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Quality of Coronary Care: Reducing Practice Variability. Can J Cardiol 2023; 39:524-526. [PMID: 36681382 DOI: 10.1016/j.cjca.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
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Hernandez MF, Rodriguez F. Health Techequity: Opportunities for Digital Health Innovations to Improve Equity and Diversity in Cardiovascular Care. CURRENT CARDIOVASCULAR RISK REPORTS 2023; 17:1-20. [PMID: 36465151 PMCID: PMC9703416 DOI: 10.1007/s12170-022-00711-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review In this review, we define health equity, disparities, and social determinants of health; the different components of digital health; the barriers to digital health equity; and cardiovascular digital health trials and possible solutions to improve health equity through digital health. Recent Findings Digital health interventions show incredible potential to improve cardiovascular diseases by obtaining longitudinal, continuous, and actionable patient data; increasing access to care; and by decreasing delivery barriers and cost. However, certain populations have experienced decreased access to digital health innovations and decreased representation in cardiovascular digital health trials. Summary Special efforts will need to be made to expand access to the different elements of digital health, ensuring that the digital divide does not exacerbate health disparities. As the expansion of digital health technologies continues, it is vital to increase representation of minoritized groups in all stages of the process: product development (needs findings and screening, concept generation, product creation, and testing), clinical research (pilot studies, feasibility studies, and randomized control trials), and finally health services deployment.
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Affiliation(s)
- Mario Funes Hernandez
- grid.168010.e0000000419368956Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA USA
| | - Fatima Rodriguez
- grid.168010.e0000000419368956Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, 453 Quarry Road, Room 332B, Stanford, CA 94305 USA
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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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Jerath A, Sutherland J, Austin PC, Ko DT, Wijeysundera HC, Fremes S, Karanicolas P, McCormack D, Wijeysundera DN. Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study. CMAJ 2020; 192:E1440-E1452. [PMID: 33199451 DOI: 10.1503/cmaj.200068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Addressing nonmedical reasons for delays in hospital discharge is important for improving the flow of patients through acute care hospital beds. Because this problem is understudied among adult surgical patients, we examined the incidence of and identified factors associated with delayed hospital discharge after major elective and emergency surgical procedures in acute care institutions. METHODS Using health administrative data, we retrospectively compared adults with and without delayed discharge after 18 major elective and emergency surgical procedures between 2006 and 2016 in Ontario hospitals. We identified delayed discharge using the alternate level of care code, applied to patients who are medically fit for discharge but remain in an acute care hospital bed. We used hierarchical logistic regression modelling to determine factors associated with delayed discharge. RESULTS Our cohort included 595 782 patients who underwent elective procedures and 180 478 who underwent emergency procedures. Delayed discharge accounted for 635 607 hospital days, of which 81.7% were related to admissions for emergency surgery. Delayed discharge affected 3.1% of patients who underwent elective surgery and 19.6% of those who underwent emergency procedures. Days attributed to delayed discharge formed about one-third of patients' total hospital stay for both surgical groups. The rate of delayed discharge across surgical specialties showed high variability (from 0.9% for lung resection or nephrectomy to 9.3% for peripheral arterial disease procedures in the elective surgery group, and from 3.8% for cardiac procedures to 33.8% for peripheral arterial disease procedures in the emergency surgery group). Risk factors for delayed discharge were older age, female sex, chronic disease burden and increasing hospital size. INTERPRETATION Delayed discharge for nonmedical reasons was more common after emergency surgery than after elective surgery, and rates varied across surgery type. Optimizing early discharge planning, evaluating the variation in delayed discharge at the hospital level and improving local access to community care services could be next steps to addressing this problem.
