Access to cardiac rehabilitation does not equate to attendance

Behavioural and psychological telehealth support for people with cardiac conditions: randomized trial of the 'back on track' self-management programme

AIMS

Behaviour modification and mood management are essential to recovery after a cardiac event. Recent times have seen a major shift to remote delivery of cardiac services. This study assessed behavioural and psychological outcomes of the Back on Track online self-management programme, comparing the programme undertaken alone (self-directed) vs. with telephone support (supported). Relevance for people with depression was also assessed.

METHODS AND RESULTS

Participants with cardiac conditions (n = 122) were randomly assigned to self-directed or supported groups and given access to the online programme for 2 months. The programme addressed depression, anxiety, physical activity, and healthy eating. Supported group participants also received two telephone sessions facilitated by a trained counsellor to further enhance their self-management skills and engagement with the online modules. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Active Australia Survey and Diet Quality Tool were administered at baseline, 2, and 6 months. χ2 tests were used to compare self-directed and supported groups. Cochrane's Q tests assessed changes over time in depression, anxiety, and physical activity (PA) and healthy diet guideline achievement. Participants in both groups showed reduced depression rates (self-directed, P < 0.05) and increased PA after programme completion (both groups, P < 0.05). Amongst those classified as depressed at baseline, significantly fewer were classified as depressed over time (P < 0.001) and significantly more were achieving the PA guidelines (P < 0.01) compared to those who were not depressed at baseline.

CONCLUSIONS

The Back on Track telehealth programme was effective in assisting with behavioural and emotional recovery after a cardiac event. The programme may be particularly beneficial for those who are depressed early in their recovery period.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12620000102976.

The application of spatial measures to analyse health service accessibility in Australia: a systematic review and recommendations for future practice

BACKGROUND

Australia's inequitable distribution of health services is well documented. Spatial access relates to the geographic limitations affecting the availability and accessibility of healthcare practitioners and services. Issues associated with spatial access are often influenced by Australia's vast landmass, challenging environments, uneven population concentration, and sparsely distributed populations in rural and remote areas. Measuring access contributes to a broader understanding of the performance of health systems, particularly in rural/remote areas. This systematic review synthesises the evidence identifying what spatial measures and geographic classifications are used and how they are applied in the Australian peer-reviewed literature.

METHODS

A systematic search of peer-reviewed literature published between 2002 and 2022 was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Search terms were derived from three major topics, including: [1] Australian population; [2] spatial analysis of health service accessibility; and [3] objective physical access measures.

RESULTS

Database searches retrieved 1,381 unique records. Records were screened for eligibility, resulting in 82 articles for inclusion. Most articles analysed access to primary health services (n = 50; 61%), followed by specialist care (n = 17; 21%), hospital services (n = 12; 15%), and health promotion and prevention (n = 3; 4%). The geographic scope of the 82 articles included national (n = 33; 40%), state (n = 27; 33%), metropolitan (n = 18; 22%), and specified regional / rural /remote area (n = 4; 5%). Most articles used distance-based physical access measures, including travel time (n = 30; 37%) and travel distance along a road network (n = 21; 26%), and Euclidean distance (n = 24; 29%).

CONCLUSION

This review is the first comprehensive systematic review to synthesise the evidence on how spatial measures have been applied to measure health service accessibility in the Australian context over the past two decades. Objective and transparent access measures that are fit for purpose are imperative to address persistent health inequities and inform equitable resource distribution and evidence-based policymaking.

Getting "Back on Track" After a Cardiac Event: Protocol for a Randomized Controlled Trial of a Web-Based Self-management Program

Background

After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management.

Objective

The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone.

Methods

People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only.

Results

Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study.

Conclusions

The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/34534

The Role of Lifestyle and Cardiovascular Risk Factors in Dropout From an Australian Cardiac Rehabilitation Program. A Longitudinal Cohort Study

BACKGROUND

Cardiac rehabilitation (CR) programs reduce the risk of further cardiac events and improve the ability of people living with cardiovascular disease to manage their symptoms. However, many people who experience a cardiac event do not attend or fail to complete their CR program. Little is known about the characteristics of people who drop out compared to those who complete CR.

AIMS

To identify subgroups of patients attending a cardiac rehabilitation program who are more likely to dropout prior to final assessment by (1) calculating the dropout rate from the program, (2) quantifying the association between dropout and socio-demographic, lifestyle, and cardiovascular risk factors, and (3) identifying independent predictors of dropout.

