabilitation; CVD, Cardiovascular Disease; SVHHH, St Vincent’s Hospital Heart Health

*Corresponding author at: St Vincent’s Hospital, 390 Victoria Street, Darlinghurst NSW 2010, Australia., Email: [email protected]

Conclusions The St Vincent’s Heart Health website shows real promise as an educational tool for patients, as an adjunct

to standard CR and for patients in remote settings. Online health resources will likely become an important

adjunct to traditional teaching methods across all medical specialties to improve patient outcomes.

Keywords Cardiovascular disease � Cardiac rehabilitation � Secondary prevention � Web-based � Internet � Online

762 N. Molan et al.

Introduction Cardiovascular disease (CVD) is the leading cause of death

globally, accounting for 31% of all deaths [1]. In Australia one

in five adults suffers from CVD, with a 30% higher incidence

for those living in remote and rural areas [2]. Improvements

in pharmacological and interventional therapies have led to a

dramatic increase in survival rates following an acute coro-

nary event, however, one third of people will have another

cardiac event within 5 years of the initial insult [3].

Cardiac rehabilitation (CR) is an effective secondary pre-

vention intervention that decreases mortality by up to 20%

[3], reduces hospital admissions, strengthens adherence to

medications, improves knowledge of risk factors, decreases

depression and anxiety and enhances quality of life [4]. The

World Health Organization and the National Heart Founda-

tion of Australia suggest that CR should be recommended to

all patients admitted to hospital with an acute coronary event

or procedure [5,6]. Yet, despite these recommendations and

the overwhelming evidence supporting its use, CR remains

underutilised with only 30% of eligible patients attending.

Furthermore, disadvantaged patients, including those from

lower socio-economic backgrounds, of older age and those

living in rural areas have even lower attendance rates [7].

There is increasing evidence that delivering information

via the internet is an effective way to improve health out-

comes. Bashi et al. [8] piloted a web-based self-management

program for heart failure patients and found that websites

were effective in improving patient knowledge and quality of

life, in addition to reducing symptoms of heart failure. Varn-

field et al. [9] demonstrated that a smartphone-based home

care CR was as effective as traditional CR in improving

physiological and psychological health outcomes after acute

myocardial infarction. Web-based education has the poten-

tial to reduce the disparities in access to CR programs by

overcoming some of the practical difficulties that deter atten-

dance to traditional cardiac rehabilitation programs.

The value of online education tools as an adjunct to tradi-

tional CR is unknown. The St Vincent’s Heart Health website

(SVHHH) was created by the St Vincent’s Hospital Cardiac

Rehabilitation team in Sydney, in collaborationwith a website

developer, an animator, a videographer and a health writer.

Within the first 12 months following launch, over 70,000 page

visits had been recorded by Google analytics, with an average

of 2.5 pages viewed per session, and an average time of

2 minutes 30 seconds per session. The vast majority of visitors

were from Sydney, 75% were from Australia and 28% were

returning visitors. The most visited sections of the website,

included information about procedures, specialists, cardiac

investigations and rehabilitation after cardiac intervention.

The purpose of this study was to evaluate the success of the

SVHHHwebsite in improving the knowledge and confidence

of patients with a newly diagnosed cardiac condition with the

hope that this websitewill be able to enhance diseasemanage-

ment for a wide population.

Methods

Trial Design This was a quasi-experimental pilot study with a one-group

pretest-post-test design. A questionnaire was devised to

evaluate the usefulness of our heart health website www.

svhhearthealth.com.au.

Development of the Website The website includes narratives, text on screen, two dimen-

sional (2D) graphics, three dimensional (3D) animations and

videos. The content was developed by cardiologists, cardio-

thoracic surgeons and members of the allied health CR team

from St Vincent’s Hospital (examples are provided in Figure

1 and the sitemap in Figure 2). The website was designed to

provide patients and their carers with access to the latest and

highest quality medical information and rehabilitation

guidelines with the purpose of empowering patients with

knowledge through their cardiac journey: before procedures;

during their inpatient stay and subsequent recovery period.

With the emphasis on visual education and animation, it was

designed to accommodate patients and caregivers with poor

reading skills and those unfamiliar with using the internet.

Participants During the recruitment period, study investigators screened

cardiology inpatient lists and cardiology outpatient clinic

lists to find suitable participants. If the patient satisfied the

inclusion criteria, then they were approached and invited to

participate in the study, as shown in Figure 3.

Inclusion Criteria Eligible participants were those admitted as inpatients or pre-

senting via outpatient clinics at St Vincent’s Hospital with a

new diagnosis of cardiac disease, including acute coronary

syndrome (acute myocardial infarction or angina), requiring

coronary revascularisation (percutaneous coronary angio-

plasty or coronary artery bypass grafting), valvular disease

(aortic stenosis, mitral stenosis, aortic regurgitation, mitral

regurgitation) or for insertion of a permanent pacemaker

Figure 1 Example of website content, with still image of an example of a page of the website (above) and of an example of an animation (below).

