Socially differentiated cardiac rehabilitation: can we improve referral, attendance and adherence among patients with first myocardial infarction?

Association between neighborhood household income and inpatient atrial fibrillation outcomes

BACKGROUND

The impact of socioeconomic status on the clinical outcomes of patients admitted to the hospital for atrial fibrillation (AF) is not well described.

OBJECTIVE

The purpose of this study was to determine the association between median neighborhood household income (mNHI) and clinical outcomes among patients admitted to the hospital for AF.

METHODS

We retrospectively analyzed primary AF hospitalizations from the United States National Inpatient Sample between 2016 and 2020. The analyzed sample was divided into quartiles based on the mNHI in the zip code of the patient's residence. The lowest quartile was used as the reference category. Study outcomes included inpatient procedure utilization (ablation, cardioversion, percutaneous left atrial appendage closure), length of stay, cost, mortality, and disposition. Weighted multivariable logistic and linear regression, adjusting for multiple patient and hospital-level characteristics, was performed.

RESULTS

Patients in the highest mNHI quartile had lower comorbidity burden, lower in-hospital mortality (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.7-0.87; P <.001), lower discharges to care facility (OR 0.86; 95% CI 0.83-0.9; P <.001), shorter length of stay (adjusted mean difference -0.26; 95% CI -0.30 to -0.22; P <.001), higher procedure utilization, and higher health care costs ($12,124 vs $10,018) compared to the lowest mNHI quartile patients.

CONCLUSION

We identified significantly higher in-hospital mortality and lower procedural/resource utilization in patients living in lower-income neighborhoods compared to higher-income neighborhoods. Further research is needed to better understand the drivers of these disparities and the strategies to improve health care disparities between socioeconomic groups.

Association of Socioeconomic Status With Long-Term Outcome in Survivors After Out-of-Hospital Cardiac Arrest: Nationwide Population-Based Longitudinal Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major public health problem and a leading cause of death worldwide. Previous studies have focused on improving the survival of people who have had OHCA by analyzing short-term survival outcomes, such as the return of spontaneous circulation, 30-day survival, and survival to discharge. Research has been conducted on prehospital prognostic factors to improve the survival of patients with OHCA, among which the association between socioeconomic status (SES) and survival has been reported. SES could affect bystander cardiopulmonary resuscitation rates and whether OHCA is witnessed, and low cardiopulmonary resuscitation education rates are associated with low SES. It has been reported that areas with high SES have shorter hospital transfer times and more public defibrillators per person. Previous studies have shown the impact of SES disparities on the short-term survival of patients with OHCA. However, understanding the impact of SES on the long-term prognosis of OHCA survivors remains limited. As long-term outcomes are more indicative of a patient's ongoing health care needs and the burden on public health than short-term outcomes, understanding the long-term prognosis of OHCA survivors is important.

OBJECTIVE

This study aimed to identify whether SES influenced the long-term outcomes of OHCA.

METHODS

Using health claims data obtained from the National Health Insurance (NHI) service in Korea, we included OHCA survivors who were hospitalized between January 2005 and December 2015. The patients were divided into 2 groups: NHI and Medical Aid (MA) groups, with the MA group defined as having a low SES. Cumulative mortality was estimated using the Kaplan-Meier method, and a Cox proportional hazards model was used to evaluate the impact of SES on long-term mortality. A subgroup analysis was performed based on whether cardiac procedures were performed.

RESULTS

We followed 4873 OHCA survivors for up to 14 years (median of 3.3 years). The Kaplan-Meier survival curve showed that the MA group had a significantly decreased long-term survival rate compared to the NHI group. With an adjusted hazard ratio (aHR) of 1.52 (95% CI 1.35-1.72), low SES was associated with increased long-term mortality. The overall mortality rate of the patients who underwent cardiac procedures in the MA group was significantly higher than that of the NHI group (aHR 1.72, 95% CI 1.05-2.82). The overall mortality rate of patients without cardiac procedures was also increased in the MA group compared to the NHI group (aHR 1.39, 95% CI 1.23-1.58).

CONCLUSIONS

OHCA survivors with low SES had an increased risk of poor long-term outcomes compared with those with higher SES. OHCA survivors with low SES who have undergone cardiac procedures need considerable care for long-term survival.

Catalogue of socioeconomic disparities and characteristics of 199+ chronic conditions-A nationwide register-based population study

BACKGROUND

Real-world information on socioeconomic differences within and between chronic conditions represents an important data source for treatments and decision-makers executing and prioritising healthcare resources.

