Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion

Factors that predict compliance in a virtual cardiac rehabilitation program

BACKGROUND

Despite the well-established benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), participation in CR remain low. Virtual CR programs present a unique opportunity to promote utilization. To date, few virtual CR cohorts have been analyzed for compliance. This study aims to determine factors that predict compliance within a large virtual CR program in the United States.

METHODS

We analyzed 1409 patients enrolled in the Kaiser Permanente Mid-Atlantic States Virtual CR program that consists of 12 CR sessions via telephone. Demographic characteristics, as well as body weight, blood pressure, HbA1c level, and smoking status were collected at admission. Patients were further classified by CVD diagnosis codes. Compliance was defined as at least 75% (9/12 sessions) attendance. Data was analyzed using simple and multiple regression models with significance defined as P < 0.05.

RESULTS

Age was the single strongest predictor for virtual CR compliance (adjusted R2 = 0.58; P < 0.001), and non-compliant patients were younger. HbA1C level, CVD diagnosis codes, and smoking status each moderately predicted compliance (adjusted R2 = 0.48, 0.42, and 0.31, respectively; P < 0.001). Smoking and HbA1C level combined in a multiple regression model significantly improved prediction of compliance (adjusted R2 = 0.79, P < 0.01). Sex, baseline weight or hypertension were not significant predictors of CR compliance.

CONCLUSIONS

Age, diabetes, CVD diagnoses, smoking status at admission are independent predictors of compliance in a large virtual CR program. Targeted intervention could be designed accordingly to improve CR compliance.

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.

Clinical outcomes and cardiac rehabilitation in underrepresented groups after percutaneous coronary intervention: an observational study

AIMS

Underrepresentation of migrants, women, and older adults in cardiovascular disease (CVD) trials may contribute to disparate care and survival. Among patients who underwent percutaneous coronary intervention (PCI), we aimed to investigate the associations of (i) underrepresented groups with major adverse cardiac events (MACE), CVD mortality, and non-CVD mortality, (ii) underrepresented groups with cardiac rehabilitation (CR) uptake, and (iii) CR uptake with outcomes.

METHODS AND RESULTS

We included 15 211 consecutive patients from the CARDIOBASE Bern PCI registry (2009-18). In multi-state models comparing transition probabilities of events, sex was not associated with increased risk of any event. For each year increase in age, the increased risk of non-CVD and CVD mortality was 8% [95% confidence interval (CI) 6-9%]. Being migrant was associated with a lower risk of non-CVD mortality [hazard ratio (HR) (95% CI) 0.49 (0.27-0.90)] but not with CVD mortality. In logistic regression analysis, CR uptake was lower among women [odds ratio (95% CI) = 0.72 (0.57-0.86)] and older adults [0.32 (0.27-0.38)], but not among migrants. In cox regression, CR was independently associated with lower all-cause [HR (95% CI) = 0.12 (0.03-0.37)] and CVD mortality [0.1 (0.02-0.7)], but not with MACE [1.08 (0.8-1.4)].

CONCLUSION

Among underrepresented groups undergoing PCI, age, but not migration status nor sex, contributed to disparities in mortality. Migrant status did not result in lower attendance of CR. Considering the protective associations of CR on CVD mortality independent of age, sex, and migration status, the lower uptake in women and older adults is noteworthy.

Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS

PURPOSE

Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR.

REVIEW METHODS

The review examines original studies and meta-analyses regarding women in CR.

SUMMARY

Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR.

An Examination of Gender Differences in the National Diabetes Prevention Program's Lifestyle Change Program

PURPOSE

The purpose of the study was to examine how gender was related to enrollment and number of sessions attended in the National Diabetes Prevention Program's Lifestyle Change Program (DPP LCP).

METHODS

To better understand program uptake, a population of those who would be eligible for the LCP was compared to those who enrolled. Estimates of those eligible were computed using data from the National Health and Nutrition Examination Survey, whereas enrollment and sessions attended were computed using data from the Centers for Disease Control and Prevention's Diabetes Prevention Recognition Program.

RESULTS

Results revealed that although similar numbers of males and females were eligible for the program, only 39 321 males versus 121 007 females had enrolled in the National DPP LCP by the end of 2017 (odds ratio = 3.20; 95% CI, 3.17-3.24). The gender differences persisted even when stratifying by age or race/ethnicity. In contrast, no significant gender differences were found between the average number of sessions attended for males (14.0) and females (13.8).

DISCUSSION

Results of the study can help inform efforts to market and tailor programs to appeal more directly to men and other groups that are underrepresented in the National DPP LCP.

Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers?

BACKGROUND

People after stroke benefit from comprehensive secondary prevention programs including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use.

OBJECTIVE

The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use.

DESIGN

This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada.

METHODS

Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators.

RESULTS

Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, have poorer attendance at OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] vs 87.1% [SD = 16.6%], respectively) and completion (66.7% vs 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%).

LIMITATIONS

Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes.

CONCLUSIONS

An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.

