Cardiac Rehabilitation in the United States

The effectiveness of cardiac telerehabilitation in comparison to centre-based cardiac rehabilitation programmes: A literature review

INTRODUCTION

Cardiac rehabilitation (CR) is an effective, yet under-utilised, form of secondary prevention in cardiac patients. Telemedicine is one method of overcoming barriers to accessing CR. Previous systematic reviews highlight variation in the effectiveness of telerehabilitation programmes and current literature lacks identification of which telemedicine interventions are most effective, despite differences in the results of primary studies. The objectives of this literature review were to: evaluate the effectiveness of cardiac telerehabilitation compared to centre-based programmes for managing cardiac risk factors, satisfaction and adherence in cardiac patients; identify the technologies used to deliver CR; identify the key components of effective interventions.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Scopus. Randomised controlled trials (RCTs) involving an intervention group that received telerehabilitation and a control group that attended a CR centre were included.

RESULTS

Twelve RCTs met the inclusion criteria. There is evidence to suggest that telerehabilitation programmes have similar effectiveness to centre-based CR. Phones were the most commonly used technology. Most studies used a combination of technologies including personal computers and self-monitoring equipment. Phase III telerehabilitation programmes using self-monitoring, motivational feedback and education were more effective than centre-based CR for increasing physical activity and functional capacity.

CONCLUSION

Cardiac telerehabilitation is delivered by a range of technologies and has a similar effectiveness to centre-based programmes. While evidence suggests that additional health benefits are seen in patients who receive a telemedicine intervention in Phase III of CR, further evidence would be required to confidently draw this conclusion.

Cost-Effectiveness of Cardiac Rehabilitation in Older Adults With Coronary Heart Disease

PURPOSE

While cardiac rehabilitation (CR) is recommended and effective following acute cardiac events, it remains underutilized, particularly in older adults. A study of 601 099 Medicare beneficiaries ≥65 yr hospitalized for coronary heart disease compared 5-yr mortality in users and nonusers of CR. Using instrumental variables (IV), CR improved mortality by 8.0% ( P < .001). A validation analysis based on 70 040 propensity-based (PB) matched pairs gave a similar gain (8.3%, P < .0001). The present cost-effectiveness analysis builds on these mortality results.

METHODS

Using the framework of the Second Panel on Cost-Effectiveness Analysis, we calculated the incremental cost-effectiveness ratio (ICER) gained due to CR. We accessed the costs from this cohort, inflated to 2022 prices, and assessed the relationship of quality-adjusted life years (QALY) to life years from a systematic review. We estimated the ICER of CR by modeling lifetime costs and QALY from national life tables using IV and PB.

RESULTS

Using IV, CR added 1.344 QALY (95% CI, 0.543-2.144) and $40 472 in costs over the remaining lifetimes of participants. The ICER was $30 188 (95% CI, $18 175-$74 484)/QALY over their lifetimes. Using the PB analysis, the corresponding lifetime values were 2.018 (95% CI, 1.001-3.035) QALY, $66 590, and an ICER of $32 996 (95% CI, $21 942-$66 494)/QALY.

CONCLUSIONS

Cardiac rehabilitation was highly cost-effective using guidelines established by the World Health Organization and the US Department of Health and Human Services. The favorable clinical effectiveness and cost-effectiveness of CR, along with low use by Medicare beneficiaries, support the need to increase CR use.

"Comfort of Sitting at Home While Getting Information I Needed": Experiences of Cardiac Patients Attending Virtual Cardiac Rehabilitation

Because of the COVID-19 pandemic, several health care services, including cardiac rehabilitation (CR), had to transition to virtual delivery, for which formal evaluations are lacking. In this pilot study, we investigated the implementation of a virtual CR program by surveying 30 patients attending virtual CR. Virtual CR was well received, although patients provided recommendations to improve delivery such as offering individual sessions and changing how education materials were delivered. Virtual delivery of CR likely has a role in health care, either independently or as part of a hybrid model; however, further evaluation is required.

Key participant characteristics influencing completion of a phase II cardiac rehabilitation program: A cross-sectional analysis

Study objective

Cardiac rehabilitation (CR) programs are effective at reducing cardiovascular disease risk factors, yet programs in the United States (US) have poor participation and completion. The current study evaluates characteristics related to completion and drop-out for CR participants.

Design

A cross-sectional study design compared participants who completed the program (finishers) and those did not finish (non-finishers). Variables were compared to determine differences between the dichotomous groups included demographic data, initial six-minute walk test, Zung Depression Index, and Quality of Life Measure (QLM). Logistical regression using variables with differences between groups determined impact on program completion.

Setting

Phase two outpatient hospital based cardiac rehabilitation program.

Participants

Ninety-seven participants were part of the sample; 61 completed the program, and 36 dropped out.

Main outcome measure

Completion of CR.

Results

Ninety-seven participants are included; 61 (63 %) were finishers and 36 (37 %) were non-finishers. Finishers were older, had a higher proportion of females and Medicare insurance recipients, had lower depression scores, and reported higher quality of life. Results of the final logistic regression revealed finishers were more likely to have Medicare (odds ratio (OR) = 5.215, confidence interval (CI) 1.897-14.338), be female (OR = 4.597, 95 % CI 1.532-13.795) and have higher QLM Family Sub scores (OR = 1.129, 95 % CI 1.023-1.246). The model correctly classified 71.9 % of cases.

Conclusion

The analysis highlights Medicare insurance and family support are associated with program completion. Interventions to increase family and social support, and to provide financial assistance for those with financial burden through lack of insurance or high co-pays may increase cardiac rehabilitation completion rates.

Web-Based Questionnaire Survey on Heart Failure in Elderly Patients Using Outpatient Rehabilitation ― Actual Conditions of Cardiac Rehabilitation in Long-Term Care Insurance Systems ―

Background: The purpose of this study was to investigate the actual conditions of cardiac rehabilitation (CR) for elderly patients with heart failure (HF) in outpatient rehabilitation (OR) facilities using long-term care insurance systems. Methods and Results: This was a cross-sectional web-based questionnaire survey conducted at 1,258 facilities in the Kansai region (6 prefectures) of Japan from October to December 2021. In all, 184 facilities responded to the web-based questionnaire (response rate 14.8%). Of these facilities, 159 (86.4%) accepted patients with HF. Among the patients with HF, 94.3% were aged ≥75 years and 66.7% were classified as New York Heart Association functional class I/II. Facilities treating patients with HF generally provided exercise therapy, patient education, and disease management, which were components of CR. Many facilities not currently treating patients with HF responded positively stating they will accept HF patients in the future. However, a few facilities responded by stating that they are waiting for clearer evidence demonstrating the beneficial effect of OR on patients with HF. Conclusions: The present results show the possibility that outpatient CR can be performed for elderly patients with HF in other than medical insurance.

