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Carvalho ACSMD, Groehs RV, Pereira C, Soares VL, Mota TP, Grace SL, Matos LDNJD. Barriers to cardiac rehabilitation and their association with hospital readmission in patients with heart failure. EINSTEIN-SAO PAULO 2025; 23:eAO0713. [PMID: 40105570 DOI: 10.31744/einstein_journal/2025ao0713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/04/2024] [Indexed: 03/20/2025] Open
Abstract
BACKGROUND High rehospitalization rates and limited access to cardiac rehabilitation characterize heart failure in South America. This study highlights the significant barriers faced by patients, including lack of energy, awareness, and accessibility. Despite these challenges, professional exercise supervision has reduced readmission rates by more than 50%, underscoring its importance. ■ Barriers to rehabilitation: high inactivity rates (88.4%) and significant barriers, such as fatigue and lack of awareness, hinder recovery. ■ Professional supervision: only 1% of patients were enrolled in formal cardiac rehabilitation; however, those who received professional supervision experienced lower readmission rates (14.6% versus 35.1%). ■ Systematic gaps: addressing systemic gaps, such as coverage and referral to rehabilitation programs, is critical for improving patient outcomes and reducing rehospitalization rates. OBJECTIVE This study assessed the barriers to cardiac rehabilitation in inpatients with heart failure, the use of formal exercise supervision, and its relationship to readmissions. METHODS This study was a prospective, observational design. The Cardiac Rehabilitation Barriers Scale, the Readiness Scale focusing on physical activity, and the International Physical Activity Questionnaire were administered before hospital discharge. Participants were followed up via telephone at 30- and 90-days post-discharge, during which the International Physical Activity Questionnaire was readministered, and formal exercise supervision and readmission rates were assessed. RESULTS Of the 95 patients who provided consent, 88.4% were inactive. A total of 85 (89.5%) were retained at the 30-day follow-up, and 86 (90.5%) patients at the 90-day follow-up; 2 patients died. The mean total Cardiac Rehabilitation Barriers Scale score was 2.3±6.5 (out of 5), with the highest item scores for lack of energy, prior exercise, lack of awareness, distance, and exercise-related pain/fatigue. Only one participant was enrolled in cardiac rehabilitation. Nearly half had engaged in professional exercise (n=48, 56.5% at 30 days and n=45, 52.3% at 90 days) at both follow-ups. At 30 days, 25.8% of the patients were readmitted, and 25.5% were readmitted at 90 days. Participants who received professional exercise supervision within 30 days had significantly fewer readmissions (n=7, 14.6%) than those who did not (n=13, 35.1%; p=0.03). CONCLUSION Barriers to cardiac rehabilitation are high among patients with heart failure. Despite access to professional exercise training, most participants remain insufficiently active. Systematic referral for cardiac rehabilitation and advocacy for coverage could mitigate poor self-management and, ultimately, reduce high readmission rates. REGISTRY OF CLINICAL TRIALS NCT03385837.
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Affiliation(s)
| | | | | | | | | | - Sherry L Grace
- York University, Toronto, Canada
- KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network,University of Toronto, Canada
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Thai NH, Post B, Young G, Noor-E-Alam M. Hospital-Physician Integration and Cardiac Rehabilitation Following Major Cardiovascular Events. JAMA Netw Open 2025; 8:e2462580. [PMID: 40029658 PMCID: PMC11877175 DOI: 10.1001/jamanetworkopen.2024.62580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 12/19/2024] [Indexed: 03/05/2025] Open
Abstract
Importance Cardiac rehabilitation (CR) is a medically supervised program designed to improve heart health after a cardiac event. Despite its demonstrated clinical benefits, CR participation among eligible patients remains poor due to low referral rates and individual barriers to care. Objectives To evaluate CR participation by patients who receive care from hospital-integrated physicians compared with independent physicians, and subsequently, to examine CR and recurrent cardiac hospitalizations. Design, Setting, and Participants This retrospective cohort study evaluated Medicare Part A and Part B claims data from calendar years 2016 to 2019. All analyses were conducted between January 1 and April 30, 2024. Patients were included if they had a qualifying event for CR between 2017 and 2018, and qualifying events were identified using diagnosis codes on inpatient claims and procedure codes on outpatient and carrier claims. Eligible patients also had to continuously enroll in fee-for-service Medicare for 12 months or more before and after the index event. Physicians' integration status and patients' CR participation were determined during the 12-month follow-up period. The study covariates were ascertained during the 12 months before the index event. Exposure Hospital-integration status of the treating physician during follow-up. Main Outcomes and Measures Postindex CR participation was determined by qualifying procedure codes on outpatient and carrier claims. Results The study consisted of 28 596 Medicare patients eligible for CR. Their mean (SD) age was 74.0 (9.6) years; 16 839 (58.9%) were male. A total of 9037 patients (31.6%) were treated by a hospital-integrated physician, of which 2995 (33.1%) received CR during follow-up. Logistic regression via propensity score weighting showed that having a hospital-integrated physician was associated with an 11% increase in the odds of receiving CR (odds ratio [OR], 1.11; 95% CI, 1.05-1.18). Additionally, CR participation was associated with a 14% decrease in the odds of recurrent cardiovascular-related hospitalizations (OR, 0.86; 95% CI, 0.81-0.91). Conclusions and Relevance The findings of this cohort study suggest that hospital integration has the potential to facilitate greater CR participation and improve heart care. Several factors may help explain this positive association, including enhanced care coordination and value-based payment policies. Further research is needed to assess the association of integration with other appropriate high-quality care activities.
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Affiliation(s)
- Ngoc H. Thai
- Center for Health Policy and Healthcare Research, Northeastern University, Boston, Massachusetts
| | - Brady Post
- Center for Health Policy and Healthcare Research, Northeastern University, Boston, Massachusetts
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Gary Young
- Center for Health Policy and Healthcare Research, Northeastern University, Boston, Massachusetts
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
- D’Amore McKim School of Business, Northeastern University, Boston, Massachusetts
| | - Md. Noor-E-Alam
- Center for Health Policy and Healthcare Research, Northeastern University, Boston, Massachusetts
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, Massachusetts
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Hag E, Bäck M, Henriksson P, Wallert J, Held C, Stomby A, Leosdottir M. Associations between cardiac rehabilitation structure and processes and dietary habits after myocardial infarction: a nationwide registry study. Eur J Cardiovasc Nurs 2025; 24:253-263. [PMID: 39743227 DOI: 10.1093/eurjcn/zvae147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 08/23/2024] [Accepted: 10/15/2024] [Indexed: 01/04/2025]
Abstract
AIMS Improved dietary habits are important for successful secondary prevention after myocardial infarction (MI), with counselling and support on healthy dietary habits constituting a cornerstone of cardiac rehabilitation (CR). However, there is limited knowledge on how to optimize CR organization to motivate patients to adopt healthy dietary habits. We aimed to explore associations between CR programme structure, processes, and self-reported dietary habits 1 year post-MI. METHODS AND RESULTS Organizational data from 73 Swedish CR centres and patient-level data from 5248 CR patients were analysed using orthogonal partial least squares discriminant analysis to identify predictors for healthy dietary habits. Variables of importance for the projection (VIP) values exceeding 0.80 were considered meaningful. Key predictors included the CR centre having a medical director [VIP (95% confidence interval)] [1.86 (1.1-2.62)], high self-reported team spirit [1.63 (1.29-1.97)], nurses have formal training in counselling methods [1.20 (0.75-1.65)], providing discharge information on risk factors [2.23 (1.82-2.64)] and lifestyle [1.81 (1.31-2.31)], time dedicated to patient interaction during follow-up [1.60 (0.80-2.40)], and centres aiming for patients to have the same nurse throughout follow-up [1.54 (1.17-1.91)]. The more positive predictors a CR centre reported to follow, the further improvement in patient-level dietary habits, were analysed by multivariable regression analysis [odds ratio for each additional positive predictor reported 1.03 (1.02-1.05), P < 0.001]. CONCLUSION Several variables related to CR structure and processes were identified as predictors for patients reporting healthier dietary habits. These findings offer guidance for CR centres in resource allocation and optimizing patient benefits of CR attendance.
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Affiliation(s)
- Emma Hag
- Department of Internal Medicine, County Hospital Ryhov, Sjukhusgatan, 551 85 Jönköping, Sweden
- Division of Prevention, Department of Health, Medicine and Caring Sciences, Rehabilitation and Community Medicine, Unit of Clinical Medicine, Linköping University, 581 83 Linköping, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Blå Stråket 5, 413 45 Gothenburg, Sweden
- Division of Prevention, Department of Health, Medicine and Caring Sciences, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, 5810 83 Linköping, Sweden
| | - Peter Henriksson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - John Wallert
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, 171 77 Stockholm, Sweden
- Stockholm HealthCare Services, Region Stockholm, Huddinge, Box 45436, 104 31 Stockholm, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala University, Box 148, 751 04 Uppsala, Sweden
| | - Andreas Stomby
- Division of Prevention, Department of Health, Medicine and Caring Sciences, Rehabilitation and Community Medicine, Unit of Clinical Medicine, Linköping University, 581 83 Linköping, Sweden
- Råslätts vårdcentral, Region Jönköping County, Törnskategatan 1, 556 14 Jönköping, Sweden
| | - Margret Leosdottir
- Department of Clinical Sciences Malmö, Lund University, Box 117, 221 00 Lund, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, 205 01 Malmö, Sweden
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Rao SV, O'Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V, Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2025:S0735-1097(24)10424-X. [PMID: 40013746 DOI: 10.1016/j.jacc.2024.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2025]
Abstract
AIM The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease." METHODS A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Rao SV, O'Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V, Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2025. [PMID: 40014670 DOI: 10.1161/cir.0000000000001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
AIM The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease." METHODS A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | - Tanveer Rab
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | | | | | | | | | | | | | - Dmitriy N Feldman
- Society for Cardiovascular Angiography and Interventions representative
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Nowatzke JF, O'Leary JM, Huang S, Wright A, Patterson TL, Bachmann JM. Implementation of a Clinical Decision Support Tool to Improve Cardiac Rehabilitation Referral. J Cardiopulm Rehabil Prev 2025; 45:29-36. [PMID: 39745999 DOI: 10.1097/hcr.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
PURPOSE Inadequate referral to cardiac rehabilitation (CR) is a major barrier to CR participation. We investigated the implementation of a clinical decision support (CDS) tool on improving CR referral for patients hospitalized with acute myocardial infarction (AMI) at an academic medical center. METHODS We developed a CDS tool that identified patients admitted with AMI and reminded physicians to refer patients to CR. We used multivariable-adjusted logistic regression to evaluate predictors of CR referral prior to the CDS tool. We then conducted an interrupted time series (ITS) analysis on CR referral rates before and after intervention. RESULTS A total of 1985 patients admitted with acute MI from December 2014 through March 2023 were included. Prior to CDS implementation, 1218 of 1657 patients (74%) were referred to CR. Multivariable-adjusted logistic regression demonstrated that ST-segment elevation myocardial infarction on arrival (OR = 1.70: 95% CI, 1.29-2.23, P < .001) and percutaneous coronary intervention during the hospitalization (OR = 2.25: 95% CI, 1.60-3.15, P < .001) were associated with a higher odds of CR referral. After implementation of the CDS tool, 308 of 328 patients (94%) received CR referrals. An ITS analysis demonstrated that the increase in CR referral from 74-94% after the CDS tool was highly significant (P < .01). CONCLUSIONS The implementation of a CDS tool reminding physicians to refer patients with AMI to CR markedly improved CR referral rates at our institution. These findings are important for institutions seeking to improve outcomes in patients with AMI.
