Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE

Assessment of clinical depression metrics in cardiac patients using the patient health Questionnaire-9 before and after phase-II cardiac rehabilitation

Cardiovascular disease remains a leading cause of morbidity and mortality, a fact that is commonly associated with co-morbidities such as clinical depression. While phase II cardiac rehabilitation is an established intervention for those with cardiovascular disease, its effect on patients who also suffer from depression are under studied. Aim: To quantify Pre- and Post-cardiac rehabilitation questionnaire scores collected from a large patient data registry. For this investigation, 27 ​670 patients completed Patient Health Questionnaire-9 questionnaires both Pre- and Post-rehabilitation (averaging [28.0 ​± ​8.7] phase II sessions). Findings reveal that questionnaire scores decreased by 40%-48% across all groups, a finding that was independent of assigned sex, race, and ethnicity. Moreover, when data were stratified for questionnaire scores that may indicate major and minor depressive disorder, phase II cardiac rehabilitation outcomes were lower by 61% and 49% respectively. While all groups exhibited lower questionnaire scores following cardiac rehabilitation participation, numerical differences at Pre- and Post-rehabilitation time points indicate that males and White patients have more favorable scores. This latter observation, while not confirmed currently, appears to be linked to referral rates to phase II cardiac rehabilitation, which remain poor for females, racial and ethnic minorities.

Increasing Access to Cardiac Rehabilitation Services Among Disadvantaged Populations

The Prince George's County Health Department encountered several challenges to increasing access to cardiac rehabilitation (CR) services among disadvantaged populations. They include excessive patient out-of-pocket costs; requirements that CR orders must be signed by a physician; provider reluctance to refer patients to CR, with most primary care providers preferring to refer clients to cardiologists for the latter to determine whether the patient needs CR referral; limited availability of CR programs; and difficulty identifying patients eligible for CR services. Discussions with other local health departments and public health practitioners indicate that these challenges are not unique to Maryland but are indicative of policy and system barriers that prevent the optimal delivery of cardiovascular health services. This practice report documents the challenges and the Prince George's County Health Department's efforts to resolve them and provides recommendations for decision-makers seeking to make CR programs more accessible to disadvantaged populations.

Technological Developments, Exercise Training Programs, and Clinical Outcomes in Cardiac Telerehabilitation in the Last Ten Years: A Systematic Review

BACKGROUND

Cardiovascular diseases (CVDs) are associated with very high rates of re-hospitalization and mortality worldwide, so the complexity of these pathologies requires frequent access to hospital facilities. The guidelines also emphasize the importance of cardiac rehabilitation (CR) programs, which have demonstrated a favorable effect on outcomes, and cardiac telerehabilitation (CTR) could represent an innovative healthcare delivery model. The aim of our review is to study how technologies used in rehabilitation have changed over time and also to understand what types of rehabilitation programs have been used in telerehabilitation.

METHODS

We searched randomized controlled trials (RCTs) in three electronic databases, PubMed, Web of Science, and Scopus, from January 2015 to January 2024, using relevant keywords. Initially, 502 articles were found, and 79 duplicates were identified and eliminated with EndNote.

RESULTS

In total, 16 RCTs fulfilled the pre-defined criteria, which were analyzed in our systematic review. The results showed that after CTR, there was a significant improvement in main outcome measures, as well as in relation to technological advances.

CONCLUSIONS

Moreover, compared to center-based rehabilitation, CTR can offer further advantages, with better cost-effectiveness, the breakdown of geographical barriers, and the improvement of access to treatment for the female population, which is traditionally more socially committed.

Effects of a physical therapist-driven individualized hybrid model of the exercise component of cardiac rehabilitation on patient outcomes: a prospective single group, time-series design

PURPOSE

The aim of this prospective single group, time-series study was to determine the feasibility, adherence, and effectiveness of an individualized physical therapist (PT)-driven hybrid model of the exercise component of cardiac rehabilitation (CR) that uses a novel intensity-recovery progression protocol (IRPP) and cardiac testing template (CTT) to assess achieved heart rate (HR) intensity, HR recovery, and intensity-recovery total to guide treatment.

METHODS

Assessment of a questionnaire, treadmill 6-min walk (6MW), 1-min sit-to-stand (1STS), 1-min step, and 1-min agility square tests were assessed on 100 participants. Compared to traditional CR the 36-visit 1:1 hybrid model was individualized using the IRPP program and CTT.

RESULTS

Adherence was 35% (timely) and 44% (overall) completion. The per-protocol analysis (PPA) and intent-to-treat (ITT) analysis suggest significant improvement in objective assessments baseline to visit 15 (PPA = 11 of 14) (ITT = 13 of 14), baseline to visit 30 (PPA = 12 of 14) (ITT = 12 of 14) and visit 15 to visit 30 (PPA = 9 of 14) (ITT = 10 of 14). Improvement beyond the minimal clinically important difference (MCID) was 94.3% in the 6MW and 91.4% in the 1STS.

CONCLUSIONS

The PT-driven IRPP program was feasible in terms of adherence and safety, showing significant improvement in a majority of assessments. Analysis of HR using the CTT may help clinical decision making for progression in CR.Implications for rehabilitationCardiac rehabilitation (CR) is an underutilized means of improving health for people recovering from cardiac surgery.People recovering from cardiac surgery have complex reasons for why they choose to enroll in, drop out from, or complete a CR program.Reporting of outcomes in CR and progression in intensity is not often individualized.An individualized physical therapist driven CR program using both subjective and objective assessments may be successful at improving adherence and effectiveness in this cohort.

