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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 48-60

Effect of nursing care by using Extended Nursing Care Model on quality of life of patients after coronary artery bypass graft


1 MGM New Bombay College of Nursing, Kamothe, Navi Mumbai, India
2 Department of General Surgery, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Sector-1, Kamothe, Navi Mumbai, India
3 MGM College of Nursing, MGM Institute of Health Sciences (Deemed to be University), Aurangabad, India
4 Department of Cardiothoracic Surgery (Adult), Fortis Health Care Ltd., Mumbai, Maharashtra, India

Date of Submission10-Jan-2022
Date of Acceptance04-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Jyoti M Chaudhari
MGM New Bombay College of Nursing, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Sector-1, Kamothe, Navi Mumbai 410209, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_2_22

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  Abstract 

Background: Though coronary artery bypass graft (CABG) is a life-saving surgery and a standardized procedure, the aim of the surgery is survival with quality of life (QOL). The extended role of the nurse was well recommended in community and clinical settings with the support of multidisciplinary team for safe care. The Extended Nursing Care Model (ENCM) provides the framework to facilitate early recovery and thereby improve the QOL and overall productivity after CABG. Aim and Objective: The aim of this article is to compare the difference in QOL of CABG patients with and without ENCM. Materials and Methods: Quasi-experimental Time Series Design with Comparison Group was used to study the effectiveness of ENCM. Among CABG patients enrolled on the day of admission with non-probability purposive sampling technique, 140 patients were randomly and equally distributed in the study and control groups on the day of discharge for recovery management. Generic EQ-5D-5L scale and MacNew Heart Disease-related QOL (MNHDRQOL) questionnaire were used to collect data at frequent intervals. The data obtained successfully from 69 patients in the study group and 63 patients in the control group were analyzed by using SPSS-21 Statistical Software, Mann–Whitney U-test, and Wilcoxon signed-rank test. Results: There was an improvement in the EQ-5D-5L score and MNHDRQOL score from baseline (before surgery) to 6th week and 12th week after surgery. This difference is statistically higher in the study group than in the control group (P <0.05) in all five domains of Euro QOL and all three domains of MNHDRQOL. Conclusion: Nursing care provided by using ENCM is effective in improving the QOL of CABG patients.

Keywords: Cardiac rehabilitation, extended care, nurse’s role, post-surgical recovery, quality of life


How to cite this article:
Chaudhari JM, Pani S, Mhaske A, Mulay A. Effect of nursing care by using Extended Nursing Care Model on quality of life of patients after coronary artery bypass graft. MGM J Med Sci 2022;9:48-60

How to cite this URL:
Chaudhari JM, Pani S, Mhaske A, Mulay A. Effect of nursing care by using Extended Nursing Care Model on quality of life of patients after coronary artery bypass graft. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:48-60. Available from: http://www.mgmjms.com/text.asp?2022/9/1/48/340583



The article has been transcribed out of a Ph.D. A thesis submitted to MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai, Maharashtra, India, for the award of Doctorate Degree in Nursing. It is certified that neither the thesis has been published in any format anywhere nor it will be published in the future. However, it is available in the Shodhganga database maintained by the UGC-INFLIBNET. Permission has been obtained from the management of the university for the publication of the manuscript in the proposed journal.


  Introduction Top


Quality of life (QOL) is a subjective phenomenon of well-being with multiple dimensions. Researchers will need to assess various aspects of care to conclude the impact of major surgery as coronary artery bypass graft (CABG). Survival is not always the primary outcome of surgery.

Patient-reported outcome measures for CABG patients range from reduction in symptom burden such as chest pain and shortness of breath to returning to normalcy in self-care and usual activities.[1] Healthcare services therefore will need to meet the needs of adults with coronary artery disease undergoing CABG at a younger age.

Unfortunately, the post-operative phase is not an easy-go process. They experience various problems such as fatigue, dyspnea, pain at the wound site, weakness, sleeplessness, loss of appetite, fear, pessimism, edema in the legs, wound dehiscence, palpitation, and constipation. It also causes anxiety among the patients. Altogether, it reduces self-efficacy and quality of life of patients.[2],[3]

Bringing CABG patients after surgery to the hospital regularly for hospital-based rehab program is the often unrealistic procedure to the caregiver in terms of time, energy, finances, and causing fatigue to the patients also.[4] For home-based rehab programs in India, we often lack skills among community health nurses who are appointed for meeting essential health services under the Primary Healthcare Approach of 1978. Hence, recovery under the hospital-based trained personnel is essential.