User-centered design of a telehealth-enhanced hybrid cardiac rehabilitation program as hospital quality improvement

Background Innovative program designs and strategies are needed to support the widespread uptake of cardiac rehabilitation (CR) programs in the post-COVID19 era. We combined user-centered design (UCD) and implementation science (ImS) principles to design a novel telehealth-enhanced hybrid (home and clinic-based) CR (THCR) program. Methods As part of a New York Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we designed a THCR program using an iterative 3 step UCD process informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research to: 1) identify user and contextual barriers to CR uptake (stakeholder interviews), 2) design an intervention prototype (design workshops and journey mapping), and 3) refine the prototype (usability testing). The process was optimized for usability and implementation outcomes. Results Step 1: Semi-structured interviews with stakeholders (n = 9) at 3 geographically diverse academic medical centers revealed behavioral (e.g., self-efficacy, knowledge) and contextual (e.g., social distancing guidelines, physical space, staffing, reimbursement) barriers to uptake. Step 2: Design workshops (n = 20) and journey-mapping sessions (n = 3) with multi-disciplinary NYPH stakeholders (e.g., digital health team, CR clinicians, creative director) yielded a THCR prototype that leveraged NYPH's investment in their remote patient monitoring (RPM) platform to optimize feasibility of home-based CR sessions. Step 3: Usability testing with CR clinicians (n = 2) administering and CR patients (n = 3) participating in home-based sessions revealed usability challenges (e.g., RPM devices/exercise equipment usability; Wi-Fi/Bluetooth connectivity/syncing; patient safety/knowledge and protocol flexibility). Design workshops (n = 24) and journey-mapping sessions (n = 3) yielded design solutions (e.g., onboarding sessions, safety surveys, fully supervised remote sessions) and a refined THCR prototype. Conclusion Combining UCD and ImS methods while engaging multi-disciplinary stakeholders in an iterative process yielded a theory-informed telehealth-enhanced hybrid CR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process, and guidance for incorporating UCD and ImS methods in early-stage intervention development. THCR may shrink the evidence-to-practice gap in CR implementation. A future hybrid type I effectiveness-implementation trial will determine its feasibility, acceptability, and effectiveness.

Israel's first national remote cardiac rehabilitation program: A retrospective analysis

Aims

Cardiac rehabilitation is an essential component of secondary prevention consistently unexploited by most eligible patients. Accordingly, the remote cardiac rehabilitation program (RCRP) was developed to create optimal conditions for remote instruction and supervision for patients to enable successful completion of the program.

Methods

This study comprised 306 patients with established coronary heart disease who underwent a 6-month RCRP. RCRP involves regular exercise, monitored by a smartwatch that relays data to the operations center and a mobile application on the patient's smartphone. A stress test was performed immediately before the RCRP and repeated after 3 months. The aims were to determine the effectiveness of the RCRP in improving aerobic capacity, and correlating the program goals and first-month activity, with attaining program goals during the last month.

Results

Participants were mostly male (81.5%), aged 58 ± 11, enrolled in the main after a myocardial infarction or coronary interventions. Patients exercised aerobically for 183 min each week, 101 min (55% of total exercise) at the target heart rate. There was a significant improvement in exercise capacity, assessed by stress tests, metabolic equivalents which increased from 9.5 ± 3 to 11.4 ± 7(p < 0.001). Independent predictors of RCRP goals were older age and more minutes of aerobic exercise during the first program month (p < 0.05).

Conclusion

Participants succeeded in performing guideline recommendations, resulting in a significant improvement in exercise capacity. Older age and increased volume of first month of exercise were significant factors associated with a greater likelihood to attain program goals.

Delivery, barriers, and enablers to patient participation in inpatient cardiac rehabilitation following cardiac surgery: An integrative review

BACKGROUND

Cardiovascular disease is the leading cause of death worldwide. Cardiac surgery is the main treatment followed by inpatient cardiac rehabilitation (ICR) to prepare patients for recovery.

AIM

The aim of this study was to describe the delivery, barriers, and enablers to patient participation in ICR programs after cardiac surgery.

METHODS

This integrative review was guided by Whittemore and Knafl's methodology. This process included database searches, data evaluation, data integration, and presentation of results. Searched databases included Medline, CINAHL Complete, PsycINFO, Cochrane Library, and Web of Science. Publications dates included 2000 to 2021. Studies included Phase 1/inpatient phase cardiac rehabilitation following cardiac surgery. The Mixed Method Appraisal Tool (2018) was used to assess the quality of the included studies. Inductive content analysis was used to analyse the textual data.

RESULTS

Using the inclusion and the exclusion criteria, 607 articles were screened. Five articles were included in this review, and they were appraised. Categories comprised of the following: i) ICR programs using a multidisciplinary approach beginning in the early postoperative stage; ii) ICR programs including multicomponents that were delivered through an individualised approach; and iii) enablers and barriers to patient participation to ICR. The enablers included religious faith and family support, whereas inconsistent pathways of cardiac rehabilitation referrals and detachment from patients' experiences and needs were barriers to participation in ICR.

CONCLUSIONS

In some instances, ICR programs were delivered using individualised approaches, but this is an area that needs improvement. A multidisciplinary team including nurses should be involved in the ICR phase after cardiac surgery to provide holistic care and enhance patients' preparedness to participate in subsequent phases of rehabilitation. Only five relevant articles addressing the delivery of inpatient cardiac rehabilitation were identified in this specific topic area.

The Impact of a Mobile App on Participation in Cardiac Rehabilitation and Understanding Barriers to Success: Comparative Cohort Study

Background

Poor patient uptake of cardiac rehabilitation (CR) remains a challenge for multiple reasons including geographic, time, cultural, cost, and psychological constraints.

Objective

We evaluated the impact on CR participation rates associated with the addition of the option of mobile app–based CR (Cardihab) for patients declining conventional CR.

Methods

A total of 204 consecutive patients were offered CR following angioplasty; of these, 99 were in cohort 1 (offered conventional CR only) and 105 were in cohort 2 (app-based CR offered to those declining conventional CR). Patients in each cohort were followed throughout a 6-week CR program and participation rates were compared for both groups. Patients in cohort 2 declining both forms of CR were interviewed to assess reasons for nonparticipation.

Results

CR participation improved from 21% (95% CI 14%-30%) to 63% (95% CI 53%-71%) with the addition of the app (P<.001). Approximately 25% (9/39) of the group declining the app-based program identified technology issues as the reason for nonparticipation. The remainder declined both CR programs or were ineligible due to frailty or comorbidities.

Conclusions

Providing patients with the additional option of an app-based CR program substantially improved CR participation. Technology and psychological barriers can limit CR participation. Further innovation in CR delivery systems is required to improve uptake.

Cardiac rehabilitation following coronary artery dissection: recommendations and patient considerations

INTRODUCTION

: Cardiac rehabilitation (CR) is a multidisciplinary intervention for secondary prevention, improving functional capacity, enhancing quality of life, and improving psychosocial wellbeing in broad range of cardiovascular disease. It has been well studied over a number of years and is a Class I recommendation in multiple guidelines. However, there is a paucity of data regarding the usefulness of CR in patients with spontaneous coronary artery dissection (SCAD).

AREAS COVERED

: This narrative review aims to give an overview of the evidence underpinning CR as well as the pathophysiological mechanisms of SCAD and how they relate to exercise and shear stress. Furthermore, the evidence of the usefulness of CR in the SCAD population will be reviewed.