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Affiliation(s)
- Joseph F Nowatzke
- Author Affiliations: Division of Cardiovascular Medicine (Drs Nowatzke, O'Leary, and Bachmann), Department of Biostatistics (Dr Huang), Department of Biomedical Informatics (Dr Wright), HealthIT (Ms Patterson), Vanderbilt University Medical Center, Nashville, Tennessee and Veterans Affairs Tennessee Valley Healthcare System (Dr Bachmann), Nashville, Tennessee
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Fu WW, Hassett KP, Labaki WW, Valley TS, Thompson MP. Use of Pulmonary Rehabilitation after Chronic Obstructive Pulmonary Disease Hospitalization: An Analysis of Statewide Patient and Hospital Data. Ann Am Thorac Soc 2024; 21:1698-1705. [PMID: 39137381 PMCID: PMC11622827 DOI: 10.1513/annalsats.202402-196oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 08/13/2024] [Indexed: 08/15/2024] Open
Abstract
Rationale: Pulmonary rehabilitation (PR) is a clinically effective and cost-effective outpatient treatment for chronic obstructive pulmonary disease (COPD) that remains highly underused. Existing analyses of PR use patterns have been focused largely on patient characteristics, but hospital-level analysis is lacking and is needed to inform interventions aimed at improving use after COPD hospitalization. Objectives: To evaluate PR use across hospitals after COPD hospitalization in the state of Michigan, with the goal of characterizing hospital-level variation and identifying the characteristics of high-performing hospitals. Methods: This is a retrospective study of patients with COPD hospitalizations between January 1, 2018, and December 31, 2021, using claims data from the Michigan Value Collaborative and hospital data from the American Hospital Association annual survey. Our primary outcome was the initiation of PR within 30 days of discharge. Chi-square tests and analysis of variance were used to test for differences in patient and hospital covariates. Multilevel logistic regression was used to analyze associations between patient covariates and the primary outcome and to characterize hospital-level variation. Results: A total of 36,389 patients and 99 hospitals were included in the analysis. The majority of patients were older than 65 years of age, female, White, and Medicare fee-for-service insured. The rate of PR initiation within 30 days after hospitalization was 0.8%. Adjusted rates of PR initiation by hospital ranged from 0.4% to 2.0%. Compared with the set reference groups, being female, in the fifth Distressed Community Index quintile, and older than 85 years of age independently decreased the odds of initiating PR. Some variation in initiation rate was attributed to the hospital level (7%; intraclass correlation coefficient = 0.07 [95% confidence interval, 0.03-0.15]). The median odds ratio was 1.6 for PR initiation by hospital. Conclusions: Rates of PR initiation after COPD hospitalization are universally low across all hospitals, though there is some variation. Interventions targeted at patients alone are not sufficient to improve use. Hospital-based strategies to improve PR use after discharge, adapted from those being successfully used with cardiac rehabilitation, should be further explored.
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Affiliation(s)
- Whitney W. Fu
- Department of General Surgery
- Center for Healthcare Outcomes and Policy
| | | | - Wassim W. Labaki
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan
| | - Michael P. Thompson
- Center for Healthcare Outcomes and Policy
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, Ann Arbor, Michigan; and
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Khadanga S, Savage P, Keteyian S, Yant B, Gaalema D, Ades P. Cardiac rehabilitation: the gateway for secondary prevention. Heart 2024; 110:1427-1436. [PMID: 38302263 DOI: 10.1136/heartjnl-2023-323152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Cardiac rehabilitation (CR) is a multidisciplinary supervised programme which typically consists of tailored exercise and education on lifestyle management and risk factor modification in cardiac patients. Participation in CR reduces morbidity and mortality, while improving quality of life following major cardiovascular events. Despite the benefits of CR, it is underutilised, generally in the 20%-30% range for eligible patients. Participation and adherence rates are particularly suboptimal in vulnerable populations, such as those of lower socioeconomic status and women. Interventions such as automated referral to CR or hybrid/virtual programmes can increase enrolment to CR. This review summarises the components of CR and provides recommendations for providers regarding participation and adherence. To better engage a larger proportion of CR-eligible patients, CR programmes may need to expand or adjust ways to deliver secondary prevention.
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Affiliation(s)
| | - Patrick Savage
- Medicine, University of Vermont, Burlington, Vermont, USA
| | - Steven Keteyian
- Preventive Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Blair Yant
- Psychiatry, University of Vermont, Burlington, Vermont, USA
| | - Diann Gaalema
- Psychiatry, University of Vermont, Burlington, Vermont, USA
| | - Philip Ades
- Medicine, University of Vermont, Burlington, Vermont, USA
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Pedersen M, Overgaard D, Boateng T, Bennich B, Beck AM, Andersen I, Sibilitz KL, Mairey IP, Thygesen LC, Petersen RA. The Effect of Peer-Mentor Support for Older Vulnerable Patients With Ischemic Heart Disease-A 24-Week Randomized Controlled Trial. J Cardiovasc Nurs 2024:00005082-990000000-00229. [PMID: 39390644 DOI: 10.1097/jcn.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
BACKGROUND The positive effects of cardiac rehabilitation (CR) are well established; however, among older and vulnerable patients, nonattendance and dropout are prevalent problems. AIM The objective of this study is to explore if a 24-week peer-mentor intervention increases initial and long-term CR attendance. Secondary aims are whether peer-mentor intervention improves lifestyle (diet and physical activity) and psychological outcomes (self-efficacy, anxiety, depression, and quality of life) among older vulnerable patients with ischemic heart disease. METHODS The study was designed as a 2-arm, single-center, parallel, 24-week, randomized controlled trial (RCT) with follow-up at 12 and 24 weeks. Patients were randomized at a ratio of 1:1 to receive either the peer-mentor intervention (in addition to standard CR) or standard CR along (control arm). RESULTS Between August 2021 and March 2023, 117 older, vulnerable patients were enrolled and randomized (59 randomized to peer-mentor intervention and 58 to usual care). The peer-mentor intervention significantly increased CR attendance. This applies to both initial participation in 1 CR session of physical training or dietary advice (78.0% vs 58.6%; P = .03), and long-term attendance in ≥50% dietary advice sessions (50.8% vs 27.6%; P = .01) and completed ≥50% (64.4% vs 41.4% P = .01) or ≥75% of the physical training sessions (59.3% vs 37.9%; P = .02). The study found no statistically significant effect on secondary outcomes. CONCLUSIONS Low CR attendance is a well-known problem, especially among older, vulnerable patients; however, we tested a low-cost, peer-mentor intervention that significantly increased both initial CR participation and long-term attendance in CR sessions in this group of patients.
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Rangkla S, Petrutchatachart T, Vitoonpong T, Rattananupong T, Champaiboon J. Exploring the Impediments: Investigating Barriers to Participation in Phase-2 Cardiac Rehabilitation Following Coronary Artery Bypass Graft Among Thai Patients. Health Serv Insights 2024; 17:11786329241287397. [PMID: 39371629 PMCID: PMC11456183 DOI: 10.1177/11786329241287397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 09/11/2024] [Indexed: 10/08/2024] Open
Abstract
Background Despite the known benefits of cardiac rehabilitation (CR), the rate of participation is low following coronary artery bypass graft (CABG). The reasons for this lack of participation are unclear and there have been few studies investigating this, particularly in Asian countries. The present study aimed to address this lack of information and identify reasons for non-participation in phase-2 CR among patients who underwent CABG. Methods We enrolled 42 patients who underwent CABG or CABG combined with valvular heart surgery in a university hospital between October 2016 to September 2018. Patients who participated in phase-1 but not phase-2 CR were interviewed by phone following an 11-item questionnaire. Results The rate of participation in phase-2 CR was only 12.5%. The most frequently reported reason for non-participation was "Did not know that there was phase-2 CR" (61.9%), followed by "Transportation problems" (31%). "Unable to take leave due to work schedule" was fairly frequently reported (19%) as was "Did not participate due to chronic diseases and complications" (14.3%). Conclusion Our study revealed low participation in phase-2 CR, despite its well-known benefits. The primary reason identified was a lack of awareness and understanding among patients regarding phase-2 CR. This highlights the need for targeted interventions aimed at increasing knowledge and awareness of the benefits and availability of CR. Additionally, it is crucial to establish an efficient referral system that ensures seamless transitions from the initial cardiac treatment to the rehabilitation phase. Implementing these strategies is expected to boost CR participation, leading to improved patient outcomes and overall cardiac health.
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Affiliation(s)
- Sarissa Rangkla
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Tanawat Petrutchatachart
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Timporn Vitoonpong
- Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Thanapoom Rattananupong
- Department of Preventive Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jirapa Champaiboon
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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11
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Mansour AI, Seth M, Thompson MP, Casey M, Keteyian SJ, Smith FA, Gurm HS, Sukul D. Use of a Liaison-Mediated Referral Strategy and Participation in Cardiac Rehabilitation After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2024; 17:e010874. [PMID: 39364590 DOI: 10.1161/circoutcomes.124.010874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 08/27/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND Cardiac rehabilitation (CR) improves outcomes following percutaneous coronary intervention (PCI) but remains underutilized. A liaison-mediated referral (LMR), where a health care professional explains CR's benefits, addresses barriers to participation, and places a referral before discharge, may promote CR use. Our objective was to assess the impact of an LMR on CR participation after PCI. METHODS This was a retrospective study of patients who underwent PCI across 48 hospitals in Michigan between January 2021 and April 2022 and referred to CR before discharge. Clinical registry data were linked to administrative claims to identify the primary outcome, CR participation, defined as ≥1 CR session within 90 days of discharge. Bayesian hierarchical logistic regression was used to compare CR participation between patients with and without an LMR. For the secondary outcome, frailty proportional hazard modeling compared days elapsed between discharge and first CR session between liaison cohorts. RESULTS Among 9023 patients referred to CR after PCI, 4323 (47.9%) underwent an LMR (mean age, 69.3 [SD=11] years; 68.3% male) and 3390 (36.7%) attended ≥1 CR session within 90 days of discharge. The LMR cohort had a higher unadjusted CR participation rate (43.1% [95% CI, 41.5%-44.6%] versus 32.4% [95% CI, 31.1%-33.8%]; P<0.001), a higher adjusted odds ratio of attending ≥1 CR session (adjusted odds ratio, 1.21; 95% credible interval, 1.07-1.38), and a shorter delay in attending the first CR session compared with the non-LMR cohort (28 [interquartile range, 19-42] versus 33 [interquartile range, 21-47] days; P<0.001). CONCLUSIONS An LMR was associated with higher odds of CR participation and may mitigate delays in CR enrollment. This referral strategy may improve CR participation and patient outcomes after PCI.
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Affiliation(s)
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine (M.S., M.C., H.S.G., D.S.), University of Michigan, Ann Arbor
| | - Michael P Thompson
- Institute of Healthcare Policy and Innovation (M.T., H.S.G., D.S.), University of Michigan, Ann Arbor
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (M.T.)
- Michigan Value Collaborative, Ann Arbor (M.T.)
| | - Mary Casey
- Department of Internal Medicine, Division of Cardiovascular Medicine (M.S., M.C., H.S.G., D.S.), University of Michigan, Ann Arbor
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Medical Group, Detroit, MI (S.J.K.)
| | - Frank A Smith
- Intensive Cardiac Rehabilitation Program, Trinity Health Ann Arbor and Trinity Health Livingston, MI (F.A.S.)