Among the multidisciplinary cardiac teams, the nurse has comprehensive knowledge and understanding regarding patient care not only for adapting the changes but also for overcoming them gradually. Nurses being the unique healthcare personnel, who have interdependent to the independent role in the management of CABG patients, are in a better position to monitor recovery and carry out interventions ranging from discharge preparation telenursing, home-based or hospital-based cardiac rehabilitation, and nurse-led recovery program for CABG patients.[4],[5],[6],[7],[8],[9],[10],[11],[12] Hence, researchers aimed to introduce the concept of extended nursing care for the benefits of early recovery of CABG patients. The researcher developed an Extended Nursing Care Model (ENCM) based on Kolcoba’s midrange comfort theory to manage the recovery phase smoothly and to bring about an overall improvement in QOL [Figure 1].
Figure 1: Conceptual framework based on Kolcaba’s Mid-range Comfort Theory

Click here to view


Aims and objectives

The study aims to compare the difference in the QOL score before and after CABG at 6 and 12 weeks in the study group managed by using ENCM and in the control group managed by the conventional method.

Null hypothesis (H01)

There is no difference in the QOL score of the CABG patients in the study and control groups at the end of 6 and 12 weeks of surgery.


  Materials and methods Top


Quasi-experimental Time Series Design with Comparison Group was used to study the effectiveness of ENCM. There was one group with intervention by using the ENCM and the other as control with conventional care. In conventional care, a patient has three follow-up visits routinely at 2 weeks after discharge, 6 weeks, and 12 weeks after surgery with the concerned surgical team in the hospital. In a few cases based on comorbidity, physician visits were also planned simultaneously with the minimal role of nurses. The telephone helpline was also provided by the hospital in case of emergency or any issues during the recovery period of 12 weeks.

Sample/participants

The non-probability purposive sampling method was used for recruiting 140 CABG patients less than 75 years of age who are staying within a 10–20 km radius from the selected tertiary care hospital. Those who got discharged after 7 days of CABG and could not continue interactions for 12 weeks were excluded from the study. On the day of discharge (DOD) after collecting the data using the EQ-5D-5L visual analog scale (VAS), odd and even number patients were enrolled every week in the study and control groups, respectively. Seventy CABG patients were enrolled in each group. The sample size was calculated based on the prevalence of CABG (0.3) and precision (0.2%), SD (2.52), and attrition rate of 15%.

Intervention

The ENCM is a systematic activity conducted to identify and address the needs and problems of patients and their caretakers in their unique home settings and during follow-up visits at the outpatient department (OPD) by a trained nurse to improve the quality of life of CABG patients and to cause early recovery. Extended nursing care was provided to the study group along with the conventional method of discharge as opposed to the control group who received discharge with only conventional method. In the study, extended nursing care refers to customized interventions provided by a nurse to each post-CABG patient in the study group during a minimum of five interactions over 12 weeks.

The first interaction (X1) took place in the hospital on the day of discharge, the second and third interactions (X2-X3) at home on the 3rd day of discharge and 15th day of post-operative CABG, and fourth and fifth (X4-X5) interactions took place either at home and/or at the hospital during their regular visit in the OPD at the end of 6 weeks and 12 weeks following surgery, respectively. Each interaction and use of ENCM took an average of 30 min.

The ENCM included the following activities:

  • Assessment of patients’ general health and expected self-care activities after discharge, issues raised against expected activities of daily living (ADL) and/or complications developed, and overall performance of CABG patients;


  • Addressing needs and problems of the patients in self-management;


  • Extended nursing interventions such as supervision, reassurance, emotional support, encouragement, and environmental modification.


  • Monitoring adherence to discharge instructions, especially related to medication management, follow-up, and care at home. The discharge summary of each patient was used as an individualized supportive document for the same.


  • The ENCM record was maintained on a case discussion sheet and utilized during the next interaction for continuity in care.


  • Validity and reliability

    The EQ-5D-5L tool is available in Marathi and Hindi versions. The MNHDRQOL tool was translated to Hindi and Marathi by the language and subject experts. The translated version was re-translated to the English language for language validity. The validity committee of the affiliated university validated the content of the study tool. Both tools used for the study have already established reliability of >0.7.[13],[14],[15],[16]

    Data collection

    After the approval from the Institutional Ethics Committee, data were collected from eligible CABG patients who gave written consent to participate in the study. Before surgery, demographic and comorbidity data were collected. Operative data were collected from operative notes of each patient documented on the discharge card.