Evaluating the Effectiveness of an Online Cardiac Rehabilitation Resource 763

(PPM) or implantable cardioverter defibrillator (ICD). Screen-

ing, recruitment and participation occurred during this initial

presentation or admission. Thus, the sample only included

patients diagnosed with coronary disease for the first time.

Exclusions Participants were excluded if their cardiac conditionwas pre-

existing, as it was assumed that many of these participants

might already be educated on their cardiac condition.

Intervention This involved 30 minutes of interacting with the SVHHH

website either from the participant’s own device, or a tablet

provided by St Vincent’s Hospital.

Outcome Measures There are no validated tools specifically available for assess-

ment of healthwebsites.We therefore combined twovalidated

questionnaires: TheBrief IllnessPerceptionQuestionnaire and

Figure 2 Site map of the St Vincent’s Hospital Heart Health Website.

764 N. Molan et al.

Figure 3 Flow chart of methods, including recruitment and completion the study.

Evaluating the Effectiveness of an Online Cardiac Rehabilitation Resource 765

thePatientActivationMeasure (PAM) [10,11]. TheBrief Illness

Perception Questionnaire is used for the rapid assessment of

the cognitive and emotional representations of illness. It has a

good test-retest reliability (r = 0.73, p < 0.001) and adequate

validity (0.47) [11]. The PAM measures the level of patient

engagement in their health care. It has good test-retest reliabil-

ity (0.81, p < 0.001) and respectable validity (0.86) [12]. Ques-

tions were combined from both of these questionnaires, to

gather a broader scope of information.

Sample Size This was considered a pilot study so a sample size was not

calculated.

Statistical Analysis Continuous variables are presented as mean � standard

deviation (SD) and discrete variables are presented as

percentage (number) unless otherwise stated. The Shapiro-

Wilks test was used to determine normality of the data

distribution and consequently, the non-parametric Wilcoxon

signed-ranks test was used to analyse the differences in

scores before and after viewing the Heart Health website.

A p-value of less than 0.05 was considered significant. All

analysis was completed using IBM SPSS version 24 (IBM,

Armonk, NY, USA).

Results

Participant Flow Shown in Figure 3.

After consenting to the study, participants completed a

questionnaire that collected information regarding demo-

graphic details, cardiovascular diagnosis, intended inves-

tigations, intended treatment and their self-rated confidence

with using the internet. Participants then completed the

Heart Health questionnaire consisting of nine questions

(pre-questionnaire, Figure 4). Participants were subse-

quently given an electronic tablet provided by St Vincent’s

Hospital, or shown how to access the website from their

own tablet or computer. The study investigator spent up to

10 minutes showing participants how to navigate the web-

site, depending on the participant’s level of need and famil-

iarity with using a computer. After 30 minutes of viewing,

exploring and interacting with the website independently,

participants completed the post-questionnaire which was

identical to the pre-questionnaire. The questionnaires were

collected by the study investigators or nursing staff for

subsequent analysis.

Recruitment A total of 67 participants were recruited from both St

Vincent’s Public and St Vincent’s Private Hospitals in Sydney

from August 2016 to January 2017.

The average age was 63+/�11 years. The largest group,

37% (25 subjects) lived in the inner city; however, there were

also a large number of participants who lived in rural areas;

31% (21 subjects). The subjects were predominantly male

(81%). Coronary artery disease was the principal diagnosis

in 79% and coronary artery bypass graft surgery was the

leading intervention in 48% (32 subjects), followed by coro-

nary angioplasty and stenting in 21% (14 subjects).

Baseline Data Baseline characteristics of the study participants are shown in

Figure 5.

Outcomes Self-rated confidence using the internet (rating 0 to 10; where

0 = no confidence and 10 = high confidence), varied widely

from 0 to 10, with an average score of 6.3 (+/�3.6). As

anticipated, there was a moderate negative correlation

between age and internet confidence (Spearman’s rho

�0.420, p < 0.01), where younger patients had the greatest

Figure 4 Heart Health Questionnaire.

766 N. Molan et al.

internet confidence, though all patients, despite age, were

able to navigate the website with minimal assistance.

Each of the 67 participants answered all nine questions.

The results of the survey are set out in Figures 6 and 7.

