Non-pharmacological interventions to support coronary artery bypass graft (CABG) patient recovery following discharge: protocol for a scoping review

Introduction

Coronary artery bypass grafting (CABG) is a well-established procedure to treat coronary artery stenosis. Since the introduction of percutaneous coronary intervention, CABG is now more common among patients with advanced coronary disease and comorbid conditions, such as diabetes.1 About 15 000 people in Canada undergo CABG each year.1

According to the 2020 Canadian Institute for Health Information Cardiac Care Quality Indicators Report, 9.5% of these patients are urgently readmitted to hospital within 30 days of surgery.1 The top 5 reasons for 30-day readmission (based on the Canadian average rate) were complications of procedures, not elsewhere classified (17.5%), heart failure (10.2%), pleural effusion, not elsewhere classified (7.7%), atrial fibrillation and flutter (5.0%) and pain in throat and chest (3.2%).1 Shawon et al2 conducted a systematic review that found the most frequently reported causes of 30-day readmissions were infection and sepsis, followed by cardiac arrythmia, congestive heart failure, respiratory complications and pleural effusion.2 Overall, their study indicated that patient factors, such as sociodemographic and clinical characteristics, were major factors leading to readmission following CABG in comparison to hospital factors.2

With an ageing population, more patients who are older and more vulnerable to complications are receiving cardiac surgery; these patient population have higher rates of readmission following surgery. For patients older than 80 years old, a retrospective study observed 30-day readmission rates of 15%–20% in patients undergoing cardiac surgery at a single centre.3

Other researchers have observed that postoperative complications were more likely among octogenarians who had longer postoperative stays in Intensive Care Unit (ICU) and hospital as well as higher rates of ICU readmission.4

Postoperative care strategies, such as self-care education and cardiac rehabilitation, can play an important role in reducing readmissions and improving patient outcomes following CABG. Regular interventions following discharge aim to reduce risk factors for heart disease, including strategies that encourage smoking cessation, blood pressure management, regular exercise, symptom management and stress reduction.5

Fredericks and DaSilva reported a statistically significant relationship between number of self-care behaviours performed and number of postoperative infections, the number of self-care behaviours performed and rate of hospital readmission, and postoperative infections and rate of hospital readmission.6 The most common self-care behaviours observed after patients were discharged include deep breathing and coughing exercises, medication administration and medication management.6

Studies examining the impact of rehabilitation programmes accessed by CABG patients following discharge have found improved quality of life with better long-term prognoses and reduced need for hospital care and readmissions.7 8 However, only 10%–25% of heart patients globally access a cardiac rehabilitation programme.9

Overall, there are significant health and economic implications associated with readmission following cardiac operations. Therefore, it is important to identify interventions and opportunities that will improve patient recovery and reduce readmission rates following postoperative discharge.

Purpose of this study

This protocol describes the methods and processes that will be used to conduct a scoping review. The primary objective of our study is to determine what non-pharmacological interventions are available to support recovery of CABG patients following discharge in the community setting. Given that patients are discharged into the community setting, in some cases to rural and remote environments, where access to necessary services may be difficult, we are interested in determining what supports are available for patients recovering from CABG as they transition from acute care to community settings. We are interested in interventions that improve patient quality of life, functioning and that reduce the risk of complications without the use of pharmaceuticals. These could include but are not limited to various interventions, such as cardiac rehabilitation programmes, lifestyle counselling or symptom management programmes.

Secondary objectives of our study include gaining insight into current gaps in support for postoperative CABG patients recovering in the community setting and the usage of digital technologies, such as mobile platforms, in CABG recovery.

Methods

Protocol development

The methodology of this study is guided by the scoping review framework developed by Arksey and O’Malley.10 This framework involves a five-stage process: (1) identify and align the study’s objective and research questions; (2) develop and align the inclusion criteria with objectives and research questions to help identify relevant studies; (3) develop a systematic approach to searching, selecting and charting data; (4) chart data from selected studies; (5) collate, summarise and report the results in relation to the research objectives and questions.