    In the study, QOL refers to ease in performing ADL and absence of complications of surgery such as death or pain, anxiety/depression and withdrawal, and regaining back to normal life. There are researchers who have used various tools to measure the quality of life such as SF 36, WHO BREF QOL, MacNew HD-related QOL, and Euro QOL among CABG patients. A few studies have determined the quality of life in terms of reduction in problems/improvement in physiological, psychosocial, and behavioral parameters such as pain, self-efficacy, and anxiety/depression. In the present study, QOL was measured by using generic as well as disease-specific QOL tools.

    The EQ-5D-5L scale developed by Euro QOL Research Foundation has five dimensions, viz., mobility, self-care activities, usual activities, pain/discomfort, and anxiety/depression. It is measured in five levels ranging from no problem to extreme difficulty to perform the activities under each domain. It also has scope to express his/her happiness or wellbeing on a VAS ranging from 0 to 100, viz., extremely worst to extremely good.[8]

    MacNew Heart Disease-related QOL measures the QOL of patients in three dimensions: physical, emotional, and social wellbeing. It has one to seven levels. It has 27 items under 3 domains of QOL, viz., emotional (14 items), physical (14 items), and social (13 items). Item 27, “Sexual Intercourse,” was excluded from the physical domain in the present study after a pilot study found that all 24 CABG patients did not answer and expressed “no concern” on inquiry. Hence, in the present study, there were only 13 items in the physical domain.

    The MNHDRQOL and EQ-5D-5L data were collected from the CABG patients before surgery (t0), at 6 weeks (t1), and at 12 weeks (t3) of the recovery period.

    Data analysis

    To meet the research objective, data were collected in a 1-year duration (August 2016–August 2017). One participant from the study group was excluded due to inaccessibility. From the control group, seven participants were dropouts, of which five were inaccessible, one died, and one had internal hemorrhage with kidney failure as per data obtained from the caretaker. Data were entered into Statistical Software Package SPSS 21 for Windows and Microsoft Excel 2007. Data obtained from 69 CABG patients from the study group and 63 patients from the control group were analyzed using descriptive and inferential statistics.


      Results Top


    A. Socio-demographic characteristics and risk profile

    The study participants ranged in the age of 45–75 years, with mean age 59.73 ± 7.10 years in the control group and 61.96 ± 7.51 years in the study group. Raised body mass index (BMI) (≥ 23), diabetes mellitus (DM), hypertension, ischemic heart disease (IHD)/angina, low ejection fraction (EF) (heart dysfunction), myocardial infarction (MI), previous percutaneous transluminal coronary angioplasty (PTCA), renal dysfunction, current smoking, stroke/cardiovascular disease (CVD), and increased cholesterol were the common risk factors and comorbid conditions present in the descending order. Both control and study groups were comparable based on various risk factors and comorbidity characteristics, except MI at a 5% significant level [Table 1].
    Table 1: Distribution of samples based on socio-demographic characteristics and risk-comorbidity variable and its association

    Click here to view


    B. Operative characteristics

    The majority of the participants from the control group (76.2%) and the study group (87%) underwent CABG without using a cardiopulmonary pump (off-pump). About 3–4 grafts and 1–2 external wounds were common in both the groups. The saphenous vein graft (SVG) and radial artery (RA) graft were the most preferred sites on conduit in both groups.

    C. QOL

    It was assessed by using two tools and hence analyzed separately.

    C.1. QOL scores obtained by using the EQ-5D-5L scale

    C.1.1. Comparison of QOL based on the EQ-5D-5L scale at different time intervals within the group

    The participants faced lesser problems under each domain of QOL mentioned under the EQ-5D-5L instrument during the 12 weeks’ recovery period from baseline before surgery to 12 weeks after surgery (t0–t2). It is also noticed that patients were able to resume their self-care and usual activities to a great extent compared with mobility, absence of anxiety/depression, and pain/discomfort [Figure 2]. The minus values of the Wilcoxon test for all five domains for the description of EQ-5D-5L at P < 0.05 are indicative of long-term improvements in EQ-5D-5L generic QOL in the control and study groups. “Mobility,” “self-care activities,” “usual activities,” “pain,” and “anxiety” have significant improvement from the baseline before CABG to 12 weeks (t0–t2) at a 95% level of confidence in the control and study groups [Table 2] and [Table 3]. Mean VAS score recorded by participants in the control group was dropped on DOD and again raised at 6 weeks from DOD and at 12 weeks from baseline. The mean of VAS score recorded by participants in the study group was improved steadily during the 12 weeks’ recovery process [Figure 3] and [Table 4].
    Figure 2: A cluster column line combo graph showing distribution of percentage of participants based on reported problems in EQ-5D-5L at different time intervals