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine (M.S., M.C., H.S.G., D.S.), University of Michigan, Ann Arbor
- Institute of Healthcare Policy and Innovation (M.T., H.S.G., D.S.), University of Michigan, Ann Arbor
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine (M.S., M.C., H.S.G., D.S.), University of Michigan, Ann Arbor
- Institute of Healthcare Policy and Innovation (M.T., H.S.G., D.S.), University of Michigan, Ann Arbor
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12
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Gadager BB, Tang LH, Doherty P, Svendsen ML, Sibilitz KL, Harrison A, Maribo T. Are cardiac rehabilitation pathways influenced by diabetes: A cohort study. Int J Cardiol 2024; 411:132275. [PMID: 38880427 DOI: 10.1016/j.ijcard.2024.132275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 06/05/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is recommended following acute coronary syndrome (ACS). Diabetes is a common long-term condition associated with ACS, and the inclusion of these patients in CR has been less studied. This study examines the referral, uptake, and completion rates in the CR pathway for ACS patients with and without diabetes to identify potential barriers in the CR pathway. METHODS The study included patients aged 18 or above who were discharged after a diagnosis of ACS in the Central Denmark Region between 1 September 2017 and 31 August 2018. Diabetes information was obtained from three sources. Logistic regression models were used to examine the associations between having diabetes and the three outcomes: non-referral, non-uptake and non-completion. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS A total of 2447 patients were eligible for the study, of which 457 (18.7%) had diabetes. Only non-uptake was found to be significantly associated with diabetes after adjustment for prespecified variables (OR = 1.38, 95% CI 1.01-1.90). Associations for non-referral (OR = 1.11, 95% CI 0.87-1.41) and non-completion (OR = 1.06, 95 %CI 0.73-1.53) were not found to be statistically significant between ACS patients with diabetes and those without diabetes. CONCLUSION This study highlights a significant disparity in the uptake of CR between patients with and without diabetes following ACS, demonstrating that patients with diabetes require early promotion and increased assistance to enrol in CR.
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Affiliation(s)
- Birgitte Bitsch Gadager
- Centre for Rehabilitation Research, Department of Public Health, Aarhus University, Aarhus, Denmark; DEFACTUM, Central Denmark Region, Aarhus, Denmark
| | - Lars Hermann Tang
- The Research and Implementation Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Denmark; The Department of Regional Health Research, University of Southern Denmark, Denmark
| | | | | | | | | | - Thomas Maribo
- Centre for Rehabilitation Research, Department of Public Health, Aarhus University, Aarhus, Denmark; DEFACTUM, Central Denmark Region, Aarhus, Denmark.
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13
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Gaalema DE, Khadanga S, Savage PD, Yant B, Katz BR, DeSarno M, Ades PA. Improving Cardiac Rehabilitation Adherence in Patients With Lower Socioeconomic Status: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:1095-1104. [PMID: 39037811 PMCID: PMC11264079 DOI: 10.1001/jamainternmed.2024.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/27/2024] [Indexed: 07/24/2024]
Abstract
Importance Participation in cardiac rehabilitation is associated with significant decreases in morbidity and mortality. Despite the proven benefits, cardiac rehabilitation is severely underutilized in certain populations, specifically those with lower socioeconomic status (SES). Objective To assess the efficacy of early case management and/or financial incentives for increasing cardiac rehabilitation adherence among patients with lower SES. Design, Setting, and Participants This randomized clinical trial enrolled patients from December 2018 to December 2022. Participants were followed up for 1 year with assessors and cardiac rehabilitation staff blinded to study condition. Patients with lower SES with a cardiac rehabilitation-qualifying diagnosis (myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, heart valve replacement/repair, or stable systolic heart failure) were recruited. Then patients attended one of 3 cardiac rehabilitation programs at 1 university or 2 community-based hospitals. A consecutively recruited sample was randomized and stratified by age (<57 vs ≥57 years) and smoking status (current smoker vs nonsmoker or former smoker). Intervention Participants were randomized 2:3:3:3 to either a usual care control, case management starting in-hospital, financial incentives for completing cardiac rehabilitation sessions, or both interventions (case management plus financial incentives). Interventions were in place for 4 months following informed consent. Main Outcomes and Measures The main outcome was cardiac rehabilitation adherence (proportion of patients completing ≥30 sessions). The a priori hypothesis was that interventions would improve adherence, with the combined intervention performing best. Results Of 314 individuals approached, 11 were ineligible, and 94 declined participation. Of the 209 individuals who were randomized, 17 were withdrawn. A total of 192 individuals (67 [35%] female; mean [SD] age, 58 [11] years) were included in the analysis. Interventions significantly improved cardiac rehabilitation adherence with 4 of 36 (11%), 13 of 51 (25%), 22 of 53 (42%), and 32 of 52 (62%) participants completing at least 30 sessions in the usual care, case management, financial incentives, and case management plus financial incentives conditions, respectively. The financial incentives and case management plus financial incentives conditions significantly improved cardiac rehabilitation adherence vs usual care (adjusted odds ratio [AOR], 5.1 [95% CI, 1.5-16.7]; P = .01; AOR, 13.2 [95% CI, 4.0-43.5]; P < .001, respectively), and the case management plus financial incentives condition was superior to both case management or financial incentives alone (AOR, 5.0 [95% CI, 2.1-11.9]; P < .001; AOR, 2.6 [95% CI, 1.2-5.9]; P = .02, respectively). Interventions were received well by participants: 86 of 105 (82%) in the financial incentives conditions earned at least some incentives, and 96 of 103 participants (93%) assigned to a case manager completed the initial needs assessment. Conclusion and Relevance In this randomized clinical trial, financial incentives improved cardiac rehabilitation adherence in a population with higher risk and lower SES with additional benefit from adding case management. Trial Registration ClinicalTrials.gov Identifier: NCT03759873.
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Affiliation(s)
- Diann E. Gaalema
- Department of Psychiatry, University of Vermont Larner College of Medicine, Burlington
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston
| | - Sherrie Khadanga
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington
| | - Patrick D. Savage
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington
| | - Blair Yant
- Department of Psychiatry, University of Vermont Larner College of Medicine, Burlington
| | - Brian R. Katz
- Department of Psychiatry, University of Vermont Larner College of Medicine, Burlington
| | - Michael DeSarno
- Biomedical Statistics Research Core, University of Vermont, Burlington
| | - Philip A. Ades
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington
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14
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Babu AS, Bhat V, Jose P, Padickaparambil S, Padmakumar R, Jeemon P. Challenges and solutions to implementing cardiac rehabilitation in a low- and middle-income country. Expert Rev Cardiovasc Ther 2024; 22:421-428. [PMID: 39009570 DOI: 10.1080/14779072.2024.2379836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 07/10/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Cardiac rehabilitation (CR) remains greatly underutilized, especially in low- and middle-income countries (LMIC). It is therefore important to explore factors that contribute to this, as perceived by health-care professionals (HCPs). RESEARCH DESIGN AND METHODS This was a qualitative study using in-depth interviews that enrolled 18 HCPs (i.e. six each of physicians, physiotherapists, and nurses; mean experience in CR: 17.9 ± 11.8 yrs) working in cardiovascular care, and CR across private and government hospitals (both teaching and non-teaching) in India. RESULTS The main challenges were related to lack of referrals, perceived lack of benefit from CR, poor infrastructure within hospitals and health systems, and differences in practice. The perceived inadequacies were lack of competencies in CR, limited task sharing strategies, and ineffective utilization of existing human resources. Devising strategies to improve awareness and competencies, facilitating task sharing, and remodeling holistic care with an active CR component may be beneficial to facilitate greater implementation of CR in India. CONCLUSIONS Challenges, inadequacies, and solutions to implementing CR have been explored by involving various HCPs commonly involved in delivering CR across different health systems in a LMIC. TRIAL REGISTRATION www.ctri.nic.in with identifier CTRI/2020/07/026807.
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Affiliation(s)
- Abraham Samuel Babu
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vibha Bhat
- Department of Clinical Psychology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Prinu Jose
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvanathapuram, Kerala, India
| | - Sebastian Padickaparambil
- Department of Clinical Psychology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ramachandran Padmakumar
- Department of Cardiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Panniyammakal Jeemon
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvanathapuram, Kerala, India
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15
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Vazquez-Guajardo M, Rivas D, Duque G. Exercise as a Therapeutic Tool in Age-Related Frailty and Cardiovascular Disease: Challenges and Strategies. Can J Cardiol 2024; 40:1458-1467. [PMID: 38215969 DOI: 10.1016/j.cjca.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/12/2023] [Accepted: 01/07/2024] [Indexed: 01/14/2024] Open
Abstract
Understanding the link between heart disease and frailty in older adults is crucial. Although medical progress has extended life, it has not fully addressed the decline in function and quality of life in frail older people. Frailty is a state of vulnerability to health stressors that needs comprehensive solutions. Its assessment within health care, especially in cardiology, is important owing to its association with worse clinical outcomes. Recent evidence and guidelines suggest that the prescription of a comprehensive exercise regimen, tailored to progressively include strength, balance, mobility, and endurance training improves adherence, functionality, and health-related quality of life, in both acute and chronic cardiovascular diseases. In addition, exercise is a vital tool that improves function, targets frailty, and holistically affects the body's systems. Still, many frail people do not exercise enough, and when they do, they usually do not follow an appropriate plan tailored for better functional outcomes. Overcoming barriers and limitations in exercise enrollment and adherence through strategies such as automated cardiac rehabilitation referral, patient education, and eHealth tools can notably improve clinical outcomes.
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Affiliation(s)
| | - Daniel Rivas
- Bone, Muscle and Geroscience Research Group, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Gustavo Duque
- Bone, Muscle and Geroscience Research Group, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada; Geriatric Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada.
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16
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Graham HL, Asakura Y, Kirby J, Prue-Owens K, Ma J. Exercise Adherence in Older and Middle-Aged Adults With Coronary Artery Disease Before and During COVID-19. J Cardiovasc Nurs 2024; 39:379-389. [PMID: 37249539 DOI: 10.1097/jcn.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Regular exercise is advised for individuals given a diagnosis of cardiovascular disease. COVID-19 presented challenges to exercise adherence. OBJECTIVE The objective of this study was to determine long-term exercise adherence and whether individuals with cardiovascular disease adhered to American Heart Association/American College of Cardiology Foundation guidelines before and during the COVID-19 pandemic. METHODS This is an observational cross-sectional study in which men (73%) and women discharged from a multiwide hospital system after an acute coronary event were enrolled. Participants completed 3 questionnaires, including the Exercise Adherence Rating Scale. RESULTS Five hundred eighty-two individuals (mean [SD] age, 67 [9.8] years) completed the survey. Fifty-three percent of participants met minimum exercise guidelines during COVID-19. Exercise days per week decreased significantly during COVID-19 in women ( P = .013) but not significant for men ( P = .301). Categorized by age, the decrease was significant for middle-aged women ( P = .002), not older women ( P = .336). Men exercised more minutes per session ( P = .034), and had greater exercise adherence ( P = .003) and greater exercise intensity ( P < .001). Overall, women participated less in cardiac rehabilitation ( P = .046) and reported the greatest disparity in exercise adherence and intensity. CONCLUSION Exercise after an acute event is beneficial, and the percentage of individuals meeting recommended guidelines should be higher considering the relationship between exercise and the possibility of future cardiac events. On the basis of the many physical and mental benefits of maintaining exercise, healthcare practitioners are encouraged to screen all patients for exercise adherence with a major emphasis on educating women and older adults.