Participants rated how well they understood their heart

condition. This improved from 6.2+/�2.3 (out of 10) before

viewing the website to 8.3+/�1.3, after viewing the website

(34% improvement), p < 0.01. Participants rated their under-

standing of their cardiac investigations as 6.3+/�2.5 prior to

viewing the website and 8.7+/�1.2 afterwards (38%

improvement), p < 0.01. Their understanding of the required

treatment was 6.3+/�2.4 before viewing the website and 8.7

+/�1.1 (38% improvement) after viewing it, p < 0.01. Par-

ticipants rated their understanding of the long-termmanage-

ment of their heart condition as 5.6+/�2.8. This increased to

8.4+/�1.3 post website viewing (50% improvement),

p < 0.01. Participants rated their baseline understanding of

their heart medications as 5.0+/�2.2. After acquiring

knowledge from the SVHHHwebsite, they rated their under-

standing as 7.3+/�2 (31% improvement), p < 0.01 (Figure 7).

In addition to knowledge, participants also showed signif-

icant improvement in their confidence, as well as a rise in the

control they believed they had over their heart condition.

Confidence in returning to regular activities improved from

6.2+/�2.7 out of 10 before viewing the website to 8.4+/�1.4

afterwards (35% improvement), p < 0.01. Confidence in liv-

ing a healthy life was 7.3+/�2.0 before viewing the website

and this improved to 8.6+/�1.1 (18% improvement),

p < 0.01 after interacting with the website. Participants

reported a significant increase in their sense of control over

their heart condition. This rose from 4.8+/�2.7 before view-

ing the website to 7.2+/�1.9 post website (50% improve-

ment), p < 0.01.

The website had no impact on participants’ level of con-

cern. This remained the same both before and after viewing

the website at 7.8+/�2.4 out of 10, p = NS.

Figure 5 Baseline characteristics of the study participants. Abbreviations: CAD, coronary artery disease; CABG, coronary artery bypass graft

Figure 6 Questionnaire findings. Abbreviations: ADLs [50_TD$DIFF], activities of daily living

Evaluating the Effectiveness of an Online Cardiac Rehabilitation Resource 767

Impact of Age The impact of age on responses was only significant for the

first question regarding understanding heart disease. Partic-

ipants older than 65 years of age had a greater improvement

in their understanding, with a mean difference of 2.5+/�1.5

in improving knowledge of their heart condition, compared

to 1.8+/�2.0, for people under 65 years old, p = 0.04. Age did

not have any impact on the results of other survey questions.

Figure 7 Results: Rating of questionnaire response before (red) and after (blue) scores viewing the website.

768 N. Molan et al.

Impact of Residence Primary place of residence had no impact on reported out-

comes. People living rurally demonstrated similar improve-

ments to those living in the city for all nine questions.

Discussion

Generalisability The results of this pilot study demonstrate that utilisation of

this purpose built cardiac rehabilitation website improved

patients’ self-reported knowledge of their heart condition

and management, and confidence to return to activities of

daily living. Self-reported improvements were observed irre-

spective of age and primary place of residence. Whilst older

subjects had the lowest confidence using the internet, they

demonstrated the greatest self-reported improvement in

knowledge. This pilot data supports that an online education

tool could be a beneficial adjunct to cardiac rehabilitation,

particularly for elderly patients and rural dwellers who have

the lowest rates of attendance to traditional cardiac rehabili-

tation programs.

Therewas a significant improvement in eight out of the nine

questions on the Heart Health survey after viewing the web-

site. The greatest improvements were seen in the amount of

controlparticipants felt theyhadover theirheart conditionand

howwell they understood their long-termmanagement; both

had a 50% improvement in self-rated scores. Whilst under-

standing improved, self-rated concern did not change. Our

pilot data suggest that the SVHHH website may have

improved participants’ knowledge of their heart condition

including pathophysiology of their illness, cardiac investiga-

tions, medications, procedures and long-term management,

with the hope that it will positively influence their lifestyle

choices and health care compliance. Although we only mea-

sured the impact of thewebsite on knowledge and confidence,

as part of overall education within cardiac rehabilitation, we

would anticipate education via the internet would help facili-

tate improved morbidity, mortality and reduced hospital

admissions, as seen with typical CR programs.

Evaluating the Effectiveness of an Online Cardiac Rehabilitation Resource 769

Interpretation Due to its wide availability, internet resources have the

capacity to educate and empower a broad population. The

leading causes for low attendance at CR have been identified

as insufficient facilities, work commitments, lack of transport

and failure of clinicians to refer [13]. As such, the need for

alternatives to traditional CR has become apparent to meet

the needs of all Australians with cardiovascular disease

including the most disadvantaged. The addition of an online

education tool to the existing CR format is in alliance with the

Australian Cardiovascular Health and Rehabilitation Asso-

ciation recommendation to expand the traditional model of

CR to make it more accessible to the Australian population

[14]. Previous studies have shown that web-based interven-

tions are effective at improving knowledge, lifestyle choices,

risk factor profile and decreasing hospitalisations [15–17]. A

recently published systematic review found that telehealth

interventions have similar outcomes to centre-based super-

vised CR [18]. The SVHHH website was launched in Febru-

ary 2016. Between February 2016 and April 2017 the website

has been viewed 78,133 times, from all over the globe, with

the top five countries viewing the website as Australia, USA,

India, UK and Canada. This website was designed for

patients and families linked to St Vincent’s Hospital in Syd-

ney, though the general content had gained broader interna-

tional interest, likely outlining the lack of suitable online

material worldwide.

