A Dual-Modality Home-Based Cardiac Rehabilitation Program for Adults with Cardiovascular Disease: Single-Arm Remote Clinical Trial

BACKGROUND

Cardiac rehabilitation (CR) is a safe and effective intervention for individuals with cardiovascular disease (CVD). However, the majority of eligible patients do not complete CR. Growing evidence suggests that home-based CR (HBCR) programs are comparable in effectiveness and safety to traditional center-based programs. More research is needed to explore different ways to deliver HBCR programs to CVD patients.

OBJECTIVE

This study aims to assess the feasibility and impact of a digital HBCR program (RecoveryPlus.Health, RPH-D) that integrates both telehealth and mHealth modalities on functional exercise capacity, resting heart rate, and quality of life among adults with cardiovascular disease (CVD).

METHODS

This 12-week prospective, single-arm remote clinical trial used a within-subject design. We recruited adults with CVD (age 40+) from the community with a CR-eligible diagnosis (stable angina pectoris, myocardial infarction, heart failure, etc.) between May and August of 2023. All enrolled patients referred to the RPH clinic in Roanoke, TX were included. The care team provided guideline-concordant CR services to study participants via two modalities: 1) a synchronous telehealth exercise training via video conferencing; and 2) an asynchronous mHealth virtual coaching App (RPH App). Baseline intake survey, electronic health record (EHR), and app log data were used to extract individual characteristics, care processes, and telehealth/mHealth engagement data. Feasibility was measured by program completion rate and CR services use. Efficacy was measured by changes in 6-minute walk test (6MWT), resting heart rate, and quality of life (SF-12) before and after the 12-week program. Paired t tests were used to examine the changes in the outcome variables pre-post intervention.

RESULTS

A total of 162 met the inclusion criteria, 75 (46.3%) consented and were enrolled. The participants' average age was 64.24 (SD 10.30) years; 37 (49%) were male, and 46 (61%) were White. Heart failure was the most common diagnosis (49%). A total of 62 (83%) participants completed the 12-week study, 62 (83%) used the telehealth modality with an average of 9.63 (SD 3.33) sessions completed, and 59 (79%) used the mHealth modality with an average of 10.97 (SD 11.70) sessions completed. Post intervention, 50 (81%) participants had improved 6MWT, with an average improvement of 40.0 meters (95% CI, 25.6 to 57.1). The average SF-12 physical and mental summary scores improved by 2.7 points (95% CI, 1.1 to 4.3) and 2.2 points (95% CI, 0.1 to 4.5), respectively. There were no changes in resting heart rate and no exercise-related adverse events were reported.

CONCLUSIONS

The RecoveryPlus.Health digital HBCR program showed feasibility and efficacy in a group of nationally recruited CVD patients. The findings add to the evidence that a telehealth and mHealth dual-modality HBCR program may be a promising approach to overcome some of the main barriers to improving CR access in the U.S.

CLINICALTRIAL

ClinicalTrials.gov NCT05804500.

It is like someone holding your hand when you need it - lived experiences of patients with cardiovascular disease participating in a digital health intervention focusing on the maintenance of physical activity after cardiac rehabilitation

PURPOSE

To explore patients with cardiovascular diseases' lived experiences of the support given by a text message intervention focusing on the maintenance of physical activity after supervised cardiac rehabilitation.

METHODS

In a qualitative study, participants from the feasibility trial FAIR were interviewed individually twice to disclose their lived experiences during and after the trial. Transcribed interviews were analysed based on a phenomenological-hermeneutic method, inspired by Paul Ricoeur's philosophy on narrative and interpretation.

RESULTS

Interviews of eight patients with cardiovascular disease (3 females, median age 57 years (range 37 to 74 years)) revealed two themes, The FAIR intervention as a bridge builder in the transition to being physically active in everyday life and Meaningful conditions for maintaining physical activity. Action plans guided physical activity, while text messages facilitated actions and left an impression of still being under supervision. A frame of reference with physical activity, family, being monitored, having to report back, and getting feedback, were incentives for being physically active.

CONCLUSION

From a patient perspective, the text message intervention in the feasibility trial FAIR was valuable to support the maintenance of physical activity in the transition from a supervised exercise-based cardiac rehabilitation programme to everyday life on an individual basis. Participants experienced the intervention to hold their hands in changing behaviour and redefining themselves. Yet, there is an extended need for belonging and personal interactions in future interventions.

A novel referral strategy to enhance the enrollment of patients with heart failure in cardiac rehabilitation: A feasibility study

Background and Aims

Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well-documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure.

Methods

This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15-20 min face-to-face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi-structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate.

Results

Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety-one percent data completeness was achieved. The intervention was well-accepted by patients and health care professionals. The enrollment rate reached 79%.

Conclusion

The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full-scale trial. The novel referral strategy was well-accepted, and enrollment rate approached an acceptable level.