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    Table 2: Distribution of % of sample of the control group based on EQ-5D-5L description at different time intervals and test statistics

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    Table 3: Distribution of % of sample of the study group based on EQ-5D-5L description at different time intervals and test statistics

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    Figure 3: A cluster column line combo graph showing mean sample VAS score at different time intervals in control and study groups
    Note: BS: before surgery


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    Table 4: Mean difference in VAS at different time intervals in control and study groups

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    C.1.2. Comparison of CABG patients based on the EQ-5D-5L VAS score between the two groups

    As the normality test showed that the VAS score was not normally distributed, a non-parametric test, namely, the Mann–Whitney U-test, was utilized to compare the levels of difference that occurred on VAS between the two groups. It reveals that before surgery (t0), the VAS score in the study group was not significantly different from that in the control group (U = 2054, P = 0.582) as P > 0.05. On the day of discharge (t0), at 6 weeks (t1), and 12 weeks (t2) of recovery, the VAS score in the study group was statistically significantly higher than that in the control group as P <0.05 for the obtained Mann–Whitney U-score and minus z-score. Hence, the null hypothesis (H01) is rejected. This difference is suggestive of the effectiveness of interventions received by the participants in the study group based on the generic QOL, EQ-5D-5L scale [Table 5].
    Table 5: Mean rank difference in VAS score of control and study groups at different time intervals and test statistics

    Click here to view


    C.2. QOL score obtained by using the MNHDRQOL questionnaire under three domains

    The highest mean of scores of emotional, physical, and social domains represents the higher significance between the two groups as well as within the group at a different time interval [Figure 4].
    Figure 4: A cluster column graph showing distribution of mean of each domain on MNHDRQOL score at different time intervals

    Click here to view


    C.2.1. Comparison of CABG patients based on the MNHDRQOL score within the group

    [Table 6] and [Figure 4] present the mean score of each domain among the control and study groups. In the control as well as in the study groups, there is betterment of score in all three dimensions of MacNew QOL at baseline (t0), at 6 weeks of surgery (t2), and after 12 weeks (t2) between all time slots. Statistical significance is tested with the help of paired t-tests with a 5% significance level between the score obtained before surgery and at 6 weeks (t0–t1) and between the score obtained before surgery and after 12 weeks (t0–t2). [Table 5] shows that the mean difference in the physical domain score of QOL in the control group was statistically significant (P = 0.001) for time slots t0–t1 and t0–t2. Although there was a slight change in emotional and social domains of QOL score at 6 weeks, it was statistically not significant (P = 0.348 for emotional and P = 0.692 for social change) for time slot t0–t1. However, statistically significant improvement (P = 0.01) has been noted at t0–t2. [Table 6] shows that there was a significant improvement in the mean score of MNHDRQOL between time slots t0–t1 and t0–t2 for emotional, physical, and social domain scores of MNHDRQOL obtained by the participants in the study group as P < 0.05 (P = 0.001).
    Table 6: Mean difference in MacNew Heart Disease-related QOL score

    Click here to view


    C.2.2. Comparison of CABG patients based on the MNHDRQOL score between the two groups

    Both the groups were statistically not different in the emotional, physical, and social domains of MNHDRQOL before surgery as P > 0.05 for obtaining the Mann–Whitney U score and z score at the baseline. However, the emotional, physical, and social domain scores in the study group were significantly higher than the control group at 6 and 12 weeks of recovery of CABG patients as P <0.05. Hence, the null hypothesis is rejected [Table 7].
    Table 7: Mean rank difference in MacNew Heart Disease-related QOL score and test statistics

    Click here to view


    D. Association of patient characteristics with MNHDRQOL domain

    To identify the association of emotional, physical, and social domains of MNHDRQOL with patient characteristics, the score was classified into three categories such as <56, 56–70, and 71–100 [Table 8] and [Table 9].
    Table 8: Association of selected demographic variables, risk factor, and operative data with MNHDRQOL for control group

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    Table 9: Association of selected demographic variables, risk factor, and operative data with MNHDRQOL for the study group

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    There was no association of age, gender, ejection fraction, BMI, and several grafts with emotional, physical, and social domain scores of MNHDRQOL before CABG in both the control and study groups.

    There was no association of age, gender, EF, BMI, and several grafts with emotional, physical, and social domain scores of MNHDRQOL at 6 weeks in the control group. There was no association of age, EF, and the number of grafts with any domain score of MacNew HDRQOL at 6 weeks in the study group.