AIMS

The aim of this study was to estimate the prevalence and mean of socioeconomic disparities from educational, income, and socioeconomic positions of 199 chronic conditions and disease groups, including sex and age group estimates, for use in planning of care services and prioritisation, by healthcare professionals, decision-makers and researchers.

METHODS

The study population includes all Danish residents 16 years and above, alive on 1 January 2013 (n = 4,555,439). The data was established by linking seven national registers encompassing educational achievements, incomes, socioeconomic positions, hospital- and general practice services, and filled-in out-of-hospital prescriptions. The health register data were used to identify the 199+ chronic conditions. Socioeconomic differences were primarily measured as differences in educational prevalence levels from low to high educational achievements using a ratio. Furthermore, multiple binary logistic regression models were carried out to control for potential confounding and residual correlations of the crude estimates.

RESULTS

The prevalence of having one or more chronic conditions for patients with no educational achievement was 768 per thousand compared to 601.3 for patients with higher educational achievement (ratio 1.3). Across disease groups, the highest educational differences were found within disease group F-mental and behavioural (ratio 2.5), E-endocrine, nutritional and metabolic disease (ratio 2.4), I-diseases of the circulatory system (ratio 2.1) and, K-diseases of the digestive system (ratio 2.1). The highest educational differences among the 29 common diseases were found among schizophrenia (ratio 5.9), hyperkinetic disorders (ratio 5.2), dementia (ratio 4.9), osteoporosis (ratio 3.9), type 2 diabetes (ratio 3.8), chronic obstructive pulmonary disease COPD (ratio 3.3), heart conditions and stroke (ratios ranging from 2.3-3.1).

CONCLUSIONS

A nationwide catalogue of socioeconomic disparities for 199+ chronic conditions and disease groups is catalogued and provided. The catalogue findings underline a large scope of socioeconomic disparities that exist across most chronic conditions. The data offer essential information on the socioeconomic disparities to inform future socially differentiated treatments, healthcare planning, etiological, economic, and other research areas.

Catalogue of multimorbidity mean based severity and associational prevalence rates between 199+ chronic conditions-A nationwide register-based population study

BACKGROUND

Real-world data on multimorbidity represents an important but underutilised source of evidence for the planning of healthcare services, including prevention, treatments, and health economic modelling.

AIMS

This study aimed to estimate means of multimorbidity and provide associated prevalence rates and frequencies between 199 x 199 chronic conditions and disease groups based on the total adult Danish population and sex, age, and educational attainment. Thus, this study provides an off-the-shelf catalogue for use in treatments and planning by clinicians, decision-makers and researchers.

METHODS

The study population contained all Danish residents above 16 years on 1 January 2013 (n = 4,555,439). The data was based on the linkage of six national registers covering hospital contacts, services in general practice, filled-in out-of-hospital prescriptions, and educational attainments. The health registers were used to identify the 199 chronic conditions based on the ICD-10 classification system.

RESULTS

The mean number of chronic conditions (NCC) was 2.2. The mean increased with age, women had a higher mean than men, and there was a social gradient with the mean increasing with lower educational attainment. The mean NCC varied from 3.3-9.8 among all conditions. Across disease groups, the highest mean NCC were found within disease group N (chronic renal failure, mean = 8.8), D (in situ and benign neoplasms; mean = 6.5), K (diseases of the digestive system; mean = 5.7), and H (diseases of the eye and the ear; mean = 5.6). The highest mean NCC among the 29 common diseases was heart failure, ischemic heart diseases, angina pectoris, stroke, and dementia, with a mean above 6.5. Several prevalent conditions like hypertension, arthritis, chronic lower respiratory diseases, depression, type 2 diabetes, and overweight transcended other conditions regarding the associated prevalence rates. As one of the most frequent, hypertensive diseases were highly associated with arthritis (50.4%), depression (37.4%), type 2 diabetes (75.4%), cancers (49.7%), and being overweight (39.7%)-meaning that 50.4% of people with arthritis, 37.4% of people with depression and so on also had hypertensive diseases. The largest differences in means between individuals with no educational attainment and individuals with high educational attainment were found within disease groups J (diseases of the respiratory system, ratio = 1.8), Q (congenital malformations, deformations, and chromosomal abnormalities, ratio = 1.7), and B (viral hepatitis and human immunodeficiency virus disease, ratio = 1.7).