EXPERT OPINION

: Traditional CR programs are safe and effective in SCAD cohorts, however SCAD specific CR (SCAD-CR) has significant benefits including reductions in MACE. The principles of SCAD-CR should be applied to any CR for SCAD patients for optimal outcomes and minimization of harm.

An Adaptive Text Message Intervention to Promote Well-Being and Health Behavior Adherence for Patients With Cardiovascular Disease: Intervention Design and Preliminary Results

BACKGROUND

Most individuals with heart disease struggle to adhere to cardiovascular health behaviors, despite their known health benefits. Text message interventions (TMIs) are a promising treatment modality for health behavior promotion, but existing TMIs typically deliver a fixed set of messages and do not target well-being constructs associated with adherence and cardiovascular health.

OBJECTIVE

To develop a 4-week TMI, which delivers daily messages to promote well-being and adherence to health behaviors and dynamically adapts based on participant feedback to deliver increasingly customized messages; and to assess its feasibility, acceptability, and preliminary efficacy in a single-arm, proof-of-concept trial in 14 individuals with coronary artery disease (age mean = 67.9, standard deviation = 8.7).

METHODS

Participants received daily text messages related to well-being, physical activity, or diet, rated each message's utility, and these ratings informed the TMI's choice of future text messages. Feasibility was assessed by the proportion of messages successfully sent, and acceptability was assessed by participant ratings of intervention burden and text message utility. Finally, the intervention's preliminary efficacy was explored by measuring pre-post changes in psychologic and behavioral outcomes.

RESULTS

The TMI was both feasible (93% of participants received all messages) and well-accepted (mean text message utility: 7.0 of 10 [standard deviation 2.5]; mean intervention utility: 6.4 of 10 [standard deviation 0.9]; mean intervention burden: 0.5 of 10 [standard deviation 0.9]). Participants reported that messages related to well-being were particularly helpful and that most messages led to an action (e.g., eating more vegetables, being kind to others). The TMI led to nonsignificant, small-to-medium effect size improvements in happiness, optimism, determination, depression, anxiety, self-rated health, and diet (d = 0.19-0.48), and, unexpectedly, small reductions in activity and physical function (d = -0.20 and -0.32).

CONCLUSIONS

The adaptive TMI was feasible, well-accepted, and associated with nonsignificant improvements in psychologic outcomes and mixed effects on behavioral outcomes. Larger, well-powered studies are needed to determine whether this TMI will be able to improve well-being and health-related outcomes in this high-risk population.

Conceptual Framework for Personal Recovery in Patients With Acute Myocardial Infarction

Background Although there has been movement in cardiology to advance patient-centered approaches to postacute myocardial infarction (AMI) care, work remains to be done in aligning patient preferences with clinical care. Our objective was to characterize patients' experience of AMI and treatment to develop a new conceptual framework of patient-centered recovery in cardiology. Methods and Results We conducted in-depth interviews with people who previously experienced an AMI (2016-2019). The interview focused on participants' experiences of their recovery, which were audio-recorded, transcribed verbatim, and analyzed using a phenomenological framework. The overarching theme described by the 42 participants was feeling like a "different person" after the AMI. This shift manifested itself in both losses and gains, each of which posed new challenges to everyday life. The experience appeared to be an active process requiring people to take responsibility for their health. In terms of loss, participants describe how the AMI threatened their sense of safety and security and led to social isolation, fragility, uncertainty about the future, and difficulty expressing emotions accompanied this new fear. A conceptual framework describing the relationship between AMI, identity change, and functioning was developed. Conclusions Participants experienced the AMI as an unexpected disruption in their lives that had far-reaching effects on their daily functioning, and were resolved in numerous ways. The conceptual framework may assist in providing a theoretical basis for future interventions in cardiology that not only engage and retain patients in care but also improve long-term adherence to secondary prevention and other aspects of self-care.

"Is My Heart Healing?" A Meta-synthesis of Patients' Experiences After Acute Myocardial Infarction

BACKGROUND

Recovery from acute myocardial infarction (AMI) has been primarily understood in a narrow medical sense. For patients who survive, secondary prevention focuses largely on enhancing clinical outcomes. As a result, there is a lack of descriptive accounts of patients' experiences after AMI and little is known about how people go about the challenge of recovering from such an event.

OBJECTIVE

We conducted a meta-synthesis of the available literature on qualitative accounts of patients' experiences after AMI.

METHODS

We searched for relevant papers that were descriptive, qualitative accounts of participants' experiences after AMI across 4 electronic databases (April 2016). Using an adapted meta-ethnography approach, we analyzed the findings by translating studies into one another and synthesizing the findings from the studies.

RESULTS

After a review of titles/abstracts, reading each article twice in full, and cross-referencing articles, this process resulted in 17 studies with 224 participants (48% women) aged 23 to 90 years. All participants provided a first-person account of an AMI within the 3-day to 25-year time frame. Two major themes emerged that characterized patients' experiences: navigating lifestyle changes and navigating the emotional reaction to the event-consisting of various subthemes.

CONCLUSION

Although AMI tends to be seen as a discrete event, participants are left with little professional guidance as to how to negotiate significant, and often discordant, psychosocial changes that have long-lasting effects on their lives, similar to persons with chronic illnesses but without research in place to figure out how to best support them.

Home-Based Cardiac Rehabilitation: EXPERIENCE FROM THE VETERANS AFFAIRS

PURPOSE

The conceptual utility of home-based cardiac rehabilitation (HBCR) is widely acknowledged. However, data substantiating its effectiveness and safety are limited. This study evaluated effectiveness and safety of the Veterans Affairs (VA) national HBCR program.

METHODS

Veterans completed a 12-wk HBCR program over 18 mo at 25 geographically dispersed VA hospitals. Pre- to post-changes were compared using paired t tests. Patient satisfaction and adverse events were also summarized descriptively.

RESULTS

Of the 923 Veterans with a mean age of 67.3 ± 10.6 yr enrolled in the HBCR program, 572 (62%) completed it. Findings included significant improvements in exercise capacity (6-min walk test distance: 355 vs 398 m; P < .05; Duke Activity Status Index: 27.1 vs 33.5; P < .05; self-reported steps/d: 3150 vs 4166; P < .05); depression measured by Patient Health Questionnaire (6.4 vs 4.9; P < .0001); cardiac self-efficacy (33.1 vs 39.2; P < .0001); body mass index (31.5 vs 31.1 kg/m2; P = .0001); and eating habits measured by Rate Your Plate, Heart (47.2 vs 51.1; P < .05). No safety issues were related to HBCR participation. Participants were highly satisfied.

CONCLUSIONS

The VA HBCR program demonstrates strong evidence of effectiveness and safety to a wide range of patients, including those with high clinical complexity and risk. HBCR provides an adjunct to site-based programs and access to cardiac rehabilitation. Additional research is needed to assess long-term effects, cost-effectiveness, and sustainability of the model.