Patient and public involvement

A patient partner was involved throughout the design and conduct of this study. The development of our research questions, objectives and methods has been guided by their input throughout the entirety of this study. To further incorporate the patient perspective, our patient partner will serve as one of our two independent reviewers to screen and review literature retrieved by our search strategy.

Inclusion criteria

Types of studies

The first CABG was performed on 2 May 1960, at the Albert Einstein College of Medicine-Bronx Municipal Hospital Center.11 However, the techniques and safety of CABG have continued to improve throughout the following decades. To reflect the latest techniques and relative safety of CABG, this study will include all primary studies published in English from 1 January 2000 to 31 December 2022.

To be comprehensive, we will aim to include articles conducted worldwide. However, we will be limited to those published in English as it is the only shared language spoken by our reviewers. Randomised controlled trials, cohort studies, case-control studies and cross-sectional studies will be included if they satisfy identified inclusion criteria. However, title searches of the references of relevant literature and systematic reviews will be conducted to identify articles that might fulfil inclusion criteria for abstract review. If a full report is unobtainable, we will include published abstracts if there is sufficient information to assess study eligibility. At this time, we will not include grey literature if available.

Participants

Studies that report on patients discharged after CABG (ie, transitioning from acute care to the community setting) will be included. Additionally, we will include over the ages of 18 years old.

Interventions

Our study will include any non-pharmacological interventions that support CABG patient recovery by improving quality of life, functioning and reducing risk of complications without the use of pharmaceuticals. For example, these interventions could include but are not limited to patient education, cardiac rehabilitation, peer-support groups, lifestyle counselling and behavioural modification therapy. Additionally, these interventions could be provided at home, outpatient setting or virtually, but must aim to support patients following postoperative discharge.

Furthermore, these can include interventions that are initiated during the acute care setting but are focused on supporting patient recovery following discharge and are primarily administered in the community setting. Interventions that take place entirely in the inpatient setting will be excluded.

Outcomes

For the purpose of our study, we will include any applicable patient health and patient-reported outcomes to gain insight into the impact of the interventions in promoting patient recovery following discharge. Patient health outcomes may include but are not limited to adverse events such as complications or readmissions, body functions and structures, exercise capacity and cardiovascular risk profile. Likewise, patient-reported outcomes may include perceived stress, social support, anxiety and depression, reported symptoms/complications, quality of life and patient perception/awareness/understanding. The validity of these measures used will also be noted where applicable.

Additional outcomes related to implementation, sustainability and feasibility, appropriateness, will also be included if applicable, but are not the primary focus of this study.

Search methods for identification of studies

Search strategy

An initial limited search of Medline will be conducted by a health sciences librarian. Text words contained in the title, abstract and index term of the retrieved articles will be assessed for additional relevant keywords.

The search strategy was then reviewed, using the PRESS tool,12 by another librarian to finalise the keywords for the search protocol, which will be conducted across the following databases: Medline, Cochrane Library, Embase and CINAHL. Search terms include a mixture of keywords and MeSH terms using combinations of the terms listed in box 1.

Box 1

Search and MeSH terms.

  • Coronary artery bypass

    • Aortocoronary bypass, aorotocoronary by pass, aorto coronary bypass, aorto coronary by pass, coronary artery by pass, coronary artery bypass, or CABG, or Coronary bypass and graft*

  • Rehabilitation

    • Recover*, rehabilitat*, convalesce*, counsel*

  • Patient readmission

    • Readmiss*

    • Readmit*

  • Enhanced recovery after surgery

  • Recovery of function

  • Social support

  • Self-help groups

  • Patient education as topic

  • Community integration

  • Internet-based interventions

    • Digital, virtual, remote, mobile app, smartphone app

  • Education*, training

  • Support*

    • Social, psychosocial, psychological, community, home

  • Home care services, hospital-based

  • Home health nursing, community health nursing

  • Home nursing

  • Homemaker services

  • Community health services

  • Adult day care centers

  • Intermediate care facilities

  • Transitional care, hospital to home transition

  • Aftercare, patient discharge

  • Home, community, transition*, discharge

    • Intermediate, healthcare, care, nursing, visit*

    • Hospital or acute

* is a wildcard symbol to broaden our search by finding words that start with the same letters.

The search strategies for the included databases are included in online supplemental appendix 1.