Evaluating the Effects of an Enhanced Strength Training Program in Remote Cardiological Rehabilitation: A Shift from Aerobic Dominance-A Pilot Randomized Controlled Trial

(1) Background: Cardiac rehabilitation often emphasizes aerobic capacity while overlooking the importance of muscle strength. This study evaluated the impact of an enhanced remote strength training program (RCR-ST) on cardiac rehabilitation. (2) Methods: In this randomized prospective study (RCT registration number SMC-9080-22), 50 patients starting cardiac rehabilitation were assessed for muscle strength, aerobic capacity, and self-reported outcomes at baseline and after 16 weeks. Participants were divided into two groups: the RCR-ST group received a targeted resistance training program via a mobile app and smartwatch, while the control group received standard care with general resistance training advice. (3) Results: The RCR-ST group demonstrated significant improvements in muscle endurance, notably in leg extension and chest press exercises, with increases of 92% compared to 25% and 92% compared to 13% in the control group, respectively. Functional assessments (5-STS and TUG tests) also showed marked improvements in agility, coordination, and balance. Both groups improved in cardiorespiratory fitness, similarly. The RCR-ST group reported enhanced physical health and showed increased engagement, as evidenced by more frequent use of the mobile app and longer participation in the rehabilitation program (p < 0.05). (4) Conclusions: Incorporating a focused strength training regimen in remote cardiac rehabilitation significantly improves muscle endurance and patient engagement. The RCR-ST program presents a promising approach for optimizing patient outcomes by addressing a crucial gap in traditional rehabilitation protocols that primarily focus on aerobic training.

Determinants of outcomes for patients with chronic low back pain and fear-avoidance beliefs following treatment with specific stabilisation exercises

BACKGROUND

Specific stabilisation exercises (SSE) can combat the debilitating effects of chronic non-specific low back pain (CLBP), improve disability, pain and fear-avoidance beliefs (FAB).

OBJECTIVE

To elicit the determinants of outcome in patients with CLBP with associated FABs after treatment with SSE.

METHOD

Twenty-nine patients (20 females) with CLBP were classified using FAB questionnaire into high or low Work and Physical Activity (PA) subscales. After 4-week treatment, evaluations were done for pain, disability and lumbar spine active range of motion (AROM). Data was analysed exploratory-descriptively with a significance level set at p< 0.05.

RESULTS

Participants were aged 55.24 ± 11.91 years. They scored 19 (65.5%) and 5 (17.2%) respectively on Work and PA subscales. The post-intervention evaluation showed significant differences in all outcomes, but no significant difference between patients with high or low FAB scores for both subscales. PA scores correlated significantly with pain while work scores correlated significantly with disability. Participants' gender predicted disability, pain and AROM with moderate to large effect sizes.

CONCLUSION

SSE can potentially improve disability, pain and range of motion for patients with chronic low back pain regardless of FABQ status. Gender and baseline patient status are potential determinants of outcome of treatment using SSE.

Clinical Trial Technologies for Improving Equity and Inclusion in Cardiovascular Clinical Research

Approximately one-third of clinical trials fail to meet their recruitment goals, which can cause costly delays to sponsors and compromise the scientific integrity and generalizability of a trial. Inadequate recruitment and retention of patient groups who have the disease under investigation may produce insufficient medical knowledge about the therapeutic effects of drugs or products for the population at large. It is essential to address these issues to ensure that certain groups are not unduly subjected to disproportionate risks or denied the benefits of research. This commentary will present opportunities for clinical trialists to use emerging technologies and decentralized approaches to improve clinical trial recruitment, mitigate disparities, and improve individual and population-level outcomes within cardiovascular medicine.

Understanding Facilitators and Challenges to Care Transition in Cardiac Rehabilitation: Perspectives and Assumptions of Healthcare Professionals

Cardiac rehabilitation is an essential part of treatment for patients with cardiovascular disease. Cardiac rehabilitation is increasingly organized outside hospital in community healthcare services. However, this transition may be challenging. The aim of this study was to examine assumptions and perspectives among healthcare professionals on how facilitators and challenges influence the transition from hospital to community healthcare services for patients in cardiac rehabilitation. The study followed the Interpretive Description methodology and data consisted of participant observations and focus group interviews. The analysis showed that despite structured guidelines aimed to support the collaboration, improvements could be made. Facilitators and challenges could occur in the collaboration between the healthcare professionals, in the collaboration with the patient, or because of the new reality for patients when diagnosed with cardiovascular disease.

Reasons for dropout in the transition from hospital to municipality during exercise-based cardiac rehabilitation in a Danish cross-sectorial setting: a qualitative study

OBJECTIVES

Despite documented benefits of cardiac rehabilitation (CR), attrition rates remain relatively high. Insights on patient perspectives concerning dropout during transition phases are deficient. This deeper understanding may help to inform on the perceived benefits and barriers in CR. This qualitative study explores the reasons why patients' dropout during the transition from a hospital-based CR programme to local healthcare facilities.

SETTING

A Danish hospital and seven local healthcare centres.

PARTICIPANTS

Twelve patients, who had dropped out of exercise-based cardiac rehabilitation (exCR) during the transition from hospital-based rehabilitation to local healthcare centres, were recruited to semistructured interviews based on a purposeful sampling.