Relevant problems of participation and education of patients in cardiac rehabilitation and secondary prevention programs

The review discusses the participation of patients with coronary artery disease after acute myocardial infarction and revascularization surgeries in cardiac rehabilitation (CR) and secondary prevention programs. The problems of patients not being included in rehabilitation programs and the reasons for low adherence to these programs are considered. The contribution of non-drug therapy to achievement of CR and secondary prevention goals is discussed. Various strategies are proposed for involving and increasing adherence of patients to CR programs.

Depression Is Associated With Reduced Outpatient Cardiac Rehabilitation Completion Rates: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

PURPOSE

Depression is associated with recurrent cardiac events and death in patients with coronary heart disease and congestive heart failure. Furthermore, depression may be associated with reduced completion of outpatient cardiac rehabilitation (CR), an empirically supported treatment for patients with coronary heart disease and congestive heart failure that reduces recurrent coronary events and cardiac mortality. The goal of the current systematic review and meta-analysis was to explore the association between depression and outpatient CR completion.

METHOD

A systematic literature review cross-referenced 3 electronic databases (PsycINFO, MEDLINE, and Dissertation Abstracts International) from inception through February 15, 2015. Studies quantifying an association between depression and outpatient CR completion were identified for review. A random-effects model was used to pool quantitative data, moderators were tested, and publication bias was analyzed.

RESULTS

Seventeen studies with 19 independent samples consisting of 30 586 cardiac patients were included in the meta-analysis. A moderate inverse relationship between depression and outpatient CR completion was observed (g = -0.44; 95% CI, -0.59 to -0.29), indicating that depressed CR patients were significantly less likely to complete their prescribed CR programs. No significant moderator variables were identified. A minor amount of publication bias was detected.

CONCLUSION

Depression is associated with reduced outpatient CR completion rates. Future research should focus on attendance interventions for depressed CR patients, as completion of outpatient CR reduces cardiac and all-cause mortality.

Regional Variability in the Access to Cardiac Rehabilitation in Poland

Equitable access to cardiological rehabilitation services is one of the important elements in the effectiveness of the treatment of cardiovascular diseases as cardiological rehabilitation is an important part of circulatory system disease prevention and treatment. However, in many countries among others, Poland suffers from the underutilization of cardiac rehabilitation services. Cardiovascular diseases are the worldwide number one cause of mortality, morbidity, and disability and are responsible for the substantial increase in health care costs. Thus, the aim of the research was the analysis of geographical accessibility to cardiac rehabilitation services in Poland. Perkal’s method was employed in this research. The conducted research allowed to recognize the regional variation, but also made it possible to classify Polish voivodeships in terms of the level of availability achieved. This enables the identification of voivodeships that provide a good, or even very good, access to cardiology rehabilitation services and those characterized by low, or very low access. It was found that there was a slight regional variability in the access to cardiological rehabilitation services. However, the sufficient development of a rehabilitation infrastructure has been also recognized.

Impact of ambulatory cardiac rehabilitation on cardiovascular outcomes: a long-term follow-up study

AIMS

To evaluate the long-term clinical impact of the application of cardiac rehabilitation (CR) early after discharge in a real-world population.

METHODS AND RESULTS

We analysed the 5-year incidence of cardiovascular mortality and hospitalization for cardiovascular causes in two populations, attenders vs. non-attenders to an ambulatory CR program which were consecutively discharged from two tertiary hospitals, after ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, coronary artery bypass graft, or planned percutaneous coronary intervention. A primary analysis using multivariable regression model and a secondary analysis using the propensity score approach were performed. Between 1 January 2009 and 31 December 2010, 839 patients attended a CR program planned at discharged, while 441 patients were discharged from Cardiovascular Department without any program of CR. During follow-up, the incidence of cardiovascular mortality was 6% in both groups (P = 0.62). The composite outcome of hospitalizations for cardiovascular causes and cardiovascular mortality were lower in CR group compared to no-CR group (18% vs. 30%, P < 0.001) and was driven by lower hospitalizations for cardiovascular causes (15 vs. 27%, P < 0.001). At multivariable Cox proportional hazard analysis, CR program was independent predictor of lower occurrence of the composite outcome (hazard ratio 0.58, 95% confidence interval 0.43-0.77; P < 0.001), while in the propensity-matched analysis CR group experienced also a lower total mortality (10% vs. 19%, P = 0.002) and cardiovascular mortality (2% vs. 7%, P = 0.008) compared to no-CR group.

CONCLUSION

This study showed, in a real-world population, the positive effects of ambulatory CR program in improving clinical outcomes and highlights the importance of a spread use of CR in order to reduce cardiovascular hospitalizations and cardiovascular mortality during a long-term follow-up.

A Framework for National Rehabilitation Policy and Strategies in Iran: A Scoping Review of Experiences in Other Countries

Background

The main objective of this study was to review the goals and programs of rehabilitative care in different countries to achieve a framework for a national operational plan for expanding rehabilitation services in Iran.

Methods

In this qualitative study (scoping review), national rehabilitation documents were reviewed in a selected list of countries. We searched several databases including Web of Science, PubMed, Scopus, and Google Scholar and main website such as WHO. Then, the review results were presented to a panel of experts to receive their feedback and opinion for a framework of national rehabilitation policy and strategies in Iran.

Results

In the preliminary phase, 1775 documents were found and 17 documents were selected from Asia, Europe, three islands near Australia, America, and Australia continents. National policies and programs regarding rehabilitation could be categorized in three fields: 1) Removing the barriers to access rehabilitative health services, 2) strengthening and improving rehabilitation, relevant appropriate technologies, Supportive Services, and Community Based Rehabilitation, and 3) Collecting international data on social support and improving the quality of research and services related to rehabilitation.

Conclusion

To achieve a successful national rehabilitation framework in any country, it is required to strengthen information and research database, implement annual monitoring of policymaking, assess the next year rehabilitation needs of society, finding causes of disabilities for effective planning.

Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation

Cardiac rehabilitation (CR) is an evidence-based intervention that uses exercise training, health behaviour modification, medication adherence and psychological counselling to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, following coronary intervention, heart failure, or cardiac surgery. These are significantly underused, with only a minority of eligible patients participating in CR in India. Novel delivery strategies and CR endorsement by healthcare organizations are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). Differing from centre-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision. It is provided mostly or entirely outside of the traditional centre-based setting and could be facilitated by the aid of technology and web based applications. The purpose of this appraisal is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR. This appears to hold promise in expanding the use of CR to eligible patients. Additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and people in remote and rural areas. HBCR may be a reasonable option for a selected group of patients and could be a game changer in low- and middle-income countries who are eligible for CR.

Association between morbidity of non-communicable disease and employment status: a comparison between Korea and the United States

Background

Globally, the prevalence of chronic disease continues to rise and is likely to grow further over the coming decades due to population ageing. Since older age is associated closely with development of chronic disease, it stands to reason that demographic changes will increase the proportion of older workers with chronic disease. The aim of the present study was to determine how chronic diseases affect employment status in Korea and the USA.

Methods

The study was based on National Health and Nutrition Survey data (2007–2014) obtained by the Korean and American Centers for Disease Control and Prevention. A total of 44,693 subjects were categorized into two geographical groups: Korea (29,260 subjects) and the USA (15,433 subjects). A chi-square test was used to compare the groups in terms of socio-demographic factors, health-related factors, and chronic disease. Multivariate logistic regression analysis was conducted to determine the effect of five chronic diseases (hypertension, diabetes, dyslipidemia, cardiovascular disease, and cancer) on employment status.