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Affiliation(s)
- Angela Jerath
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont.
| | - Jason Sutherland
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Peter C Austin
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Dennis T Ko
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Harindra C Wijeysundera
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Stephen Fremes
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Paul Karanicolas
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Daniel McCormack
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
| | - Duminda N Wijeysundera
- Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael's Hospital, Toronto, Ont
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Santiago de Araújo Pio C, Gagliardi A, Suskin N, Ahmad F, Grace SL. Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course. BMC Health Serv Res 2020; 20:768. [PMID: 32819388 PMCID: PMC7439558 DOI: 10.1186/s12913-020-05619-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 08/03/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A policy statement recommending that healthcare providers (HCPs) encourage cardiac patients to enroll in cardiac rehabilitation (CR) was recently endorsed by 23 medical societies. This study describes the development and evaluation of a guideline implementation tool. METHODS A stepwise multiple-method study was conducted. Inpatient cardiac HCPs were recruited between September 2018-May 2019 from two academic hospitals in Toronto, Canada. First, HCPs were observed during discharge discussions with patients to determine needs. Results informed selection and development of the tool by the multidisciplinary planning committee, namely an online course. It was pilot-tested with target users through a think-aloud protocol with subsequent semi-structured interviews, until saturation was achieved. Results informed refinement before launching the course. Finally, to evaluate impact, HCPs were surveyed to test whether knowledge, attitudes, self-efficacy and practice changed from before watching the course, through to post-course and 1 month later. RESULTS Seven nurses (71.4% female) were observed. Five (62.5%) initiated dialogue about CR, which lasted on average 12 s. Patients asked questions, which HCPs could not answer. The planning committee decided to develop an online course to reach inpatient cardiac HCPs, to educate them on how to encourage patients to participate in CR at the bedside. The course was pilot-tested with 5 HCPs (60.0% nurse-practitioners). Revisions included providing evidence of CR benefits and clarification regarding pre-CR stress test screening. HCPs did not remember the key points to convey, so a downloadable handout was embedded for the point-of-care. The course was launched, with the surveys. Twenty-four HCPs (83.3% nurses) completed the pre-course survey, 21 (87.5%) post, and 9 (37.5%) 1 month later. CR knowledge increased from pre (mean = 2.71 ± 0.95/5) to post-course (mean = 4.10 ± 0.62; p ≤ .001), as did self-efficacy in answering patient CR questions (mean = 2.29 ± 0.95/5 pre and 3.67 ± 0.58 post; p ≤ 0.001). CR attitudes were significantly more positive post-course (mean = 4.13 ± 0.95/5 pre and 4.62 ± 0.59 post; p ≤ 0.05). With regard to practice, 8 (33.3%) HCPs reported providing patients CR handouts pre-course at least sometimes or more, and 6 (66.7%) 1 month later. CONCLUSIONS Preliminary results support broader dissemination, and hence a genericized version has been created ( http://learnonthego.ca/Courses/promoting_patient_participation_in_CR_2020/promoting_patient_participation_in_CR_2020EN/story_html5.html ). Continuing education credits have been secured.
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Affiliation(s)
| | - Anna Gagliardi
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Neville Suskin
- Western University, London, ON, Canada
- St. Joseph's Health Care London, London, ON, Canada
| | | | - Sherry L Grace
- York University, Toronto, ON, Canada.
- University Health Network, University of Toronto, Toronto, ON, Canada.
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Soroush A, Heydarpour B, Komasi S, Saeidi M, Ezzati P. Barriers for the referral to outpatient cardiac rehabilitation: A predictive model including actual and perceived risk factors and perceived control. Ann Card Anaesth 2018; 21:249-254. [PMID: 30052210 PMCID: PMC6078027 DOI: 10.4103/aca.aca_87_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the roles of demographic factors, actual and perceived risk factors, and perceived control in the referral to cardiac rehabilitation (CR) after coronary artery bypass graft (CABG). METHODS In this cross-sectional study, data related to 312 CABG patients in a hospital of the Western part of Iran, gathered through demographics and actual risk factors' checklist, open single item of perceived heart risk factors, life stressful events scale, and perceived control questionnaire. Data analyzed by binary logistic regression. RESULTS The results showed that only 8.3% of CABG patients refer to CR. The facilitators of this referral included official employment (P < 0.05), coronary history (P = 0.016), and hyperlipidemia (P = 0.030) but more distance to the CR center (P = 0.042) and perceived physiological risk factor (P = 0.025) are concerned as the barriers for the referral to CR. CONCLUSION Providing appropriate awareness about the benefits of CR for patients with regard to their job status, coronary history, and perception about the illness risk factors can be effective in referral to CR. In addition, the presence of CR centers in towns and facilitated achievement to these centers can play a significant role in patients' participation.