METHODS

The study population is from a large metropolitan teaching hospital in Sydney, Australia, and consists of all participants consecutively enrolled in an outpatient CR program between 2006 and 2017. Items assessed included diagnoses and co-morbidities, quality of life (SF-36), psychological health (DASS-21), lifestyle factors and physical assessment. Dropout was defined as failure to complete the outpatient CR program and post CR assessment.

RESULTS

Of the 3,350 patients enrolled in the CR program, 784 (23.4%; 95%CI: 22.0-24.9%) dropped out prior to completion. The independent predictors of dropout were smoking (OR 2.4; 95%CI: 1.9-3.0), being separated or divorced (OR 2.0; 95%CI: 1.5-2.6), younger age (<55 years) (OR 1.9; 95%CI: 1.6-2.4), obesity (OR 1.6; 95%CI: 1.3-2.0), diabetes (OR 1.6; 95%CI: 1.3-2.0), sedentary lifestyle (OR 1.3; 95%CI: 1.1-1.6) and depressive symptoms (OR 1.3; 95%CI: 1.1-1.6).

CONCLUSION

To improve the CR program completion rate, clinicians need to consider the impact of socio-demographic, lifestyle, and cardiovascular risk factors on their patients' ability to complete CR. Tailored strategies which target the independent predictors of dropout are required to promote adherence to CR programs and thereby potentially reduce long-term cardiovascular risk.

Regional Variability in the Access to Cardiac Rehabilitation in Poland

Equitable access to cardiological rehabilitation services is one of the important elements in the effectiveness of the treatment of cardiovascular diseases as cardiological rehabilitation is an important part of circulatory system disease prevention and treatment. However, in many countries among others, Poland suffers from the underutilization of cardiac rehabilitation services. Cardiovascular diseases are the worldwide number one cause of mortality, morbidity, and disability and are responsible for the substantial increase in health care costs. Thus, the aim of the research was the analysis of geographical accessibility to cardiac rehabilitation services in Poland. Perkal’s method was employed in this research. The conducted research allowed to recognize the regional variation, but also made it possible to classify Polish voivodeships in terms of the level of availability achieved. This enables the identification of voivodeships that provide a good, or even very good, access to cardiology rehabilitation services and those characterized by low, or very low access. It was found that there was a slight regional variability in the access to cardiological rehabilitation services. However, the sufficient development of a rehabilitation infrastructure has been also recognized.

Cost-utility analysis of cardiovascular outpatient rehabilitation care and spa treatment care for patients with heart disease

BACKGROUND

Cardiovascular diseases have the highest mortality rates and the costs for treatment are very high so far. Cardiovascular rehabilitation helps to reduce the risk of relapses or deterioration of cardiovascular diseases, however, the number of patients that participate is insufficient, especially in later stages of the rehabilitation process. The aim of the study is to evaluate cost-effectiveness of cardiovascular rehabilitation care using cost-utility analysis.

METHODS

The study evaluate the Cardio ambulance Late Phase, Late Phase of The Spa treatment and for comparison also Early Phase of The Spa treatment in Konstantin Spa. The research was conducted in outpatient facility and spa facility. For QALY, a prospective questionnaire survey was conducted in patients with cardiovascular disease using generic EQ-5D-5L questionnaires. The costs were calculated from the perspective of the health care payer. The cost-utility analysis was carried out at the end of the study and results are presented in incremental cost-utility ratio.

RESULTS

The average cost per patient in outpatient facility is CZK 12,459. The average amount for an overall early phase of spa treatment per patient is CZK 35,161. The average amount for an overall late phase spa treatment per patient is CZK 30,503. QALY obtained from Index Value was 0.092 (Konstantin Spa Early Phase), 0.054 (Konstantin Spa Late Phase), 0.26 (Cardio ambulance Late Phase). For Konstantin Spa Late Phase, the ICUR value was 644,436 and for Konstantin Spa Early Phase was 343,981 (comparator is the Cardio ambulance Late Phase). Konstantin Spa Early Phase compared to Konstantin Spa Late Phase had an ICUR value of 122,592.

CONCLUSIONS

The results of this study suggest that the spa treatment in later stage of the cardiovascular rehabilitation process is cost effective with use of cost effectiveness threshold three times the Gross Domestic Product (GDP) per capita.