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17
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Beleigoli A, Foote J, Gebremichael LG, Bulamu NB, Astley C, Keech W, Tavella R, Gulyani A, Nesbitt K, Pinero de Plaza MA, Ramos JS, Ludlow M, Nicholls SJ, Chew DP, Beltrame J, Clark RA. Clinical Effectiveness and Utilisation of Cardiac Rehabilitation After Hospital Discharge: Data Linkage Analysis of 84,064 Eligible Discharged Patients (2016-2021). Heart Lung Circ 2024; 33:1036-1045. [PMID: 38443278 DOI: 10.1016/j.hlc.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Despite the highest levels of evidence on cardiac rehabilitation (CR) effectiveness, its translation into practice is compromised by low participation. AIM This study aimed to investigate CR utilisation and effectiveness in South Australia. METHODS This retrospective cohort study used data linkage of clinical and administrative databases from 2016 to 2021 to assess the association between CR utilisation (no CR received, commenced without completing, or completed) and the composite primary outcome (mortality/cardiovascular re-admissions within 12 months after discharge). Cox survival models were adjusted for sociodemographic and clinical data and applied to a population balanced by inverse probability weighting. Associations with non-completion were assessed by logistic regression. RESULTS Among 84,064 eligible participants, 74,189 did not receive CR, with 26,833 of the 84,064 (31.9%) participants referred. Of these, 9,875 (36.8%) commenced CR, and 7,681 of the 9,875 (77.8%) completed CR. Median waiting time from discharge to commencement was 40 days (interquartile range, 23-79 days). Female sex (odds ratio [OR] 1.12; 95% CI 1.01-1.24; p=0.024), depression (OR 1.17; 95% CI 1.05-1.30; p=0.002), and waiting time >28 days (OR 1.15; 95% CI 1.05-1.26; p=0.005) were associated with higher odds of non-completion, whereas enrolment in a telehealth program (OR 0.35; 95% CI 0.31-0.40; p<0.001) was associated with lower odds of non-completion. Completing CR (hazard ratio [HR] 0.62; 95% CI 0.58-0.66; p<0.001) was associated with a lower risk of 12-month mortality/cardiovascular re-admissions. Commencing without completing was also associated with decreased risk (HR 0.81; 95% CI 0.73-0.90; p<0.001), but the effect was lower than for those completing CR (p<0.001). CONCLUSIONS Cardiac rehabilitation (CR) attendance is associated with lower all-cause mortality/cardiovascular re-admissions, with CR completion leading to additional benefits. Quality improvement initiatives should include promoting referral, women's participation, access to telehealth, and reduction of waiting times to increase completion.
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Affiliation(s)
- Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.
| | - Jonathon Foote
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Lemlem G Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Norma B Bulamu
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Carolyn Astley
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Wendy Keech
- Health Translation SA, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Aarti Gulyani
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | | | - Joyce S Ramos
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Marie Ludlow
- National Heart Foundation of Australia, Adelaide, SA, Australia
| | | | - Derek P Chew
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - John Beltrame
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia; Southern Adelaide Local Health Network, SA, Australia
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18
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Lidin M, Michelsen HÖ, Hag E, Stomby A, Schlyter M, Bäck M, Hagström E, Leosdottir M. The Nurses' Role in the Cardiac Rehabilitation Team: Data From the Perfect-CR Study. J Cardiovasc Nurs 2024:00005082-990000000-00201. [PMID: 38912908 DOI: 10.1097/jcn.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
BACKGROUND Nurses constitute a central profession in the cardiac rehabilitation (CR) team delivering comprehensive CR to individuals with cardiovascular disease. We aimed to identify specific components reflecting the nurses' role in the CR team associated with attainment of risk factor targets post myocardial infarction. METHODS Center-level data (n = 78) was used from the Perfect-CR study, in which structure and processes applied at CR centers in Sweden (including details on the nurses' role) were surveyed. Patient-level data (n = 6755) was retrieved from the SWEDEHEART registry. Associations between structure/processes and target achievement for systolic blood pressure (BP) (<140 mm Hg) and low-density lipoprotein cholesterol (LDL-C, <1.8 mmol/L) at 1 year post myocardial infarction were assessed using logistic regression. RESULTS Structure and processes reflecting nurses' autonomy and role in the CR team associated with patients achieving systolic BP and/or LDL-C targets included the following: nurses having treatment algorithms to adjust BP medication (odds ratio [95% confidence interval]: systolic BP, 1.22 [1.05-1.42]; LDL-C, 1.17 [1.03-1.34]) and lipid-lowering medication (systolic BP, 1.14 [1.00-1.29]; LDL-C, 1.17 [1.05-1.30]), patients having the same nurse throughout follow-up (systolic BP, 1.07 [1.03-1.11]; LDL-C, 1.10 [1.06-1.14]), number of follow-up hours with a nurse (systolic BP, 1.13 [1.07-1.19]), having regular case rounds to discuss patient cases during follow-up (LDL-C, 1.22 [1.09-1.35]), and nurses having training in counseling methods (systolic BP, 1.06 [1.03-1.10]). CONCLUSION Components reflecting CR nurses' autonomy and role in the team are of importance for patients attaining risk factor targets post myocardial infarction. The results could provide guidance for optimizing nurses' competence and responsibilities within the CR team to improve patient care.
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19
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Rasmussen B, Maribo T, Skovsby Toft B. The content and characteristics of face-to-face interventions to encourage patients' enrollment in cardiac rehabilitation; a scoping review. Disabil Rehabil 2024; 46:2734-2746. [PMID: 37480155 DOI: 10.1080/09638288.2023.2236014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/07/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To provide an overview of the content and characteristics of face-to-face interventions to encourage enrollment in exercise-based cardiac rehabilitation (CR). METHODS Following a published protocol describing the methods, six databases were searched. The search was limited to studies published from January 2000 to December 2021. Two reviewers independently performed study selection and data extraction. RESULTS 5583 studies were identified and 20 studies with a variety of study designs met the inclusion criteria. Eight studies specified important content in face-to-face interventions to be: Education, problem-solving, support of autonomy, exploring reasons for change, emotional and cognitive support while showing understanding. Studies targeting patients' experiences used motivational interviewing and addressed worries and anticipated difficulties. Intention to attend, CR barriers, practical barriers, exercise self-efficacy, and patients asking questions supported enrollment. Reassurance could lead to nonattendance if patients had a high degree of worry and distress. CONCLUSION Face-to-face interventions are important to support patients' enrollment in CR and should integrate a person-centered dialogue exploring reasons for change and providing support to overcome barriers. Focus on the patients' perspectives, the mechanisms of change, and the evaluation of the intervention to inform implementation should be further explored.Implications for RehabilitationIn-hospital face-to-face interventions support enrollment in cardiac rehabilitation (CR) in patients with ischemic heart disease.This study suggests that individual worries and barriers toward CR should be jointly explored while considering patients' capacity for making choices as well as their vulnerability.Patients should be encouraged to ask questions.A too strong focus on reassurance and problem-solving can impede enrollment.
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Affiliation(s)
- Birgit Rasmussen
- Department of Physio- and Occupational Therapy, Horsens Regional Hospital, Horsens, Denmark
| | - Thomas Maribo
- Department of Public Health, Aarhus University, Aarhus, Denmark
- DEFACTUM - Social & Health Services and Labour Market, Corporate Quality, Aarhus, Denmark
| | - Bente Skovsby Toft
- Research Centre for Patient Involvement, Aarhus University Hospital, Aarhus, Denmark
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20
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Whitler C, Varkoly KS, Patel H, Assaf AD, Hoose J, Brannan GD, Miller R, Zughaib M. Improved Cardiac Rehabilitation Referral Rate Utilizing a Multidisciplinary Quality Improvement Team. Cureus 2024; 16:e61157. [PMID: 38933616 PMCID: PMC11200930 DOI: 10.7759/cureus.61157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.
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Affiliation(s)
- Cameron Whitler
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Kyle S Varkoly
- Department of Internal Medicine, McLaren Macomb Hospital, Mount Clemens, USA
| | - Harshil Patel
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Andrew D Assaf
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Jennifer Hoose
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Grace D Brannan
- Department of Research, GDB Research and Statistical Consulting, Athens, USA
| | - Ronald Miller
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Marcel Zughaib
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
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Iyngkaran P, Appuhamilage PY, Patabandige G, Sarathchandra Peru Kandage PS, Usmani W, Hanna F. Barriers to Cardiac Rehabilitation among Patients Diagnosed with Cardiovascular Diseases-A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:339. [PMID: 38541338 PMCID: PMC10970436 DOI: 10.3390/ijerph21030339] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are a rising global burden. Preventative strategies such as cardiac rehabilitation (CR) have shown a marked reduction in disease burden. Despite this, CR is underutilized worldwide. This study aims to identify the barriers to CR among patients diagnosed with CVD. METHODS A scoping review of the literature was conducted following the Joanna Briggs Institute (JBI) guidelines. Four major databases, including CINAHL, PubMed, EBSCOhost, and Scopus, were used to obtain studies published between 2010 and 2023. Search terms such as "Cardiac rehab*", "Barrier*", "Cardiovascular", "Disease", and "diagnosis*" were utilized in order to obtain subject-specific studies relevant to the research question. RESULTS From the initial 2098 studies, only 14 were included in the final analysis, consisting of both qualitative and quantitative designs. The thematic analysis included "healthcare system-related factors", "Socioeconomic factors", and "individual characteristics". Healthcare system-related factors were mostly related to the poor availability of CR programs, lack of proper referral strategies, inadequate knowledge of CR provider and inter-provider communication issues, and lack of alternative methods of CR delivery. The socioeconomic barriers were lack of education, longer distance to CR facilities, high cost of care, unemployment, and poor income status. The identified individual characteristics were female gender, older age, and comorbidities. CONCLUSIONS Lack of resources, poor access, educational attainment, and high cost of care were some of the barriers to CR, particularly in low- and middle-income countries (LMICs). Health policymakers and healthcare providers should implement strategies incorporating the issues identified in this scoping review. Systematic reviews may be required to confirm these findings.
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Affiliation(s)
- Pupalan Iyngkaran
- Torrens University Australia, Melbourne, VIC 3000, Australia
- University of Notre Dame, Melbourne, VIC 3000, Australia
| | - Pavithra Yapa Appuhamilage
- Program of Public Health, Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.Y.A.); (G.P.); (P.S.S.P.K.)
| | - Gayani Patabandige
- Program of Public Health, Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.Y.A.); (G.P.); (P.S.S.P.K.)
| | | | - Wania Usmani
- Program of Public Health, Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.Y.A.); (G.P.); (P.S.S.P.K.)
| | - Fahad Hanna
- Program of Public Health, Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.Y.A.); (G.P.); (P.S.S.P.K.)
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22
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Schmidt AM, Bloch‐Nielsen JR, Nørgaard H, Hannibal L, Jensen SHJ, Tang LH, Rolving N. A novel referral strategy to enhance the enrollment of patients with heart failure in cardiac rehabilitation: A feasibility study. Health Sci Rep 2024; 7:e1961. [PMID: 38469113 PMCID: PMC10925803 DOI: 10.1002/hsr2.1961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/25/2024] [Accepted: 02/07/2024] [Indexed: 03/13/2024] Open
Abstract
Background and Aims Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well-documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure. Methods This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15-20 min face-to-face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi-structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate. Results Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety-one percent data completeness was achieved. The intervention was well-accepted by patients and health care professionals. The enrollment rate reached 79%. Conclusion The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full-scale trial. The novel referral strategy was well-accepted, and enrollment rate approached an acceptable level.
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Affiliation(s)
- Anne Mette Schmidt
- Medical Diagnostic CenterUniversity Research Clinic for Innovative Patient PathwaysSilkeborgDenmark
| | | | - Helene Nørgaard
- Department of Physio‐ and Occupational Therapy, Diagnostic CenterSilkeborg Regional HospitalDenmark
| | - Loui Hannibal
- Department of Physio‐ and Occupational Therapy, Diagnostic CenterSilkeborg Regional HospitalDenmark
| | - Sarah Holm Junge Jensen
- Medical Diagnostic CenterUniversity Research Clinic for Innovative Patient PathwaysSilkeborgDenmark
| | - Lars Hermann Tang
- Department of Physiotherapy and Occupational Therapy, Næstved‐Ringsted‐Slagelse HospitalThe Research Unit PROgrezSlagelseDenmark
- The Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Nanna Rolving
- Department of Physiotherapy and Occupational TherapyAarhus University HospitalAarhus NDenmark
- Department of Public HealthAarhus UniversityAarhus CDenmark
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23
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Thomas RJ. Cardiac Rehabilitation - Challenges, Advances, and the Road Ahead. N Engl J Med 2024; 390:830-841. [PMID: 38416431 DOI: 10.1056/nejmra2302291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Randal J Thomas
- From the Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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24
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Puri SN, Lalwani L. A Comparison Between Cardiac Telerehabilitation Program and Outpatient Hospital-Based Cardiac Rehabilitation Program for Patients Undergoing Coronary Artery Bypass Graft (CABG) Surgery: A Review. Cureus 2023; 15:e48488. [PMID: 38073989 PMCID: PMC10704402 DOI: 10.7759/cureus.48488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/08/2023] [Indexed: 06/09/2024] Open
Abstract
Coronary artery disease (CAD) is a prevalent and possibly fatal cardiovascular ailment, and it is treated surgically by coronary artery bypass grafting (CABG). The coronary arteries, which supply the heart with oxygen and nutrients, are the most commonly affected. Even though CABG is a frequently employed procedure to restore cardiac blood flow, prolonged rehabilitation is necessary for long-term success. For patients with heart disease, cardiac rehabilitation (CR) involves a comprehensive therapeutic approach. It consists of risk mitigation, regular exercise, health education, and efficient stress management. Information and communication technology is used in telerehabilitation (TR), a rehabilitation service that offers a flexible choice that improves self-management. This study examined novel approaches and effective intervention elements while comparing cardiac TR with center-based programs in terms of risk factor management, patient commitment, and satisfaction.