CONCLUSIONS

The current study provides a nationwide off-the-shelf catalogue of multimorbidity means and real-world associations estimates of 199+ chronic conditions for future clinical treatments and health care systems planning. The findings described are just one example of numerous results and underline that multimorbidity is highly prevalent in the adult Danish population and that it is a vital condition transcending all future medical treatment. The data offer essential information on the multimorbidity burden of disease in future differentiated treatments, healthcare planning, and economic, aetiological, and other research.

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.

Taking no for an answer. Nurses' consultations with people with cardiac disease about rehabilitation: A qualitative study

BACKGROUND

Research shows that many people with cardiac disease decline cardiac rehabilitation. There is little or no knowledge on how health professionals respond to these people.

OBJECTIVES

To investigate how nurses respond to people who do not wish to participate in cardiac rehabilitation and what influences the nurses´ approach towards these people.

DESIGN

A qualitative study involving interviews and video-recordings using an analysis inspired by ethnographic principles and categorisation theory.

SETTING

A rehabilitation clinic at a large hospital in the Capital Region of Denmark.

PARTICIPANTS

Five cardiac nurses and 28 people with cardiac disease.

METHODS

We video-recorded the first consultation people with cardiac disease attended regarding cardiac rehabilitation, where the nurses followed up on these people's recovery, medication, lifestyle and need for rehabilitation. We conducted semi-structured interviews with the cardiac nurses. We asked the nurses about the purpose of the first rehabilitation consultation and how they handle people with cardiac disease who say no to rehabilitation. The nurses were shown video-clips with the people they had talked to in their consultation in order to facilitate a dialogue.

RESULTS

When people with cardiac disease were reluctant to participate in rehabilitation, the nurses made an individual assessment of how much effort to put into motivating them, taking a complex range of factors into account. The effort among the nurses towards people with cardiac disease who decline rehabilitation was smaller in cases when the nurses believed an individual would benefit less from rehabilitation or have difficulty participating. It was important for the nurses to balance their motivational efforts with showing respect for people's autonomy.

CONCLUSION

Even when nurses endorse rehabilitation, some people with cardiac disease decline rehabilitation. The nurses' recommendation of the rehabilitation programme is influenced by the knowledge they obtain about the people with cardiac disease during consultations.

Effect of a virtual cardiac rehabilitation program on patients with hypertension: A randomized trial

Abstract Introduction: Hypertension is among the main primary factors for the cause of death from cardiovascular diseases. Among the treatments for hypertension, physical exercise has stood out. However, the adherence of patients with hypertension to the practice of physical exercises is low, and thus strategies such as virtual rehabilitation may be beneficial, in addition to increasing adherence. Objective: This study aimed to evaluate the effect of a virtual cardiovascular rehabilitation (VCR) program on arterial blood pressure, physical conditioning and the quality of life of patients with hypertension. Methods: This is a randomized clinical trial with 59 patients with hypertension, divided into three groups: conventional cardiac rehabilitation (CCR), VCR and control (CO). Before and after the intervention period the patients were submitted to anthropometric data (BMI, body mass index), vital data (SBP, systolic blood pressure; DBP, diastolic blood pressure), quality of life (SF-36 questionnaire), respiratory muscle strength (MIP, maximum inspiratory pressure; MEP, maximum expiratory pressure) and functional capacity (6-MWT, six-minute walk test) assessment. Both VCR and CCR groups underwent aerobic training. Results: VCR protocol increased functional capacity (p < 0.001), expiratory muscle strength (p < 0.002), and quality of life in the domains in relation to limitation of physical (p < 0.018), emotional aspects (p < 0.019), social aspects (p < 0.042), and mental health (p < 0.002) when baseline and post-intervention were compared. Conclusion: The VCR program is an effective treatment strategy for improving the physical capacity and quality of life of patients with hypertension.

Resources in vulnerable young adults: self-assessments during preventive consultation with their general practitioner in Denmark

Inequality in health is increasing. People with many problems often lack energy to improve well-being and reduce their problems. This study analyses how psycho-socially challenged younger (20- to 44-year-old) patients described their own resources to reach lifestyle goals or alter life circumstances. Within the context of a randomized controlled trial, Danish participants had two structured preventive person-centred consultations with their general practitioner. Consultations focused on well-being, salutogenesis, resources, barriers and support of autonomy. Using the qualitative method: Systematic Text Condensation, we made thematic cross-analysis of patients’ goal-specific resource statements described at the first consultation. Of the 209 patients, 191 (91%) chose one or two goals for a better life next year; nearly all (179) could recall and describe which resources they would use to reach their goal. We categorized resource statements into (i) personal constitution as ‘willpower’ and ‘tenacity’; (ii) network, e.g. family; (iii) personal experience with identical or similar problems. Some patients needed to free up resources by handling psychological problems before being able to focus on lifestyle goals. The study demonstrates that patients with particular psycho-social problems could describe essential resources in a structured, salutogenic, preventive consultation with their general practitioner. Reflecting intrinsic and extrinsic motivation, these resources reflected dimensions of essential health theories like sense of coherence, self-efficacy and self-determination theory. Increased awareness of these resources seems essential for vulnerable patients by improving psychological well-being and optimism, thereby facilitating health-related changes. This may be an important step to reducing inequality in health.