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Affiliation(s)
- Ali Soroush
- Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behzad Heydarpour
- Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeid Komasi
- Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mozhgan Saeidi
- Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Parvin Ezzati
- Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Disparities in Cardiac Rehabilitation Among Individuals from Racial and Ethnic Groups and Rural Communities-A Systematic Review. J Racial Ethn Health Disparities 2018. [PMID: 29536369 DOI: 10.1007/s40615-018-0478-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Despite the well-described benefits of cardiac rehabilitation (CR) on long-term health outcomes, CR is a resource that is underutilized by a significant proportion of patients that suffer from cardiovascular diseases. The main purpose of this study was to examine disparities in CR referral and participation rates among individuals from rural communities and racial and ethnic minority groups with coronary heart disease (CHD) when compared to the general population. METHODS A systematic search of standard databases including MedlLine, PubMed, and Cochrane databases was conducted using keywords that included cardiac rehabilitation, women, race and ethnicity, disparities, and rural populations. Twenty-eight clinical studies from 1990 to 2017 were selected and included 478,955 patients with CHD. RESULTS The majority of available clinical studies showed significantly lower CR referral and participation rates among individuals from rural communities, women, and racial and ethnic groups when compared to the general population. Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs. Patients of lower SES have significantly lower CR referral and participation rates than patients of higher SES. CONCLUSIONS Data presented underscores the need for systematic referrals using electronic health records for patients with CHD in order to increase overall CR referral and participation rates of minority populations and other vulnerable groups. Educational programs that target healthcare provider biases towards racial and ethnic groups may help attenuate observed disparities. Alternative modalities such as home-based and internet-based CR programs may also help improve CR participation rates among vulnerable populations.
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Pedersen M, Egerod I, Overgaard D, Baastrup M, Andersen I. Social inequality in phase II cardiac rehabilitation attendance: The impact of potential mediators. Eur J Cardiovasc Nurs 2017; 17:345-355. [PMID: 29185799 DOI: 10.1177/1474515117746011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac rehabilitation participation is an essential component of the contemporary management of coronary heart disease. However, patients with low socioeconomic position are less likely to attend the rehabilitation programme. AIM We aimed to explore the effect of potential mediators between socioeconomic position defined by educational attainment and cardiac rehabilitation attendance. METHODS Prospective observational study of patients with acute coronary syndrome ( N=302). Logistic regression and mediation analysis was conducted to explore mechanisms of non-attendance. RESULTS Thirty per cent attended full cardiac rehabilitation. Patients with low educational attainment, comorbidities, long commute to cardiac rehabilitation centre, and lone dwelling were less likely to attend full cardiac rehabilitation, whereas patients with high anxiety and depression score were more likely to attend full cardiac rehabilitation. Patients with low educational attainment had lower self-efficacy and longer commute compared with patients with high educational attainment. The potential mediators included in the study, however, did not have a significant mediation effect. CONCLUSION Our study demonstrated a variety of mechanisms contributing to cardiac rehabilitation non-attendance. Further, the study demonstrated that non-attendance was especially related to the cardiac rehabilitation elements involving lifestyle modifications. However, the mechanisms explaining social inequality in full cardiac rehabilitation are still not fully understood.
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Affiliation(s)
- Maria Pedersen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, University of Copenhagen, Denmark
| | - Ingrid Egerod
- 2 University of Copenhagen, Rigshospitalet, Intensive Care Unit 4131, Denmark
| | - Dorthe Overgaard
- 3 Department of Nursing, Metropolitan University College, Copenhagen, Denmark
| | - Marie Baastrup
- 4 Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Denmark
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Ferdinand KC, Yadav K, Nasser SA, Clayton-Jeter HD, Lewin J, Cryer DR, Senatore FF. Disparities in hypertension and cardiovascular disease in blacks: The critical role of medication adherence. J Clin Hypertens (Greenwich) 2017; 19:1015-1024. [PMID: 28856834 DOI: 10.1111/jch.13089] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 05/21/2017] [Accepted: 05/22/2017] [Indexed: 12/21/2022]
Abstract
Blacks are two to three times as likely as whites to die of preventable heart disease and stroke. Declines in mortality from heart disease have not eliminated racial disparities. Control and effective treatment of hypertension, a leading cause of cardiovascular disease, among blacks is less than in whites and remains a challenge. One of the driving forces behind this racial/ethnic disparity is medication nonadherence whose cause is embedded in social determinants. Eight practical approaches to addressing medication adherence with the potential to attenuate disparities were identified and include: (1) patient engagement strategies, (2) consumer-directed health care, (3) patient portals, (4) smart apps and text messages, (5) digital pillboxes, (6) pharmacist-led engagement, (7) cardiac rehabilitation, and (8) cognitive-based behavior. However, while data suggest that these strategies may improve medication adherence, the effect on ameliorating racial/ethnic disparities is not certain. This review describes the relationship between disparities and medication adherence, which likely plays a role in persistent disparities in cardiovascular morbidity and mortality.