RESULTS

Important patient needs during rehabilitation was the ability to identify and reflect oneself in a group of peers in a safe, specialised hospital-based environment. At the transition point, the meaningfulness of continuation of CR was revaluated. Findings showed that reasons for discontinuation varied within individuals. It encompassed on a balanced choice of reassessing benefits against competing agendas as work demands versus expectations of benefits in a changed exercise environment and own exercise capabilities.

CONCLUSION

The study indicated that patient needs as timely relevance, a specialised safe environment and peer support are significant for participation in exCR. These needs may change during the transition stage due to competing agendas as work obligations and assessment of own ability to take control themselves. Perceived meaningfulness may be a major motivational driver for both initiating and making a judiciously choice of leaving an exCR programme.

Heart Rehabilitation for All (HeRTA): Protocol for a feasibility study and pilot randomized trial

Introduction

Today, 50% of people with cardiac disease do not participate in rehabilitation. The HeRTA-study aims to develop and test a sustainable rehabilitation model supporting vulnerable patients in participating in rehabilitation and long-term physical activity.

Methods

A feasibility study with a non-blinded pilot randomized trial was developed in collaboration with partners and cardiac patients to test a multi-component rehabilitation intervention across hospital, municipality, and civil society. The study runs from January 2020 to December 2024. Eligibility criteria for participants: a) diagnosed with either ischemic heart disease, persistent atrial fibrillation, heart failure, or have had cardiac valve surgery, b) residents in Hvidovre Hospitals uptake area, c) cognitively functional, d) physically able to participate in rehabilitation. Patient recruitment will be located at Hvidovre Hospital, Capital Region of Denmark, data collection at Hvidovre Hospital, Rehabilitation Center Albertslund, the Danish Heart Association, and in two municipalities (Hvidovre and Brøndby). Patients in the control group have access to usual care at the hospital: rehabilitation-needs-assessment, patient education, and physical training. After or instead of hospital rehabilitation, the patient can be referred to municipal rehabilitation with patient education, and a total of 12 weeks of physical training across sectors. Patients in the intervention group will in addition to usual care, have access to an information book about cardiac disease, patient supporters from the Danish Heart Association, Information materials to inform employers about the employees’ rehabilitation participation, a rehabilitation goal setting plan, a support café for relatives, and follow-up phone calls from physiotherapists 1 and 3 months after rehabilitation to support physical activities. Patients with vulnerabilities will additionally receive patient education conducted in small groups, pro-active counselling by a cardiac nurse, psychologist, or social worker, paid transportation to rehabilitation, and paid membership in a sports association. Patients are computer block-randomized so patients with vulnerability are distributed evenly in the two study arms by stratifying on a) a cut-off score of ≥ 5 in the Tilburg Frailty Indicator questionnaire and/or b) need of language translator support. A power calculation, based on an estimated 20% difference in participation proportion between groups, 80% power, a type 1 error of 5% (two-tailed), results in 91 participants in each study arm. The primary outcome: rehabilitation participation (attending ≥ two activities: patient education, smoking cessation, dietary counseling, and physical training) and reaching at least 50% attendance. Secondary outcomes: health-related quality of life, coping strategies, level of physical activities, and sustainability regarding participation in active communities after rehabilitation. The study is registered at ClinicalTrials.gov (NCT05104658).

Results

Differences between changes in outcomes between groups will be analyzed according to the intention-to-treat principle. Sensitivity analysis and analysis of the effect of the combined activities will be made. A process evaluation will clarify the implementation of the model, the partnership, and patients’ experiences.

Conclusion

Cross-sectoral collaborations between hospitals, municipalities, and organizations in civil society may lead to sustainable and affordable long-term physical activities for persons with chronic illness. The results can lead to improve cross-sectoral collaborations in other locations and patient groups.

Why Do Patients With Ischaemic Heart Disease Drop Out From Cardiac Rehabilitation in Primary Health Settings. A Qualitative Audit of Patient Charts

Background

Cardiac rehabilitation (CR) and medical treatment are integrated parts of the intervention for cardiac patients and are a class 1A recommendation. However, CR dropout is reported to be relatively high and little is known about the reasons for CR dropout in primary health settings.

Aim

This study investigates causes for CR dropout through a qualitative audit of medical charts among patients with ischaemic heart disease.

Methods

This was a qualitative retrospective audit of patient's medical charts. Patients who dropped out from CR between 1 January and 31 December 2018 in five primary health settings were included. Local patient charts provided information related to causes and formed the basis of the analysis. Data were analyzed using thematic analysis.

Results

A total of 690 patients were referred for and commenced CR and 199 (29%) dropped out. Twenty-five (12.6%) patients finished CR but were excluded due to standards of ≥180 days between CR meetings, leaving 118 patients included. Four themes as causes for patient's dropout were identified: (1) CR-programmes, (2) logistical, (3) intrapersonal and (4) clinical factors.

Conclusion

This study identified new focus areas to which health professionals may attend in reducing drop-out from CR. Organisation of CR, challenges with combining labor market attachment and CR, focus on patient education and comorbidities. The results underline the importance of health professionals emphasizing the benefits of CR and explains that CR enhances long-term labor market attachment. Furthermore, health professionals should encourage participation in patient education and adapt exercise to the individual patient's potential.