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Vanzella LM, Konidis R, Pakosh M, Aultman C, Ghisi GLDM. A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2024; 44:83-90. [PMID: 37820282 DOI: 10.1097/hcr.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
OBJECTIVE The aim of this study was to systematically review the impact and characteristics of interventions with an educational component designed to improve enrollment and participation in cardiac rehabilitation (CR) among patients with cardiovascular disease. REVIEW METHODS Five electronic databases were searched from data inception to February 2023. Randomized controlled trials and controlled, cohort, and case-control studies were considered for inclusion. Title, abstract, and full text of records were screened by two independent reviewers. The quality of included studies was rated using the Mixed Methods Assessment Tool. Results were analyzed in accordance with the Synthesis Without Meta-analysis reporting guideline. RESULTS From 7601 initial records, 13 studies were included, six of which were randomized controlled trials ("high" quality = 53%). Two studies evaluated interventions with an educational component for health care providers (multidisciplinary team) and 11 evaluated interventions for patient participants (n = 2678). These interventions were delivered in a hybrid (n = 6; 46%), in-person (n = 4; 30%), or virtual (n = 3; 23%) environment, mainly by nurses (n = 4; 30%) via discussion and orientation. Only three studies described the inclusion of printed or electronic materials (eg, pamphlets) to support the education. Eleven of 12 studies reported that patients who participated in interventions with an educational component or were cared for by health care providers who were educated about CR benefits (inhospital and/or after discharge) were more likely to enroll and participate in CR. CONCLUSION Interventions with an educational component for patients or health care providers play an important role in increasing CR enrollment and participation and should be pursued. Studies investigating the effects of such interventions in people from ethnic minority groups and living in low-and-middle-income countries, as well as the development of standard educational materials are recommended.
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Affiliation(s)
- Lais Manata Vanzella
- University Health Network, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (Drs Vanzella and Ghisi and Mss Konidis and Aultman); The KITE Research Institute, Toronto, Ontario, Canada (Drs Vanzella and Ghisi); Library & Information Services, University Health Network, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (Ms Pakosh); and Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada (Dr Ghisi)
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Vanzella LM, Cotie LM, Flores-Hukom M, Marzolini S, Konidis R, Ghisi GLDM. Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study. J Cardiovasc Nurs 2024:i. [PMID: 38206327 DOI: 10.1097/jcn.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models. OBJECTIVE The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic. METHODS Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis. RESULTS Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation. CONCLUSIONS Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.
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Li S, Fonarow GC, Mukamal K, Xu H, Matsouaka RA, Devore AD, Bhatt DL. Sex and Racial Disparities in Cardiac Rehabilitation Referral at Hospital Discharge and Gaps in Long-Term Mortality. J Am Heart Assoc 2018; 7:JAHA.117.008088. [PMID: 29626153 PMCID: PMC6015394 DOI: 10.1161/jaha.117.008088] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Cardiac rehabilitation (CR) referral is recommended for eligible patients, regardless of sex or race. It is unclear whether inequality in CR referral practices was associated with patients’ long‐term survival. Methods and Results We linked the American Heart Association Get With The Guidelines Coronary Artery Disease registry with Medicare claims data for 48 993 coronary artery disease patients from 365 hospitals across the United States between 2003 and 2009. We used generalized estimation equations to estimate the association between CR referral and mortality accounting for clustering within hospitals. Between 2003 and 2009, only 40% of eligible patients received CR referrals. Females were 12% less likely to receive CR referral compared with males. Black, Hispanic, and Asian patients were 20%, 36%, and 50% less likely, respectively, to receive CR referral than white patients. CR referral was associated with 40% lower 3‐year all‐cause mortality. Women and minorities who received CR referral at hospital discharge had significantly lower mortality compared with those who did not (odds ratios=0.61 [95% confidence interval, 0.56–0.66] for women, 0.75 [95% confidence interval, 0.63–0.88] for black, 0.62 [95% confidence interval, 0.50–0.79] for Hispanic, and 0.63 [95% confidence interval, 0.46–0.85] for Asian patients). Seven percent of the black versus white mortality gap could potentially be reduced by equitable CR referral. Conclusions CR referral rates at hospital discharge remained low. Gaps in receiving CR referral at hospital discharge were large for women and minorities, and the mortality gap could potentially be reduced through elimination of inequality in CR referral.