    Nevertheless, there was an association of gender with physical and social domain scores at 6 weeks in the study group (χ²= 7.736 at P = 0.021 and χ²= 7.744 at P = 0.021, respectively). There was an association of BMI with emotional domain score at 6 weeks (χ²= 9.607, P = 0.008) in the study group. There was no association of age, gender, EF, BMI, and several grafts with emotional, physical, and social domain scores of MNHDRQOL at 12 weeks of recovery in the control group.


      Discussion Top


    A long-term improvement is observed in the EQ-5D-5L generic QOL descriptive score in all five domains among participants over the period from baseline to 12 weeks (t0–t2) in the control group as well as in the study group.

    In the present study, the mean EQ-5D-5L VAS score of participants before surgery (t0) and difference in VAS before surgery and on the day of discharge confirms that participants in the control and study groups were comparable. Among the control group, the VAS score improvement has been observed only at t0–t2 time intervals [Table 4], whereas in the study group this improvement was found to be significantly higher than the control group at each time interval. This shows the effectiveness of the interventions reflected through the VAS score “Perception of Health Today” among participants of the study group [Table 4] and [Table 5]. This confirms the positive effects of interventions carried out among the study groups from an early period. Similar improvement was noticed in cardiac patients including CABG at 1 month of the non-nursing cardiac rehabilitation program on the EQ-5D-5L VAS scale.[17]

    One prospective observational study has shown that there was a significant improvement in patients in the high-risk group of patients (EuroSCORE ≥6) in a greater number of health domains following surgery than the low-risk and medium-risk groups (EuroSCORE) over a year. In the present study, an attempt has not been made to categorize the data based on risk category. However, it was observed that those who have lesser scores are with more differences in the QOL after 12 weeks. Though the present study is limited to 12 weeks after CABG, similar types of improvement were observed at 12 weeks.[18]

    The improvement in the emotional domain score of disease-specific MNHDRQOL [Table 6] and anxiety/depression dimension of generic Euro QOL [Table 2] and [Table 3] was significantly better among participants of the study group than among those of the control group. This reiterates the findings of the randomized control trial study conducted by using telenursing interventions. Proactively and timely providing information and emotional support showed improvement in the anxiety score of the patients.[11],[12]

    The present study reiterates the effectiveness of these interventions under the heading of ENCM. There was a significant improvement in the physical and social domain scores of MNHDRQOL in both the groups over some time, but there was a significantly better improvement in the study group [Table 6] and [Table 7]. This shows that patients and caretakers in the study group were adequately coached in taking the challenges positively and meeting the patients’ need for a better recovery. As a result of these, problems were fewer in the intervention group than in the control group. Few studies have also recommended similar types of interventions and changes in care delivery after the discharge of the patients.[19],[20],[21] This reiterates the significance of extended nursing care by someone credible and competent,[22] which was met easily through encouragement, reassurance, emotional support, and supervision in the study group and bolstered the functioning of CABG patients.[19],[20]

    In the present study, there was no association of age, EF, and the number of grafts placed during the CABG on MacNew disease-specific QOL score. The present study disagrees with the findings of other researchers,[20],[23],[24] who state that belonging to the female gender is a risk factor influencing the post-operative QOL of a CABG patient. Similarly, there was no association between BMI and MNHDRQOL (P >0.001). It means the difference in the QOL score is limited to interventions provided in the study group.


      Conclusion Top


    The discharge process and supervision during the recovery process of CABG is a crucial area in improving the QOL and reviving the patients back to normalcy. This indirectly results in nursing excellence. The use of ENCM was able to accelerate the phase of transition from dependency to independence in various aspects of life among patients operated for CABG.


      Limitations of the study Top


    As the study is limited to QOL, a study could be undertaken to know the cost-effectiveness to decide best practice over institutional recovery programs for CABG patients. The present study is limited to the only early recovery period and limited to CABG patients.


      Recommendations of the study Top


    There is scope to identify the impact of ENCM interventions on the care burden of CABG patients at home and also to identify the long-term impact on lifestyle changes among CABG patients. There is further scope to carry out reliability and external validity study by taking the feedback from CABG patients and nurses after imparting training and utilization of ENCM by many nurses.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Ethical consideration

    The research work was part of the PhD of the corresponding author affiliated to MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai, India; the clearance was obtained from the Institutional Ethical Committee of the University vide their letter no. MGM/HIS/RS/2014/ dated August 11, 2014. Since the actual research was undertaken at Fortis Health Care Limited, Mulund, Mumbai, India, the approval to undertake the proposed research work was obtained from their Institutional Review Committee vide letter of June 6, 2014.



     
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        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



     

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