From the Walter I. Berman Department of Cardiovascular Prevention and Rehabilitation Center, Baylor Health Care System, Dallas, Texas.

Corresponding author: Jenny Adams, PhD, Walter I. Berman Department of Cardiovascular Prevention and Rehabilitation Center, Baylor Health Care System, 411 North Washington, Suite 3100, Dallas, Texas 75246 (e-mail: jennya@baylordallas.edu).

For more information on the Leap for Life program, visit www.leapforlife.com.

Although more extensive inpatient (phase 1) cardiac rehabilitation programs have been offered that consist of an exercise protocol, risk factor assessment, activity counseling, and patient and family education, many hospitals are discontinuing such programs. Outpatient cardiac rehabilitation programs (phase II) are more extensive, meeting 3 days a week for 12 weeks. However, only an estimated 10% of patients with cardiovascular events participate in phase II programs, despite evidence that participation results in reduced readmission rates, increased patient functionality, improved quality of life, and decreased mortality (1). One likely reason for low referrals to cardiac rehabilitation is limited insurance coverage for particular cardiovascular diagnoses.

To fill this educational gap, in 1994 Baylor Health Care System (BHCS) developed the Leap for Life program for patients who either are unable to attend or have limited access to a cardiac rehabilitation facility. In 1998, Leap for Life was made the primary educational component of phase II cardiac rehabilitation programs in the Baylor Health Care System in addition to being offered separately.

By enrolling in Leap for Life, a patient with cardiovascular disease receives 6 hours of education and 3 follow-up telephone calls over a 12-month period to assess progress toward meeting personal lifestyle modification goals set at the workshop. In addition, participants receive a user-friendly 42-page workbook that reviews cardiovascular disease, cardiovascular medications, exercise and physical activity, nutrition, and stress management. Participants are encouraged to bring a guest so that family members may be involved in risk factor modification. The workshops, taught by an interdisciplinary team of professionals that includes nurses, pharmacists, exercise specialists, dietitians, social workers, chaplains, and physicians, are offered at different times and locations in several North Texas communities to meet the needs of patients soon after they have experienced a cardiovascular event.

In a Leap for Life workshop, the educators attempt to empower patients to identify, plan, and implement cardiovascular risk factor lifestyle modifications by creating a learning environment that promotes self-discovery. In combination with this self-discovery process, necessary clinical and behavioral guidelines are addressed. A typical Leap for Life workshop is not conducted in an ordinary lecture format. Instead, educators lead participants through discussions by motivating them to ask questions. As discussed in Engines for Education, “Schools cannot simply tell the answers, they have to motivate the questions first. Schools that fail to do this will simply not work” (2).

The Leap for Life team utilizes 2 concepts, adherence and alliance, within its educational model. Ideally, patients who identify personal goals will better adhere to risk factor modification procedures. It is also important for educators and participants to form an alliance in which they consider themselves active partners. Participants are responsible for creating individualized, specific, measurable, attainable, realistic, and timed goals that are prospectively tracked by Leap for Life personnel at baseline and at 3, 6, and 12 months after. Rather than simply asking participants to memorize clinical information, progress and outcomes are assessed.

The Leap for Life workshops have not required an extensive investment by the Baylor Health Care System. Currently employed staff members teach educational sessions, sometimes adjusting work schedules to participate in weekend workshops. Many community members, organizations, and former Leap for Life participants have made cash donations for operational expenses and program funding. Furthermore, pharmaceutical representatives have often provided lunch for workshop participants.

The year 1997 marked the first time that the Leap for Life program followed up on participants' goals and satisfaction with the program; prior to that date, follow-up focused on participants' knowledge retention. After the first full year of such tracking, the measures were evaluated, as described below.

METHODS

Between January 1 and December 31, 1997, 161 persons attended a Leap for Life workshop. Of these, 152 (94%) gave written consent to participate in the telephone follow-up process. The workshops were conducted at 4 Baylor Health Care System hospitals and one senior center, all located in the Dallas, Texas, area.