Results

There were 29,260 Korean and 15,433 American respondents. Chronic disease increased the risk of unemployment in Korea markedly (Odds ratio [OR] range, 1.17–2.47). Cardiovascular disease and cancer had the most profound negative effect on Korean unemployment (OR = 2.47 and 2.03, respectively). The risk of unemployment was generally 2–3-fold lower in the USA (OR range, 0.5–1.04).

Conclusions

Chronic disease had a significant impact on economic activity in Korea, but a smaller impact in the USA. This difference may be related to different health insurance schemes and cultural approaches to people with diseases in the two countries. It is important to explore factors that limit economic participation by people with chronic diseases, and to identify social policies that will overcome these factors. Further between-country studies are needed to identify social solutions to the socio-economic burden of chronic illness.

Synergy Between Licensed Rehabilitation Professionals and Clinical Exercise Physiologists: Optimizing Patient Care for Cancer Rehabilitation

OBJECTIVES

To differentiate between rehabilitation and exercise training and propose how rehabilitation professionals and exercise physiologists can collaborate to optimize cancer survivor care.

DATA SOURCE

Professional organizations and peer-reviewed manuscripts.

CONCLUSION

Both professions offer complementary skillsets that, when integrated, optimize the ability of the cancer care team to implement more effective survivorship care plans. Future models of care must incorporate efficient communications between the cancer rehabilitation program and oncology team, include various reimbursement/payment/funding options, and continuously assess program efficacy.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be cognizant of physical needs (ie, functional and conditioning status) and cancer-related comorbidities when referring cancer survivors for exercise reconditioning.

The six-minute walk test as a fall risk screening tool in community programs for persons with stroke: a cross-sectional analysis

Background and Purpose: Persons with stroke have increased risk for recurrent stroke. Group exercise programs like cardiac rehabilitation might reduce this risk. These programs commonly use the six-minute walk test to measure aerobic capacity. However, failure to assess fall risk may compromise safety for persons with stroke. The study aim was to determine the association between the six-minute walk test and fall risk in persons with stroke.Methods: Cross-sectional analysis measured the association between the six-minute walk test and fall risk in 66 persons with stroke with a mean age of 66 years (SD 12) and median stroke chronicity of 60.9 months (range 6.0-272.1). The six-minute walk test was evaluated using logistic regression. The best fit model was used in Receiver Operating Characteristic analysis. Likelihood ratios and post-test probabilities were calculated.Results: Lower six-minute walk test distance was associated with increased fall risk in logistic regression (p = .002). The area under the curve for the univariate six-minute walk test model (best fit) was 0.701 (p = .006). The cutoff for increased fall risk was six-minute walk test <331.65 m. The post-test probability of fall risk increased to 74.3% from a pre-test probability of 59.1%.Discussion: The moderate association between fall risk and six-minute walk test suggests that in addition to assessing capacity, the six-minute walk test provides insight into fall risk/balance confidence.Conclusion: Using the six-minute walk test cutoff to screen fall risk in community exercise programs may enhance safety for persons with stroke without additional testing required.

‘A bridge to normal’: a qualitative study of Indonesian women’s attendance in a phase two cardiac rehabilitation programme

Background:

Cardiac rehabilitation is effective in reducing mortality and morbidity, in improving life expectancy and quality of life for people with cardiovascular disease. Despite these recognised benefits, women’s attendance rates in cardiac rehabilitation programmes remain suboptimal.

Aims:

This paper details the study that explored factors that influence women’s attendance of a phase two cardiac rehabilitation programme in Indonesia

Methods:

An exploratory qualitative research design was used in the study. Semi-structured interviews were used as the main method of data collection. Data were collected from June to September 2016. Twenty-three women aged between 30 and 66 years were interviewed. Transcribed interview data were analysed using a qualitative framework analysis.

Results:

Three major themes were inferred from the analysis: (a) a bridge to normal; (b) connecting with others; and (c) contextual factors. The first theme is illustrated by two subthemes: ‘making my heart work again’ and ‘performing social roles’. The second theme was illustrated by the following subthemes: ‘exchanging knowledge and experience’ and ‘developing a give-and-take relationship’. The third theme was illustrated by three subthemes: ‘recommendations from the staff’, ‘family support’ and ‘availability of health insurance’.

Conclusion:

Women’s attendance in cardiac rehabilitation in Indonesia is mainly influenced by their expectations and desire to be able to resume their previous social roles in the family and society. The findings of this study can assist healthcare professionals to understand better the needs of women and the fit between women’s needs and existing cardiac rehabilitation programmes. Such understanding could provide direction for more effective approaches to the cardiac rehabilitation programmes that are currently offered in Indonesia.

Short-Term Water- and Land-Based Exercise Training Comparably Improve Exercise Capacity and Vascular Function in Patients After a Recent Coronary Event: A Pilot Randomized Controlled Trial

Background

We hypothesized that a 2-week twice daily aquatic endurance plus calisthenics exercise training program: (i) increases aerobic exercise capacity (peak oxygen uptake/ V ˙ O₂peak), (ii) improves endothelium-dependent flow-mediated vasodilation (FMD), and (iii) reduces circulating markers of low-grade inflammation and hemostasis, as compared to land-based endurance plus calisthenics exercise training or no exercise in patients undergoing short-term residential cardiac rehabilitation after a recent coronary artery disease (CAD) event.

Methods

Patients with a recent myocardial infarction or revascularization procedure were randomized into two interventional groups and a control group. The interventional groups underwent supervised aerobic endurance plus calisthenics exercise training either in thermo-neutral water or on land at moderate intensity (60-80% of the peak heart rate achieved during symptom-limited graded exercise testing) for 30 min twice daily for 2 weeks (i.e., 24 sessions). The control group was deferred from supervised exercise training for the 2-week duration of the intervention, but was advised low-to-moderate intensity physical activity at home while waiting. At baseline and after the intervention period, all participants underwent estimation of aerobic exercise capacity, brachial artery flow-mediated dilatation (FMD, measured ultrasonographically at rest and during reactive hyperemia after 4.5 min of forearm cuff inflation), markers of cardiac dysfunction (NT-proBNP), inflammation (hsCRP, IL-6, IL-8, IL-10), cell adhesion (ICAM, P-selectin), and hemostasis (fibrinogen, D-dimer).