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Affiliation(s)
- Keith C Ferdinand
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kapil Yadav
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Samar A Nasser
- Department of Clinical Research & Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Helene D Clayton-Jeter
- Cardiovascular and Endocrine Liaison Program, Office of the Commissioner/External Affairs/Health & Constituent Affairs, Food and Drug Administration, Silver Springs, MD, USA
| | - John Lewin
- Lewin and Associates LLC, National Coalition on Health Care, Washington, DC, USA
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Sumner J, Grace SL, Doherty P. Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit. J Am Heart Assoc 2016; 5:e003903. [PMID: 27792657 PMCID: PMC5121492 DOI: 10.1161/jaha.116.003903] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/14/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation. METHODS AND RESULTS Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees, using the Huber-White-sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98-0.99), having a partner (OR 1.31, 95% CI 1.17-1.48), not being employed (OR 0.86, 95% CI 0.77-0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77-0.92), greater anxiety (OR 1.02, 95% CI 1.003-1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42-0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09-2.47). CONCLUSIONS CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized.
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Affiliation(s)
| | - Sherry L Grace
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada University Health Network University of Toronto, Canada
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Grace SL, Turk-Adawi K, Santiago de Araújo Pio C, Alter DA. Ensuring Cardiac Rehabilitation Access for the Majority of Those in Need: A Call to Action for Canada. Can J Cardiol 2016; 32:S358-S364. [PMID: 27692116 DOI: 10.1016/j.cjca.2016.07.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/04/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022] Open
Abstract
Cardiac rehabilitation (CR) is a proven model of secondary prevention. Indicated cardiac conditions for CR are well established, and participation of these patients results in significantly lower mortality and morbidity when compared with usual care. There are approximately 170 CR programs in Canada, which varies widely by province. There is a grossly insufficient capacity to treat all patients with cardiac indications in Canada and beyond. The density of CR services is about half that in the United States, at 1 program per 208,823 inhabitants or 1 program per 7779 patients with cardiac disease. Despite the Canadian Cardiovascular Society's target of 85% referral for CR for cardiac inpatients with the appropriate indications, significantly fewer patients are referred for CR. Moreover, certain patient groups-such as women, ethnocultural minorities, and those of low socioeconomic status-are less likely to access CR, despite greater need because of poorer outcomes. CR appears to be reaching a healthier population that is perhaps more adherent to secondary prevention recommendations and hence in less need of the limited CR spots available. The reasons for CR underuse are well established and include factors at patient, referring provider, CR program, and health system levels. A Cochrane review has established some effective interventions to increase CR use, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must reallocate our CR resources to patients with the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely available, lower-cost, and effective alternative model of CR.
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Affiliation(s)
- Sherry L Grace
- York University, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada.