Influence of socioeconomic status on the referral process to cardiac rehabilitation following acute coronary syndrome: a cross-sectional study

OBJECTIVE

To evaluate the association between socioeconomic status (SES) and referral to cardiac rehabilitation (CR) after incident acute coronary syndrome (ACS) by dividing the referral process into three phases: (1) informed about CR, (2) willingness to participate in CR, (3) and assigned CR setting.

DESIGN

Cross-sectional study.

SETTING

Department of Cardiology at a Danish University Hospital from 1 January 2011 to 31 December 2014.

PARTICIPANTS

A total of 1229 patients assessed for CR during hospitalisation with ACS were prospectively registered in the Rehab-North Register from 2011 to 2014. SES was assessed using data from national registers, concerning: personal income, occupational status, educational level and civil status. Patients were excluded if one of the following criteria was fulfilled: (1) missing data on SES, or (2) acceptable reason for not informing patients about CR (treatment with coronary artery bypass grafting, transfer to another hospital, still under treatment or death).

MAIN OUTCOME MEASURES

Outcomes were defined by dividing the referral process into three phases: (1) informed about CR, (2) willingness to participate, and (3) assigned CR setting (in-hospital/community centre) after ACS.

RESULTS

A total of 854 (69.5 %) patients were referred to CR. After adjustment for age, gender, ACS diagnosis (ST-elevated myocardial infarction, non-ST-elevated myocardial infarction, unstable angina pectoris) and comorbidity, high income had the strongest association of referral to CR in all three phases (informed about CR: OR 2.17, 95% CI 1.01 to 4.64; willingness to participate in CR: OR 1.55, 95% CI 1.02 to 2.35; assigned in-hospital CR: OR 1.47, 95% CI 0.91 to 2.36). Educational level showed similar tendencies, however not statistically significant. The results did not vary according to gender.

CONCLUSION

This is the first study to investigate the referral process to CR using a three-phase structure. It suggests income and education to influence all phases in the referral process to CR after ACS.

The challenge of non-adherence to early rehabilitation after coronary artery bypass surgery: Secondary results from the SheppHeartCABG trial

BACKGROUND

Attending and maintaining a cardiac rehabilitation programme is a challenge.

AIMS

The purpose of this study was to explore associations between non-adherence to early coronary artery bypass graft rehabilitation and sociodemographic and clinical baseline data.

METHODS

Coronary artery bypass graft patients were randomised 1:1 to either four weeks of comprehensive early rehabilitation or usual care. Outcomes were assessed at three time-points points: baseline, discharge and four weeks post-coronary artery bypass graft. Differences in sociodemographic and clinical baseline data in adherent versus non-adherent patients were tested using the Pearson χ² test for categorical variables. To test associations between non-adherence to exercise training and sociodemographic and clinical baseline data, multivariate logistic regression was used to estimate the odds ratio for in-hospital training and post-discharge training adjusted for age, sex and left ventricular ejection fraction.

RESULTS

Non-adherence to in-hospital versus post-discharge exercise training was 31% (n=48) versus 53% (n=81). Female non-adherence was 20% versus 70%. Non-adherence to in-hospital versus post-discharge mindfulness was 87% versus 70%. Male non-adherence to mindfulness was 85% versus 70%. Non-adherence to psycho-educational consultations was 3%, most of whom were men. Patients with university level education were more adherent to in-hospital exercise training than patients with lower educational level (odds ratio=3.14 (95% confidence interval; 1.16-8.51), p=0.02). Diabetic patients were more non-adherent to exercise training after discharge (3.74 (1.54-9.08), p=0.004) as were overweight patients (0.37 (0.17-0.80), p=0.01).

CONCLUSIONS

This study demonstrated wide acceptance of psycho-educational consultations in post-coronary artery bypass graft patients. Adherence to physical rehabilitation was low especially after discharge from hospital and the opportunity to attend a mindfulness programme was not used.