County-Level Cardiac Rehabilitation and Broadband Availability: Opportunities for Hybrid Care in the United States

PURPOSE

Cardiac rehabilitation (CR) improves patient outcomes and quality of life and can be provided virtually through hybrid CR. However, little is known about CR availability in conjunction with broadband access, a requirement for hybrid CR. This study examined the intersection of CR and broadband availability at the county level, nationwide.

METHODS

Data were gathered and analyzed in 2022 from the 2019 American Community Survey, the Centers for Medicare & Medicaid Services, and the Federal Communications Commission. Spatially adaptive floating catchments were used to calculate county-level percent CR availability among Medicare fee-for-service beneficiaries. Counties were categorized: by CR availability, whether lowest (ie, CR deserts), medium, or highest; and by broadband availability, whether CR deserts with majority-available broadband, or dual deserts. Results were stratified by state. County-level characteristics were examined for statistical significance by CR availability category.

RESULTS

Almost half of US adults (n = 116 325 976, 47.2%) lived in CR desert counties (1691 counties). Among adults in CR desert counties, 96.8% were in CR deserts with majority-available broadband (112 626 906). By state, the percentage of the adult population living in CR desert counties ranged from 3.2% (New Hampshire) to 100% (Hawaii and Washington, DC). Statistically significant differences in county CR availability existed by race/ethnicity, education, and income.

CONCLUSIONS

Almost half of US adults live in CR deserts. Given that up to 97% of adults living in CR deserts may have broadband access, implementation of hybrid CR programs that include a telehealth component could expand CR availability to as many as 113 million US adults.

Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries

BACKGROUND

Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting.

METHODS

Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers.

RESULTS

A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge.

CONCLUSIONS

A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.

The iATTEND Trial: A Trial Comparing Hybrid Versus Standard Cardiac Rehabilitation

The improving ATTENDance (iATTEND) to cardiac rehabilitation (CR) trial tested the hypotheses that hybrid CR (HYCR) (combination of virtual and in-facility CR sessions) would result in greater attendance compared with traditional, facility-based only CR (FBCR) and yield equivalent improvements in exercise capacity and health status. Patients were randomized to HYCR (n = 142) or FBCR (n = 140), stratified by gender and race. Attendance was assessed as number of CR sessions completed within 6 months (primary end point) and the percentage of patients completing 36 CR sessions. Other end points (tested for equivalency) included exercise capacity and self-reported health status. HYCR patients completed 1 to 12 sessions in-facility, with the balance completed virtually using synchronized, 2-way audiovisual technology. Neither total number of CR sessions completed within 6 months (29 ± 12 vs 28 ± 12 visits, adjusted p = 0.94) nor percentage of patients completing 36 sessions (59 ± 4% vs 51 ± 4%, adjusted p = 0.32) were significantly different between HYCR and FBCR, respectively. The between-group changes for exercise capacity (peak oxygen uptake, 6-minute walk distance) and health status were equivalent. Regarding safety, no sessions required physician involvement, there was 1 major adverse event after a virtual session, and no falls required medical attention. In conclusion, although we rejected our primary hypothesis that attendance would be greater with HYCR versus FBCR, we showed that FBCR and HYCR resulted in similar patient attendance patterns and equivalent improvements in exercise capacity and health status. HYCR which incorporates virtually supervised exercise should be considered an acceptable alternative to FBCR. NCT Identifier: 03646760; The Improving ATTENDance to Cardiac Rehabilitation Trial - Full-Text View - ClinicalTrials. gov; https://classic.clinicaltrials.gov/ct2/show/NCT03646760.

Cardiac Rehabilitation Use After Heart Failure Hospitalization Associated With Advanced Heart Failure Center Status

PURPOSE

Cardiac rehabilitation (CR) is an evidence-based, guideline-endorsed therapy for patients with heart failure with reduced ejection fraction (HFrEF) but is broadly underutilized. Identifying structural factors contributing to increased CR use may inform quality improvement efforts. The objective here was to associate hospitalization at a center providing advanced heart failure (HF) therapies and subsequent CR participation among patients with HFrEF.

METHODS

A retrospective analysis was performed on a 20% sample of Medicare beneficiaries primarily hospitalized with an HFrEF diagnosis between January 2008 and December 2018. Outpatient claims were used to identify CR use (no/yes), days to first session, number of attended sessions, and completion of 36 sessions. The association between advanced HF status (hospitals performing heart transplantation or ventricular assist device implantations) and CR participation was evaluated with logistic regression, accounting for patient, hospital, and regional factors.

RESULTS

Among 143 392 Medicare beneficiaries, 29 487 (20.6%) were admitted to advanced HF centers (HFCs) and 5317 (3.7%) attended a single CR session within 1 yr of discharge. In multivariable analysis, advanced HFC status was associated with significantly greater relative odds of participating in CR (OR = 2.20: 95% CI, 2.08-2.33; P < .001) and earlier initiation of CR participation (-8.5 d; 95% CI, -12.6 to 4.4; P < .001). Advanced HFC status had little to no association with the intensity of CR participation (number of visits or 36 visit completion).

CONCLUSIONS

Medicare beneficiaries hospitalized for HF were more likely to attend CR after discharge if admitted to an advanced HFC than a nonadvanced HFC.