Barriers physicians face when referring patients to cardiac rehabilitation: a narrative review

While cardiac rehabilitation (CR) has been shown to be a beneficial form of secondary prevention for patients with cardiovascular disease, barriers of referral to CR still exist for patients. Barriers that specifically make it difficult for physicians to make the referral could be worthwhile to examine. This narrative review hypothesizes that increasing awareness and education on the various aspects of CR as well as simplifying the referral process could lead to increased referral rates as they target physician-related barriers. This narrative review seeks to further understand the physician-related barriers of low CR awareness and hindering referral processes. A search in Scopus was conducted with preference for articles examining CR referral strategies used by physicians; physicians' awareness of CR programs; physicians' perceptions, beliefs, or knowledge of the benefits of CR; or physicians' experience with or understanding of the selection process of CR programs, including indications for referral. Two systematic reviews and two observational studies were selected for discussion. Three of the selected studies had findings supporting the notion that increasing physicians' awareness of CR could impact referral rates. One of the studies evaluated the perceptions that physicians and CR programs had on various referral strategies. While more study is needed to assess the actual level of knowledge and awareness physicians have regarding CR, this review supports using educational interventions as well as targeting various aspects of the referral process for improving referral rates.

"When what is taken for granted disappears": women's experiences and perceptions after a cardiac event

BACKGROUND AND PURPOSE

On entering Cardiac Rehabilitation (CR), the female cardiac population shows greater fear of overexertion and sense of uncertainty than similarly affected men. The purpose of this study was to explore how women experienced the recovery process after a cardiac event and what impact the event had on bodily experiences.

METHODS

A qualitative, descriptive design, inspired by a phenomenological approach. Information was collected from 20 women through focus groups and individual in-depth interviews. The material was analyzed with a method of systematic text condensation.

RESULTS

The women's recovery after a CE could be a lonely and difficult process. Their own perspectives on what they need in the process is often overlooked, focus being on medical care and clinical recovery in the early phase. Returning home, the women suffered vulnerability, fragility, and insecurity, affecting well-being as well as activity levels. Lack of support and follow-up post-discharge seemed to disturb the progress of the recovery process.

CONCLUSIONS

Helping the women regain confidence in their new bodies, supporting the personal recovery processes, and bridging the gap between discharge and enrolling in a CR-program could reduce personal stress and withdrawal, thereby empowering more women to start and complete CR programs.

Optimal Gender-Specific Strategies for the Secondary Prevention of Heart Disease in Women: A SYSTEMATIC REVIEW

BACKGROUND

There is a paucity of evidence on gender-specific, individually tailored secondary prevention (cardiac rehabilitation [CR]) services for women with heart disease. Women participate less in CR programs, thus increasing their risk of further cardiac events. This review aims to (1) determine the effectiveness of gender-specific interventions specifically designed for women with heart disease, delivered in outpatient CR settings; and (2) classify key elements of effective CR strategies/models for women with heart disease.

METHODS

Using the PRISMA guidelines, this is a systematic review of CR models tailored to women to improve cardiovascular risk. Four databases were searched for randomized controlled trials (RCTs) between January 1974 and July 2017 published in peer-reviewed English language journals.

RESULTS

Three RCTs comprising 725 women of gender-specific CR strategies were identified. Significant improvements were found in one-third (1 study) of the included multicomponent CR strategies for outcomes including general health, social functioning, vitality, mental health, depression, and quality of life.

CONCLUSION

Further large-scale RCTs are required to replicate positive findings and accurately assess the capacity for gender-specific multicomponent CR programs that incorporate participant-driven collaborative models to moderate psychological risk and improve functional capacity and quality of life for women with heart disease.

Mobile Technology Utilization Among Patients From Diverse Cultural and Linguistic Backgrounds Attending Cardiac Rehabilitation in Australia: Descriptive, Case-Matched Comparative Study

Background

Barriers to attending cardiac rehabilitation (CR), including cultural and linguistic differences, may be addressed by recent technological developments. However, the feasibility of using these approaches in culturally and linguistically diverse patients is yet to be determined.

Objective

This study aims to assess the use of mobile technologies and features, as well as confidence in utilization across patients speaking different languages at home (ie, English, Mandarin Chinese, and a language other than English and Mandarin [other]) and are both eligible and physically suitable for CR. In addition, the study aims to determine the sociodemographic correlates of the mobile technology/feature use, including language spoken at home in the three groups mentioned above.

Methods

This is a descriptive, case matched, comparative study. Age and gender-matched patients speaking English, Mandarin and other languages (n=30/group) eligible for CR were surveyed for their mobile technology and mobile feature use.

Results

‘Participants had a mean age of 66.7 years (SD 13, n=90, range 46-95), with 53.3% (48/90) male. The majority (82/90, 91.1%) used at least one technology device, with 87.8% (79/90) using mobile devices, the most common being smartphones (57/90, 63.3%), tablets (28/90, 31.1%), and text/voice-only phones (24/90, 26.7%). More English-speaking participants used computers than Mandarin or “other” language speaking participants (P=.003 and .02) and were more confident in doing so compared to Mandarin-speaking participants (P=.003). More Mandarin-speaking participants used smartphones compared with “other” language speaking participants (P=.03). Most commonly used mobile features were voice calls (77/82, 93.9%), text message (54/82, 65.9%), the internet (39/82, 47.6%), email (36/82, 43.9%), and videoconferencing (Skype or FaceTime [WeChat or QQ] 35/82, 42.7%). Less Mandarin-speaking participants used emails (P=.001) and social media (P=.007) than English-speaking participants. Speaking Mandarin was independently associated with using smartphone, emails, and accessing the web-based medication information (OR 7.238, 95% CI 1.262-41.522; P=.03, OR 0.089, 95% CI 0.016-0.490; P=.006 and OR 0.191, 95% CI 0.037-0.984; P=.05).