Supplemental material

Study selection

Search results were deduplicated using EndNote then uploaded to Covidence where two independent reviewers will select studies using the inclusion/exclusion criteria at the title and abstract levels. Full text of selected articles will then be retrieved, read and assessed by the same independent reviewers.

If there is any disagreement, the two reviewers will meet to discuss and determine whether the study or studies in question will be included. Studies found to not satisfy inclusion criteria on full-text review will be excluded. Decisions and reasons for exclusions will be documented. Covidence will be used to manage references throughout the entire process.

Studies that do not involve CABG patients or interventions primarily available in the community setting will be excluded. Additionally, protocols, editorials/opinions, literature reviews, systematic reviews and meta-analyses will be excluded. However, title searches of the references of relevant literature and systematic reviews will be conducted to identify articles that might fulfil inclusion criteria for abstract review.

Lastly, non-English publications will be excluded.

Data extraction

The following data will be extracted: type of intervention; setting; mode of delivery; results, including outcome, patient experiences/perspectives and implementation outcomes measures regarding feasibility, appropriateness and acceptability. At least two independent reviewers will use the data collection form below (box 2) to collect relevant data from selected studies. If there is any data found to be missing, we will contact authors to obtain any information needed if possible.

Box 2

Data collection items.

  • General:

    • Author(s), publication date, title, journal, volume, issue and pages

    • Country

  • Methods

    • Purpose

    • Study design

    • Date range of data collection

    • Participant details (eg, age, sample size, surgical techniques if specified)

  • Intervention details

    • Type of intervention (eg, educational, supervised, unsupervised, cardiac rehabilitation, telemonitoring, counselling, lifestyle modification, behavioural therapy, patient individualisation, peer support)

    • Setting (eg, urban, rural, outpatient, remote, home, rehabilitation centre)

    • Administration (eg, patient-led, provider-led or both)

    • Professionals involved (eg, nurse, physician, counsellor, social workers, self-managed)

    • Mode of delivery (eg, in-person, virtual meetings, telephone, e-mail, text/SMS, pre-recorded videos, pre-recorded listening tapes, information package, group sessions, individual sessions)

    • Duration and frequency

    • Follow-up duration (if applicable)

  • Results

Data charting

To chart the data, we will use simple descriptive tables to report basic information of the selected studies (ie, citation, objectives, relevant findings/outcomes).

Furthermore, thematic analysis will be used to identify categories and central themes from the scoping review.

There will be no statistical analyses conducted. However, this review will aim to broadly describe the literature to be inclusive.

Research timeline

Our study started preliminary searches March 2022 and following abstract screening, full-text screening was completed May 2023. Data extraction is planned to begin September 2023 with an expected finish date of October 2023. The study is expected to be completed by January 2024.

Ethics and dissemination

The aim of this scoping review is to enumerate available non-pharmacological interventions to support recovery of patients who are discharged after CABG in the community setting, gain insight into their impact on patient recovery where possible and identify gaps in support for postoperative recovery in the community setting. On completion of this review, we will ensure broad dissemination of our findings through peer-reviewed, open-access journals, conference presentations and hold meetings to engage stakeholders, including clinicians, policy makers and others.

The results may be used to inform future strategies to improve CABG patient recovery, reduce readmission rates and improve quality of life of patients. Additionally, this study may help identify potential opportunities to bridge gaps in patient recovery using innovative strategies, such as enabling digital technologies.

This scoping review will retrieve and analyse previously published studies in which informed consent was obtained by primary investigators. Therefore, no ethical review or approval will be required.

Strengths and limitations of this study

This study employs the methodological framework described by Arksey and O’Malley and a comprehensive search strategy encompassing four electronic databases for peer-reviewed literature. Furthermore, this study has been developed in collaboration with a patient-partner who previously underwent CABG surgery and will serve as one of the two independent reviewers throughout the study review process. Although this study will identify and examine non-pharmacological interventions to support CABG patient recovery following discharge, studies will not be formally assessed using a critical appraisal tool and effectiveness of interventions will not be compared. Finally, our study will be limited to examining only English language literature.

This post was originally published on https://bmjopen.bmj.com