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Affiliation(s)
- Shanshan Li
- Boston University School of Medicine, Boston, MA
| | | | | | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA
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Supervía M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Pérez-Terzic CM, Brewer LC, Leth SE, Thomas RJ. Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions. Mayo Clin Proc 2017; 92:S0025-6196(17)30026-5. [PMID: 28365100 PMCID: PMC5597478 DOI: 10.1016/j.mayocp.2017.01.002] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/28/2016] [Accepted: 01/04/2017] [Indexed: 10/19/2022]
Abstract
Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.
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Affiliation(s)
- Marta Supervía
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Jose R Medina-Inojosa
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Colin Yeung
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Francisco Lopez-Jimenez
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ray W Squires
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Carmen M Pérez-Terzic
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - LaPrincess C Brewer
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Shawn E Leth
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Randal J Thomas
- Cardiovascular Rehabilitation Program, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Gravely S, Anand SS, Stewart DE, Grace SL. Effect of referral strategies on access to cardiac rehabilitation among women. Eur J Prev Cardiol 2014; 21:1018-25. [PMID: 23471593 PMCID: PMC4522313 DOI: 10.1177/2047487313482280] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 02/21/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite its proven benefits and need, women's access to cardiac rehabilitation (CR) is suboptimal. Referral strategies, such as systematic referral, have been advocated to improve access to CR. This study examined sex differences in CR referral and enrollment by referral strategies; and the impact of referral strategies for referral and enrollment concordance among women. DESIGN Prospective cohort study. METHODS This prospective study included 2635 coronary artery disease inpatients from 11 Ontario hospitals that utilized one of four referral strategies. Participants completed a sociodemographic survey, and clinical data were extracted from charts. One year later, 1809 participants (452 (25%) women) completed a mailed survey that assessed CR utilization. Referral strategies were compared among women using generalized estimating equations to control for the effect of hospital. RESULTS Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p < 0.001), and enrolled in CR (58.6% and 49.3% respectively, p = 0.001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (OR 10.3, 95% CI 4.11-25.58) and enrollment (OR 6.6, 95% CI 4.34-9.92) among women when compared with usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (K = 0.85), and decreased with referral intensity. CONCLUSIONS While a lower proportion of referred patients enroll, systematic and liaison-facilitated inpatient referral strategies result in the greatest CR enrollment rates among women. Such strategies have the potential to improve access among women, and reduce 'cherry picking' of patients for referral.
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Affiliation(s)
- Shannon Gravely
- Peter Munk Cardiac Center Cardiovascular Rehabilitation & Prevention Program, Toronto General Research Institute, University Health Network, Toronto, Canada
| | - Sonia S Anand
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Donna E Stewart
- Peter Munk Cardiac Center Cardiovascular Rehabilitation & Prevention Program, Toronto General Research Institute, University Health Network, Toronto, Canada Department of Psychiatry, University of Toronto, Canada
| | - Sherry L Grace
- Peter Munk Cardiac Center Cardiovascular Rehabilitation & Prevention Program, Toronto General Research Institute, University Health Network, Toronto, Canada Department of Psychiatry, University of Toronto, Canada School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada
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Brady S, Purdham D, Oh P, Grace S. Clinical and sociodemographic correlates of referral for cardiac rehabilitation following cardiac revascularization in Ontario. Heart Lung 2014; 42:320-5. [PMID: 23998380 DOI: 10.1016/j.hrtlng.2013.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 06/28/2013] [Accepted: 07/03/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Describe rates of, and examine factors affecting, referral to cardiac rehabilitation (CR) following revascularization in Ontario. BACKGROUND CR reduces mortality following cardiac revascularization, but is largely underutilized, partly due to poor referral rates. METHODS In this retrospective study, the sample consisted of all CR-indicated patients who underwent revascularization at the Cardiac Care Network of Ontario hospitals between October 2011 through March 2012. Referral rates were described, and multivariate analyses performed to identify disparities. RESULTS Of the 3739 patients included, 51.8% were referred to CR. Patients aged ≥85 or requiring a translator, and patients with hyperlipidemia, heart failure, or comorbid pulmonary, renal or peripheral vascular disease, were significantly less likely to be referred. Patients with a history of smoking or myocardial infarction, or who underwent coronary artery bypass graft surgery, were significantly more likely. CONCLUSIONS A national policy statement recommends 85% referral of indicated patients to CR, a target currently missed by almost 35%.