Impact of Prior COVID-19 Infections on Cardiac Rehabilitation Completion Rates and Outcomes

PURPOSE

This is a retrospective cohort study designed to evaluate the impact of having a prior COVID-19 infection on cardiac rehabilitation (CR) completion rates and outcomes.

METHODS

Participants enrolled into the CR program from June 1, 2020, to March 30, 2022. They completed both physical and mental health assessments prior to enrollment and upon completion of the program. The cohort was divided into (-) COVID and (+) COVID based on whether they self-reported a prior COVID-19 infection. Outcome measures included General Anxiety Disorder-7, Patient Health Questionnaire-9, Mental Composite Score (Short Form Health Survey-36), Physical Composite Score (Short Form Health Survey-36), and exercise capacity (reported in METs). Program completion rates and outcome measures were compared between (-) COVID and (+) COVID cohorts.

RESULTS

A total of 806 participants were enrolled in the study. Program completion rates were 58.7% in the (-) COVID group and 67.2% in the (+) COVID group ( P = .072). African Americans ( P = .017), diabetics ( P = .017), and current smokers ( P = .003) were less likely to complete the program. Both (-) COVID and (+) COVID groups showed significant improvement in all outcome measures after completing the CR program. However, there was no difference in outcomes between groups.

CONCLUSIONS

Having a prior COVID-19 infection did not negatively impact the mental and physical health benefits obtained by completing the CR program, regardless of the American Association of Cardiovascular and Pulmonary Rehabilitation risk category.

Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands

PURPOSE

Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components.

METHODS

Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components.

RESULTS

In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization.

CONCLUSIONS

CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries

OBJECTIVE

Despite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes.

METHODS

This retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use.

RESULTS

Overall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001).

CONCLUSIONS

Identifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

A National Approach to Promoting Health Equity in Cardiovascular Disease Prevention: Implementation Science Strengths, Opportunities, and a Changing Chronic Disease Context

In the USA, structural racism contributes to higher rates of cardiovascular disease (CVD) including hypertension, heart disease, and stroke among African American persons. Evidence-based interventions (EBIs), which include programs, policies, and practices, can help mitigate health inequities, but have historically been underutilized or misapplied among communities experiencing discrimination and exclusion. This commentary on the special issue of Prevention Science, "Advancing the Adaptability of Chronic Disease Prevention and Management Through Implementation Science," describes the Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention's (DHDSP's) efforts to support implementation practice and highlights several studies in the issue that align with DHDSP's methods and mission. This work includes EBI identification, scale, and spread as well as health services and policy research. We conclude that implementation practice to enhance CVD health equity will require greater coordination with diverse implementation science partners as well as continued innovation and capacity building to ensure meaningful community engagement throughout EBI development, translation, dissemination, and implementation.

The relationship between discharge location and cardiac rehabilitation use after cardiac surgery

BACKGROUND

Cardiac rehabilitation (CR) is a guideline-recommended risk-reduction program offered to cardiac surgical patients. Despite CR's association with better outcomes, attendance remains poor. The relationship between discharge location and CR use is poorly understood.

METHODS

This study was a nationwide, retrospective cohort analysis of Medicare fee-for-service claims for beneficiaries undergoing coronary artery bypass grafting and/or surgical aortic valve repair between July 1, 2016, and December 31, 2018. The primary outcome was attendance of any CR session. Discharge location was categorized as home discharge or discharge to extended care facility (ECF) (including skilled nursing facility, inpatient rehabilitation, and long-term acute care). Multivariable logistic regression models evaluated the association between discharge location, CR attendance, and 1-year mortality.

RESULTS

Of the 167,966 patients who met inclusion criteria, 34.1% discharged to an ECF. Overall CR usage rate was 53.9%. Unadjusted and adjusted CR use was lower among patients discharged ECFs versus those discharged home (42.1% vs 60.0%; adjusted odds ratio, 0.66; P < .001). Patients discharged to long-term acute care were less likely to use CR than those discharged to skilled nursing facility or inpatient rehabilitation (reference category: home; adjusted odds ratio for long-term acute care, 0.36, adjusted odds ratio for skilled nursing facility, 0.69, and adjusted odds ratio for inpatient rehabilitation, 0.71; P < .001). CR attendance was associated with a greater reduction in adjusted 1-year mortality in patients discharged to ECFs (9.7% reduction) versus those discharged home (4.3% reduction).

CONCLUSIONS

In this national analysis of Medicare beneficiaries, discharge to ECF was associated with lower CR use, despite a greater association with improved 1-year mortality. Interventions aimed at increasing CR enrollment at ECFs may improve CR use and advance surgical quality.

Cardiovascular Rehabilitation With a WCD-Data From the CR3 Study (Cardiac Rehab Retrospective Review)

PURPOSE

Patients at risk for sudden cardiac death may temporarily need a wearable cardioverter-defibrillator (WCD). Exercise-based cardiac rehabilitation (CR) has a class I recommendation in patients with cardiac disease. The aim of this study was to evaluate the safety and feasibility of undergoing CR with a WCD.

METHODS

We performed a retrospective analysis of all patients with a WCD who completed a CR in Austria (2010-2020).