Access to cardiac rehabilitation and the role of language barriers in the provision of cardiac rehabilitation to migrants

Background

Cardiac rehabilitation (CR) has proven health benefits and, according to international guidelines, CR must be offered to all eligible patients. Studies have reported lower uptake of CR among migrants, and migrants are known to face several barriers in their access to healthcare, of which language is the most common. The aim of this study is to examine the provision of CR core components for migrants; and the role of language barriers in the provision of CR in Danish hospitals and municipalities.

Methods

This is a descriptive study based on repeated nationwide surveys conducted in 2013 and 2015 by the Danish Cardiac Rehabilitation Database. The surveys collected information on provision and organization of CR in hospitals (n = 35) and municipalities (n = 98) in Denmark. The survey in 2015 had additional items related to migrants, such as provision of interpreter services and multilingual information material.

Results

Not all CR core components were provided by hospitals to non-Danish speaking patients. There was no improvement from 2013 to 2015. Hospitals had full coverage (19/19) of interpreter services compared to 84% (26/31) of municipalities. Provision of multilingual information material was low in hospitals 32% (6/19) and in municipalities 3% (1/31).

Conclusion

This study found language-related barriers in migrants’ access to CR, in the form of inadequate provision of CR core components for non-Danish speaking patients at some Danish hospitals and suboptimal provision of interpreter services in municipalities. The findings call for increased attention to language barriers and further studies are needed to map the extent of the problem.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4041-1) contains supplementary material, which is available to authorized users.

Dietary interventions in cardiac rehabilitation - The gap between guidelines and clinical practice

BACKGROUND & AIMS

An unhealthy diet is a risk factor for ischemic heart disease (IHD) and therefore cardiac rehabilitation (CR) should include dietary interventions. In 2007, CR became a shared responsibility between Danish hospitals and municipalities. Later, a national clinical guideline including recommendations on dietary interventions was developed to facilitate implementation of CR. The aim of the present study is: 1) To describe provision of dietary interventions in CR for IHD patients in Denmark in 2013 and 2015 emphasizing differences between hospitals and municipalities, and 2) To evaluate the implementation of the national clinical guideline in clinical practice.

METHODS

A repeated nationwide cross-sectional electronic survey was carried out in 2013 and 2015. Participation was mandatory for all Danish hospital departments offering CR (n = 36), but voluntary for municipalities (n = 98) reaching response rates of 82% and 89% in 2013 and 2015, respectively. The electronic survey covered the core components of dietary interventions in CR as described in the national clinical guideline.

RESULTS

In 2015, 72% of municipalities provided dietary interventions. This proportion was significantly higher in hospitals (94%, p = 0.007). 26% and 38% of hospitals screened systematically for dietary intervention needs in 2013 and 2015, respectively. Corresponding results from municipalities were 26% and 29%. No significant differences were seen in clinical practice over time.

CONCLUSIONS

The results of this study identified a major gap between recommendations in the national clinical guideline and actual clinical practice on dietary interventions in CR in Danish hospitals and municipalities. The study confirmed that implementation of guidelines in clinical practice takes time and requires an intensive effort.

Disparities in Cardiac Rehabilitation Among Individuals from Racial and Ethnic Groups and Rural Communities-A Systematic Review

PURPOSE

Despite the well-described benefits of cardiac rehabilitation (CR) on long-term health outcomes, CR is a resource that is underutilized by a significant proportion of patients that suffer from cardiovascular diseases. The main purpose of this study was to examine disparities in CR referral and participation rates among individuals from rural communities and racial and ethnic minority groups with coronary heart disease (CHD) when compared to the general population.

METHODS

A systematic search of standard databases including MedlLine, PubMed, and Cochrane databases was conducted using keywords that included cardiac rehabilitation, women, race and ethnicity, disparities, and rural populations. Twenty-eight clinical studies from 1990 to 2017 were selected and included 478,955 patients with CHD.

RESULTS

The majority of available clinical studies showed significantly lower CR referral and participation rates among individuals from rural communities, women, and racial and ethnic groups when compared to the general population. Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs. Patients of lower SES have significantly lower CR referral and participation rates than patients of higher SES.

CONCLUSIONS

Data presented underscores the need for systematic referrals using electronic health records for patients with CHD in order to increase overall CR referral and participation rates of minority populations and other vulnerable groups. Educational programs that target healthcare provider biases towards racial and ethnic groups may help attenuate observed disparities. Alternative modalities such as home-based and internet-based CR programs may also help improve CR participation rates among vulnerable populations.