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Affiliation(s)
- Saurabh N Puri
- Department of Cardiorespiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education And Research (DU), Wardha, IND
| | - Lajwanti Lalwani
- Department of Cardiorespiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education And Research (DU), Wardha, IND
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25
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Talha KM, Pandey A, Fudim M, Butler J, Anker SD, Khan MS. Frailty and heart failure: State-of-the-art review. J Cachexia Sarcopenia Muscle 2023; 14:1959-1972. [PMID: 37586848 PMCID: PMC10570089 DOI: 10.1002/jcsm.13306] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/16/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.
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Affiliation(s)
- Khawaja M. Talha
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Ambarish Pandey
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Marat Fudim
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
- Baylor Scott and White Research InstituteDallasTXUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center CharitéInstitute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité UniversitätsmedizinBerlinGermany
- Institute of Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - Muhammad Shahzeb Khan
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
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26
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Keshvani N, Subramanian V, Wrobel CA, Solomon N, Alhanti B, Greene SJ, DeVore A, Yancy C, Allen LA, Fonarow GC, Pandey A. Patterns of Referral and Postdischarge Utilization of Cardiac Rehabilitation Among Patients Hospitalized With Heart Failure: An Analysis From the GWTG-HF Registry. Circ Heart Fail 2023; 16:e010144. [PMID: 37431671 PMCID: PMC11092317 DOI: 10.1161/circheartfailure.122.010144] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 05/10/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Coverage for cardiac rehabilitation (CR) for patients with heart failure with reduced ejection fraction was expanded in 2014, but contemporary referral and participation rates remain unknown. METHODS Patients hospitalized for heart failure with reduced ejection fraction (≤35%) in the American Heart Association Get With The Guidelines-Heart Failure registry from 2010 to 2020 were included, and CR referral status was described as yes, no, or not captured. Temporal trends in CR referral were assessed in the overall cohort. Patient and hospital-level predictors of CR referral were assessed using multivariable-adjusted logistic regression models. Additionally, CR referral and proportional utilization of CR within 1-year of referral were evaluated among patients aged >65 years with available Medicare administrative claims data who were clinically stable for 6-weeks postdischarge. Finally, the association of CR referral with the risk of 1-year death and readmission was evaluated using multivariable-adjusted Cox models. RESULTS Of 69,441 patients with heart failure with reduced ejection fraction who were eligible for CR (median age 67 years; 33% women; 30% Black), 17,076 (24.6%) were referred to CR, and referral rates increased from 8.1% in 2010 to 24.1% in 2020 (Ptrend<0.001). Of 8310 patients with Medicare who remained clinically stable 6-weeks after discharge, the CR referral rate was 25.8%, and utilization of CR among referred patients was 4.1% (mean sessions attended: 6.7). Patients not referred were more likely to be older, of Black race, and with a higher burden of comorbidities. In adjusted analysis, eligible patients with heart failure with reduced ejection fraction who were referred to CR (versus not referred) had a lower risk of 1-year death (hazard ratio, 0.84 [95% CI, 0.70-1.00]; P=0.049) without significant differences in 1-year readmission. CONCLUSIONS CR referral rates have increased from 2010 to 2020. However, only 1 in 4 patients are referred to CR. Among eligible patients who received CR referral, participation was low, with <1 of 20 participating in CR.
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Affiliation(s)
- Neil Keshvani
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX
- Parkland Health and Hospital System, Dallas, TX
| | - Vinayak Subramanian
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX
- Parkland Health and Hospital System, Dallas, TX
| | | | | | | | - Stephen J. Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Adam DeVore
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Clyde Yancy
- Northwestern University Medical School, Chicago, IL
| | | | | | - Ambarish Pandey
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX
- Parkland Health and Hospital System, Dallas, TX
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27
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White DA, Layton AM, Curran T, Gauthier N, Orr WB, Ward K, Vernon M, Martinez MN, Rice MC, Hansen K, Prusi M, Hansen JE. ehealth technology in cardiac exercise therapeutics for pediatric patients with congenital and acquired heart conditions: a summary of evidence and future directions. Front Cardiovasc Med 2023; 10:1155861. [PMID: 37332590 PMCID: PMC10272804 DOI: 10.3389/fcvm.2023.1155861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/18/2023] [Indexed: 06/20/2023] Open
Abstract
Many children and adolescents with congenital and acquired heart disease (CHD) are physically inactive and participate in an insufficient amount of moderate-to-vigorous intensity exercise. Although physical activity (PA) and exercise interventions are effective at improving short- and long-term physiological and psychosocial outcomes in youth with CHD, several barriers including resource limitations, financial costs, and knowledge inhibit widespread implementation and dissemination of these beneficial programs. New and developing eHealth, mHealth, and remote monitoring technologies offer a potentially transformative and cost-effective solution to increase access to PA and exercise programs for youth with CHD, yet little has been written on this topic. In this review, a cardiac exercise therapeutics (CET) model is presented as a systematic approach to PA and exercise, with assessment and testing guiding three sequential PA and exercise intervention approaches of progressive intensity and resource requirements: (1) PA and exercise promotion within a clinical setting; (2) unsupervised exercise prescription; and (3) medically supervised fitness training intervention (i.e., cardiac rehabilitation). Using the CET model, the goal of this review is to summarize the current evidence describing the application of novel technologies within CET in populations of children and adolescents with CHD and introduce potential future applications of these technologies with an emphasis on improving equity and access to patients in low-resource settings and underserved communities.
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Affiliation(s)
- David A. White
- Ward Family Heart Center, Children’s Mercy Kansas City, Kansas City, MO, United States
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, United States
| | - Aimee M. Layton
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Tracy Curran
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Naomi Gauthier
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - William B. Orr
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Kendra Ward
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Meg Vernon
- Division of Cardiology, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA, United States
| | - Matthew N. Martinez
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, United States
| | - Malloree C. Rice
- Division of Pediatric Cardiology, Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Katherine Hansen
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Megan Prusi
- Division of Pediatric Cardiology, Department of Pediatrics, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
| | - Jesse E. Hansen
- Division of Pediatric Cardiology, Department of Pediatrics, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
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28
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Kotejoshyer R, Eve J, Priya A, Mazor K, Spitzer KA, Pekow PS, Pack QR, Lindenauer PK. Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY. J Cardiopulm Rehabil Prev 2023; 43:192-197. [PMID: 36137210 PMCID: PMC10148891 DOI: 10.1097/hcr.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD. METHODS A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors. RESULTS Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy. CONCLUSIONS This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.
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Affiliation(s)
- Rajashree Kotejoshyer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield (Drs Kotejoshyer, Eve, Spitzer, Pekow, Pack, and Lindenauer and Ms Priya); University of Massachusetts Chan Medical School, Worcester (Dr Mazor); and UMass Donahue Institute, Amherst, Massachusetts (Dr Spitzer)
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29
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Beatty AL, Beckie TM, Dodson J, Goldstein CM, Hughes JW, Kraus WE, Martin SS, Olson TP, Pack QR, Stolp H, Thomas RJ, Wu WC, Franklin BA. A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities. Circulation 2023; 147:254-266. [PMID: 36649394 PMCID: PMC9988237 DOI: 10.1161/circulationaha.122.061046] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.
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Affiliation(s)
- Alexis L Beatty
- Department of Epidemiology and Biostatistics (A.L.B.), University of California, San Francisco.,Department of Medicine, Division of Cardiology (A.L.B.), University of California, San Francisco
| | - Theresa M Beckie
- College of Nursing (T.M.B.), University of South Florida, Tampa.,College of Medicine, Division of Cardiovascular Sciences (T.M.B.), University of South Florida, Tampa
| | - John Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine (J.D.), New York University School of Medicine, New York.,Department of Population Health (J.D.), New York University School of Medicine, New York
| | - Carly M Goldstein
- The Weight Control and Diabetes Research Center, the Miriam Hospital, Providence, RI (C.M.G.).,Department of Psychiatry and Human Behavior, The Warren Alpert Medical School (C.M.G.), Brown University, Providence, RI
| | - Joel W Hughes
- Department of Psychological Sciences, Kent State University, OH (J.W.H.)
| | - William E Kraus
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC (W.E.K.)
| | - Seth S Martin
- Department of Medicine, Division of Cardiology, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (S.S.M.)
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic, Rochester, MN (T.P.O., R.J.T.)
| | - Quinn R Pack
- Department of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield (Q.R.P.)
| | - Haley Stolp
- ASRT, Inc, Atlanta, GA (H.S.).,Centers for Disease Control and Prevention, Atlanta, GA (H.S.)
| | - Randal J Thomas
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic, Rochester, MN (T.P.O., R.J.T.)
| | - Wen-Chih Wu
- Lifespan Cardiovascular Institute (W.-C.W.), Brown University, Providence, RI.,Division of Cardiology, Providence VA Medical Center, RI (W.-C.W.)
| | - Barry A Franklin
- William Beaumont Hospital, Royal Oak, MI (B.A.F.).,Oakland University William Beaumont School of Medicine, Rochester, MI (B.A.F.)
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30
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Factors Associated With Participation Rate and Predictive of Improvement After Cardiac Rehabilitation in Patients With Heart Failure. J Cardiopulm Rehabil Prev 2023; 43:49-54. [PMID: 35836335 DOI: 10.1097/hcr.0000000000000708] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Patients with heart failure (HF) are often limited in their ability to perform exercise. Cardiac rehabilitation (CR) improves aerobic capacity and quality of life (QOL) and is recommended for patients with clinically stable HF; however, it is underutilized. The aim of this study was to investigate the factors associated with participation and completion rates and predictive of improvement after phase II CR in patients with HF. METHODS Participation and completion rates were calculated for all patients with HF enrolled in a multidisciplinary management program from October 2008 to December 2018. Functional capacity and QOL were estimated. In patients undergoing CR, changes in peak oxygen uptake (V˙ o2peak ) were measured. RESULTS Of 662 patients enrolled, 448 (68%) completed the cardiopulmonary exercise test (CPX). Phase II CR was recommended in 411 patients, of whom 291 (71%) participated in CR. Participation was significantly related to sex and the time interval in days between hospital discharge and the CPX. Overall, 171 patients completed 36 sessions of CR (with a completion rate of 59%). During CR, there were 18 (6%) adverse events. Cardiac rehabilitation was associated with improvement in V˙ o2peak from 1153 ± 393 to 1342 ± 470 mL/min (a 16% improvement; P < .001) and in QOL. The independent predictors of increase in V˙ o2peak included sex, age, diabetes mellitus, and entry V˙ o2peak . CONCLUSIONS In patients with HF, factors associated with CR participation rate included sex and days between hospital discharge and the CPX. Participation in CR improved V˙ o2peak and QOL. The improvement was related to male sex, younger age, no diabetes mellitus, and higher entry V˙ o2peak .