RESULTS

Patients (n = 55, 60 ± 11 yr, 16% female) with a median baseline left ventricular ejection fraction (LVEF) of 36 (30, 41)% at the start of CR showed a daily WCD wearing duration of 23.4 (22, 24) hr. There were 2848 (8 [1, 26]/patient) automatic alarms and 340 (3 [1, 7]/patient) manual alarms generated. No shocks were delivered by the WCD during the CR period. One patient had recurrent hemodynamically tolerated ventricular tachycardias that were controlled with antiarrhythmic drugs.No severe WCD-associated adverse events occurred during the CR stay of a median 28 (28, 28) d. The fabric garment and the device setting needed to be adjusted in two patients to diminish inappropriate automatic alarms. Left ventricular ejection fraction after CR increased significantly to 42 (30, 44)% ( P < .001). Wearable cardioverter-defibrillator therapy was stopped due to LVEF restitution in 53% of patients. In 36% of patients an implantable cardioverter-defibrillator was implanted, 6% had LVEF improvement after coronary revascularization, one patient received a heart transplantation (2%), two patients discontinued WCD treatment at their own request (4%).

CONCLUSION

Completing CR is feasible and safe for WCD patients and may contribute positively to the restitution of cardiac function.

A Detailed Analysis of Cardiac Rehabilitation on 180-Day All-Cause Hospital Readmission and Mortality

PURPOSE

Cardiac rehabilitation (CR) is endorsed for coronary artery disease (CAD), but studies report inconsistent findings regarding efficacy. The objective of this study was to determine whether confounding factors, potentially contributing to these heterogeneous findings, impact the effect of CR on all-cause readmission and mortality.

METHODS

Patients (n = 2641) with CAD, CR eligible, and physically able were identified. Electronic medical records were inspected individually for each patient to extract demographic, clinical characteristic, readmission, and mortality information. Patients (n = 214) attended ≥1 CR session (CR group). Survival was considered free from: all-cause readmission; or composite outcome of all-cause readmission or death. Cox proportional hazards models, adjusting for demographics, comorbidities, and discharge criteria, were used to determine HR with 95% CI and to compare 180-d survival rates between the CR and no-CR groups.

RESULTS

During 180 d of follow-up, 12.1% and 18.7% of the CR and non-CR patients were readmitted to the hospital. There was one death (0.5%) in the CR group, while 98 deaths (4.0%) occurred in the non-CR group. After adjustment for age, sex, race, depression, anxiety, dyslipidemia, hypertension, obesity, smoking, type 2 diabetes, and discharge criteria, the final model revealed a significant 42.7% reduction in readmission or mortality risk for patients who attended CR (HR = 0.57: 95% CI, 0.33-0.98; P = .043).

CONCLUSIONS

Regardless of demographic characteristics, comorbidities, and cardiovascular discharge criteria, the risk of 180-d all-cause readmission or death was markedly decreased in patients who attended CR compared with those who did not.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acceptability, Preferred Medium, and Components of Nurse-Led Cardiac Telerehabilitation: A Cross-Sectional Study

Cardiac rehabilitation (CR) is a comprehensive and multidisciplinary secondary prevention care in coronary heart disease (CHD). There are barriers at the patient and health system levels that prevent CR from being utilized. Cardiac telerehabilitation led by nurses (Ne-CTR) can alleviate the obstacles to participation in CR. A patient perspective can improve CR access. This study was the first pre-program investigation to clarify the status of knowledge and participation in CTR. We sought to clarify the acceptability, the reasons for rejection, the desired form, components, and associated factors with the components needed for (Ne-CTR) in patients with CHD. The study aimed to help develop a protocol for Ne-CTR for Chinese patients with CHD. A cross-sectional study was conducted between 2020 and 2021. Hospitals in four provinces in China were included. The participants were 671 patients with CHD in hospitals located in three regions of China. A self-administered questionnaire collected information about demographics, knowledge, and participation in CTR, acceptability, preferred medium, and components of Ne-CTR. Student's t-test, analysis of variance, and multiple linear regression analyzed the factors associated with component needs. All the analyses were conducted using IBM SPSS version 25.0. Most participants (n = 434, 66.77%) had a poor understanding and participation in CTR. In addition, 65.38% (n = 439) of participants were willing to accept the Ne-CTR program, and 43.56% (n = 98) identified safety as reasons for not accepting such a program. In the group accepting Ne-CTR, 35% chose hospital-designed professional applications as a medium for Ne-CTR when offered. Education (4.44 ± 1.056) and drug information (4.44 ± 1.040) had the highest average need score. Education, monthly income, marital status, previous CTR participation, and health insurance were associated with the demand level scores of Ne-CTR. This study demonstrated high levels of need for Ne-CTR among patients with CHD and identified the desired medium, components, and associated factors of Ne-CTR. These findings provide reference information for the construction of a Ne-CTR program.

Barriers and Facilitators of Center-Based Cardiac Rehabilitation Utilization in South Asian Ethnic Minorities: A META-SYNTHESIS

AIM

The aim of this review was to synthesize literature on the perceptions of South Asian ethnic minorities of the barriers and facilitators to center-based, phase II cardiac rehabilitation (CR).

METHODS

A meta-synthesis approach was used, and findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was conducted from database inception dates to July 2022 using the following databases: MEDLINE, EMBASE, APA PsycINFO, Cochrane Database of Systematic Review, CINAHL, Scopus, and Web of Science. The inclusion criteria were studies that examined the barriers and/or facilitators of structured center-based CR among South Asian adult ethnic minorities. Critical appraisal of the included studies was conducted using the Mixed Methods Appraisal Tool. Findings were synthesized using a thematic synthesis approach.