Cardiac rehabilitation in patients who underwent primary percutaneous coronary intervention for acute myocardial infarction: determinants of programme participation and completion

Background

Hospital length of stay after acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (pPCI) has reduced, resulting in more limited patient education during admission. Therefore, systematic participation in cardiac rehabilitation (CR) has become more essential. We aimed to identify patient-related factors that are associated with participation in and completion of a CR programme.

Methods

We identified 3,871 consecutive AMI patients who underwent pPCI between 2003 and 2011. These patients were linked to the database of Capri CR, which provides dedicated, multi-disciplinary CR. ‘Participation’ was defined as registration at Capri CR within 6 months after pPCI. CR was ‘complete’ if a patient undertook the final exercise test.

Results

In total, 1,497 patients (39%) were registered at Capri CR. Factors independently associated with CR participation included age (<50 vs. >70 year: odds ratio (OR) 7.0, 95% confidence interval (CI) 5.1–9.6), gender (men vs. women: OR 1.9, 95% CI 1.3–1.8), index diagnosis (ST-elevation myocardial infarction [STEMI] vs. non-ST-elevation myocardial infarction [NSTEMI]: OR 2.4, 95% CI 2.0–2.7) and socio-economic status (high vs. low: OR 2.0, 95% CI 1.6–2.5). The model based on these factors discriminated well (c-index 0.75). CR programme completion was 80% and was inversely related with diabetes, current smoking and previous MI. The discrimination of the model based on these factors was poor (c-index 0.59).

Conclusions

Only a minority of AMI/pPCI patients participated in a CR programme. Completion rates, however, were better. Increased physician and patient awareness of the benefits of CR are still needed, with focus on the elderly, women and patients with low socio-economic status.

Balancing trust and power: a qualitative study of GPs perceptions and strategies for retaining patients in preventive health checks

OBJECTIVE

Little is known about how strategies of retaining patients are acted out by general practitioners (GPs) in the clinical encounter. With this study, we apply Grimens' (2009) analytical connection between trust and power to explore how trust and power appear in preventive health checks from the GPs' perspectives, and in what way trust and power affect and/or challenge strategies towards retaining patients without formal education.

DESIGN

Data in this study were obtained through semi-structured interviews with GPs participating in an intervention project, as well as observations of clinical encounters.

RESULTS

From the empirical data, we identified three dimensions of respect: respect for the patient's autonomy, respect for professional authority and respect as a mutual exchange. A balance of respect influenced trust in the relationship between GP and patients and the transfer of power in the encounter. The GPs articulated that a balance was needed in preventive health checks in order to establish trust and thus retain the patient in the clinic. One way this balance of respect was carried out was with the use of humour.

CONCLUSIONS

To retain patients without formal education in the clinical encounter, the GPs balanced trust and power executed through three dimensions of respect. In this study, retaining patients was equivalent to maintaining a trusting relationship. A strategic use of the three dimensions of respect was applied to balance trust and power and thus build or maintain a trusting relationship with patients. KEY POINTS   Little is known about how strategies for retaining patients are acted out by GPs in preventive health checks.  •  Retaining patients requires a balance of trust and power, which is executed through three dimensions of respect by the GPs.  •  Challenges of recruiting and retaining patients in public health initiatives might be associated with the balance of respect.

Effectiveness of person-centred care after acute coronary syndrome in relation to educational level: Subgroup analysis of a two-armed randomised controlled trial

AIM

The aim of this study was to evaluate the effects of person-centred care (PCC) after acute coronary syndrome (ACS) in relation to educational level of participants.

METHOD

199 Patients <75years with ACS were randomised to PCC plus usual care or usual care alone and followed for 6months from hospital to outpatient care and primary care. For the PCC group, patients and health care professionals co-created a PCC health plan reflecting both perspectives, which induced a continued collaboration in person-centred teams at each health care level. A composite score of changes that included general self-efficacy assessment, return to work or previous activity level, re-hospitalisation or death was used as outcome measure.

RESULTS

In the group of patients without postsecondary education (n=90) the composite score showed a significant improvement in favour of the PCC intervention (n=40) vs. usual care (n=50) at six months (35.0%, n=14 vs. 16.0%, n=8; odds ratio (OR)=2.8, 95% confidence interval (CI): 1.0-7.7, P=0.041). In patients with postsecondary education (n=109), a non-significant difference in favour of the PCC intervention (n=54) vs. usual care (n=55) was observed in the composite score (13.0%, n=7 vs 3.6%, n=2; OR=3.9, 95% CI: 0.8-19.9, P=0.097).