Limitations of online CR programs include availability of

internet access and motivation to utilise the resource. Our

model has been designed to complement rather than replace

the already existing CR model. By providing patients with

access to an electronic tablet whilst they are in hospital, we

are not only providing equal access to all patients, we are also

taking advantage of a time period where people do not have

the usual time constraints of daily life. Our model has been

created to educate and empower patients during their hos-

pital admission, whilst simultaneously encouraging them to

attend local centre-based CR.

Web based information regarding health is prolific. As

many as 30% of people rely on the internet to learn about

their health condition [19]. Although the internet is readily

accessible and available, it is difficult for the user to deter-

mine which information is correct and reliable. Patients,

therefore, need access to information that is endorsed by

their health professionals: evidence-based, reliable, accu-

rate and up to date, which, we propose, can be achieved

via hospital-based websites. We also propose that these

web based learning tools could be rapidly expanded to

create individualised plans for patients. An individual-

ised platform would highlight the relevant information of

specific heart diseases and guide patients through their

disease management plans, including medications, diet,

exercise and follow-up. With readily available technology,

it is conceivable that such an individual approach could

also allow for monitoring of basic parameters, including

heart rate, blood pressure, smoking status, alcohol intake

and exercise. Algorithms could be generated to provide

feedback on these parameters with links to the appropri-

ate online tutorials and helpful hints when targets are not

met.

Limitations We acknowledge several limitations to this pilot study,

including a small sample size, no blinding and no control

group. The study only observed the impact of age and place

of residence on outcomes. We recognise that there may be

other extraneous variables which would alter the outcomes.

End user perceptions were not assessed. Additionally, the

questionnaire relied on self-reporting and data was col-

lected by a single, relatively short point measurement,

30 minutes after viewing the website with no longer term

follow-up. Using a more objective assessment, such as the

‘Beliefs about Medicine Questionnaire’, may have resulted

in a smaller improvement in the outcomes. The study may

be compromised by a risk of validity given that the timing

between the pre-test and post-test timing is only 30 minutes.

Although use of the website showed clear improvement in

patients’ knowledge and confidence, further research is

essential to investigate whether there are long-term benefits

particularly in clinical outcomes, CR attendance rates and

hospital readmission rates. This will be the focus of a larger

study.

Conclusion Despite evidence to support the efficacy of traditional cen-

tre-based supervised cardiac rehabilitation, attendance rates

remain poor. To address this, the Australian Cardiovascular

Health and Rehabilitation Association is recommending

alternatives to meet the needs of people who do not have

access to, or cannot attend, a local CR program. The purpose

of the SVHHH website was to educate patients about their

heart condition at the time of diagnosis in hospital, a time

when they are available to interact with a web-based pro-

gram. Through delivery of web-based heart health educa-

tion this pilot study has shown improvements in health care

understanding and confidence, which will hopefully trans-

late to better outcomes, including increased completion

rates at CR, adherence to medication and selection of better

lifestyle choices to reduce overall mortality and morbidity

from heart disease. A larger appropriately powered study

would allow us to determine if similar online resources

translated to long-term change in health behaviour. We

anticipate that online health resources will become an

important adjunct to cardiac rehabilitation and suggest fur-

ther research to assess the impact of online education on

patient outcomes.

Conflict of Interest None of the authors have any conflict of interest to declare.

770 N. Molan et al.

Funding The website was funded by the ‘‘Supporters In the Resusci-

tation of Emergency Department Needs” (SIRENS) Group at

St Vincent’s Hospital.

Other Information Registration

All study participants provided informed consent to par-

ticipate in the study, which was approved by the Local

Research Ethics Committee (reference number HREC/16/

SVH/172).

Acknowledgements Thewebsite was funded by the SIRENSGroup at St Vincent’s

Hospital and created by a local working group including

Jeffrey Candiloro, David Faktor and Heather Schoenheimer.

We would like to acknowledge Wendy Upcott, Kathryn

Tonini, Madeline Attrill and Terry Bartlett for their assistance

with data collection, and Elise Crothers for her assistance

with writing and technical editing of the manuscript. We

would also like to thank our colleagues from St Vincent’ s

Public and Private Hospitals working in the Day Procedure

Centre, Coronary Care Units and Cardiothoracic Units for

their assistance with this project.

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