Results

A total of 89 patients (mean age 59.9 ± 8.2 years, 77.5% males, V ˙ O₂peak at baseline 14.8 ± 3.5 ml kg^-1 min^-1) completed the study. Both exercise modalities were safe (no significant adverse events recorded) and associated with a significant improvement in V ˙ O₂peak as compared to controls: age and baseline V ˙ O₂peak-adjusted end-of-study V ˙ O₂peak increased to 16.7 (95% CI 16.0-17.4) ml kg^-1 min^-1 with land-based training (p < 0.001 for change from baseline) and to 18.6 (95% CI 17.9-19.3) ml kg^-1 min^-1 with water-based training (p < 0.001 for change from baseline), but not in controls (14.9 ml kg^-1 min^-1; 95% CI 14.2-15.6; p = 0.775 for change from baseline). FMD also increased in both intervention groups (from 5.5 to 8.8%, p < 0.001 with land-based, and from 7.2 to 9.2%, p < 0.001 with water-based training, respectively), as compared to controls (p for change 0.629). No significant changes were detected in biomarkers of inflammation, cell adhesion or hemostasis, whereas levels of NT-proBNP (marker of cardiac dysfunction) decreased in the water-based training group (p = 0.07 vs. controls).

Conclusion

Endurance plus calisthenics exercise training in thermo-neutral water is safe, and improves aerobic exercise capacity and vascular function in patients undergoing short-term residential cardiac rehabilitation after a recent CAD event.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT02831829.

Young patients with myocardial infarction – particularities of cardiovascular rehabilitation

Abstract Acute coronary syndromes (ACS) are one of the main causes of morbidity and mortality in the world. It affects people in the middle and late-life, but the biggest psycho-social and financial impact is among the active young population. After the acute event they have to return to work and to their families for which they represent the principal support. Besides medication and prompt revascularization therapies, cardiac rehabilitation (CR) has an important role in regaining most of the initial physical and psychological state. Despite the proved benefit of the CR, referral and participation rate is very low, suggesting that there is more to do in this old but very underappreciated field. Key words: acute coronary syndromes, myocardial infarction, young, cardiac rehabilitation, secondary prevention,

Trends and Costs Associated With Suboptimal Physical Activity Among US Women With Cardiovascular Disease

IMPORTANCE

Cardiovascular disease (CVD) is the leading cause of death and disability among women. Achievement of recommended physical activity (PA) levels is an essential component of CVD management.

OBJECTIVE

To describe trends, sociodemographic factors, and health care expenditures associated with suboptimal PA among a nationally representative sample of US women with CVD.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used serial data from the Medical Expenditure Panel Survey from 2006 through 2015. The analyses were conducted in August 2018. Women who had self-reported and/or International Classification of Diseases, Ninth Revision, diagnosis of CVD were included.

MAIN OUTCOMES AND MEASURES

Recommended PA was defined as 30 minutes or more of moderate- to vigorous-intensity exercise, 5 or more days per week. Weighted logistic regression was used to examine the associations of various sociodemographic factors with suboptimal PA, adjusted for comorbidities. A 2-part econometric model was used to assess health care expenditures.

RESULTS

A total of 18 027 women were included in this study. The results were weighted to provide estimates for approximately 19.5 million adult women in the United States with CVD (mean [SD] age, 60.4 [16.9] years). More than half of the women with CVD reported suboptimal PA, a trend that increased during the 10-year period, with 58.2% (95% CI, 55.9%-60.5%) of participants reporting suboptimal PA in 2006-2007 vs 61.9% (95% CI, 59.7%-64.2%) in 2014-2015 (P = .004). The proportion of women with suboptimal PA differed by sociodemographic factors. In adjusted models, compared with non-Hispanic white women, African American women (odds ratio, 1.22; 95% CI, 1.08-1.38) and Hispanic women (odds ratio, 1.33; 95% CI, 1.13-1.58) were more likely to have suboptimal PA. Women from low- or very low-income strata (compared with high-income strata), enrolled in public insurance (compared with private insurance), and with less than high school education (compared with at least some college education) were more likely to have suboptimal PA. Health care costs among women with CVD with suboptimal PA were higher compared with those among women who met the recommended PA, and this increased through time, from a mean total health care expenditure of $12 724 (95% CI, $11 627-$13 821) in 2006-2007 to $14 820 (95% CI, $13 521-$16 119) in 2014-2015.

CONCLUSIONS AND RELEVANCE

The proportion of women with CVD not meeting recommended PA is high and increasing, particularly among certain racial/ethnic and socioeconomic groups, and is associated with significant health care costs. More must be done to improve PA for secondary prevention and reduction of expenditures among women with CVD.

Cardiac rehabilitation fitness changes and subsequent survival

Aims

Assessments of cardiac rehabilitation (CR) in coronary heart disease (CHD) cohorts usually examine mortality in aggregate. This study examines the prognosis and characteristics of patients who enrolled and completed CR, stratified by their level of improvement in cardiorespiratory fitness (CRF) by examining the characteristics, outcomes and predictors of non-response in CRF (NonRes) compared with low-responders (LowRes) and high-responders (HighRes) after CR.

Methods and results

A total of 1171 CHD patients were referred for a phase II CR programme after therapy for an acute coronary syndrome, coronary artery bypass graft procedure or a percutaneous coronary intervention between 1 January 2000 and 30 June 2013 underwent cardiopulmonary exercise testing before and after CR. This cohort was divided according to absolute improvements in CRF (i.e. change in peak oxygen consumption expressed in mL⋅kg-1⋅min-1). Mortality was analysed after 0.5-13.4 years of follow-up (mean 6.4 years). A total of 266 (23%) subjects were NonRes. After adjustment for body mass index, age, gender, left ventricular ejection fraction and baseline CRF, NonRes, and LowRes had a statistically significant three-fold and two-fold higher mortality, respectively, when compared with HighRes (HighRes 8% vs. LowRes 17% vs. NonRes 22%; P < 0.001). Age, female gender, baseline CRF, hostility, and presence of diabetes were significant predictors of NonRes and LowRes. In addition, higher waist circumference was a predictor of NonRes.

Conclusion

Significant proportions of subjects referred to CR have no/low improvement in CRF and higher associated mortality risks. Greater attention is required to increase improvements in CRF following CR and avoid NonRes.

Factors associated with objectively measured exercise participation after hospitalization for acute coronary syndrome

BACKGROUND

Guidelines recommend exercise for secondary prevention of acute coronary syndrome (ACS), however adherence to guidelines is low. A paucity of data examining factors associated with objectively-measured exercise post-discharge in ACS survivors exists. The purpose of this study was to identify factors associated with exercise during the 5 weeks after ACS discharge.

METHODS

A sample of 151 ACS patients treated at a university hospital were enrolled into an observational cohort study and wore an accelerometer for 35 days post-discharge. Days on which participants accumulated ≥30 min of moderate-to-vigorous physical activity in bouts ≥10 min were considered exercise days. Participants were categorized as non-exercisers (0 exercise days) or exercisers (≥1 exercise day). A multi-variable logistic regression model was used to examine the association between exercise and socio-demographics, depression, SF-12 physical and mental health scores, disease severity, length of hospitalization, and percutaneous coronary intervention.

RESULTS

39.7% of participants were non-exercisers. Factors associated with non-exercise were age (OR: 1.11; 95% CI: 1.06-1.17, p < 0.001), female sex (OR: 2.76; 95% CI: 1.10-6.95, p = 0.031), and lower SF-12 physical health score (OR: 0.94; 95% CI: 0.90-0.98, p = 0.005).

CONCLUSION

In ACS patients in whom exercise participation was objectively measured for 5 weeks post-discharge, demographic and poor physical health factors were associated with non-exercise. These findings identify populations (e.g. older adults, women) at especially high risk for being physically inactive in whom more intense intervention may be warranted.