The Keeping on Track Study: Exploring the Activity Levels and Utilization of Healthcare Services of Acute Coronary Syndrome (ACS) Patients in the First 30-Days after Discharge from Hospital

The aim of this study was to investigate the impact of bedside discharge education on activity levels and healthcare utilization for patients with acute coronary syndrome (ACS) in the first 30 days post-discharge. Knowledge recall and objective activity and location data were collected by global positioning systems (GPS). Participants were asked to carry the tracking applications (apps) for 30–90 days. Eighteen participants were recruited (6 metropolitan 12 rural) 61% ST elevation myocardial infarction (STEMI), mean age 55 years, 83% male. Recall of discharge education included knowledge of diagnosis (recall = 100%), procedures (e.g., angiogram = 40%), and comorbidities (e.g., hypertension = 60%, diabetes = 100%). In the first 30 days post-discharge, median steps per day was 2506 (standard deviation (SD) ± 369) steps (one participant completed 10,000 steps), 62% visited a general practitioner (GP) 16% attended cardiac rehabilitation, 16% visited a cardiologist, 72% a pharmacist, 27% visited the emergency department for cardiac event, and 61% a pathology service (blood tests). Adherence to using the activity tracking apps was 87%. Managing Big Data from the GPS and physical activity tracking apps was a challenge with over 300,000 lines of raw data cleaned to 90,000 data points for analysis. This study was an example of the application of objective data from the real world to help understand post-ACS discharge patient activity. Rates of access to services in the first 30 days continue to be of concern.

Randomized Controlled Trial of Symptom Management Patient Education for People With Acute Coronary Syndrome

BACKGROUND

Poorly managed acute coronary syndrome symptoms increase the risk of subsequent cardiovascular events.

PURPOSE

The aim of this study was to evaluate the effectiveness of symptom management patient education on the knowledge of sublingual nitroglycerin for people with acute coronary syndrome.

METHODS

A randomized controlled trial was used to evaluate the 3-resource intervention. The study was conducted in a 448-bed Australian public hospital. The instrument used was the modified Sublingual Nitroglycerin Interview Schedule.

RESULTS

A total of 169 participants completed the study. The intervention group significantly improved their knowledge of sublingual nitroglycerin when compared with the control group (P = .002).

CONCLUSION

This 3-resource symptom management patient education shows promise in improving sublingual nitroglycerin knowledge for people with acute coronary syndrome.

Patient preferences for the delivery of cardiac rehabilitation

OBJECTIVE

To elicit patients' preferences for cardiac rehabilitation(CR).

METHODS

A Discrete Choice Experiment was used to quantify patients' preferences for the delivery of CR. This survey-based method elicited the relative importance of different characteristics of a program.

RESULTS

200 in-patients eligible to attend CR completed the survey. Over half of the patients strongly preferred a centre-based compared to a home-based program. Many but not all preferred a program starting within two rather than six weeks of discharge and exercise delivered in a group rather than individual setting, with exercise via the internet using telehealth strongly disliked. Some respondents preferred lifestyle information delivered one-to-one by a health professional, and there was an overall preference against delivery by smart phone Apps. Some preferred a program out of rather than within working hours and a shorter program (four weeks compared to eight weeks).

CONCLUSIONS

This study provides further insight into patient preferences for a CR program. Although the strongest preferences were for centre-based programs with healthcare professionals facilitating exercise classes and one-on-one education, it is important to offer flexible delivery as one approach will not suit everyone.

PRACTICE IMPLICATIONS

There is the potential to improve CR programs by focusing on patient preferences.

Auswirkung motivierender Gesprächsführung auf die Krankheitswahrnehmung bei stabiler koronarer Herzkrankheit. Eine randomisiert-kontrollierte Studie

Zusammenfassung.Hintergrund: Koronare Herzkrankheit ist eine der häufigsten Todesursachen für Menschen > 60 Jahre. Vom Lebensstil abhängige Risikofaktoren sind wesentlich beteiligt. Kardiale Rehabilitation ist daher essenziell für eine optimale Behandlung. Leider verstehen die Betroffenen ihre Krankheit kaum. Motivierende Gesprächsführung kann die Krankheitswahrnehmung verbessern. Ziel / Methode: In einer randomisiert-kontrollierten Studie wurde die Wirksamkeit einer Intervention mit motivierender Gesprächsführung auf die Krankheitswahrnehmung untersucht. Personen mit stabiler koronarer Herzkrankheit wurden konsekutiv nach perkutaner transluminaler Koronarangioplastie (PTCA) in die Studie aufgenommen. Die Interventionsgruppe erhielt ein kurzes motivierendes Gespräch zur Erkrankung und den Risikofaktoren als Intervention. Die Kontrollgruppe erhielt die Standardbetreuung. Vor der Intervention und sechs Monate später wurden Daten zur Krankheitswahrnehmung (Illness Perception Questionnaire-Revised) erhoben. Ergebnisse: Total wurden 312 Personen (n = 148 Intervention, n = 164 Kontrollgruppe) in die Studie aufgenommen (Durchschnittsalter: 66,2 Jahre). Nach der Intervention zeigte sich eine signifikante Veränderung im Bereich der emotionalen Reaktionen auf die Erkrankung. Schlussfolgerung: Um die Krankheitswahrnehmung bei Personen mit stabiler koronarer Herzkrankheit zu verbessern, ist eine kurze Intervention mit motivierender Gesprächsführung möglicherweise wirksam. Ob eine Intensivierung der Intervention das Resultat weiter verbessert, muss noch untersucht werden.

Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia

BACKGROUND

Cardiovascular disease (CVD), a leading cause of morbidity and mortality, has similar incidence in metropolitan and rural areas but poorer cardiovascular outcomes for residents living in rural and remote Australia. Cardiac Rehabilitation (CR) is an evidence-based intervention that helps reduce subsequent cardiovascular events and rehospitalisation. Unfortunately CR attendance rates are as low as 10-30% with rural/remote populations under-represented. This in-depth assessment investigated the provision of CR and secondary prevention services in Western Australia (WA) with a focus on rural and remote populations.

METHODS

CR and Aboriginal Community Controlled Health Services were identified through the Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Structured interviews with CR coordinators included questions specific to program delivery, content, referral and attendance.

RESULTS

Of the 38 CR services identified, 23 (61%) were located in rural (n = 11, 29%) and remote (n = 12, 32%) regions. Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) found 77% of rural/remote services were hospital-based, with no service providing a comprehensive home-based or alternative method of program delivery. The majority of rural (60%) and remote (80%) services provided CR through chronic condition exercise programs compared with 17% of metropolitan services; only 27% of rural/remote programs provided education classes. Rural/remote coordinators were overwhelmingly physiotherapists, and only 50% of rural and 33% of remote programs had face-to-face access to multidisciplinary support. Patient referral and attendance rates differed greatly across WA and referrals to rural/remote services generally numbered less than 5 per month. Program evaluation was reported by 33% of rural/remote coordinators.

CONCLUSION

Geography, population density and service availability limits patient access to CR services in rural/remote WA. Current inadequacies in delivering comprehensive centre-based CR in rural/remote settings impedes management of cardiovascular risk and opportunities for event reduction. Health pathways that ensure referral and continuity of care are needed, with emerging technology-based CR support to supplement centre-based CR services requiring assessment. Implementing systematic data collection across services to establish benchmarks and enable service monitoring and evaluation is needed.

Structures, processes and outcomes of the Aussie Heart Guide Program: A nurse mentor supported, home based cardiac rehabilitation program for rural patients with acute coronary syndrome

BACKGROUND

Cardiac rehabilitation has a number of benefits for patients, yet participation in it is sub-optimal, especially in regional Australia. Innovative models of cardiac rehabilitation are needed to improve participation. Providing nurse mentors to support patients transitioning from hospital to home represents a new model of service delivery in Australia.

OBJECTIVES

To explore the impact of a home-based cardiac rehabilitation program in assisting patients to recover from Acute Coronary Syndrome and meeting the expectations of nurse mentors delivering the program.

METHODS

This case study was underpinned by the structure, process and outcomes model and occurred in three Australian hospitals 2008-2011. Thirteen patients recovering from acute coronary syndrome were interviewed by telephone and seven nurse mentors completed a survey after completing the program.

FINDINGS

Mentor perceptions concerning the structures of the home-based CR program included the timely recruitment of patients, mentor training to operationalise the program, commitment to development of the mentor role, and the acquisition of knowledge and skills about cognitive behavioural therapy and patient centred care. Processes included the therapeutic relationship between mentors and patients, suitability of the program and the promotion of healthier lifestyle behaviours. Outcomes identified that patients were satisfied with the program's audiovisual resources, and the level of support and guidance provided by their nurse mentors. Mentors believed that the program was easy to use in terms of its delivery.

DISCUSSION AND CONCLUSION

Patients believed the program assisted their recovery and were satisfied with the information, guidance and support received from mentors. There were positive signs that the program influenced patients' decisions to change unhealthy lifestyle behaviours. Outcomes highlighted both rewards and barriers associated with mentoring patients in their homes by telephone. Experience gained from developing a therapeutic relationship with patients during their recovery, assisted nurses in developing the mentor role.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people.

METHODS

Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people.

RESULTS

Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services.

CONCLUSION

The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.