RESULTS

Among the 7110 records initially retrieved only nine studies conducted in the United Kingdom or Canada met the inclusion criteria. More barriers than facilitators were studied and reported. Key barriers were the English language difficulty, fatalistic beliefs, previous bad interactions with and negative perception of health care professionals, transportation problems, work schedule conflict, safety issues, and long-distance CR centers. The facilitators included patient-preferred environment, presence of family members during exercise, family and friends support, and encouragement to change lifestyle and enroll in a CR program.

CONCLUSION

The review findings revealed that South Asian ethnic minorities encounter various barriers and facilitators to enroll and complete CR. The findings can inform researchers and clinicians in the development of interventions that are tailored to their cultural needs.

PRACTICE IMPLICATIONS

The findings can be valuable to health care professionals and policy makers in designing customized CR programs for South Asian minorities.

A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation

OBJECTIVE

The aim of this study was to systematically review the impact and characteristics of interventions with an educational component designed to improve enrollment and participation in cardiac rehabilitation (CR) among patients with cardiovascular disease.

REVIEW METHODS

Five electronic databases were searched from data inception to February 2023. Randomized controlled trials and controlled, cohort, and case-control studies were considered for inclusion. Title, abstract, and full text of records were screened by two independent reviewers. The quality of included studies was rated using the Mixed Methods Assessment Tool. Results were analyzed in accordance with the Synthesis Without Meta-analysis reporting guideline.

RESULTS

From 7601 initial records, 13 studies were included, six of which were randomized controlled trials ("high" quality = 53%). Two studies evaluated interventions with an educational component for health care providers (multidisciplinary team) and 11 evaluated interventions for patient participants (n = 2678). These interventions were delivered in a hybrid (n = 6; 46%), in-person (n = 4; 30%), or virtual (n = 3; 23%) environment, mainly by nurses (n = 4; 30%) via discussion and orientation. Only three studies described the inclusion of printed or electronic materials (eg, pamphlets) to support the education. Eleven of 12 studies reported that patients who participated in interventions with an educational component or were cared for by health care providers who were educated about CR benefits (inhospital and/or after discharge) were more likely to enroll and participate in CR.

CONCLUSION

Interventions with an educational component for patients or health care providers play an important role in increasing CR enrollment and participation and should be pursued. Studies investigating the effects of such interventions in people from ethnic minority groups and living in low-and-middle-income countries, as well as the development of standard educational materials are recommended.

Initiating and Continuing Long-Term Exercise in Heart Failure: A Qualitative Analysis From the GEtting iNTo Light Exercise-Heart Failure Study

BACKGROUND

Exercise is a class 1A recommendation to improve the lives of patients with heart failure, yet less than one-third adhere to physical activity guidelines, and less than 3% attend cardiac rehabilitation.

OBJECTIVE

The aim of this study was to determine the effect of gentle nonaerobic exercise on initial and long-term adherence in patients with heart failure.

METHODS

We used a qualitative descriptive approach with qualitative content analysis to analyze previously recorded interview data collected as part of the 6-month GEtting iNTo Light Exercise-Heart Failure study and looked for trends in responses among our sample. Thematic statements, representing salient aspects of the participants' experiences, were created and supported by illustrative excerpts from the data.

RESULTS

Twenty-two interviews were analyzed. Eight participants had ≥80% adherence, and the remaining 14 participants were super-adherers (>100% adherence). Super-adherers tended to be male and 65 years or older, and have no exercise for 3 months before the study, a body mass index ≥ 30, and poor to good Kansas City Cardiomyopathy Questionnaire scores. Participants initially enrolled because they saw the program as an opportunity to improve a health issue and to exercise. Long-term adherence was facilitated by convenience, individualization, experiencing psychological and physical improvements, and peer fellowship.

CONCLUSIONS

The GEtting iNTo Light Exercise-Heart Failure study that used home-based gentle nonaerobic exercise had 64% of participants come more than was asked. It is imperative that clinicians incorporate what participants with heart failure have directly stated is important for their initiation and long-term adherence to exercise so that we can work toward bridging sedentary patients to the full exercise guidelines to reduce morbidity and mortality.

Role of exercise therapy and cardiac rehabilitation in heart failure

Heart failure (HF) is a common cause of hospitalization and death, and the hallmark symptoms of HF, including dyspnea, fatigue, and exercise intolerance, contribute to poor patient quality of life (QoL). Cardiac rehabilitation (CR) is a comprehensive disease management program incorporating exercise training, cardiovascular risk factor management, and psychosocial support. CR has been demonstrated to effectively improve patient functional status and QoL among patients with HF. However, CR participation among patients with HF is poor. This review details the mechanisms of dyspnea and exercise intolerance among patients with HF, the physiologic and clinical improvements observed with CR, and the key components of a CR program for patients with HF. Furthermore, unmet needs and future strategies to improve patient participation and engagement in CR for HF are reviewed.

A Mobile Health Behavior Change Intervention for Women With Coronary Heart Disease: A RANDOMIZED CONTROLLED PILOT STUDY

PURPOSE

The aim of this study was to evaluate the effects of a mobile health (mHealth) intervention, HerBeat, compared with educational usual care (E-UC) for improving exercise capacity (EC) and other patient-reported outcomes at 3 mo among women with coronary heart disease.

METHODS

Women were randomized to the HerBeat group (n = 23), a behavior change mHealth intervention with a smartphone, smartwatch, and health coach or to the E-UC group (n = 24) who received a standardized cardiac rehabilitation workbook. The primary endpoint was EC measured with the 6-min walk test (6MWT). Secondary outcomes included cardiovascular disease risk factors and psychosocial well-being.