Participant diagnoses and cardiovascular disease risk factors were assessed before workshop participation. After the workshop, patients set nutrition and exercise goals for the future and filled out a satisfaction questionnaire. Participants were resurveyed by telephone at 3, 6, and 12 months after the workshop to assess goal achievement, hospital readmission, patient satisfaction, and educational model preference. The response rate at 3 months was 72% (109 of 152); at 6 months, 73% (111 of 152); and at 12 months, 80% (121 of 152). Reasons for nonresponse included wrong phone numbers, participant illness, hospital stay, or reaching the maximum number of telephone attempts without contact.

RESULTS

Leap for Life participants were primarily male (59%), with an average age of 66 years. Each participant reported having at least one of the following: coronary artery disease (18%), interventional procedures (18%) (e.g., percutaneous transluminal coronary angioplasty, stent, cardiac catheterization), angina (17%), myocardial infarction (13%), coronary artery bypass graft (10%), and risk factors for coronary artery disease (i.e., tobacco use, sedentary lifestyle, excessive body weight, hypercholesterolemia, hypertension, diabetes, age, male gender, family history), congestive heart failure, and electrical abnormalities (6% each).

The participants had an average of 4 cardiovascular disease risk factors. Risk factors were determined using the guidelines of the American Heart Association and the National Heart, Lung, and Blood Institute (3, 4). Hypercholesterolemia (59%) was the controllable risk factor most frequently reported, followed by hypertension (58%) and excessive body weight (48%); age or gender (85%) was the most common uncontrollable risk factor reported (Figure 1).

Of the 152 participants who took part in the telephone follow-up program, 19% reported a hospital admission with a cardiovascular diagnosis at some point during the 12-month follow-up period (Figure 2). Overall, 21% of participants met all of their goals, 56% met some of their goals, and 23% met none of their goals (Table). Of those participants who completed a workshop satisfaction questionnaire, 100% reported (on a dichotomous yes or no instrument) that the educational sessions met their needs. The majority (75%) preferred to learn about cardiovascular disease risk factors in a Leap for Life setting, while 5% would have rather acquired the information in the hospital setting. The remaining 20% of participants preferred alternative learning environments such as home study or physician interaction.

DISCUSSION

The goal of this internal evaluation of the Leap for Life program was to determine if patients were satisfied with the program and if they were motivated by the program to work toward their goals. Based on these measures, the Leap for Life program achieved some degree of success, since 77% of participants reported meeting at least some of their goals and all reported that the program met their educational needs. Further, the methodology of Leap for Life has been backed up by published studies. For example, research in the context of smoking cessation programs indicates that the number of months subjects are in contact with the programs is the strongest predictor of success (5) and that “even brief telephone contacts have been found to be effective aids” and to improve overall results (6). It has been widely reported that those who exercise regularly and successfully decrease cardiovascular risk factors have decreased mortality (7, 8). Both exercise and decreased risk factors are common goals set by participants in the Leap for Life program.

Since the evaluation was not designed as a research study and has no control group, general conclusions about its effectiveness must be limited. It is difficult to compare Leap for Life data with published data from other educational programs since model design and goal evaluation processes almost always differ. Nevertheless, comparison with a similar research project allows some degree of analysis. There are similarities in follow-up design between Leap for Life and the Cardiovascular Outcomes Measurement Program (COMP) research project. This study is currently under way in the Baylor University Medical Center cardiac rehabilitation department. In this study, patients who attend cardiac rehabilitation (versus controls who do not) are evaluated for risk factor assessment 5 times during the 12 months following a cardiovascular event. A typical control patient from the COMP study receives no cardiovascular education or rehabilitation other than that provided during the hospital stay.

The COMP follow-up model is very similar to that for Leap for Life. Interestingly, the rehospitalization rate of 19% for the Leap for Life group is low compared with the 41% rehospitalization rate for control patients in COMP. Other preliminary 1-year follow-up results from the COMP control patient database indicate that 50% of participants showed an increase in total cholesterol, 46% had higher systolic blood pressure, and 60% had an increase in body weight. As reported in the Table, 52% of Leap for Life participants met their cholesterol-related goals, and 59% met their blood pressure-related goals. These goals were individualized and cannot be compared with data obtained on COMP patients, but it seems appropriate to speculate that educational programming such as Leap for Life may indeed have a positive effect on patient risk factor outcomes. These recent findings are encouraging from an educational standpoint and may be reason for further study.