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Grace SL, Angevaare KL, Reid RD, Oh P, Anand S, Gupta M, Brister S, Stewart DE. Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study. Implement Sci 2012; 7:120. [PMID: 23234558 PMCID: PMC3541119 DOI: 10.1186/1748-5908-7-120] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 12/11/2012] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite the evidence of benefit, cardiac rehabilitation (CR) remains highly underutilized. The present study examined the effect of two inpatient and one outpatient strategy on CR utilization: allied healthcare provider completion of referral (a policy that had been endorsed and approved by the cardiac program leadership in advance; PRE-APPROVED); CR intake appointment booked before hospital discharge (PRE-BOOKED); and early outpatient education provided at the CR program shortly after inpatient discharge (EARLY ED).In this prospective observational study, 2,635 stable cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey, and clinical data were extracted from charts. One year later, participants were a mailed survey that assessed CR use. Participating inpatient units and CR programs to which patients were referred were coded to reflect whether each of the strategies was used (yes/no). The effect of each strategy on participants' CR referral and enrollment was examined using generalized estimating equations. RESULTS A total of 1,809 participants completed the post-test survey. Adjusted analyses revealed that the implementation of one of the inpatient strategies was significantly related to greater referral and enrollment (PRE-APPROVED: OR = 1.96, 95%CI = 1.26 to 3.05, and OR = 2.91, 95%CI = 2.20 to 3.85, respectively). EARLY ED also resulted in significantly greater enrollment (OR = 4.85, 95%CI = 2.96 to 7.95). CONCLUSIONS These readily-implementable strategies could significantly increase access to and enrollment in CR for the cardiac population. The impact of these strategies on wait times warrants exploration.
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Affiliation(s)
- Sherry L Grace
- School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, Canada
- Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, Canada
- Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, Canada
- Mackenzie Health, 10 Trench Street, Richmond Hill, Canada
- Cardiac Program, Toronto Rehabilitation Institute, University Health Network, 347 Rumsey Road, Toronto, Canada
| | - Kelly L Angevaare
- Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, Canada
| | - Robert D Reid
- Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Canada
| | - Paul Oh
- Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, Canada
- Cardiac Program, Toronto Rehabilitation Institute, University Health Network, 347 Rumsey Road, Toronto, Canada
| | - Sonia Anand
- Clinical Epidemiology and Biostatistics, McMaster University, 237 Barton St. E, Hamilton, Canada
| | - Milan Gupta
- William Osler Health Centre, 2100 Bovaird Drive East, Brampton, Canada
| | - Stephanie Brister
- Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, Canada
| | - Donna E Stewart
- Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, Canada
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Grace SL, Leung YW, Reid R, Oh P, Wu G, Alter DA, CRCARE Investigators. The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization. J Cardiopulm Rehabil Prev 2012; 32:41-7. [PMID: 22193933 PMCID: PMC4508132 DOI: 10.1097/hcr.0b013e31823be13b] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral. METHODS Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using χ. RESULTS When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy. CONCLUSION Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.
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Affiliation(s)
- Sherry L Grace
- Kinesiology and Health Science, 368 Bethune College, York University, Toronto, Ontario, Canada.
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Look MA, Kaholokula JK, Carvhalo A, Seto T, de Silva M. Developing a culturally based cardiac rehabilitation program: the HELA study. Prog Community Health Partnersh 2012; 6:103-10. [PMID: 22643794 PMCID: PMC3524268 DOI: 10.1353/cpr.2012.0012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Heart disease disproportionately affects Native Hawaiians and other Pacific people. In response, researchers proposed and communities endorsed, developing a cardiac rehabilitation (CR) program based on the hula, a Native Hawaiian dance form. The utilization of cultural practices in health interventions can improve outcomes and increase enrollment and retention, but requires sensitivity and understanding. OBJECTIVE This paper provides the conceptual framework and methods used for integration of multiple communities' perspectives to inform the design of a hula-based CR intervention. METHODS Specific strategies and processes were established to ensure the equity of scientific-clinical and patient- cultural knowledge and perspectives. Multiple methods were used and a flow diagram defined steps for the intervention development. RESULTS Patient and cultural consultations provided information about the multidimensional benefits of hula and its use in a CR intervention. Clinical and scientific consultations provided specific guidelines for exercise prescription and patient monitoring. Integrating findings from all consultations identified important direction and requirements. CONCLUSIONS Community-based participatory research (CBPR) principles guided a complex collaboration of multiple communities; although time consuming, inclusive consultations provided valuable information and relationships.