Conclusions

This study reveals a high usage of mobile technology among CR patients and provides further insights into differences in the technology use across CALD patients in Australia. The findings of this study may inform the design and implementation of future technology-based CR.

Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies

BACKGROUND

Although evidence exists for the efficacy of cardiac rehabilitation programmes to reduce morbidity and mortality among patients with cardiovascular disease, cardiac rehabilitation programmes are underused. We aimed systematically to review the evidence from prospective cohort studies on factors associated with non-participation in and/or dropping out from cardiac rehabilitation programmes.

METHODS

MedLine, Embase, Scopus, Open Grey and Cochrane Database were searched for relevant publications from inception to February 2018. Search terms included (a) coronary heart disease and other cardiac conditions; (b) cardiac rehabilitation and secondary prevention; and (c) non-participation in and/or dropout. Databases were searched following the PRISMA statement. Study selection, data extraction and the assessment of study quality were performed in duplicate.

RESULTS

We selected 43 studies with a total of 63,425 patients from 10 different countries that met the inclusion criteria. Factors associated with non-participation in and dropout from cardiac rehabilitation were grouped into six broad categories: intrapersonal factors, clinical factors, interpersonal factors, logistical factors, cardiac rehabilitation programme factors and health system factors. We found that clinical factors, logistical factors and health system factors were the main factors assessed for non-participation in cardiac rehabilitation. We also found differences between the factors associated with non-participation and dropout.

CONCLUSIONS

Several factors were determinant for non-participation in and dropout from cardiac rehabilitation. These findings could be useful to clinicians and policymakers for developing interventions aimed at improving participation and completion of cardiac rehabilitation, such as E-health or home-based delivery programmes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) identifier: CRD42016032973.

Tai Chi Is a Promising Exercise Option for Patients With Coronary Heart Disease Declining Cardiac Rehabilitation

BACKGROUND

More than 60% of patients decline participation in cardiac rehabilitation after a myocardial infarction. Options to improve physical activity (PA) and other risk factors in these high-risk individuals are limited. We conducted a phase 2 randomized controlled trial to determine feasibility, safety, acceptability, and estimates of effect of tai chi on PA, fitness, weight, and quality of life.

METHODS AND RESULTS

Patients with coronary heart disease declining cardiac rehabilitation enrollment were randomized to a "LITE" (2 sessions/week for 12 weeks) or to a "PLUS" (3 sessions/week for 12 weeks, then maintenance classes for 12 additional weeks) condition. PA (accelerometry), weight, and quality of life (Health Survey Short Form) were measured at baseline and 3, 6, and 9 months after baseline; aerobic fitness (stress test) was measured at 3 months. Twenty-nine participants (13 PLUS and 16 LITE) were enrolled. Retention at 9 months was 90% (LITE) and 88% (PLUS). No serious tai chi-related adverse events occurred. Significant mean between group differences in favor of the PLUS group were observed at 3 and 6 months for moderate-to-vigorous PA (100.33 min/week [95% confidence interval, 15.70-184.95 min/week] and 111.62 min/week; [95% confidence interval, 26.17-197.07 min/week], respectively, with a trend toward significance at 9 months), percentage change in weight, and quality of life. No changes in aerobic fitness were observed within and between groups.

CONCLUSIONS

In this community sample of patients with coronary heart disease declining enrollment in cardiac rehabilitation, a 6-month tai chi program was safe and improved PA, weight, and quality of life compared with a 3-month intervention. Tai chi could be an effective option to improve PA in this high-risk population.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02165254.

Participation in Cardiac Rehabilitation Among Patients With Heart Failure

BACKGROUND

Cardiac rehabilitation (CR) is linked to reduced mortality and morbidity, including improvements in cardiorespiratory fitness, psychosocial state, and quality of life in patients with heart failure (HF). However, little is known about CR utilization among patients with HF.

OBJECTIVE

We sought to determine (a) the proportion of patients with HF who participated in CR and (b) patient characteristics associated with participation.

METHODS

A retrospective study was conducted with the use of national data from the Centers for Medicare and Medicaid Services and the Veterans Health Administration. We used primary discharge ICD-9 codes to identify patients hospitalized for HF during 2007-2011 and identified CR participation with the use of current procedure terminology codes from claims data. Multivariate logistic regression was used to identify patient characteristics associated with CR participation.

RESULTS

There were 66,710 veterans and 243,208 Medicare beneficiaries hospitalized for HF and 1554 (2.3%) and 6280 (2.6%), respectively, who attended ≥1 sessions of outpatient CR. Among Medicare beneficiaries, men were more likely than women to participate in CR (3.7% vs 1.8%; P < .001), but there was no gender difference among veterans (2.3% vs 2.8%; P = .40). Characteristics associated with participation in CR in both groups included younger age, white race, and history of ischemic heart disease.

CONCLUSIONS

Very few HF patients participated in CR, with lower rates among older non-white women with a history of depression or other chronic medical conditions. Because Medicare has recently introduced coverage for CR in patients with systolic HF, we must increase efforts to improve CR participation, especially among these vulnerable groups.