One limitation of the study concerns the voluntary nature of participation. Baylor University Medical Center now uses automatic Leap for Life referral order sets for patients admitted to the hospital with a myocardial infarction or for cardiac catheterization. Even in 1997, approximately 4000 patients were told about the program, yet only 167 chose to participate. Since the individuals volunteered to participate in the program, they may have been predisposed to make lifestyle modifications. Further, since they chose this program instead of seeking other options, it is not surprising that they indicated that the program met their needs and was their preferred method for instruction.

Another study limitation is that information on whether goals were achieved comes from participants' verbal report. The staff members hope to improve evaluation of the program through expansion of a pilot program, which began in December 2000, targeted toward primary and secondary cardiovascular disease prevention populations. The pilot program includes implementation of a new participant survey instrument to be completed at both 6- and 12-month follow-up dates. The improved survey instrument incorporates the stage of readiness model defined by Prochaska and DiClemente (9), several previously validated diet and exercise self-efficacy measures, and the SF-12 quality-of-life questionnaire (10).

Additionally, the pilot program includes individualized health enhancement messages for each participant at 6- and 12-month intervals; this initiative corresponds with the current literature regarding tailored health messages evoking positive behavior change (11, 12). A tailored approach allows individuals to receive information that is relevant to their stage of readiness regarding exercise and proper nutrition. Campbell and colleagues found a “positive effect of tailored nutrition messages in promoting dietary change efforts for disease prevention” (11). Bennett and colleagues determined that the individualized approach increases the “likelihood of compliance with the behavior” (12). With these additions to the Leap for Life program, individual participant needs are addressed in relation to each person's risk factor modification plan.

In conclusion, patients enrolled in Leap for Life are encouraged to accept responsibility for improved health during their recovery phase. Participants are more likely to seek out additional services offered by a health care system during this impressionable and sensitive period following hospitalization. Leap for Life is an example of the importance of continued patient care education following hospital discharge.

Acknowledgments

This article is dedicated to the memory of Walter I. Berman, MD. The authors would also like to thank Cynthia Orticio for her help in formulating this manuscript.

1. Johnson C, Pinschmidt S. Cardiac Rehab Statistics. Washington, DC: Cardiology Preeminence Roundtable, the Advisory Board Company, 1999.
2. Schank RC, Cleary C. Engines for Education. Hillsdale, NJ: Lawrence Erlbaum Associates, 1995.
3. National Institutes of Health. Second Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Bethesda, Md: National Institutes of Health, 1993.
4. Smith SC Jr, Blair SN, Criqui MH, Fletcher GF, Fuster V, Gersh BJ, Gotto AM, Gould KL, Greenland P, Grundy SM, et al. AHA consensus panel statement. Preventing heart attack and death in patients with coronary disease. The Secondary Prevention Panel. J Am Coll Cardiol 1995;26:292-294.
5. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice. A meta-analysis of 39 controlled trials. JAMA 1988;259:2883-2889.
6. Lando HA, Hellerstedt WL, Pirie PL, McGovern PG. Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation. Am J Public Health 1992;82:41-46.
7. Hamalainen H, Luurila OJ, Kallio V, Knuts LR, Arstila M, Hakkila J. Long-term reduction in sudden deaths after a multifactorial intervention programme in patients with myocardial infarction: 10-year results of a controlled investigation. Eur Heart J 1989;10:55-62.
8. Kallio V, Hamalainen H, Hakkila J, Luurila OJ. Reduction in sudden deaths by a multifactorial intervention programme after acute myocardial infarction. Lancet 1979;2:1091-1094.
9. Prochaska JO, DiClemente RC. Toward a comprehensive model of change. In Miller WE, Heather N, eds. Treating Addictive Behaviors: Process of Change. New York: Plenum, 1986:3-26.
10. Ware JE, Kosinski M, Keller SD. SF-12: How to Score the SF-12, Physical and Mental Health Summary Scales, 3rd ed. Lincoln: QualityMetric Inc, 1998.
11. Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandler RS. Improving dietary behavior: the effectiveness of tailored messages in primary care settings. Am J Public Health 1994;84:783-787.
12. Bennett SJ, Hays LM, Embree JL, Arnould M. Heart messages: a tailored message intervention for improving heart failure outcomes. J Cardiovasc Nurs 2000;14:94-105.