RESULTS

A total of 47 women (age 61.2 ± 9.1 yr) underwent randomization. The HerBeat group significantly improved on the 6MWT from baseline to 3 mo ( P = .016, d = .558) while the E-UC group did not ( P = .894, d =-0.030). The between-group difference of 38 m at 3 mo was not statistically significant. From baseline to 3 mo, the HerBeat group improved in anxiety ( P = .021), eating habits confidence ( P = .028), self-efficacy for managing chronic disease ( P = .001), diastolic blood pressure ( P = .03), general health perceptions ( P = .047), perceived bodily pain ( P = .02), and waist circumference ( P = .008) while the E-UC group showed no improvement on any outcomes.

CONCLUSIONS

The mHealth intervention led to improvements in EC and several secondary outcomes from baseline to 3 mo while the E-UC intervention did not. A larger study is required to detect small differences between groups. The implementation and outcomes evaluation of the HerBeat intervention was feasible and acceptable with minimal attrition.

Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation

PURPOSE

Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention.

METHODS

Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance.

RESULTS

The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A 1c , with more abnormal lipid profiles (all P s < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both P s < .001).

CONCLUSION

Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.

Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization

BACKGROUND

Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes.

METHODS

A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization.

RESULTS

A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles.

CONCLUSIONS

Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.

Predictors and Variation in Cardiac Rehabilitation Participation After Transcatheter Aortic Valve Replacement

Background

Cardiac rehabilitation (CR) is strongly recommended for a spectrum of cardiovascular conditions and procedures including aortic valve replacement.

Objectives

The purpose of this study was to characterize patient and hospital factors associated with CR participation after transcatheter aortic valve replacement (TAVR) and determine which factors explain hospital-level variation in CR participation.

Methods

We linked clinical and administrative claims data from patients who underwent TAVR at 24 Michigan hospitals between January 1, 2016 and June 30, 2020 and obtained rates of CR enrollment within 90 days of discharge. Sequential mixed models were fit to evaluate hospital variation in 90-day post-TAVR CR participation.

Results

Among 3,372 patients, 30.6% participated in CR within 90-days after discharge. Several patient factors were negatively associated with CR participation after TAVR including older age, Medicaid insurance, atrial fibrillation/flutter, dialysis use, and slower baseline 5-m walk times. There was substantial hospital variation in CR participation after TAVR ranging from 5% to 60% across 24 hospitals. Patient case mix did not explain hospital variation in CR across hospitals with median OR numerically increasing from 2.11 (95% CI: 1.62-2.67) to 2.13 (95% CI: 1.61-2.68) after accounting for patient-level factors.

Conclusions

Less than 1 in 3 patients who underwent TAVR in Michigan participated in CR within 90-days of discharge. Although several patient factors are associated with CR participation, hospital-level variation in CR participation after TAVR is not explained by patient case mix. Identifying hospital processes of care that promote CR participation after TAVR will be critical to improving CR participation after TAVR.

Medical Disruptions During Center-Based Cardiac Rehabilitation: A Necessary Appraisal for the Development of Emerging Remote and Virtual Care Models

PURPOSE

The purpose of this study is to show that with remote and virtual cardiac rehabilitation (CR) care models rapidly emerging, CR core components must be maintained to prioritize safety and effectiveness. Currently, there is a paucity of data on medical disruptions in phase 2 center-based CR (cCR). This study aimed to characterize the frequency and types of unplanned medical disruptions.

METHODS

We reviewed 5038 consecutive sessions from 251 patients enrolled in cCR program from October 2018 to September 2021. Quantification of events was normalized to sessions to control for multiple disruptions that occurred to a single patient. A multivariate logistical regression model was used to predict comorbid risk factors for disruptions.

RESULTS

Fifty percent of patients experienced one or more disruptions during cCR. Glycemic events (71%) and blood pressure (12%) abnormalities accounted for most of these while symptomatic arrhythmias (8%) and chest pain (7%) were less frequent. Sixty-six percent of events occurred within the first 12 wk. The regression model showed that a diagnosis of diabetes mellitus was the strongest predictor for disruptions (OR = 2.66: 95% CI, 1.57-4.52; P < .0001).

CONCLUSIONS

Medical disruptions were frequent during cCR, with glycemic events being most common and occurring early. A diagnosis of diabetes mellitus was a strong independent risk factor for events. This appraisal suggests that patients living with diabetes mellitus, particularly those on insulin, need to be the highest priority for monitoring and planning and suggests that a hybrid care model may be beneficial in this population.

Clinical Predictors of Adherence to Exercise Training Among Individuals With Heart Failure: THE HF-ACTION STUDY

PURPOSE

Suboptimal adherence is a major limitation to achieving the benefits of exercise interventions, and our ability to predict and improve adherence is limited. The purpose of this analysis was to identify baseline clinical and demographic characteristics predicting exercise training adherence in the HF-ACTION study cohort.

METHODS

Adherence to exercise training, defined by the total duration of exercise performed (min/wk), was evaluated in 1159 participants randomized to the HF-ACTION exercise intervention. More than 50 clinical, demographic, and exercise testing variables were considered in developing a model of the min/wk end point for 1-3 mo (supervised training) and 10-12 mo (home-based training).

RESULTS

In the multivariable model for 1-3 mo, younger age, lower income, more severe mitral regurgitation, shorter 6-min walk test distance, lower exercise capacity, and Black or African American race were associated with poorer exercise intervention adherence. No variable accounted for >2% of the variance and the adjusted R2 for the final model was 0.14. Prediction of adherence was similarly limited for 10-12 mo.