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31
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Kim C, Kwak HB, Sung J, Han JY, Lee JW, Lee JH, Kim WS, Bang HJ, Baek S, Joa KL, Kim AR, Lee SY, Kim J, Kim CR, Kwon OP, Sohn MK, Moon CW, Lee JI, Jee S. A survey of the perceptions of barriers to and facilitators of cardiac rehabilitation in healthcare providers and policy stakeholders. BMC Health Serv Res 2022; 22:999. [PMID: 35932056 PMCID: PMC9356496 DOI: 10.1186/s12913-022-08298-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background Cardiac rehabilitation (CR) is a prognostic management strategy to help patients with CVD achieve a good quality of life and lower the rates of recurrence, readmission, and premature death from disease. Globally, cardiac rehabilitation is poorly established in hospitals and communities. Hence, this study aimed to investigate the discrepancies in the perceptions of the need for CR programs and relevant health policies between directors of hospitals and health policy personnel in South Korea to shed light on the status and to establish practically superior and effective strategies to promote CR in South Korea. Methods We sent a questionnaire to 592 public health policy managers and directors of selected hospitals, 132 of whom returned a completed questionnaire (response rate: 22.3%). The participants were categorized into five types of organizations depending on their practice of PCI (Percutaneous Coronary Intervention), establishment of cardiac rehabilitation, director of hospital, and government's policy makers. Differences in the opinions between directors of hospitals that perform/do not perform PCI, directors of hospitals with/without cardiac rehabilitation, and between hospital directors and health policy makers were analyzed. Results Responses about targeting diseases for cardiac rehabilitation, patients’ roles in cardiac rehabilitation, hospitals’ roles in cardiac rehabilitation, and governmental health policies’ roles in cardiac rehabilitation were more positive among hospitals that perform PCI than those that do not. Responses to questions about the effectiveness of cardiac rehabilitation and hospitals’ roles in cardiac rehabilitation tended to be more positive in hospitals with cardiac rehabilitation than in those without. Hospital directors responded more positively to questions about targeting diseases for cardiac rehabilitation and governmental health policies’ roles in cardiac rehabilitation than policy makers, and both hospitals and public organizations provided negative responses to the question about patients’ roles in cardiac rehabilitation. Responses to questions about targeting diseases for cardiac rehabilitation, patients’ roles in cardiac rehabilitation, and governmental health policies’ roles in cardiac rehabilitation were more positive in hospitals that perform PCI than those that do not and public organizations. Conclusions Hospitals must ensure timely referral, provide education, and promote the need for cardiac rehabilitation. In addition, governmental socioeconomic support is needed in a varity of aspects. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08298-3.
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Affiliation(s)
- Chul Kim
- Department of Rehabilitation Medicine, Inje University Sanggye Paik Hospital, Seoul, South Korea
| | - Hae-Bin Kwak
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Chungnam National Univeristy College of Medicine, Daejeon, South Korea
| | - Jidong Sung
- Division of Cardiology, Department of Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae-Young Han
- Department of Physical Medicine and Rehabilitation, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Jang Woo Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Jong Hwa Lee
- Department of Physical Medicine and Rehabilitation, Dong-A University College of Medicine, Busan, South Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Heui Je Bang
- Department of Rehabilitation Medicine, Chungbuk National University, College of Medicine, Cheongju, South Korea
| | - Sora Baek
- Department of Rehabilitation Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Kyung Lim Joa
- Department of Physical Medicine and Rehabilitation, Inha University Hospital, Incheon, South Korea
| | - Ae Ryoung Kim
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - So Young Lee
- Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, South Korea
| | - Jihee Kim
- Department of Rehabilitation Medicine, Wonkwang University Hospital, Wonkwang University Medical School, Iksan, South Korea
| | - Chung Reen Kim
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Oh Pum Kwon
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Chungnam National Univeristy College of Medicine, Daejeon, South Korea
| | - Chang-Won Moon
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Chungnam National Univeristy College of Medicine, Daejeon, South Korea
| | - Jae-In Lee
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Chungnam National Univeristy College of Medicine, Daejeon, South Korea
| | - Sungju Jee
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Chungnam National Univeristy College of Medicine, Daejeon, South Korea.
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Parry M, Van Spall HG, Mullen KA, Mulvagh SL, Pacheco C, Colella TJ, Clavel MA, Jaffer S, Foulds HJ, Grewal J, Hardy M, Price JA, Levinsson AL, Gonsalves CA, Norris CM. The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 6: Sex- and Gender-Specific Diagnosis and Treatment. CJC Open 2022; 4:589-608. [PMID: 35865023 PMCID: PMC9294990 DOI: 10.1016/j.cjco.2022.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/12/2022] [Indexed: 10/26/2022] Open
Abstract
This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed.
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Affiliation(s)
- Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Harriette G.C. Van Spall
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Research Institute of St. Joe’s, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kerri-Anne Mullen
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Tracey J.F. Colella
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- KITE, Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de pneumologie de Québec— Université Laval, Quebec City, Quebec, Canada
| | - Shahin Jaffer
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jasmine Grewal
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marsha Hardy
- Canadian Women's Heart Health Alliance, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Kottke TE, Gupta AK, Thomas RJ. Failing Cardiovascular Health. J Am Coll Cardiol 2022; 80:152-154. [DOI: 10.1016/j.jacc.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 10/17/2022]
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Miralles-Resurreccion KV, Grace SL, Cuenza LR. Trends in cardiac rehabilitation enrollment post-coronary artery bypass grafting upon implementation of automatic referral in Southeast Asia: A retrospective cohort study. J Cardiovasc Thorac Res 2022; 14:84-89. [PMID: 35935385 PMCID: PMC9339729 DOI: 10.34172/jcvtr.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cardiac rehabilitation (CR) is an effective but underutilized intervention. Strategies have been identified to increase its use, but there is paucity of data testing them in low-resource settings. We sought to determine the effect of automatic referral post-coronary artery bypass graft (CABG) surgery on CR enrollment.
Methods: This is a retrospective cohort study assessing cardiac patients referred to CR at a tertiary center in Southeast Asia from 2013 to 2019. The paper-based pathway was introduced at the end of 2012. The checklist with automatic CR referral on the third day post-operation prompted a nurse to educate the patient about CR, initiate phase 1 and encourage enrollment in phase 2. Patients who were not eligible for the pathway for administrative or clinical reasons were referred at the discretion of the attending physician (i.e., usual care). Enrollment was defined as attendance at≥1 CR visit. Results: Of 4792 patients referred during the study period, 394 enrolled in CR. Significantly more patients referred automatically enrolled compared to usual care (225 [11.8%] vs. 169 [5.8%]; OR=2.2, 95% CI=1.8-2.7), with increases up to 23.4% enrollment in 2014 (vs. average enrollment rate of 5.9% under usual referral). Patients who enrolled following automatic referral were significantly younger and more often employed (both P<0.001); no other differences were observed. Conclusion: In a lower-resource, Southeast Asian setting, automatic CR referral is associated with over two times greater enrollment in phase 2 CR, although efforts to maintain this effect are required.
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Affiliation(s)
| | - Sherry L. Grace
- York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada
| | - Lucky R. Cuenza
- Section of Cardiac Rehabilitation, Philippine Heart Center, Quezon City, Philippines
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Mathews L, Akhiwu O, Mukherjee M, Blumenthal RS, Matsushita K, Ndumele CE. Disparities in the Use of Cardiac Rehabilitation in African Americans. CURRENT CARDIOVASCULAR RISK REPORTS 2022; 16:31-41. [PMID: 35573267 PMCID: PMC9077032 DOI: 10.1007/s12170-022-00690-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/03/2022]
Abstract
Purpose of review Cardiac rehabilitation (CR) is a comprehensive outpatient program that reduces the risk of mortality and recurrent events and improves functional status and quality of life for patients recovering from acute cardiovascular disease (CVD) events. Among individuals with established CVD, African Americans have a higher risk of major cardiac events, which underscores the importance of CR use among African Americans. However, despite their high likelihood of adverse outcomes, CR is poorly utilized in African Americans with CVD. We review data on CR utilization among African Americans, barriers to participation, and the implications for policy and practice. Recent findings Although established as a highly effective secondary prevention strategy, CR is underutilized in general, but especially by African Americans. Notwithstanding efforts to increase CR participation among all groups, participation rates remain low for African Americans and other minorities compared to Non-Hispanic Whites. The low CR participation rates by African Americans can be attributed to an array of factors including differential referral patterns, access to care, and socioeconomic factors. There are several promising strategies to improve CR participation which include promoting evidence-based guidelines, reducing barriers to access, novel CR delivery modalities, including more African Americans in CR clinical research, and increasing diversity in the CR workforce. Summary African Americans with CVD events are less likely to be referred to, enroll in, and complete CR than Non-Hispanic Whites. There are many factors that impact CR participation by African Americans. Initiatives at the health policy, health system, individual, and community level will be needed to reduce these disparities in CR use.
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Affiliation(s)
- Lena Mathews
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins School of Medicine, Baltimore, MD USA
- Division of Cardiology, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
| | - Ofure Akhiwu
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
| | - Roger S. Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD USA
- Division of Cardiology, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
| | - Kunihiro Matsushita
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins School of Medicine, Baltimore, MD USA
- Division of Cardiology, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA
| | - Chiadi E. Ndumele
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins School of Medicine, Baltimore, MD USA
- Division of Cardiology, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21218 USA
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Gómez González L, Supervia M, Medina-Inojosa JR, Smith JR, López Blanco ME, Miranda Vivas MT, López-Jiménez F, Arroyo-Riaño MO. Predictors of Rehabilitation Referral Among Cardiovascular Surgical Patients. Front Cardiovasc Med 2022; 9:848610. [PMID: 35592404 PMCID: PMC9110648 DOI: 10.3389/fcvm.2022.848610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/17/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Cardiovascular disease (CVD) continues to be the leading cause of mortality globally. Cardiac rehabilitation (CR) programs act by modifying the evolution of CVD and mortality; however, CR programs are under-used. The aim was to determine the profile of patients that received rehabilitation after cardiac surgery. Patients and Methods A retrospective observational study was conducted from January 2017 to December 2017 at a single center. The study sample was chosen among patients admitted to the Intensive Care Unit of the Hospital Gregorio Marañón/Gregorio Marañón General University Hospital. Socio-demographic and clinical variables were collected. Results In the present study, 336 patients underwent cardiac surgery of which 63.8% were men and 87.1% had ≥1 cardiovascular risk factors. Of the total cohort, 24.7% were operated for ischemic heart disease, 47.9% valvulopathy, 11% underwent combined surgery, 3.6% cardiac transplantation, 6.5% aneurysms, and 3.9% congenital disease. In-hospital respiratory rehabilitation was prescribed to all patients. Only 4.8% of the patients received motor rehabilitation and 13.8% were referred to CR. We found higher referral rates among patients with more cardiovascular risk factors, <65 years of age, and those undergoing coronary surgery and heart transplantation. Age, ischemic heart disease, and overweight were independent predictors of CR referral. Conclusion The benefit of CR programs after cardiac surgery is widely described; however, the referral rate to CR remains low. It is crucial to optimize referral protocols for these patients.
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Affiliation(s)
- Laura Gómez González
- Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
- *Correspondence: Laura Gómez González,
| | - Marta Supervia
- Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - José R. Medina-Inojosa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
- Amita St. Joseph Hospital Internal Medicine Residency Program, University of Illinois Chicago, Chicago, IL, United States
| | - Joshua R. Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - M. Esther López Blanco
- Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - M. Teresa Miranda Vivas
- Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | | | - M. Olga Arroyo-Riaño
- Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
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Abstract
Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Randal J Thomas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Shane M Hammer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Borges GLB, da Cruz MMA, Ricci-Vitor AL, da Silva PF, Grace SL, Vanderlei LCM. Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study. SAO PAULO MED J 2022; 140:108-114. [PMID: 35043870 PMCID: PMC9623829 DOI: 10.1590/1516-3180.2020.0782.r1.31052021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/31/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges. OBJECTIVE To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence. DESIGN AND SETTING Observational, cross-sectional study in public and private CR programs offered in Brazil. METHODS Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale. RESULTS From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012). CONCLUSION Publicly funded programs need to be tailored to meet their patients' requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.