Barriers for Nonparticipation and Dropout of Women in Cardiac Rehabilitation Programs: A Systematic Review

BACKGROUND

Cardiovascular disease (CVD) is a major health problem worldwide. Cardiac rehabilitation (CR) programs are effective in reducing mortality and improving the quality of life of patients with CVD. Women are under-represented in CR and have a higher dropout rate than men. We aimed to systematically review the literature on barriers perceived by women with CVD affecting their nonparticipation in and/or dropping out from CR programs.

METHODS

Systematic review was done using MEDLINE, Embase, Scopus, Open Grey, and Cochrane Database from inception to September 2016. Search terms included (1) heart disease and other cardiac conditions, (2) CR and secondary prevention, and (3) nonparticipation in and/or dropout. Databases were searched following the "participants, interventions, comparisons, outcomes, and study design" method.

RESULTS

A total of 24 studies (17 descriptive, 6 qualitative, and 1 randomized controlled trial) reporting several barriers were grouped into five broad categories: intrapersonal barriers (self-reported health, health beliefs, lack of time, motivation, and religious reasons); interpersonal barriers (lack of family/social support and work conflicts); logistical barriers (transport, distance, and availability of personal/community resources); CR program barriers (services offered, group format, exercise component, and CR sessions); and health system barriers (lack of referral, cost, negative experiences with the health system, and language). We found differences between the barriers related to nonparticipation in and dropout from CR programs.

CONCLUSIONS

Women reported multilevel barriers for nonparticipation in and dropout from CR programs. Future clinical guidelines should evaluate and eliminate these barriers to improve adherence to CR programs in women. In addition, understanding the barriers for nonparticipation and dropout may be beneficial for future intervention trials.

Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions

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.

Functional Recovery and Exercise Behavior in Men and Women 5 to 6 Years Following Coronary Artery Bypass Graft (CABG) Surgery

Improvement following coronary artery bypass graft (CABG) surgery has been reported to be less in women than men. Relationships between exercise behavior and functional status of men and women 5 to 6 years after CABG have not been examined in a representative patient sample. This study compared the 5- to 6-year recovery in a cohort of 184 patients at the Minnesota site of the Post CABG Biobehavioral Study. Data were collected by telephone interviewand self-administered questionnaires. Results showed that women had lower physical ( p ≤ .004) and social ( p = .001) functioning scores; men were more likely to participate in regular exercise ( p = .01). Exercisers had higher functional status scores. ANCOVA demonstrated that differences in measures of functional status by exercise category were maintained even after controlling for age, sex, and symptom severity ( p ≤ .01). In conclusion, individuals who exercised had more positive functional outcomes 5 to 6 years post-CABG.

Gender and Cardiovascular Disease

Coronary artery disease is the most common cause of morbidity, mortality, and economic loss in all industrialized countries. Although there are gender differences in the prevalence, causes, symptoms, treatment, and outcome of heart disease, the differences are complex and often misunderstood. These gender differences are a function of psychological influences, physiological influences, and an interaction of the two. Understanding these complex interactions and how they differentially influence the development and progression of heart disease will ultimately contribute to a greater understanding of how to integrate information from medicine and epidemiology with that from psychology and behavioral medicine. Ultimately, it is this integrated approach that will allow us to better understand heart disease in both men and women.

Usefulness of Cardiac Rehabilitation After Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction; however, the role of cardiac rehabilitation (CR) for patients with SCAD has not been well defined. To further understand CR in patients with SCAD, we studied a large cohort of patients with confirmed SCAD enrolled in the Mayo Clinic SCAD Registry from January 2010 to December 2014 (n = 354). Demographics, clinical characteristics, mental health status, and details about CR participation and experience were collected through medical record review and questionnaires. Participants at time of SCAD were 46 ± 10 years old; 96% were women. Most (76%) attended ≥1 CR sessions, averaging 18 ± 12 sessions. Most reported CR-related physical and emotional benefits (82% and 75%, respectively). Of the CR nonparticipants, 57 of 85 reported not participating because CR was not recommended by their health care provider. Other reasons included inadequate transportation (10 of 85), no insurance coverage (7 of 85), cost (2 of 85), no energy (2 of 85), being too ill (2 of 85), and miscellaneous comments (5 of 85). In conclusion, 3 of 4 of patients with SCAD participated in CR, most of whom reported benefit. Lack of recommendation for CR by a health care provider was the primary reason patients did not participate.

Sex Differences in Cardiac Rehabilitation Adherence: A Meta-analysis

BACKGROUND

Cardiac rehabilitation (CR) participation is associated with significantly lower mortality, and this benefit has been established as dose-dependent. Because it has been suggested that women are adherent to CR programs less than men, the objective of this study was to review CR adherence among women and men, and to determine whether a sex difference exists.

METHODS

MedLine, CINAHL, EMBASE, PsycINFO, and the Cochrane databases were systematically searched. Titles and abstracts were screened, and selected full-text articles were independently considered on the basis of predefined inclusion/exclusion criteria. Data from included articles were extracted by 2 authors independently and assessed for quality. The meta-analysis was undertaken with predefined subgroup analyses.