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Ali-Faisal SF, Benz Scott L, Johnston L, Grace SL. Cardiac rehabilitation referral and enrolment across an academic health sciences centre with eReferral and peer navigation: a randomised controlled pilot trial. BMJ Open 2016; 6:e010214. [PMID: 27000785 PMCID: PMC4809077 DOI: 10.1136/bmjopen-2015-010214] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To describe (1) cardiac rehabilitation (CR) referral across cardiac units in a tertiary centre with eReferral; (2) characteristics associated with CR referral and enrolment and (3) the effects of peer navigation (PN) on referral and enrolment. This pilot was a 2 parallel-arm, randomised, single-blind trial with allocation concealment. SETTING 3 cardiac units (ie, interventional, general cardiology, and cardiac surgery) in 1 of 2 hospitals of a tertiary centre. PARTICIPANTS CR-eligible adult cardiac inpatients were randomised to PN or usual care. 94 (54.7%) patients consented, of which 46 (48.9%) were randomised to PN. Outcomes were ascertained in 76 (80.9%) participants. INTERVENTION The PN (1) visited participant at the bedside, (2) mailed a card to participant's home reminding about CR and (3) called participant 2 weeks postdischarge to discuss CR barriers. OUTCOME MEASURES The primary outcome of enrolment was defined as participant attendance at a scheduled CR intake appointment (yes/no). The secondary outcome was referral. Blinded outcome assessment was conducted 12 weeks postdischarge, via CR chart extraction. RESULTS Those who received care on the cardiac surgery unit (77.9%) were more likely to be referred than those treated on the general cardiology (61.1%) or interventional unit (33.3%; p=0.04). Patients who had cardiac surgery, hypertension and hyperlipidaemia were significantly more likely, and those with congenital heart disease, cancer and a previous cardiac diagnosis were less likely to be referred. Participants referred to a site closer to home (76.2% of those referred) were more likely to enrol than those not (23.7%, p<0.05). PN had no effect on referral (77.6%, p=0.45) or enrolment (46.0%, p=0.24). CONCLUSIONS There is wide variability in CR referral, even within academic centres, and despite eReferral. Referral was quite high, and thus, PN did not improve CR utilisation. Results support triaging patients to the CR programme closest to their home. TRIAL REGISTRATION NUMBER NCT02204449; Results.
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Affiliation(s)
- Sobia F Ali-Faisal
- York University, Toronto, Ontario, Canada
- Stony Brook University, Program in Public Health, Stony Brook Medicine, School of Health, Technology and Management, Stony Brook, New York, USA
| | - Lisa Benz Scott
- Stony Brook University, Program in Public Health, Stony Brook Medicine, School of Health, Technology and Management, Stony Brook, New York, USA
| | - Lauren Johnston
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Sherry L Grace
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
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Grace SL, Oh PI, Marzolini S, Colella T, Tan Y, Alter DA. Observing temporal trends in cardiac rehabilitation from 1996 to 2010 in Ontario: characteristics of referred patients, programme participation and mortality rates. BMJ Open 2015; 5:e009523. [PMID: 26537501 PMCID: PMC4636616 DOI: 10.1136/bmjopen-2015-009523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We sought to describe temporal trends in the sociodemographic and clinical characteristics of participants referred to cardiac rehabilitation (CR), and its effect on programme participation and all-cause mortality over 14 years. SETTING A large CR centre in Toronto, Canada. PARTICIPANTS Consecutive patients between 1996 and 2010. PRIMARY AND SECONDARY OUTCOME MEASURES Referrals received were deterministically linked to administrative data, to complement referral form abstraction. Out-of-hospital deaths were identified using vital statistics. Patients were tracked until 2012, and mortality was ascertained. Percentage attendance at prescribed sessions was also assessed. RESULTS There were 29,171 referrals received, of which 28,767 (98.6%) were successfully linked, of whom 22,795 (79.2%) attended an intake assessment. The age of the referred population steadily increased, with more females, less affluent and more single patients referred over time (p<0.001). More patients were referred following percutaneous coronary intervention and less following coronary artery bypass graft surgery (p<0.001). The number of comorbidities decreased (p<0.001). Hypertension increased over time (p<0.001), yet the control of cholesterol steadily improved over time. The proportion of smokers decreased over time (p<0.001). Participation in CR significantly declined, and there were no significant changes in mortality. 3-year mortality rates were less than 5%. CONCLUSIONS Characteristics of referred patients tended to reflect broader trends in risk factors and cardiovascular disease burden. Physicians appear to be referring more sociodemographically diverse patients to CR; however, programmes may need to better adapt to engage these patients to fully participate. More complex patients should be referred, using explicit criteria-based referral processes.