CONCLUSIONS

Clinical and demographic variables available at the initiation of exercise training provide very limited information for identifying patients with heart failure who are at risk for poor adherence to exercise interventions.

Surveillance of the Initiation of, Participation in, and Completion of Cardiac Rehabilitation in Minnesota, 2017-2018

INTRODUCTION

Cardiac rehabilitation (CR) is an evidence-based secondary prevention program designed to improve cardiovascular health after a cardiac event. The objective of our study was to identify gaps in CR use among publicly and privately insured people in Minnesota to assist in developing shared goals among public health, cardiac rehabilitation professionals, and program delivery sites to improve CR delivery.

METHODS

We applied a published claims-based surveillance methodology to the Minnesota All Payer Claims Database to assess eligibility for, initiation of, participation in, and completion of CR by patients with qualifying events in 2017. We stratified results by sociodemographic and geographic factors and qualifying condition and used adjusted prevalence ratios to make statistical comparisons.

RESULTS

Less than half (47.6%) of qualifying patients initiated CR within 1 year of their qualifying event; the rate was higher among men (vs women), adults aged 45 to 64 years (vs ≥65 y), and patients with commercial or Medicaid insurance coverage (vs Medicare). Among those who initiated CR, only 14.0% completed the full series of 36 sessions. Participation in at least 12 sessions and completion of 36 sessions was less likely among adults aged 18 to 64 (vs 65-74 y) and among patients covered by Medicaid (vs Medicare). Patterns of CR initiation, participation, and completion also varied geographically.

CONCLUSION

This analysis expands on previous Medicare fee-for-service population CR surveillance and provides a first detailed look at the CR landscape in Minnesota, renewing attention to CR as a key secondary prevention strategy. Collaboration and sharing with partners has established the Minnesota Department of Health as a valuable partner in driving health system change to improve equitable provision of CR in Minnesota.

Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK

PURPOSE

Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation.

METHODS

Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement.

RESULTS

A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers.

CONCLUSIONS

This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.

Cardiac Rehabilitation and the COVID-19 Pandemic: Persistent Declines in Cardiac Rehabilitation Participation and Access Among US Medicare Beneficiaries

BACKGROUND

The impact of the COVID-19 pandemic on participation in and availability of cardiac rehabilitation (CR) is unknown.

METHODS

Among eligible Medicare fee-for-service beneficiaries, we evaluated, by month, the number of CR sessions attended per 100 000 beneficiaries, individuals eligible to initiate CR, and centers offering in-person CR between January 2019 and December 2021. We compared these outcomes between 2 periods: December 1, 2019 through February 28, 2020 (period 1, before declaration of the pandemic-related national emergency) and October 1, 2021 through December 31, 2021 (period 2, the latest period for which data are currently available).

RESULTS

In period 1, Medicare beneficiaries participated in (mean±SD) 895±84 CR sessions per 100 000 beneficiaries each month. After the national emergency was declared, CR participation sharply declined to 56 CR sessions per 100 000 beneficiaries in April 2020. CR participation recovered gradually through December 2021 but remained lower than prepandemic levels (period 2: 698±29 CR sessions per month per 100 000 beneficiaries, P=0.02). Declines in CR participation were most marked among dual Medicare and Medicaid enrollees and patients residing in rural areas or socially vulnerable communities. There was no statistically significant change in CR eligibility between the 2 periods. Compared with 2618±5 CR centers in period 1, there were 2464±7 in period 2 (P<0.01). Compared with CR centers that survived the pandemic, 220 CR centers that closed were more likely to be affiliated with public hospitals, located in rural areas, and serve the most socially vulnerable communities.

CONCLUSIONS

The COVID-19 pandemic was associated with a persistent decline in CR participation and the closure of CR centers, which disproportionately affected rural and low-income patients and the most socially vulnerable communities. Innovation in CR financing and delivery is urgently needed to equitably enhance CR participation among Medicare beneficiaries.

Clinical Determinants and Barriers to Cardiac Rehabilitation Enrollment of Patients with Heart Failure with Reduced Ejection Fraction: A Single-Center Study in Portugal

Despite cardiac rehabilitation (CR) being a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF), it is still underused. This study investigated the clinical determinants and barriers to enrollment in a CR program for HFrEF patients. We conducted a cohort study using the Cardiac Rehabilitation Barriers Scale (CRBS) to assess the reason for non-enrollment. Of 214 HFrEF patients, 65% had not been enrolled in CR. Patients not enrolled in CR programs were older (63 vs. 58 years; p < 0.01) and were more likely to have chronic obstructive pulmonary disease (COPD) (20% vs. 5%; p < 0.01). Patients enrolled in CR were more likely to be treated with sacubitril/valsartan (34% vs. 19%; p = 0.01), mineralocorticoid receptor antagonists (84% vs. 72%; p = 0.04), an implantable cardioverter defibrillator (ICD) (41% vs. 20%; p < 0.01), and cardiac resynchronization therapy (21% vs. 10%; p = 0.03). Multivariate analysis revealed that age (adjusted OR 1.04; 95% CI 1.01−1.07), higher education level (adjusted OR 3.31; 95% CI 1.63−6.70), stroke (adjusted OR 3.29; 95% CI 1.06−10.27), COPD (adjusted OR 4.82; 95% CI 1.53−15.16), and no ICD status (adjusted OR 2.68; 95% CI 1.36−5.26) were independently associated with CR non-enrollment. The main reasons for not being enrolled in CR were no medical referral (31%), concomitant medical problems (28%), patient refusal (11%), and geographical distance to the hospital (9%). Despite the relatively high proportion (35%) of HFrEF patients who underwent CR, the enrollment rate can be further improved. Innovative multi-level strategies addressing physicians’ awareness, patients’ comorbidities, and geographical issues should be pursued.