RESULTS

The search identified 5148 articles, of which 149 were fully examined for inclusion consideration. Fourteen studies reporting data on 8176 participants (2234 [27.3%] women) were included. Overall, CR adherence ranged from 36.7% to 84.6% of sessions, with a mean of 66.5 ± 18.2% (median, 72.5%). Men and women enrolled in CR adhered to 68.6% and 64.2% of prescribed sessions, respectively (mean difference = -3.6; 95% confidence interval, -6.9 to -0.3). The sex difference persisted in studies of high quality, that were undertaken in Canada, published since 2010, and where programs were longer than 12 weeks' duration and offered fewer than 3 sessions per week.

CONCLUSIONS

To our knowledge, this is the first meta-analysis to systematically report CR adherence rates, and results suggest that patients adhere to more than two-thirds of prescribed sessions. CR adherence is significantly lower among women than men. Identified strategies to promote adherence need to be tested among women.

Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States

BACKGROUND

Physical activity (PA) is recommended for primary and secondary prevention of cardiovascular disease (CVD). This study described the prevalence of self-reported and accelerometer-measured PA and sedentary behavior, using a nationally representative sample from the United States, a subset of whom had CVD, including angina, coronary heart disease (CHD), congestive heart failure (CHF), and myocardial infarction (MI).

METHODS

Using the most recently available accelerometer data (combined 2003-2006) from the National Health and Nutrition Examination Survey, the study sample included 680 adults with CVD, who completed a questionnaire and wore an ActiGraph accelerometer for 1 week. A group without CVD (n = 1000) was also selected as the referent, with similar age, gender, and race/ethnic distributions as those with CVD (angina, CHD, CHF, MI) to compare PA and sedentary behavior estimates. Percentages and means were weighted to reflect the US population from 2003 to 2006.

RESULTS

Among those with CVD, the proportion of individuals who engaged in self-reported past-month, moderate-intensity leisure activity ranged from 39.7% (CHF) to 53.8% (CHD) and vigorous-intensity leisure activity from 12.9% (CHF) to 18.4% (CHD), with walking being the most commonly reported activity. Television watching ≥4 h/d ranged from 36.2% (MI) to 44.8% (CHF). Using accelerometry, moderate- to vigorous-intensity PA ranged from 8.6 (CHF) to 11.4 min/d (angina). Sedentary behavior ranged from 9.6 (angina) to 10.1 h/d (CHF). All 4 CVD groups had lower leisure activity and moderate- to vigorous-intensity PA, and higher television watching and sedentary behavior, when compared with the referent group.

CONCLUSIONS

Further efforts are needed to encourage PA and reduce sedentary behavior for secondary prevention of CVD.

Design and methods of the Gentle Cardiac Rehabilitation Study--A behavioral study of tai chi exercise for patients not attending cardiac rehabilitation

INTRODUCTION

Cardiac rehabilitation (CR) programs reduce overall and cardiovascular mortality in patients with a history of acute coronary events or revascularization procedures, but only 30% of patients enroll in CR and attrition rates reach up to 60%. Tai chi, a mind-body practice based on light/moderate aerobic exercise accompanied by meditative components could be a possible exercise option for patients who do not attend CR.

METHODS/DESIGN

Sixty patients will be randomized to a "LITE" condition (one tai chi session twice weekly for 12 weeks) or to a "PLUS" condition (one tai chi session 3 times weekly for 12 weeks, followed by maintenance classes 1-2 times weekly for an additional 12 weeks). Measurements will be conducted at baseline, 3-, 6-, and 9 months after enrollment. The primary outcome is to determine the feasibility, acceptability and safety of each dose. Secondary outcomes include estimates of effect size of each dose on accelerometry-assessed physical activity; the proportion of patients meeting current recommendations for physical activity; and measures of fitness, quality of life, body weight, and sleep. In addition, we will collect exploratory information on possible mediators (exercise self-efficacy, perceived social support, resilience, mindfulness, and depression).

CONCLUSIONS

Findings from this pilot study will provide preliminary indications about the usefulness of tai chi as an exercise option for patients not attending traditional CR programs. Results will also shed light on the possible mechanisms by which tai chi practice may improve overall physical activity among patients with atherosclerotic coronary heart disease.

The association between sleep disturbance, depressive symptoms, and health-related quality of life among cardiac rehabilitation participants

PURPOSE

Recent guidelines from the Canadian Association of Cardiac Rehabilitation highlight the importance of addressing sleep disturbance among participants of cardiac rehabilitation (CR) programs. The primary objective of this study was to examine the relationship between depressive symptoms, health-related quality of life, and sleep disturbance in CR participants. The secondary objective was to estimate the prevalence of sleep disturbance among CR participants with and without depressive symptoms and explore demographic, medical, and psychological predictors of poor sleep quality.

METHODS

Cardiac rehabilitation participants (N = 259) were included in this study. Participants completed a standardized questionnaire package including demographic, health-related, and psychosocial measures. Physiologic and anthropometric measurements were taken at baseline. Descriptive statistics were calculated for all variables, and data were analyzed using multivariate logistic regression.

RESULTS

Poor sleep quality was reported by 52% of participants in the sample, and 47% of participants in the sample reported experiencing at least mild depressive symptoms. Poor sleep occurred more often in individuals with depressive symptoms, and after adjustment for medical factors and health-related quality of life, participants with symptoms of depression were still more likely to experience sleep disturbance than those without depressive symptoms (OR = 2.80; 95% CI, 1.37-5.77). An important gender difference emerged in the relationship between symptoms of depression and sleep disturbance.