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Affiliation(s)
- Giovanna Lombardi Bonini Borges
- PT. Physiotherapist, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
| | - Mayara Moura Alves da Cruz
- PT, MSc. Physiotherapist and Doctoral Student, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
| | - Ana Laura Ricci-Vitor
- PT, PhD. Professor, Escola Superior de Saúde Egas Moniz (ESSEM), Egas Moniz - Cooperativa de Ensino Superior (CRL), Almada, Setúbal, Portugal.
| | - Paula Fernanda da Silva
- PT. Physiotherapist and Master's Student, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
| | - Sherry Lynn Grace
- PhD, CRFC. Professor, Faculty of Health, York University, Toronto, Ontario, Canada; and Senior Scientist, KITE & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Luiz Carlos Marques Vanderlei
- PhD. Professor, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
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Ades PA, Khadanga S, Savage PD, Gaalema DE. Enhancing participation in cardiac rehabilitation: Focus on underserved populations. Prog Cardiovasc Dis 2022; 70:102-110. [PMID: 35108567 PMCID: PMC9119375 DOI: 10.1016/j.pcad.2022.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 02/07/2023]
Abstract
Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.
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Affiliation(s)
- Philip A Ades
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America.
| | - Sherrie Khadanga
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| | - Patrick D Savage
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| | - Diann E Gaalema
- Department of Psychiatry, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
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Alfaraidhy MA, Regan C, Forman DE. Cardiac rehabilitation for older adults: current evidence and future potential. Expert Rev Cardiovasc Ther 2022; 20:13-34. [PMID: 35098848 PMCID: PMC8858649 DOI: 10.1080/14779072.2022.2035722] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Growth of the older adult demographic has resulted in an increased number of older patients with cardiovascular disease (CVD) in combination with comorbid diseases and geriatric syndromes. Cardiac rehabilitation (CR) is utilized to promote recovery and improve outcomes, but remains underutilized, particularly by older adults. CR provides an opportunity to address the distinctive needs of older adults, with focus on CVD as well as geriatric domains that often dominate management and outcomes. AREAS COVERED Utility of CR for CVD in older adults as well as pertinent geriatric syndromes (e.g. multimorbidity, frailty, polypharmacy, cognitive decline, psychosocial stress, and diminished function) that affect CVD management. EXPERT OPINION Mounting data substantiate the importance of CR as part of recovery for older adults with CVD. The application of CR as a standard therapy is especially important as the combination of CVD and geriatric syndromes catalyzes functional decline and can trigger progressive clinical deterioration and dependency. While benefits of CR for older adults with CVD are already evident, further reengineering of CR is necessary to better address the needs of older candidates who may be frail, especially as remote and hybrid formats of CR are becoming more widespread.
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Affiliation(s)
- Maha A. Alfaraidhy
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD,Department of Medicine, King Abdulaziz University School of Medicine, Jeddah, KSA
| | - Claire Regan
- University of Maryland School of Nursing, Baltimore, MD
| | - Daniel E. Forman
- Department of Medicine (Geriatrics and Cardiology), Section of Geriatric Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, PA,Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA
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Heindl B, Ramirez L, Joseph L, Clarkson S, Thomas R, Bittner V. Hybrid cardiac rehabilitation - The state of the science and the way forward. Prog Cardiovasc Dis 2021; 70:175-182. [PMID: 34958846 DOI: 10.1016/j.pcad.2021.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 01/01/2023]
Abstract
Cardiac rehabilitation (CR) improves exercise capacity and health-related quality of life (HRQoL) in a broad range of patients, including those with coronary artery disease, heart failure (HF), after heart valve surgery, and after heart transplantation. Unfortunately, in traditional center-based CR programs participation and adherence are low. A hybrid model of CR, combining center-based and home-based CR services, has been proposed and is currently being studied as a potential way to help bridge the participation gap, while maintaining the beneficial patient outcomes from CR. However, the ideal composition of a hybrid CR program has not been universally agreed upon. In the present review, we define hybrid CR as any combination of supervised center-based and monitored home-based exercise, where at least two of the core components of CR are addressed. Using this definition, we searched for studies comparing hybrid CR with: (1) traditional center-based CR among CAD patients, (2) usual care among CAD patients, and (3) usual care among HF patients. We found nine studies which fit both our definition and comparison groups. The structure of the hybrid CR programs differed for each study, but typically began with a center-based component lasting 2-11 weeks and transitioned to a home-based component lasting 10-22 weeks, with 3-5 exercise sessions per week composed of either walking (usually with a treadmill) or cycling for 25-35 min at 60-75% maximal heart rate. Patients recorded data from home exercise sessions, via either a digital heart rate monitor or accelerometer, into logbooks which were reviewed by a therapist at specified intervals (often via telephone). Counseling on risk factor management was predominantly provided during the center-based component. In these studies, hybrid CR led to similar short-term outcomes compared to traditional CR in patients with coronary artery disease (CAD), as well as increased adherence and reduced delivery costs. Compared with usual care, in patients with CAD, hybrid CR reduced cardiovascular events, and improved lipid profiles, exercise capacity, and HRQoL. In patients with HF, compared with usual care, hybrid CR improved physical function, exercise capacity, and HRQoL. Ongoing studies may clarify the combination of center-based and home-based CR which produces superior outcomes, and may also better define the role that technology should play in CR interventions.
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Affiliation(s)
- Brittain Heindl
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Luke Ramirez
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Luke Joseph
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Stephen Clarkson
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Randal Thomas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Vera Bittner
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America.
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Kaihara T, Scherrenberg M, Falter M, Frederix I, Itoh H, Makita S, Akashi YJ, Dendale P. Cardiac Telerehabilitation - A Solution for Cardiovascular Care in Japan. Circ Rep 2021; 3:733-736. [PMID: 34950799 PMCID: PMC8651469 DOI: 10.1253/circrep.cr-21-0126] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 01/02/2023] Open
Abstract
Cardiac rehabilitation (CR) is a well-known intervention for the secondary prevention of cardiovascular diseases. However, in Japan, the outpatient CR participation rate is estimated to be very low. Cardiac telerehabilitation (CTR) can be defined as a remote CR program using digital health technology to support it. Evidence regarding the use of CTR has been accumulated, and the COVID-19 pandemic has accelerated the need for CTR. Japan has sufficient potential to benefit from CTR because, nationally, digital literacy is high and the infrastructure for telemedicine is developed. To overcome several barriers, evidence of CTR in Japan, well-educated multidisciplinary CTR teams, a good combination of center-based CR and CTR, and sophisticated systems including social insurance and adequate legislation need to be developed immediately. CTR has the potential to increase the low CR participation rate in Japan. CTR also has many different effects that not only cardiologists, but also paramedics who engage in CTR, have to be aware of.
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Affiliation(s)
- Toshiki Kaihara
- Heart Centre Hasselt, Jessa Hospital Hasselt Belgium
- Hasselt University, Faculty of Medicine and Life Sciences Diepenbeek Belgium
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine Kawasaki Japan
| | - Martijn Scherrenberg
- Heart Centre Hasselt, Jessa Hospital Hasselt Belgium
- Hasselt University, Faculty of Medicine and Life Sciences Diepenbeek Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences Antwerp Belgium
| | - Maarten Falter
- Heart Centre Hasselt, Jessa Hospital Hasselt Belgium
- Hasselt University, Faculty of Medicine and Life Sciences Diepenbeek Belgium
- University of Leuven, Faculty of Medicine Leuven Belgium
| | - Ines Frederix
- Heart Centre Hasselt, Jessa Hospital Hasselt Belgium
- Hasselt University, Faculty of Medicine and Life Sciences Diepenbeek Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences Antwerp Belgium
- Antwerp University Hospital Edegem Belgium
| | - Haruki Itoh
- Department of Cardiology, Sakakibara Heart Institute Tokyo Japan
| | - Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center Saitama Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine Kawasaki Japan
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital Hasselt Belgium
- Hasselt University, Faculty of Medicine and Life Sciences Diepenbeek Belgium
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Tang LH, Harrison A, Skou ST, Doherty P. To what extent are comorbidity profiles associated with referral and uptake to cardiac rehabilitation. Int J Cardiol 2021; 343:85-91. [PMID: 34534605 DOI: 10.1016/j.ijcard.2021.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Given the high proportion of comorbidities in patients with coronary heart disease (CHD) and low participation rates in cardiac rehabilitation (CR), a better understanding of how comorbidity interacts with the CR pathway is needed. We investigated associations between comorbidity profiles and referral and uptake in everyday clinical CR across UK. METHOD Patients (≥18 years) diagnosed with a CHD between 1st of January 2014 and 31st of December 2019 registered in the National Audit of Cardiac Rehabilitation (NACR) database were eligible. Self-reported comorbidities from 15 disease categories were conceptualized into similar or dissimilar based on overall related pathophysiologic profile and care management as CHD. Regression models were conducted with four comorbidity profiles; similar conditions, dissimilar conditions, similar and dissimilar and no comorbidity. RESULTS 399,348 (61.8%) patients were eligible for referral from 198 programmes. The majority were males (70%), mean age of 67 (±12 SD) years. A non-significant association was found between comorbidity profiles and referral. Odds ratios (OR) for CR uptake were higher in patients with dissimilar (OR = 1.38 (95% CI 1.26-1.54)) and dissimilar and similar comorbidities profiles (OR = 1.35 (95% CI 1.21-1.43)) compared to patients with similar comorbidities. No significant differences in uptake were found between patients with similar comorbidities and those without comorbidities (OR = 0.985 (95% CI 0.854-1.125). CONCLUSION Using routine practice data, comorbidity profiles were not significantly associated with CR referral suggesting equality in referral. Dissimilar comorbidity profiles were associated with uptake. To increase the likelihood of starting CR, services should consider developing tailored participation strategies that include comorbidity profiles.
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Affiliation(s)
- Lars Hermann Tang
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Denmark; The Department of Regional Health Research, University of Southern Denmark, Denmark; Department of Health Sciences, University of York, England, United Kingdom.
| | - Alexander Harrison
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Denmark; The Department of Regional Health Research, University of Southern Denmark, Denmark; Department of Health Sciences, University of York, England, United Kingdom
| | - Søren T Skou
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Denmark; Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
| | - Patrick Doherty
- Department of Health Sciences, University of York, England, United Kingdom
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Sukul D, Seth M, Thompson MP, Keteyian SJ, Boyden TF, Syrjamaki JD, Yaser J, Likosky DS, Gurm HS. Hospital and Operator Variation in Cardiac Rehabilitation Referral and Participation After Percutaneous Coronary Intervention: Insights From Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Circ Cardiovasc Qual Outcomes 2021; 14:e008242. [PMID: 34749515 DOI: 10.1161/circoutcomes.121.008242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite its established benefit and strong endorsement in international guidelines, cardiac rehabilitation (CR) use remains low. Identifying determinants of CR referral and use may help develop targeted policies and quality improvement efforts. We evaluated the variation in CR referral and use across percutaneous coronary intervention (PCI) hospitals and operators. METHODS We performed a retrospective observational cohort study of all patients who underwent PCI at 48 nonfederal Michigan hospitals between January 1, 2012 and March 31, 2018 and who had their PCI clinical registry record linked to administrative claims data. The primary outcomes included in-hospital CR referral and CR participation, defined as at least one outpatient CR visit within 90 days of discharge. Bayesian hierarchical regression models were fit to evaluate the association between PCI hospital and operator with CR referral and use after adjusting for patient characteristics. RESULTS Among 54 217 patients who underwent PCI, 76.3% received an in-hospital referral for CR, and 27.1% attended CR within 90 days after discharge. There was significant hospital and operator level variation in in-hospital CR referral with median odds ratios of 3.88 (95% credible interval [CI], 3.06-5.42) and 1.64 (95% CI, 1.55-1.75), respectively, and in CR participation with median odds ratios of 1.83 (95% CI, 1.63-2.15) and 1.40 (95% CI, 1.35-1.47), respectively. In-hospital CR referral was significantly associated with an increased likelihood of CR participation (adjusted odds ratio, 1.75 [95% CI, 1.52-2.01]), and this association varied by treating PCI hospital (odds ratio range, 0.92-3.75) and operator (odds ratio range, 1.26-2.82). CONCLUSIONS In-hospital CR referral and 90-day CR use after PCI varied significantly by hospital and operator. The association of in-hospital CR referral with downstream CR use also varied across hospitals and less so across operators suggesting that specific hospitals and operators may more effectively translate CR referrals into downstream use. Understanding the factors that explain this variation will be critical to developing strategies to improve CR participation overall.