Predictors of Patient Participation and Completion of Home-Based Cardiac Rehabilitation in the Veterans Health Administration for Patients With Coronary Heart Disease

Traditional, facility-based cardiac rehabilitation (CR) is vastly underutilized in the United States. The Veterans Health Administration (VA) has developed new home-based cardiac rehabilitation (HBCR) programs to address this issue. However, the characteristics of patients who choose HBCR are unknown. We sought to determine predictors of participation and completion of HBCR at the San Francisco VA (SFVA). We evaluated patients hospitalized for ischemic heart disease between 2013 and 2016 at SFVA. Logistic regression models were used to identify predictors of participation and completion of HBCR. In 724 patients with ischemic heart disease who were eligible for CR between 2013 and 2016, 314 (43%) enrolled in HBCR. Older age was associated with lower odds of participation in HBCR (odds ratio [OR] 0.84; p <0.01). Additionally, patients with coronary artery bypass grafting (CABG) were twice as likely as those with percutaneous coronary intervention to participate in HBCR (OR 2.03; 95% confidence interval 1.40, 2.97). In HBCR participants, 48% (150/314) completed ≥9 sessions. Patients with CABG were twice as likely as those with percutaneous coronary intervention to complete the HBCR program (OR 2.02; 95% confidence interval 1.18, 3.44). There were no differences in participation or completion rates by gender, race, ethnicity, or rurality. Our study showed that the SFVAMC HCBR program achieved a 43% participation rate, well above the VA average of 13%. There were no disparities by gender, race, or rurality in terms of participation and adherence. CABG as the indication for CR was the most significant predictor of participation and completion of HBCR.

The use of modern telemedicine technologies in an innovative optimal cardiac rehabilitation program for patients after myocardial revascularization: Concept and design of RESTORE, a randomized clinical trial

Despite proven efficacy of cardiac rehabilitation (CR) in reducing the all-cause mortality in patients after myocardial revascularization, the penetration of CR, due to patient-related factors and referral rates remains limited. To improve the outcomes, home-based tele-rehabilitation (TR) has been proposed recently. In theory TR enhances the effects of standard CR procedures due to implementation of an intelligent monitoring system designed to ensure optimal training through on-demand transmission of vital signs, aimed at motivating the patients through daily schedule reminders, setting daily goals and creating a platform for mutual feedback. Several meta-analyses assessing various studies comparing these two methods (CR and TR) have proven that they are at least equally effective, with some of the research showing superiority of TR. Although there was a small sample size, lack of long-term follow-up, reporting effects of TR itself, no integration with tools designed for coaching, motivating and promoting a healthy lifestyle constitutes an important limitation. The latter carries a hopeful prognosis for improvement when utilizing a broad-spectrum approach, especially with use of dedicated technological solutions exploiting the fact of a large and yet rapidly increasing penetration of smartphones, mobile PCs and tablets in the population. The above-mentioned findings worked as the basis and rationale for commencing the RESTORE project aimed at developing and delivering state-of-the-art, comprehensive TR for patients after myocardial revascularization and evaluating its molecular aspect in view of how it influences the atherosclerosis progression attenuation. This paper presents the current state and rationale behind the project based on up-to-date TR efficacy data.

An "Exercise" in Cardiac Metabolism

Research has demonstrated that the high capacity requirements of the heart are satisfied by a preference for oxidation of fatty acids. However, it is well known that a stressed heart, as in pathological hypertrophy, deviates from its inherent profile and relies heavily on glucose metabolism, primarily achieved by an acceleration in glycolysis. Moreover, it has been suggested that the chronically lipid overloaded heart augments fatty acid oxidation and triglyceride synthesis to an even greater degree and, thus, develops a lipotoxic phenotype. In comparison, classic studies in exercise physiology have provided a basis for the acute metabolic changes that occur during physical activity. During an acute bout of exercise, whole body glucose metabolism increases proportionately to intensity while fatty acid metabolism gradually increases throughout the duration of activity, particularly during moderate intensity. However, the studies in chronic exercise training are primarily limited to metabolic adaptations in skeletal muscle or to the mechanisms that govern physiological signaling pathways in the heart. Therefore, the purpose of this review is to discuss the precise changes that chronic exercise training elicits on cardiac metabolism, particularly on substrate utilization. Although conflicting data exists, a pattern of enhanced fatty oxidation and normalization of glycolysis emerges, which may be a therapeutic strategy to prevent or regress the metabolic phenotype of the hypertrophied heart. This review also expands on the metabolic adaptations that chronic exercise training elicits in amino acid and ketone body metabolism, which have become of increased interest recently. Lastly, challenges with exercise training studies, which could relate to several variables including model, training modality, and metabolic parameter assessed, are examined.

Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis

OBJECTIVE

Secondary vascular risk reduction is critical to preventing recurrent stroke. We aimed to evaluate the effect of exercise interventions on vascular risk factors and recurrent ischaemic events after stroke or transient ischaemic attack (TIA).

DESIGN

Intervention systematic review and meta-analysis.

DATA SOURCES

OVID MEDLINE, PubMed, The Cochrane Library, Web of Science, The National Institute for Health and Care Excellence, TRIP Database, CINAHL, PsycINFO, SCOPUS, UK Clinical Trials Gateway and the China National Knowledge Infrastructure were searched from 1966 to October 2017.

ELIGIBILITY CRITERIA

Randomised controlled trials evaluating aerobic or resistance exercise interventions on vascular risk factors and recurrent ischaemic events among patients with stroke or TIA, compared with control.

RESULTS

Twenty studies (n=1031) were included. Exercise interventions resulted in significant reductions in systolic blood pressure (SBP) -4.30 mm Hg (95% CI -6.77 to -1.83) and diastolic blood pressure -2.58 mm Hg (95% CI -4.7 to -0.46) compared with control. Reduction in SBP was most pronounced among studies initiating exercise within 6 months of stroke or TIA (-8.46 mm Hg, 95% CI -12.18 to -4.75 vs -2.33 mm Hg, 95% CI -3.94 to -0.72), and in those incorporating an educational component (-7.81 mm Hg, 95% CI -14.34 to -1.28 vs -2.78 mm Hg, 95% CI -4.33 to -1.23). Exercise was also associated with reductions in total cholesterol (-0.27 mmol/L, 95% CI -0.54 to 0.00), but not fasting glucose or body mass index. One trial reported reductions in secondary vascular events with exercise, but was insufficiently powered.

SUMMARY

Exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education.

Needs and unmet needs for rehabilitation services: a scoping review

BACKGROUND

There is a global demand for rehabilitation services but to date little attention has been paid to rehabilitation as part of the health agenda, especially in low- and middle-income countries. The objective of the scoping review was to get an overview of the needs and unmet needs for rehabilitation services described in the literature.

MATERIALS AND METHODS

Electronic search was performed in PubMed and REHABDATA for studies published between 2000 and 2017.