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Affiliation(s)
- Mele A Look
- University of Hawai'i, School of Medicine, USA
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Grace SL, Chessex C, Arthur H, Chan S, Cyr C, Dafoe W, Juneau M, Oh P, Suskin N. Systematizing Inpatient Referral to Cardiac Rehabilitation 2010: Canadian association of cardiac rehabilitation and Canadian cardiovascular society joint position paper. J Cardiopulm Rehabil Prev 2011; 31:E1-8. [PMID: 21460733 DOI: 10.1097/hcr.0b013e318219721f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters ("other"), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.
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Savage PD, Sanderson BK, Brown TM, Berra K, Ades PA. Clinical research in cardiac rehabilitation and secondary prevention: looking back and moving forward. J Cardiopulm Rehabil Prev 2011; 31:333-41. [PMID: 21946418 PMCID: PMC3219833 DOI: 10.1097/hcr.0b013e31822f0f79] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Cardiac rehabilitation/secondary prevention (CR/SP) programs are considered standard of care and provide critically important resources for optimizing the care of cardiac patients. The objective of this article is to briefly review the evolution of CR/SP programs from a singular exercise intervention to its current, more comprehensive multifaceted approach. In addition, we offer perspective on critical concerns and suggest future research considerations to optimize the effectiveness and utilization of CR/SP program interventions.
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Affiliation(s)
- Patrick D. Savage
- Division of Cardiology, Cardiac Rehabilitation & Prevention, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT
| | | | - Todd M. Brown
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Kathy Berra
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, CA
| | - Philip A. Ades
- Division of Cardiology, Cardiac Rehabilitation & Prevention, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT
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Dankner R, Geulayov G, Ziv A, Novikov I, Goldbourt U, Drory Y. The effect of an educational intervention on coronary artery bypass graft surgery patients' participation rate in cardiac rehabilitation programs: a controlled health care trial. BMC Cardiovasc Disord 2011; 11:60. [PMID: 21982052 PMCID: PMC3214809 DOI: 10.1186/1471-2261-11-60] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 10/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac rehabilitation has a beneficial effect on the prognosis and quality of life of cardiac patients, and has been found to be cost-effective. This report describes a comprehensive and low cost educational intervention designed to increase the attendance at cardiac rehabilitation programs of patients who have undergone coronary artery bypass graft surgery. METHODS/DESIGN A controlled prospective intervention trial. The control arm comprised 520 patients who underwent coronary artery bypass graft surgery between January 2004 and May 2005 in five medical centers across Israel. This group received no additional treatment beyond usual care. The intervention arm comprised 504 patients recruited from the same cardiothoracic departments between June 2005 and November 2006. This group received oral and written explanations about the advantages of participating in cardiac rehabilitation programs and a telephone call two weeks after hospital discharge intended to further encourage their enrollment. The medical staff attended a one-hour seminar on cardiac rehabilitation. In addition, it was recommended that referral to cardiac rehabilitation be added to the letter of discharge from the hospital. Both study groups were interviewed before surgery and one-year post surgery. A one-year post-operative interview assessed factors affecting patient attendance at cardiac rehabilitation programs, as well as the structure and content of the cardiac rehabilitation programs attended. Anthropometric parameters were measured at pre- and post-operative interviews;- and medical information was obtained from patient medical records. The effect of cardiac rehabilitation on one- and three-year mortality was assessed. DISCUSSION We report a low cost yet comprehensive intervention designed to increase cardiac rehabilitation participation by raising both patient and medical staff awareness to the potential benefits of cardiac rehabilitation. TRIAL REGISTRATION ClinicalTrials.gov: NCT00356863.