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Affiliation(s)
- Sherry L Grace
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
| | - Paul I Oh
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan Marzolini
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
| | - Tracey Colella
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yongyao Tan
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
| | - David A Alter
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Gaalema DE, Cutler AY, Higgins ST, Ades PA. Smoking and cardiac rehabilitation participation: Associations with referral, attendance and adherence. Prev Med 2015; 80:67-74. [PMID: 25900804 PMCID: PMC4592377 DOI: 10.1016/j.ypmed.2015.04.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/08/2015] [Accepted: 04/14/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Continued smoking after a cardiac event greatly increases mortality risk. Smoking cessation and participation in cardiac rehabilitation (CR) are effective in reducing morbidity and mortality. However, these two behaviors may interact; those who smoke may be less likely to access or complete CR. This review explores the association between smoking status and CR referral, attendance, and adherence. METHODS A systematic literature search was conducted examining associations between smoking status and CR referral, attendance and completion in peer-reviewed studies published through July 1st, 2014. For inclusion, studies had to report data on outpatient CR referral, attendance or completion rates and smoking status had to be considered as a variable associated with these outcomes. RESULTS Fifty-six studies met inclusion criteria. In summary, a history of smoking was associated with an increased likelihood of referral to CR. However, smoking status also predicted not attending CR and was a strong predictor of CR dropout. CONCLUSION Continued smoking after a cardiac event predicts lack of attendance in, and completion of CR. The issue of smoking following a coronary event deserves renewed attention.
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Affiliation(s)
- Diann E Gaalema
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA; Department of Psychology, University of Vermont, USA.
| | - Alexander Y Cutler
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA; Department of Psychology, University of Vermont, USA
| | - Philip A Ades
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Medicine, Division of Cardiology, University of Vermont Medical Center, USA
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Mead H, Ramos C, Grantham SC. Drivers of Racial and Ethnic Disparities in Cardiac Rehabilitation Use: Patient and Provider Perspectives. Med Care Res Rev 2015; 73:251-82. [PMID: 26400868 DOI: 10.1177/1077558715606261] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 08/20/2015] [Indexed: 01/24/2023]
Abstract
Cardiac rehabilitation (CR) use is lower for racial and ethnic minorities than White patients. The purpose of this study was to identify factors that drive this disparity at the system, provider, and patient levels. A mixed methods study combined descriptive analysis of 2007 Medicare claims data and thematic analysis of 19 clinician interviews, 8 minority patient focus groups and 8 one-on-one interviews with minority heart patients across three communities. The disparity between White and non-White CR use ranged from 7 to 11 percentage points among study sites (p < .05). Key themes suggest disparities are driven by (a) flawed financing and reimbursement that creates disincentives to invest in CR programs, (b) a health care system whose priorities are misaligned with the needs of patients, and (c) subjective decision-making around referral processes. These findings suggest that the health care system needs to address multiple levels of problems to mitigate disparities in CR use.
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Affiliation(s)
- Holly Mead
- George Washington University, Washington, DC, USA
| | | | - Sarah C Grantham
- Center for Consumer Information and Insurance Oversight, Bethesda, MD, USA
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Abstract
Cardiovascular disease (CVD) is the most-prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low-income and middle-income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost-effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient's functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under-used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high-income and 23% of LMICs (8.3% for low-income and 28.2% for middle-income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.
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Affiliation(s)
- Karam Turk-Adawi
- Cardiovascular Rehabilitation &Prevention, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Seddigheh Tahereh Research and Treatment Hospital, Khorram Ave, PO Box 81465-1148, Isfahan, Iran
| | - Sherry L Grace
- School of Kinesiology and Health Science, Bethune 368, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada
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Lv A, Tao L, Cao F, Li Y, Guo W, Wang H. The key features of percutaneous coronary intervention with chronic total obstruction lesion of right coronary artery. Ther Adv Cardiovasc Dis 2014; 8:22-7. [PMID: 24441174 DOI: 10.1177/1753944713517022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We summarize recent research on percutaneous coronary intervention of chronic total occlusion of the right coronary artery. We then explain the method and technology of forward and backward revascularization in chronic total occlusion of the right coronary artery. Finally, we emphasize the monitoring methods and key treating measures for better prognosis of the patients.
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Affiliation(s)
- Anlin Lv
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shanxi, China
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