RESULTS

Eighty-six articles met the inclusion criteria. Results revealed a profound need for rehabilitation among different user groups with non-communicable diseases and injuries across countries. However, this need considerably outstripped the provision of services, which left many people with substantial unmet needs for rehabilitation. The main reasons for the unmet needs for rehabilitation were the absence of or unequal geographical distribution of services within a country, lack of transportation, and unaffordability of the services.

CONCLUSIONS

There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Efforts need to focus on building the capacity for rehabilitation research predominantly in low- and middle-income countries. The comprehensive data that this review provides is useful for raising awareness for the need of rehabilitation at policy level. Implications for rehabilitation There is a profound need for rehabilitation services due to the ageing population and growing prevalence of non-communicable diseases. This scoping review shows that the need for rehabilitation considerably outstrips the provision of services. There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Concerted global action to scale up quality rehabilitation services is needed, especially in low- and middle-income countries.

Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis

OBJECTIVE

To ascertain the effect of cardiac rehabilitation (CR) dose (ie, duration × frequency/wk; categorized as low [<12 sessions], medium [12-35 sessions], or high [≥36 sessions]) on mortality and morbidity.

METHODS

The Cochrane, CINAHL, EMBASE, PsycINFO, and MEDLINE databases were systematically searched from inception through November 30, 2015. Inclusion criteria included randomized or nonrandomized studies with a minimum CR dose of 4 or higher and presence of a control/comparison group. Citations were considered for inclusion, and data were extracted in included studies independently by 2 investigators. Studies were pooled using random-effects meta-analysis and meta-regression where warranted (covariates included study quality, country, publication year, and diagnosis).

RESULTS

Of 4630 unique citations, 33 trials were included comparing CR to usual care (ie, no dose). In meta-regression, greater dose was significantly related to lower all-cause mortality (high: -0.77; SE, 0.22; P<.001; medium: -0.80; SE, 0.21; P<.001) when compared with low dose. With regard to morbidity, meta-analysis revealed that dose was significantly associated with fewer percutaneous coronary interventions (high: relative risk, 0.65; 95% CI, 0.50-0.84; medium/low: relative risk, 1.04; 95% CI, 0.74-1.48; between subgroup difference P=.03). This reduction was also significant in meta-regression (high vs medium/low: -0.73; SE, 0.20; P<.001). Publication bias was not evident. No dose-response association was found for cardiovascular mortality, all-cause hospitalization, coronary artery bypass graft surgery, or myocardial infarction.

CONCLUSION

A minimum of 36 CR sessions may be needed to reduce percutaneous coronary interventions. Future studies should examine the effect of actual dose of CR, and trials are needed comparing different doses.

PROSPERO REGISTRATION

CRD42016036029.

A Review of Cardiac Rehabilitation Delivery Around the World

Herein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases. Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.

The Impact of Text Messaging on Medication Adherence and Exercise Among Postmyocardial Infarction Patients: Randomized Controlled Pilot Trial

Background

Adherence to evidence-based therapies such as medications and exercise remains poor among patients after a myocardial infarction (MI). Text message reminders have been shown to improve rates of adherence to medication and exercise, but the existing studies have been of short duration.

Objective

Two single-center randomized controlled pilot trials were conducted to evaluate the impact of text message reminders over 12 months on adherence to cardiac medications and exercise among patients receiving cardiac rehabilitation after hospitalization for MI.

Methods

In the medication adherence trial, 34 patients were randomized to receive usual care alone or usual care plus daily text message reminders delivered at the time of day at which medications were to be taken. In the exercise adherence trial, 50 patients were randomized to receive usual care alone or usual care plus 4 daily text messages reminding them to exercise as directed.

Results

The text message reminders led to a mean 14.2 percentage point improvement in self-reported medication adherence over usual care (P<.001, 95% CI 7-21). In the exercise trial, text message reminders resulted in an additional 4.2 days (P=.001, 95% CI 1.9-6.4) and 4.0 hours (P<.001, 95% CI 2.4-5.6) of exercise per month over usual care and a nonsignificant increase of 1.2 metabolic equivalents (METS; P=.06) in exercise capacity as assessed by a BRUCE protocol at 12 months.

Conclusions

Text message reminders significantly increased adherence to medication and exercise among post-MI patients receiving care in a structured cardiac rehabilitation program. This technology represents a simple and scalable method to ensure consistent use of evidence-based cardiovascular therapies.

Trial Registration

Clinicaltrials.gov NCT02783287; https://clinicaltrials.gov/ct2/show/NCT02783287 (Archived by WebCite at http://www.webcitation.org/6sBnvNb05)

Exercise adherence in the elderly: Experience with abdominal aortic aneurysm simple treatment and prevention

Poor adherence to health-related behaviors can have serious health consequences. Cardiac rehabilitation has been documented to have physiological and psychosocial benefits; however, optimizing adherence to exercise in patients with cardiovascular disease is a particular challenge. We recently completed a large, 6-year randomized trial of exercise training in elderly patients with abdominal aortic aneurysm (AAA) disease (50-85 years), which provided an opportunity to describe adherence strategies in this unique group of elderly individuals. Patients were randomized to exercise therapy or usual care. Using a case-management approach, a combination of center and home-based training was used during which patients trained for up to 3 years. We observed that overall, 84% of subjects in the exercise group completed ≥1 year in the study, achieving a mean energy expenditure of 1,999 ± 1,030 kcals per week. Subjects in the exercise group were more likely to drop out of the study as compared with usual care, though none of the reasons for dropping out were associated with exercise participation (eg, exercise-related injury). Reasons for withdrawal included orthopedic problems, lost physician coverage, time constraints, and AAA repair. Although the groups were matched for AAA size at baseline, there was a trend for more AAA repairs among usual care subjects versus those in the exercise group (12 [17.6%] vs 5 [6.9%], P = 0.09). The case-managed approach to optimizing adherence used was reasonably successful in achieving a training response (ie, improvement in exercise capacity) in elderly patients with AAA, a group for whom little is previously known regarding the effects of rehabilitation.

Kinect system in home-based cardiovascular rehabilitation

Cardiovascular diseases lead to a high consumption of financial resources. An important part of the recovery process is the cardiovascular rehabilitation. This study aimed to present a new cardiovascular rehabilitation system to 11 outpatients with coronary artery disease from a Hospital in Porto, Portugal, later collecting their opinions. This system is based on a virtual reality game system, using the Kinect sensor while performing an exercise protocol which is integrated in a home-based cardiovascular rehabilitation programme, with a duration of 6 months and at the maintenance phase. The participants responded to a questionnaire asking for their opinion about the system. The results demonstrated that 91% of the participants (n = 10) enjoyed the artwork, while 100% (n = 11) agreed on the importance and usefulness of the automatic counting of the number of repetitions, moreover 64% (n = 7) reported motivation to continue performing the programme after the end of the study, and 100% (n = 11) recognized Kinect as an instrument with potential to be an asset in cardiovascular rehabilitation. Criticisms included limitations in motion capture and gesture recognition, 91% (n = 10), and the lack of home space, 27% (n = 3). According to the participants’ opinions, the Kinect has the potential to be used in cardiovascular rehabilitation; however, several technical details require improvement, particularly regarding the motion capture and gesture recognition.