CONCLUSION

Among participants of a CR program, disturbed sleep was strongly associated with depressive symptoms and decreased health-related quality of life. Results demonstrate the importance of sleep evaluation in CR programs.

Cardiac rehabilitation in African Americans: evidence for poorer outcomes compared with whites, especially in women and diabetic participants

BACKGROUND

Cardiac rehabilitation (CR) improves coronary artery disease risk factors and mortality. Outcomes after CR in African Americans (AAs) compared with whites have not been studied extensively.

METHODS

A total of 1,096 patients (169 AAs, 927 whites) were enrolled in a 36-session CR program for ischemic heart disease or postcardiac surgery. The program consisted of exercise, lifestyle modification, and pharmacotherapy.

RESULTS

After CR, quality of life, blood pressure, and low-density lipoprotein cholesterol improved significantly in both AAs and whites, although to a lesser degree in AAs. Whites also had significant improvements in weight and triglyceride concentrations. Overall, mean peak exercise capacity, measured in metabolic equivalents (METs), improved by only 1.6 (95% CI 1.3-1.8) in AAs compared with 2.4 (2.3-2.6) in CCs (P< .001 for AAs vs CCs). African American women had the least improvement in METs, but changes were still significant (1.1 [CI 0.9-1.4]). The subgroup with the least improvement in METs was AA diabetic patients (1.4 (CI 1.1-1.7]).

CONCLUSION

African Americans derive a significant benefit from CR, but not to the same degree as whites, based on changes in risk factors and in exercise capacity. Within both ethnic groups, both women and diabetic patients appeared to have markedly less improvement.

Women's preferences for cardiac rehabilitation program model: a randomized controlled trial

BACKGROUND

Although cardiac rehabilitation (CR) is effective, women often report programs do not meet their needs. Innovative models have been developed that may better suit women. The objectives of the study were to describe: (1) adherence to CR model allocation; (2) satisfaction by model attended; and (3) CR preferences.

DESIGN AND METHODS

Tertiary objectives from a randomized controlled trial of female patients randomized to mixed-sex, women-only, or home-based CR were tested. Patients were recruited from six hospitals. Consenting participants were asked to complete a survey and undertook a CR intake assessment. Eligible patients were randomized. Participants were mailed a follow-up survey six months later. Adherence to model allocation was ascertained from CR charts.

RESULTS

Overall 169 (18.6%) patients were randomized, of which 116 (68.6%) completed the post-test survey. Forty-five (26.6%) participants did not receive the allocated model, with those referred to home-based CR least likely to attend the allocated model (n = 25; 45.4%). Semi-structured interviews revealed participants also often switched from women-only to mixed-sex CR due to time conflicts. Satisfaction was high across all models (mean = 4.23 ± 1.16/5; p = 0.85) but participants in the women-only program felt significantly more comfortable in their workout attire (p = 0.003) and perceived the environment as less competitive (p = 0.02). Patients equally preferred mixed-sex (n = 44, 41.9%) and women-only (n = 44, 41.9%) CR, over home-based (n = 17, 16.2%), with patients preferring the model they attended.

CONCLUSION

Females were highly satisfied regardless of CR model attended but preferred supervised programs most. Patient preference and session timing should be considered in program model allocation decisions.

Examining the effect of a patient navigation intervention on outpatient cardiac rehabilitation awareness and enrollment

PURPOSE

Awareness of and enrollment in outpatient cardiac rehabilitation (OCR) following a cardiac event or procedure remain suboptimal. Thus, it is important to identify new approaches to improve these outcomes. The objectives of this study were to identify (1) the contributions of a patient navigation (PN) intervention and other patient characteristics on OCR awareness; and (2) the contributions of OCR awareness and other patient characteristics on OCR enrollment among eligible cardiac patients up to 12 weeks posthospitalization.

METHODS

In this randomized controlled study, 181 eligible and consenting patients were assigned to either PN (n = 90) or usual care (UC; n = 91) prior to hospital discharge. Awareness of OCR was assessed by telephone interview at 12 weeks posthospitalization, and OCR enrollment was confirmed by staff at collaborating OCR programs. Of the 181 study participants, 3 died within 1 month of hospital discharge and 147 completed the 12-week telephone interview.

RESULTS

Participants in the PN intervention arm were nearly 6 times more likely to have at least some awareness of OCR than UC participants (OR = 5.99; P = .001). Moreover, participants who reported at least some OCR awareness were more than 9 times more likely to enroll in OCR (OR = 9.27, P = .034) and participants who were married were less likely to enroll (P = .031).

CONCLUSIONS

Lay health advisors have potential to improve awareness of outpatient rehabilitation services among cardiac patients, which, in turn, can yield greater enrollment rates in a program.

Physicians' tacit and stated policies for determining patient benefit and referral to cardiac rehabilitation

BACKGROUND / PURPOSE

The benefits of prescribing cardiac rehabilitation (CR) for patients following heart surgery is well documented; however, physicians continue to underuse CR programs, and disparities in the referral of women are common. Previous research into the causes of these problems has relied on self-report methods, which presume that physicians have insight into their referral behavior and can describe it accurately. In contrast, the research presented here used clinical judgment analysis (CJA) to discover the tacit judgment and referral policies of individual physicians. The specific aims were to determine 1) what these policies were, 2) the degree of self-insight that individual physicians had into their own policies, 3) the amount of agreement among physicians, and 4) the extent to which judgments were related to attitudes toward CR.