CONCLUSION

A PCC approach, which stresses the necessity of a patient-health care professional partnership, is beneficial in patients with low education after an ACS event. Because these patients have been identified as a vulnerable group in cardiac rehabilitation, we suggest that PCC can be integrated into conventional cardiac rehabilitation programmes to improve both equity in uptake and health outcomes.

TRIAL REGISTRATION

Swedish registry, Researchweb.org, ID NR 65 791.

Impact of socioeconomic status on mortality and unplanned readmission in septic intensive care unit patients

BACKGROUND

Little is known about the potential association between socioeconomic status (SES) and prognosis after sepsis. We analysed how SES impacted mortality and readmission in septic patients treated at the intensive care unit (ICU) of a university hospital.

METHODS

We performed a cohort study including all adult patients admitted to a general tertiary ICU with severe sepsis or septic shock during 2008-2010. Data on SES (educational level, personal income, and cohabitation), comorbidity, readmissions, and mortality were obtained from public registries. We used Cox regression analysis to examine the impact of SES on 30- and 180-day mortality and on first unplanned readmission within 180 days after hospital discharge.

RESULTS

A total of 387 patients were included of whom 111 (29%) died within 30 days after ICU admission, and 55 (20%) died within 180 days after hospital discharge. Adjusted for sex, comorbidity and SAPS II, patients with low income had a substantially greater risk of dying within 30 days of admission compared to those with high income (35.7% vs. 23.3%; adjusted hazard ratio (HR) 1.99; 95% confidence interval (CI) 1.24-3.21), and tended to show higher 180-day mortality (25.0% vs. 15.5%; adjusted HR 1.72; 95% CI 0.86-3.45). Among patients discharged from hospital, 125 (45%) were readmitted within 180 days. Patients with low education and low income showed a tendency towards early readmission.

CONCLUSIONS

Among septic ICU patients, low income was significantly associated with increased 30-day mortality. There was a trend towards earlier readmission among surviving patients with low educational level and personal income.

Visualization of Coronary Artery Calcification: Influence on Risk Modification

OBJECTIVES

Direct health provider to patient presentation of coronary computed tomography angiography findings may increase adherence to preventive therapy and risk modification. The purpose of this study was to assess the influence of visualization of coronary artery calcification and lifestyle recommendations on cholesterol concentrations and other risk variables in symptomatic patients with nonobstructive coronary artery disease and hyperlipidemia.

METHODS

We performed a prospective 2-center randomized controlled trial. Patients were randomized 1:1 to intervention or standard follow-up in general practice. The primary end point was change in plasma total cholesterol concentration at 6 months follow-up.

RESULTS

We included 189 patients (mean [± standard deviation] age 61 [12] years, 57% were male). Median (range) Agatston score was 166 (70-2054). The reduction in plasma total cholesterol concentrations tended to be higher in the intervention group than in the control group, 51.04 mg/dL versus 45.63 mg/dL (P = .181). In a subgroup including patients continuing statin therapy during follow-up (n = 147), the reduction in plasma total cholesterol concentrations was more pronounced in the intervention group than in the control group, 66.13 mg/dL versus 55.68 mg/dL (P = .027). In the intervention group, there was a higher degree of statin adherence and a higher proportion of patients who stopped smoking and commenced healthier dietary behavior than in the control group.

CONCLUSIONS

Visualization of coronary artery calcification and brief recommendations about risk modification after coronary computed tomography angiography in symptomatic patients with nonobstructive coronary artery disease and hyperlipidemia may have a favorable influence on plasma total cholesterol concentration, adherence to statin therapy, and risk behavior. Further investigations are needed.

Healthcare Contacts after Myocardial Infarction According to Mental Health and Socioeconomic Position: A Population-Based Cohort Study

OBJECTIVE

To examine the long-term use of healthcare contacts to general practice (GP) and hospital after a first-time myocardial infarction (MI) according to mental health and socioeconomic position.

METHODS

Population-based cohort study of all patients discharged with first-time MI in the Central Denmark Region in 2009 (n=908) using questionnaires and nationwide registers. We estimated adjusted incidence rates and incidence rate ratios (IRR) for GP and hospital contacts according to depressive and anxiety symptoms, educational level and cohabitation status.