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Affiliation(s)
- Rachel Dankner
- Unit for Cardiovascular Epidemiology, the Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer 52621, Israel
- Division of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Galit Geulayov
- Unit for Cardiovascular Epidemiology, the Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer 52621, Israel
| | - Arnona Ziv
- Department for Data Management, the Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer 52621, Israel
| | - Ilia Novikov
- Unit for Biostatistics, the Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer 52621, Israel
| | - Uri Goldbourt
- Division of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yaakov Drory
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Grace SL, Chessex C, Arthur H, Chan S, Cyr C, Dafoe W, Juneau M, Oh P, Suskin N. Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper endorsed by the Cardiac Care Network of Ontario. Can J Cardiol 2011; 27:192-9. [PMID: 21459268 DOI: 10.1016/j.cjca.2010.12.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 12/07/2010] [Accepted: 12/07/2010] [Indexed: 02/07/2023] Open
Abstract
Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters ("other"), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.
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Affiliation(s)
- Sherry L Grace
- York University and University Health Network, Toronto, Ontario, Canada
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14
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Abstract
Despite recommendations in clinical practice guidelines, evidence suggests that utilization of cardiac rehabilitation (CR) following indicated cardiac events is low. Referral strategies, such as automatic referral, have been advocated to improve CR utilization. In this Review, we evaluate the effects of referral strategies on rates of CR referral and enrollment. Referral strategies are categorized as 'automatic' (the use of electronic health records or systematic discharge order sets), as 'liaison' (discussions with allied health-care providers), or as 'other' (for example, the use of motivational letter to patients). The highest rates of CR referral have been achieved in studies implementing automatic referral orders, whereas the highest rates of CR enrollment have resulted from a combination of automatic and liaison methods. Overall, innovative referral strategies significantly increase CR utilization. While further investigation is needed, institutions should evaluate their CR referral practice in light of these findings.
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Exercise-based cardiac rehabilitation for very old patients (> or =75 years): focus on physical function. J Cardiopulm Rehabil Prev 2008; 28:163-73. [PMID: 18496314 DOI: 10.1097/01.hcr.0000320066.58599.e5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Older patients have high rates of physical function impairment and disability following a cardiac event. Exercise training has been shown to favorably affect such limitations, as well as cardiovascular risk factors, symptoms, and mortality post coronary event in middle-aged patients. Aerobic capacity, body strength, quality of life, and physical function are improved with exercise-based cardiac rehabilitation (CR) in patients older than 65 years. However, there have been relatively few studies of the effects of exercise-based CR on physical function recovery in the very old patients (> or =75 years), despite the continuous growth of this segment of the population. After hospitalization for a cardiac event, postacute inpatient CR serves as a bridge between acute care and independent home living for the most disabled older patients. It plays an important role in the physical recovery process, particularly after cardiac surgery. Exercise-based outpatient (phase II) CR, starting early after hospital discharge, is safe in very old patients and studies demonstrate that these patients derive similar benefits from CR, compared with younger patients, regarding physical function improvement. Older patients, however, are less likely than younger cardiac patients to participate in outpatient CR programs. There is a need to find protocols that could increase the referral and participation rates of the frailer and older cardiac patient to exercise-based CR.
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Scott LB. Referral to outpatient cardiac rehabilitation: intervention research at the patient, provider, and health system levels. ACTA ACUST UNITED AC 2008; 5:671-2. [PMID: 18695694 DOI: 10.1038/ncpcardio1320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 07/02/2008] [Indexed: 11/09/2022]
Abstract
This article sets out the clinical context of the research presented by Grace et al. in an accompanying article in this journal. Secondary preventive measures against cardiovascular disease, such as outpatient cardiac rehabilitation (OCR), can greatly reduce associated burden on health systems. Here, I discuss the study carried out by Grace and colleagues--a multilevel study of the contribution of patient and physician factors to cardiac rehabilitation referral. Grace et al. demonstrate that both physician and patient factors have key roles in OCR referral. In this commentary I explore the limitations of studying the factors that contribute to referral alone as a final end point given the lower-than-desired rates of enrollment among referred patients.
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Affiliation(s)
- Lisa Benz Scott
- Health Sciences Center, Stony Brook University, Stony Brook, NY 11794-8204, USA.
