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Michelsen HÖ, Lidin M, Bäck M, Duncan TS, Ekman B, Hagström E, Hägglund M, Lindahl B, Schlyter M, Leósdóttir M. The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial. Implement Sci 2024; 19:35. [PMID: 38790045 DOI: 10.1186/s13012-024-01366-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs. METHODS The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation. DISCUSSION Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI. TRIAL REGISTRATION ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23.
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Affiliation(s)
- Halldóra Ögmundsdóttir Michelsen
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
- Department of Emergency medicine and Geriatrics, Helsingborg Hospital, Helsingborg, Sweden.
| | - Matthias Lidin
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Health, Medicine and Caring Sciences, Unit of Physiotherapy, Linköping University, Linköping, Sweden
| | - Therese Scott Duncan
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Björn Ekman
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Mona Schlyter
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Margrét Leósdóttir
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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Bäck M, Leosdottir M, Ekström M, Hambraeus K, Ravn-Fischer A, Öberg B, Östlund O, James S. The remote exercise SWEDEHEART study-Rationale and design of a multicenter registry-based cluster randomized crossover clinical trial (RRCT). Am Heart J 2023; 262:110-118. [PMID: 37105430 DOI: 10.1016/j.ahj.2023.04.014] [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] [Received: 10/01/2022] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Despite proven benefits of exercise-based cardiac rehabilitation (EBCR), few patients with myocardial infarction (MI) participate in and complete these programs. STUDY DESIGN AND OBJECTIVES The Remote Exercise SWEDEHEART study is a large multicenter registry-based cluster randomized crossover clinical trial with a planned enrollment of 1500 patients with a recent MI. Patients at intervention centers will be offered supervised EBCR, either delivered remotely, center-based or as a combination of both modes, as self-preferred choice. At control centers, patients will be offered supervised center-based EBCR, only. The duration of each time period (intervention/control) for each center will be 15 months and then cross-over occurs. The primary aim is to evaluate if remotely delivered EBCR, offered as an alternative to center-based EBCR, can increase participation in EBCR sessions. The proportion completers in each group will be presented in a supportive responder analysis. The key secondary aim is to investigate if remote EBCR is as least as effective as center-based EBCR, in terms of physical fitness and patient-reported outcome measures. Follow-up of major adverse cardiovascular events (cardiovascular- and all-cause mortality, recurrent hospitalization for acute coronary syndrome, heart failure hospitalization, stroke, and coronary revascularization) will be performed at 1 and 3 years. Safety monitoring of serious adverse events will be registered, and a cost-effectiveness analysis will be conducted to estimate the cost per quality-adjusted life-year (QALY) associated with the intervention compared with control. CONCLUSIONS The cluster randomized crossover clinical trial Remote Exercise SWEDEHEART study is evaluating if participation in EBCR sessions can be increased, which may contribute to health benefits both on a group level and for individual patients including a more equal access to health care. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (Identifier: NCT04260958).
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Affiliation(s)
- Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden.
| | - Margret Leosdottir
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Mattias Ekström
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | | | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan James
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Michelsen HÖ, Henriksson P, Wallert J, Bäck M, Sjölin I, Schlyter M, Hagström E, Kiessling A, Held C, Hag E, Nilsson L, Schiopu A, Zaman MJ, Leosdottir M. Organizational and patient-level predictors for attaining key risk factor targets in cardiac rehabilitation after myocardial infarction: The Perfect-CR study. Int J Cardiol 2023; 371:40-48. [PMID: 36089158 DOI: 10.1016/j.ijcard.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/24/2022] [Accepted: 09/06/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Benefits of cardiac rehabilitation (CR) programme components on attaining risk factor targets post-myocardial infarction (MI) and their predictive strength relative to patient characteristics remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at one-year post-MI. METHODS In this observational study data on CR organization at 78 Swedish CR centres was collected and merged with patient-level registry data (n = 7549). Orthogonal partial least squares discriminant analysis identified predictors (Variables of Importance for the Projection (VIP) values >0.8) of attaining low-density lipoprotein-cholesterol (LDL-C) <1.8 mmol/L, blood pressure (BP) <140/90 mmHg and smoking abstinence. RESULTS The strongest predictors (VIP [95% CI]) for attaining LDL-C and BP targets were offering psychosocial management (2.14 [1.78-2.50]; 2.45 [1.91-2.99]), having a psychologist in the CR team (1.62 [1.36-1.87]; 2.05 [1.67-2.44]), extended opening hours (2.13 [2.00-2.27]; 1.50 [0.91-2.10]), adequate facilities (1.54 [0.91-2.18]; 1.89 [1.38-2.40]), and having a medical director (1.70 [0.91-2.48]; 1.46 [1.04-1.88]). The strongest patient-level predictors of attaining LDL-C and/or BP targets were low baseline LDL-C (3.95 [3.39-4.51]) and having no history of hypertension (2.93 [2.60-3.26]), respectively, followed by exercise-based CR participation (1.38 [0.66-2.10]; 1.46 [1.14-1.78]). For smoking abstinence, the strongest organizational predictor was varenicline being prescribed by CR physicians (1.88 [0.95-2.80]) and patient-level predictors were participation in exercise-based CR (2.47 [2.07-2.88]) and group education (1.92 [1.43-2-42]), and no cardiovascular disease history (2.13 [1.78-2.48]). CONCLUSIONS We identified multiple CR organizational and patient-level predictors of attaining risk factor targets post-MI. These results may influence the future design of comprehensive CR programmes.
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Affiliation(s)
- Halldora Ögmundsdottir Michelsen
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Internal Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - Peter Henriksson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - John Wallert
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Sweden
| | - Maria Bäck
- Department of Occupational therapy and Physiotherapy, Sahlgrenska University Hospital Gothenburg, Sweden; Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ingela Sjölin
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Mona Schlyter
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Anna Kiessling
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Emma Hag
- Department of Internal Medicine, County hospital Ryhov, Jönköping, Sweden
| | - Lennart Nilsson
- Department of Health Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Alexandru Schiopu
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Internal Medicine, Skåne University Hospital, Lund, Sweden; Department of Pathology, University of Medicine Pharmacy Sciences and Technology of Targu-Mures, Targu-Mures, Romania
| | - M Justin Zaman
- Cardiac Centre, West Suffolk Hospital, Bury St Edmunds, UK
| | - Margret Leosdottir
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
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