METHODS

Thirty-six Canadian physicians made judgments and decisions regarding 32 hypothetical cardiac patients, each described on 5 characteristics (gender, age, type of cardiovascular procedure, presence/absence of musculoskeletal pain, and degree of motivation) and then completed the 19 items of the Attitude towards Cardiac Rehabilitation Referral scale.

RESULTS

Consistent with previous studies, there was wide variation among physicians in their tacit and stated judgment policies, and self-insight was modest. On the whole, physicians showed evidence of systematic gender bias as they judged women as less likely than men to benefit from CR. Insight data suggest that 1 in 3 physicians were unaware of their own bias. There was greater agreement among physicians in how they described their judgments (stated policies) than in how they actually made them (tacit policies). Correlations between attitude statements and CJA measures were modest.

CONCLUSIONS

These findings offer some explanation for the slow progress of efforts to improve CR referrals and for gender disparities in referral rates.

Sex differences in cardiac rehabilitation enrollment: a meta-analysis

BACKGROUND

The present systematic review and meta-analysis examines studies published in the past 10 years that described cardiac rehabilitation (CR) enrollment among women and men, to determine whether a significant sex difference persists despite the evidence supporting the benefits of CR to women as well as men.

METHODS

Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases were systematically searched for peer-reviewed articles published from July 2000 to July 2011. Titles and abstracts were screened, and the 623 selected full-text articles were independently screened based on predefined inclusion/exclusion criteria (guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA) and assessed for quality using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement form. The meta-analysis was undertaken using Review Manager software.

RESULTS

Twenty-six eligible observational studies reporting data for 297,719 participants (128,499 [43.2%] women) were included. On average, 45.0% of men and 38.5% of women enrolled in CR. In the pooled analysis, men were more likely to be enrolled in CR compared with women (female enrollment vs male enrollment odds ratio, 0.64; 95% confidence interval, 0.57-0.72; P < 0.00001). Heterogeneity was considered high (I(2) = 78%). In the subgroup analyses, systematic CR referral during inpatient tertiary care resulted in significantly greater enrollment among women than nonsystematic referral.

CONCLUSIONS

Overall, rates of CR enrollment among women are significantly lower compared with men, with women being 36% less likely to enroll in a rehabilitation program.

Perceptions of barriers to cardiac rehabilitation use in Brazil

Cardiovascular diseases (CVD) are the leading cause of mortality in middle-income countries, such as Brazil. However, given the diversity in health care systems in Brazil, access to proven services, such as cardiac rehabilitation (CR), varies widely.

Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review

Physicians play an important role in CR referral and enrollment. Despite established benefits and recommendations, cardiac rehabilitation (CR) enrollment rates are pervasively low. The reasons cardiac patients are missing from CR programs are multifactorial and include provider factors. A number of studies have now investigated physician factors associated with referral to CR programs and patient enrollment. The objective of this study was to qualitatively and systematically review this literature. A literature search of MEDLINE, PsycINFO, CINAHL, Embase, and EBM was conducted for published articles from database inception to October 2011. Overall, 17 articles were included following a process of independent review of each article by 2 authors. Seven (41.2%) were graded as good quality according to Downs and Black criteria. There were no randomized controlled trials. Results showed that medical specialty (ie, cardiac specialists more likely to refer; n = 8 studies) and other physician-reported reasons (eg, physician report of their reasons for CR referral and physician sex) were related to referral. Physician factors related to patient enrollment in CR were physician endorsement, medical specialty, being referred, and physician attitudes toward CR. Physician factors are consistently related to CR referral and enrollment. The role of physician endorsements in promoting patient enrollment should be optimized and exploited.

A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change

BACKGROUND

Healthy lifestyles are an important facet of cardiovascular risk management. Unfortunately many individuals fail to engage with lifestyle change programmes. There are many factors that patients report as influencing their decisions about initiating lifestyle change. This is challenging for health care professionals who may lack the skills and time to address a broad range of barriers to lifestyle behaviour. Guidance on which factors to focus on during lifestyle consultations may assist healthcare professionals to hone their skills and knowledge leading to more productive patient interactions with ultimately better uptake of lifestyle behaviour change support. The aim of our study was to clarify which influences reported by patients predict uptake and completion of formal lifestyle change programmes.

METHODS

A systematic narrative review of quantitative observational studies reporting factors (influences) associated with uptake and completion of lifestyle behaviour change programmes. Quantitative observational studies involving patients at high risk of cardiovascular events were identified through electronic searching and screened against pre-defined selection criteria. Factors were extracted and organised into an existing qualitative framework.

RESULTS

374 factors were extracted from 32 studies. Factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Many factors show inconsistent patterns with respect to uptake and completion of lifestyle change programmes.

CONCLUSION

There are a small number of factors that consistently appear to influence uptake and completion of cardiovascular lifestyle behaviour change. These factors could be considered during patient consultations to promote a tailored approach to decision making about the most suitable type and level lifestyle behaviour change support.

Cardiac rehabilitation and the therapeutic environment: the importance of physical, social, and symbolic safety for programme participation among women

AIM

To report an exploration of the multidimensionality of safety in cardiac rehabilitation programmes as perceived by women who were enrolled in the Women's Cardiovascular Health Initiative in Toronto, Canada.