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Affiliation(s)
- Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.S., M.S., H.S.G.), University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation (D.S., M.P.T., D.S.L.), University of Michigan, Ann Arbor.,Division of Cardiology, Department of Internal Medicine, VA Ann Arbor Healthcare System, MI (D.S.. H.S.G.)
| | - Milan Seth
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.S., M.S., H.S.G.), University of Michigan, Ann Arbor
| | - Michael P Thompson
- Institute for Healthcare Policy and Innovation (D.S., M.P.T., D.S.L.), University of Michigan, Ann Arbor.,Michigan Value Collaborative (M.P.T., J.D.S., J.Y.), University of Michigan, Ann Arbor.,Department of Cardiac Surgery (M.P.T., D.S.L.), University of Michigan, Ann Arbor
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Thomas F Boyden
- Division of Cardiology, Spectrum Health, Grand Rapids, MI (T.F.B.)
| | - John D Syrjamaki
- Michigan Value Collaborative (M.P.T., J.D.S., J.Y.), University of Michigan, Ann Arbor
| | - Jessica Yaser
- Michigan Value Collaborative (M.P.T., J.D.S., J.Y.), University of Michigan, Ann Arbor
| | - Donald S Likosky
- Institute for Healthcare Policy and Innovation (D.S., M.P.T., D.S.L.), University of Michigan, Ann Arbor.,Department of Cardiac Surgery (M.P.T., D.S.L.), University of Michigan, Ann Arbor
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.S., M.S., H.S.G.), University of Michigan, Ann Arbor.,Division of Cardiology, Department of Internal Medicine, VA Ann Arbor Healthcare System, MI (D.S.. H.S.G.)
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45
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Spindel JF, Albers L, Brislin G, Toft LEB. Increasing Cardiac Rehabilitation Referrals Through an Outpatient Intervention. J Cardiopulm Rehabil Prev 2021; 41:434-435. [PMID: 34508037 DOI: 10.1097/hcr.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jeffrey Fraser Spindel
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Lauren Albers
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Gregory Brislin
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Lorrel Elizabeth Brown Toft
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, Kentucky, and Department of Medicine, Cardiology, University of Nevada, Reno, Reno, Nevada
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Abstract
PURPOSE Cardiac rehabilitation (CR) has been shown to improve functional status, quality of life, and recurrent cardiovascular disease (CVD) events. Despite its demonstrated compelling benefits and guideline recommendation, CR is underutilized, and there are significant disparities in CR utilization particularly by race, ethnicity, sex, and socioeconomic status. The purpose of this review is to summarize the evidence and drivers of these disparities and recommend potential solutions. METHODS In this review, key studies documenting disparities in CR referrals, enrollment, and completion are discussed. Additionally, potential mechanisms for these disparities are summarized and strategies are reviewed for addressing them. SUMMARY There is a wealth of literature demonstrating disparities among racial and ethnic minorities, women, those with lower income and education attainment, and those living in rural and dense urban areas. However, there was minimal focus on how the social determinants of health contribute to the observed disparities in CR utilization in many of the studies reviewed. Interventions such as automatic referrals, inpatient liaisons, mitigation of economic barriers, novel delivery mechanisms, community partnerships, and health equity metrics to incentivize health care organizations to reduce care disparities are potential solutions.
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Affiliation(s)
- Lena Mathews
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine
- Welch Center for Prevention, Epidemiology and Clinical Research; Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - LaPrincess C. Brewer
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota
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47
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Rodrigo SF, Van Exel HJ, Van Keulen N, Van Winden L, Beeres SLMA, Schalij MJ. Referral and participation in cardiac rehabilitation of patients following acute coronary syndrome; lessons learned. IJC HEART & VASCULATURE 2021; 36:100858. [PMID: 34466654 PMCID: PMC8382985 DOI: 10.1016/j.ijcha.2021.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/27/2021] [Accepted: 08/10/2021] [Indexed: 10/31/2022]
Abstract
PURPOSE Cardiac rehabilitation (CR) after hospitalization for acute coronary syndrome (ACS) has shown to reduce mortality, readmissions, and improve quality of life. CR is recommended by international guidelines but previous studies have shown low participation rates. Systematic CR referral might improve CR participation. METHODS The present study evaluates CR referral and CR participation of patients hospitalized for ACS in 2017 and treated according to local protocol, which includes systematic CR referral. Participation rate was divided into a group that finished the CR program and drop outs. In addition, factors associated with CR referral and participation rate were evaluated. RESULTS A total of 469 patients eligible for CR were included in the study, of which 377 (80%) were referred for CR and 353 (75%) participated in CR. Ninety percent of participants completed the CR program. Factors independently associated with CR referral included age (50-60 year vs. > 70 year: odds ratio [OR] 4.7, 95% confidence interval [CI] 1.98-11.2), diagnosis (ST-elevation myocardial infarction vs. unstable angina: OR 17.7, CI 7.59-41.7), previous cardiovascular disease (OR 0.4, CI 0.19-0.73) and left ventricular dysfunction vs. normal function (OR 2.2, CI 1.11-4.52). A larger distance to the CR center was associated with lower CR participation (<5km vs. > 20 km: OR 3.1, CI 1.20-7.72). CONCLUSIONS Systematic CR referral in ACS patients results in high CR referral (80%) and participation (75%) rates. CR adherence might be further improved by increasing CR referral, especially in older patients and patients with NSTEMI or unstable angina.
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Key Words
- ACS, Acute coronary syndrome
- CI, Confidence interval
- CR, Cardiac rehabilitation
- CVA, Cerebrovascular accident
- Cardiac rehabilitation
- DBC, Diagnosis treatment combination (Diagnose behandel combinatie)
- EPD, Electronic patient dossier
- LV, Left ventricular
- NSTEMI, Non ST-elevation myocardial infarction
- OR, Odds ratio
- Patient participation
- Referral
- SES, Socio-economic status
- STEMI, ST-elevation myocardial infarction
- Secondary prevention
- TIA, Transient ischemic attack
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Affiliation(s)
- Sander F Rodrigo
- Basalt Rehabilitation, Leiden, the Netherlands
- Deparment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nicole Van Keulen
- Deparment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Loes Van Winden
- Deparment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia L M A Beeres
- Deparment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin J Schalij
- Deparment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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48
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Matthia EL, Mohadjer A, Randall MH, Canha C, Warren E, Ashraf HM, Plasschaert JM, Winchester DE, Keeley EC. Promoting Cardiac Rehabilitation in Acute Coronary Syndrome Patients: Quality Initiative Based on Education, Automated Referral, and Multidisciplinary Rounds. Crit Pathw Cardiol 2021; 20:115-118. [PMID: 34238793 DOI: 10.1097/hpc.0000000000000263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiac rehabilitation is a class 1 recommendation for acute coronary syndrome (ACS) patients according to the American College of Cardiology/American Heart Association. However, only 1 in 5 ACS patients are referred for cardiac rehabilitation nationally, and even fewer at our institution. We sought to improve the number of referrals to cardiac rehabilitation for post-ACS patients admitted to our inpatient cardiology service, and ultimately their participation in the program. We designed a quality improvement initiative that included education of patients and house staff, automated referral order, and participation of cardiac rehabilitation staff members on multidisciplinary rounds. We compared the number of patients who received a referral to cardiac rehabilitation, had the first appointment scheduled before hospital discharge, and attended the program before and after our intervention. Six months after initiation of the project, the proportion of ACS patients referred to cardiac rehabilitation before hospital discharge increased from 10% to 43% (P < 0.001). The mean number of patients with a cardiac rehabilitation appointment scheduled before discharge was 2 before and 5 after the intervention (P < 0.001), and the mean number of patients who attended their scheduled appointment was 1 before and 3 after the intervention (P = 0.001). Run charts demonstrated that the number of referrals and the number of scheduled appointments remained above the median following the intervention. In conclusion, an initiative that included education, automated referrals, and direct one-on-one contact with cardiac rehabilitation staff before discharge increased the number of cardiac rehabilitation referrals, and appointments scheduled and attended in post-ACS patients.
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Affiliation(s)
| | - Ashley Mohadjer
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Morgan H Randall
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Catarina Canha
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Elizabeth Warren
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | | | | | - David E Winchester
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
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Khadanga S, Savage PD, Gaalema DE, Ades PA. Predictors of Cardiac Rehabilitation Participation: OPPORTUNITIES TO INCREASE ENROLLMENT. J Cardiopulm Rehabil Prev 2021; 41:322-327. [PMID: 33512979 PMCID: PMC8310538 DOI: 10.1097/hcr.0000000000000573] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Participation in cardiac rehabilitation (CR) is low despite proven benefits. The aim of this study was to assess medical, psychosocial, and behavioral predictors of participation in a phase 2 CR. METHODS This was a prospective observational study. Participants hospitalized for an acute cardiac event and eligible for CR completed in-hospital assessments, and the primary outcome was CR participation over a 4-mo follow-up. Measures included age, sex, educational attainment, smoking status, medical diagnosis, ejection fraction, and electronic referral to CR. Data included General Anxiety Disorder, Patient Health Questionnaire, Medical Outcomes Study Short Form-36, Behavioral Rating Inventory of Executive Function, and Duke Social Support Index. Logistic regression and Classification and Regression Tree analysis were performed. RESULTS Of 378 hospitalized patients approached, 294 (31% females) enrolled in the study and 175 participated in CR. The presence of electronic referral, surgical diagnosis, non/former smoker, and strength of physician recommendation (all Ps < .02) were independent predictors for CR participation. No differences were seen in participation by measures of anxiety, depression, or executive function. Males with a profile of electronic referral to CR, high school or higher education, ejection fraction >50%, and strong physician recommendation were the most likely cohort to participate in CR (89%). Patients not referred to CR were the least likely to attend (20%). CONCLUSIONS Lack of CR referral, lower educational attainment, nonsurgical diagnosis, current smoking, and reduced ejection fraction can predict patients at a highest risk of CR nonparticipation. Specific interventions such as electronic referral and a strong in-person recommendation from a medical provider may enhance CR participation rates.
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Affiliation(s)
- Sherrie Khadanga
- Division of Cardiology, Department of Medicine (Drs Khadanga and Ades and Mr Savage), Vermont Center on Behavior and Health (Drs Khadanga, Gaalema, and Ades and Mr Savage), and Departments of Psychiatry and Psychology (Dr Gaalema), University of Vermont, Burlington
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50
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Abstract
PURPOSE OF REVIEW Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. RECENT FINDINGS ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.
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Affiliation(s)
- Sherry L Grace
- Faculty of Health, York University, 4700 Keele Street, Toronto, Canada. .,KITE-Toronto Rehabilitation Institute, Toronto, ON, Canada. .,Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Kornelia Kotseva
- National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland.,Imperial College Healthcare NHS Trust, London, UK
| | - Mary A Whooley
- US Department of Veterans Affairs Quality Enhancement Research Initiative, San Francisco, USA.,University of California, San Francisco, USA
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