RESULTS

During the 24-month period after the MI, patients with anxiety symptoms had 24% more GP contacts (adjusted IRR 1.24, 95% confidence interval (CI) 1.12-1.36) than patients with no anxiety symptoms. In contrast, patients with depressive symptoms (1.05, 0.94-1.16) and with short and medium education (<10 years: 0.96, 0.84-1.08; 10-12 years: 0.91, 0.80-1.03) and patients living alone (0.95, 0.87-1.04) had the same number of GP contacts as their counterparts (patients with no depressive symptoms, with long education [>12 years] and patients living with a partner). During the first 6 months after the MI, patients living alone had 13% fewer hospital contacts (0.87, 0.77-0.99), patients with short education had 16% fewer hospital contacts (<10 years: 0.84, 0.72-0.98) and patients with anxiety symptoms had 27% fewer hospital contacts (0.73, 0.62-0.86) than their counterparts. In contrast, patients with depressive symptoms (0.92, 0.77-1.10) and medium education (10-12 years: 1.05, 0.91-1.22) had the same number of hospital contacts as their counterparts.

CONCLUSIONS

This study indicates that patients with depressive symptoms, short and medium education and patients living alone have a lower long-term use of healthcare contacts following MI than patients without these risk factors. Patients with depressive symptoms and low socioeconomic position would be expected to have a higher need of healthcare after MI as they have a poorer prognosis.

Impact of health care system delay in patients with ST-elevation myocardial infarction on return to labor market and work retirement

System delay (delay from emergency medical service call to reperfusion with primary percutaneous coronary intervention [PPCI]) is acknowledged as a performance measure in ST-elevation myocardial infarction (STEMI), as shorter system delay is associated with lower mortality. It is unknown whether system delay also impacts ability to stay in the labor market. Therefore, the aim of the study was to evaluate whether system delay is associated with duration of absence from work or time to retirement from work among patients with STEMI treated with PPCI. We conducted a population-based cohort study including patients ≤67 years of age who were admitted with STEMI from January 1, 1999, to December 1, 2011 and treated with PPCI. Data were derived from Danish population-based registries. Only patients who were full- or part-time employed before their STEMI admission were included. Association between system delay and time to return to the labor market was analyzed using a competing-risk regression analysis. Association between system delay and time to retirement from work was analyzed using a Cox regression model. A total of 4,061 patients were included. Ninety-three percent returned to the labor market during 4 years of follow-up, and 41% retired during 8 years of follow-up. After adjustment, system delay >120 minutes was associated with reduced resumption of work (subhazard ratio 0.86, 95% confidence interval 0.81 to 0.92) and earlier retirement from work (hazard ratio 1.21, 95% confidence interval 1.08 to 1.36). In conclusion, system delay was associated with reduced work resumption and earlier retirement. This highlights the value of system delay as a performance measure in treating patients with STEMI.

Promoting patient uptake and adherence in cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review.

OBJECTIVES

To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation.

SEARCH METHODS

We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions.

SELECTION CRITERIA

Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome.

DATA COLLECTION AND ANALYSIS

At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias.

MAIN RESULTS

The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization.

AUTHORS' CONCLUSIONS

We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed. 

Cardiac rehabilitation barriers by rurality and socioeconomic status: a cross-sectional study

INTRODUCTION

Despite greater need, rural inhabitants and individuals of low socioeconomic status (SES) are less likely to undertake cardiac rehabilitation (CR). This study examined barriers to enrollment and participation in CR among these under-represented groups.

METHOD

Cardiac inpatients from 11 hospitals across Ontario were approached to participate in a larger study. Rurality was assessed by asking participants whether they lived within a 30-minute drive-time from the nearest hospital, with those >30 minutes considered "rural." Participants completed a sociodemographic survey, which included the MacArthur Scale of Subjective Social Status. One year later, they were mailed a survey which assessed CR utilization and included the Cardiac Rehabilitation Barriers Scale. In this cross-sectional study, CR utilization and barriers were compared by rurality and SES.

RESULTS

Of the 1809 (80.4%) retained, there were 215 (11.9%) rural participants, and the mean subjective SES was 6.37 ± 1.76. The mean CRBS score was 2.03 ± 0.73. Rural inhabitants reported attending significantly fewer CR sessions (p < .05), and greater CR barriers overall compared to urban inhabitants (p < .01). Patients of lower subjective SES were significantly less likely to be referred, enroll, and participate in CR, and reported significantly greater barriers to CR compared to their high SES counterparts (p < .01). Prominent barriers for both groups included distance, cost, and transportation problems. These relationships sustained adjustment, and a significant relationship between having undergone coronary artery bypass graft surgery and lower barriers was also identified.

CONCLUSIONS

The results confirm that rural inhabitants and patients of low SES experience greater barriers to CR utilization when compared to their urban, high SES counterparts. It is time to implement known strategies to overcome these barriers, to achieve equitable and greater use of CR.

Alternative models of cardiac rehabilitation: a systematic review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.