BACKGROUND

Cardiovascular disease is the leading cause of death among women. Although cardiac rehabilitation is clinically effective, significantly fewer women than men participate in available programmes. The literature identifies factors affecting women's cardiac rehabilitation participation, and provides possible explanations for this gender disparity. Although safety is mentioned among the barriers to women's cardiac rehabilitation participation, the extent to which safety contributes to programme participation, completion, and maintenance remains under-explored in the cardiac rehabilitation literature.

DESIGN

We conducted an exploratory qualitative study to examine the role safety and place play for women engaged in cardiac prevention and rehabilitation at the Women's Cardiovascular Health Initiative. Methods.  From 2005-2006, 14 participants engaged in semi-structured, qualitative interviews lasting 30-90 minutes. Discussions addressed women's experiences at the Women's Cardiovascular Health Initiative. Interview transcripts were analysed using thematic analysis.

FINDINGS

Three themes were developed: 'Safety', which was sub-categorized according to physical, social, and symbolic interpretations of safety, 'searching for a sense of place', and 'confidence and empowerment'.

CONCLUSION

Feeling physically, socially, and symbolically safe in one's cardiac rehabilitation environment may contribute to programme adherence and exercise maintenance for women. Focusing on comprehensive notions of safety in future cardiac rehabilitation research could offer insight into why many women do not maintain an exercise regimen in currently structured cardiac rehabilitation and community programmes.

Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents

Cardiac rehabilitation (CR) services in the United States are underutilized and participation is particularly low for racial and ethnic minorities, low socioeconomic status patients, and rural residents. Reduced participation may not only indicate a failure in transitional cardiac care during the in hospital referral process but also could be due to barriers attributed to patients, providers, employers, or medical systems. In-depth analysis of this problem is impeded by difficulties with the identification of underserved groups in clinical settings. Disparities in CR participation certainly contribute to poor medical outcomes in these populations that stand to benefit greatly from lifestyle modifications. It is critical that CR providers survey their communities for underserved populations and coordinate creative efforts aimed at overcoming barriers to participation. Moreover, it is likely that referral to, and participation in, CR will soon be considered a quality indicator, providing further incentive for programs to optimize CR utilization among all eligible patients.

Psychometric validation of the cardiac rehabilitation barriers scale

OBJECTIVE

The purpose of this study was to investigate the factor structure and psychometric properties of the Cardiac Rehabilitation Barriers Scale (CRBS).

DESIGN, SETTING, AND PARTICIPANTS

In total, 2636 cardiac inpatients from 11 hospitals completed a survey. One year later, participants completed a follow-up survey, which included the CRBS. A subsample of patients also completed a third survey which included the CRBS, the Cardiac Rehabilitation Enrolment Obstacles scale, and the Beliefs About Cardiac Rehabilitation scale three weeks later. The CRBS asked participants to rate 21 cardiac rehabilitation barriers on a five-point Likert scale regardless of cardiac rehabilitation referral or enrolment.

RESULTS

Maximum likelihood factor analysis with oblique rotation resulted in a four-factor solution: perceived need/healthcare factors (eigenvalue = 6.13, Cronbach's α = .89), logistical factors (eigenvalue = 5.83, Cronbach's α = .88), work/time conflicts (eigenvalue = 3.78, Cronbach's α = .71), and comorbidities/functional status (eigenvalue = 4.85, Cronbach's α = .83). Mean total perceived barriers were significantly greater among non-enrollees than cardiac rehabilitation enrollees (P < .001). Convergent validity with the Beliefs About Cardiac Rehabilitation and Cardiac Rehabilitation Enrolment Obstacles scales was also demonstrated. Test-retest reliability of the CRBS was acceptable (intraclass correlation coefficient = .64).

CONCLUSION

The CRBS consists of four subscales and has sound psychometric properties. The extent to which identified barriers can be addressed to facilitate greater cardiac rehabilitation utilization warrants future study.

Rates of enrollment for men and women referred to outpatient cardiac rehabilitation

OBJECTIVE

Outpatient cardiac rehabilitation (CR) services are underutilized. Fewer women participate in CR than men. It is unclear whether women referred to CR enroll at the same rate as men. The purpose of this study was to compare enrollment rates of men and women who were referred to CR.

METHODS

A retrospective medical record review was performed for selected variables for all adult patients who resided in Olmsted County, Minnesota, were hospitalized from January 2005 through July 2007 and were referred to a CR program. Enrollment in CR was defined as attendance at 1 or more CR sessions.

RESULTS

A total of 450 patients referred to CR were identified. Of them, 286 patients (64%) enrolled in CR. Rates of enrollment for men and women were similar (65% vs 62%, P = .54). Patients of either gender who did not enroll were older, less educated, less often married, more likely to smoke, more likely to be diabetic, and less likely to have had cardiac surgery. Enrollment rates of women with or without comorbidities were similar (62% vs 61%, P = .87), while enrollment rate of men with comorbidities was lower than for men without comorbidities (52% vs 75%, P < .01).

CONCLUSION

In our CR program, enrollment rates for men and women, once referred, are similar. Enrollment rates are lower for older patients of both genders and for men with comorbidities. Lower utilization of CR by women than by men does not appear to be because of a gender difference in enrollment rates after a referral is made.