Relation of Exercise Capacity to Incident Heart Failure Among Men and Women With Coronary Heart Disease (from the Henry Ford Exercise Testing [FIT] Project)

Exercise capacity (EC) is inversely related to the risk of cardiovascular disease and incident heart failure (HF) in healthy subjects. However, there are no present studies that exclusively evaluate EC and the risk of incident HF in patients with known coronary heart disease (CHD). We aimed to determine the relation between EC and incident HF in patients with an established clinical diagnosis of CHD. We retrospectively identified 8,387 patients (age 61 ± 12 years; 30% women; 33% non-White) with a history of myocardial infarction (MI) or coronary revascularization procedure and no history of HF at the time of a clinically indicated exercise stress test completed between 1991 and 2009. EC was quantified in metabolic equivalents of task (METs) estimated from treadmill testing. Incident HF was identified through June 2010 from administrative databases based on ≥3 encounters with International Classification of Diseases, Ninth Revision 428.x. Cox regression analysis was used to evaluate the risk of incident HF associated with METs. Covariates included age; gender; race; hypertension, diabetes, hyperlipidemia, smoking, and MI; medications for CHD and lung diseases; and clinical indication for treadmill testing. During a median follow-up of 8.2 years (interquartile range 4.7 to 12.4 years) after the exercise test, 23% of the cohort experienced a new HF diagnosis. Lower EC categories were associated with higher HF incidence compared with METs ≥12, with nearly fourfold greater adjusted risk among patients with METs <6. Per unit increase in METs of EC was associated with a 12% lower adjusted risk for HF. There was no significant interaction based on race (p = 0.06), gender (p = 0.88), age ≤61 years (p = 0.60), history of MI (p = 0.31), or diabetes (p = 0.38). This study reveals that among men and women with CHD and no history of HF, EC is independently and inversely related to the risk of future HF.

Decision Aids for Determining Facility Versus Non-Facility-Based Exercise in Those with Symptomatic Peripheral Artery Disease

PURPOSE OF REVIEW

This paper sought to provide rationale for determining when a patient with symptomatic peripheral artery disease (PAD) might be referred for home-based versus facility-based exercise therapy.

RECENT FINDINGS

Multiple randomized controlled studies have embedded supervised, structured exercise therapy as a class IA recommended therapy for those with symptomatic PAD. More recently, there is interest in non-facility-based exercise training as an alternative. The current literature is mixed on the effectiveness of non-facility-based training and is influenced by the amount of contact with clinical staff providing some supervision (e.g., occasional facility-based exercise or coaching phone calls), and the intensity (e.g., performed intermittently by inducing pain or continually and not inducing pain) and frequency (e.g., 12-week common supervised exercise program or those longer than 24 weeks) of exercise. Certainly, the data suggests non-facility-based exercise, while possibly improving walking performance, is inferior to facility-based supervised exercise training. Comprehensive data is lacking on utilization of supervised exercise therapy in those with symptomatic PAD, but is likely <2% of those eligible who participate. This suggests a possible important role for alternatives including non-facility-based (e.g., home, fitness center). Exercise training in the supervised, facility-based setting appears to be greatly underutilized. Non-facility-based exercise may help to overcome some of the most common barriers to participating in facility-based exercise including those related to motivation, transportation, and proximity. However, facility-based training is considered the gold standard so decisions about allowing a patient to exercise train at home must take into account issues including disease severity, patient motivation and available exercise resources, mobility and balance, cognitive function, and other medical concerns (e.g., symptomatic coronary artery disease or heart failure).

Trends in cardiac rehabilitation enrollment post-coronary artery bypass grafting upon implementation of automatic referral in Southeast Asia: A retrospective cohort study

Introduction: Cardiac rehabilitation (CR) is an effective but underutilized intervention. Strategies have been identified to increase its use, but there is paucity of data testing them in low-resource settings. We sought to determine the effect of automatic referral post-coronary artery bypass graft (CABG) surgery on CR enrollment.

Methods: This is a retrospective cohort study assessing cardiac patients referred to CR at a tertiary center in Southeast Asia from 2013 to 2019. The paper-based pathway was introduced at the end of 2012. The checklist with automatic CR referral on the third day post-operation prompted a nurse to educate the patient about CR, initiate phase 1 and encourage enrollment in phase 2. Patients who were not eligible for the pathway for administrative or clinical reasons were referred at the discretion of the attending physician (i.e., usual care). Enrollment was defined as attendance at≥1 CR visit.

Results: Of 4792 patients referred during the study period, 394 enrolled in CR. Significantly more patients referred automatically enrolled compared to usual care (225 [11.8%] vs. 169 [5.8%]; OR=2.2, 95% CI=1.8-2.7), with increases up to 23.4% enrollment in 2014 (vs. average enrollment rate of 5.9% under usual referral). Patients who enrolled following automatic referral were significantly younger and more often employed (both P<0.001); no other differences were observed.

Conclusion: In a lower-resource, Southeast Asian setting, automatic CR referral is associated with over two times greater enrollment in phase 2 CR, although efforts to maintain this effect are required.