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Chan DS, Chau JP, Chang AM. Psychosocial outcomes of Hong Kong Chinese diagnosed with acute coronary syndromes: A prospective repeated measures study. Int J Nurs Stud 2007; 44:945-52. [DOI: 10.1016/j.ijnurstu.2006.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 02/15/2006] [Accepted: 03/25/2006] [Indexed: 10/24/2022]
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Harkness K, Smith KM, Taraba L, Mackenzie CL, Gunn E, Arthur HM. Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery. Heart Lung 2005; 34:179-86. [PMID: 16015222 DOI: 10.1016/j.hrtlng.2004.07.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Enrollment in cardiac rehabilitation (CR) after coronary artery bypass graft (CABG) surgery is suboptimal (25%-30%). OBJECTIVES The purpose of this study was to examine the effect of a nurse-initiated telephone call (NIC) on attendance at a CR intake appointment. METHODS By using a retrospective cohort design, data were collected on 3536 patients who underwent CABG between April 1996 and March 2000 and were referred to CR. Of these, 2285 patients received standard care (no NIC) and 1251 received the NIC. RESULTS Patients who received the NIC were significantly more likely to attend their CR intake appointment compared with standard care (78.1% vs. 50.1%; P < .0001). Hierarchic logistic regression analysis revealed the NIC as the strongest predictor of attendance at a CR intake explaining 56.9% of the total variance (odds ratio =3.429; 95% confidence interval = 2.919-4.028; P < .0001). CONCLUSION These findings suggest that pre-appointment telephone contact by a cardiovascular nurse is a valuable tool to enhance attendance at a CR intake appointment after CABG.
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Chan DSK, Chau JPC, Chang AM. Acute coronary syndromes: cardiac rehabilitation programmes and quality of life. J Adv Nurs 2005; 49:591-9. [PMID: 15737219 DOI: 10.1111/j.1365-2648.2004.03334.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS This paper reports a study examining the quality of life of clients following hospital admission with acute coronary syndrome in Hong Kong and their use of cardiac rehabilitation. BACKGROUND Coronary heart disease is a major source of mortality and morbidity in Hong Kong. Western studies have suggested that participation in cardiac rehabilitation improves the quality of life of clients with coronary heart disease yet the use of cardiac rehabilitation has been reported to be low. Better understanding is needed of the psychosocial status of these clients in Hong Kong and their use of cardiac rehabilitation services. METHODS A prospective, pretest-post-test study was carried out, with data collected over a period of 6 months with convenience sample of 182 participants. Baseline data were obtained within one week after hospital admission for individuals experiencing ACS. The second phase of data collection commenced at 6 months after hospital discharge. Total period of data collection took over 12 months between 2002 and 2003. The Chinese version of the SF-36 was used to assess quality of life, and demographic data and the extent to which clients participated in the cardiac rehabilitation programme were assessed. RESULTS Only 25% of the participants attended at least one session of the cardiac rehabilitation programme. Significant improvement occurred in all clients' perceived quality of life 6 months following initial hospital admission. No significant group differences in perceived quality of life were found according to whether or not clients used the cardiac rehabilitation services. CONCLUSION Improvement in perceived health-related quality of life was evident over a 6-month period. Yet our findings suggested that participation in the cardiac rehabilitation programme did not have any apparent effects in subjects' perceived quality of life. Further studies using both generic and disease-specific health-related quality of life instruments, as well as the inclusion of control group, are recommended. Continual improvement in cardiac rehabilitation programmes, and consideration of alternative modes of delivery other than the traditional attendance at hospital outpatient services, are also recommended.
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Affiliation(s)
- Dominic S K Chan
- School of Nursing, Australian Catholic University, 115 Victoria Parade, Fitzroy, Melbourne, VIC 3065, Australia.
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Johnson N, Fisher J, Nagle A, Inder K, Wiggers J. Factors Associated With Referral to Outpatient Cardiac Rehabilitation Services. ACTA ACUST UNITED AC 2004; 24:165-70. [PMID: 15235296 DOI: 10.1097/00008483-200405000-00005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low. PURPOSE This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia. METHODS The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral. RESULTS : Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery. CONCLUSIONS Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.
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Affiliation(s)
- Natalie Johnson
- Centre for Clinical Epidemiology and Biostatistics, School of Medical Practice and Population Health, The University of Newcastle, NSW, Australia.
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