Effects of community based cardiac rehabilitation: Comparison with a hospital-based programme

Global Prevalence of Anxiety in Adult Cardiology Outpatients: A Systematic Review and Meta-analysis

Anxiety and anxiety disorders are associated with adverse cardiovascular outcomes, and reduced quality of life. Despite this, no comprehensive study on the global prevalence of anxiety symptoms and disorders among adult cardiology outpatients exists. This systematic review and meta-analysis aims to provide cardiologists with a precise estimate of the prevalence of anxiety in their outpatient clinics. PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched from database inception to January 23, 2023. Data characteristics were extracted independently by 2 investigators. Ninety-three studies, n = 36,687 participants across 31 countries, were included. Global prevalence of anxiety symptoms/disorders was 28.9% (95%CI 25.7-32.4; 8927/36, 687; I2 = 97.33; n = 93). The highest rates were found in patients presenting with hypertension, 43.6%. Subgroup analyses revealed higher prevalence estimates when using self-report screening compared to gold-standard diagnostic interview. When using diagnostic interview, the highest rates were reported in outpatients with undifferentiated chest pain/palpitations, 19·0%. Panic disorder was the most frequent diagnosis 15.3%, and rates were significantly higher in patients with undifferentiated chest pain/palpitations compared to ischemic heart disease. Higher rates of anxiety were found in studies of outpatients from developing countries, and female outpatients tended to have higher rates compared to males. Anxiety occurred frequently among cardiology outpatients and at a higher rate than estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective identification and management strategies be developed to support cardiologists in identifying and treating these conditions in their clinics.

Reference Equation of a New Incremental Step Test to Assess Exercise Capacity in the Portuguese Adult Population

Step tests are important in community- and home-based rehabilitation programs to assess patients' exercise capacity. A new incremental step test was developed for this purpose, but its clinical interpretability is currently limited. This study aimed to establish a reference equation for this new incremental step test (IST) for the Portuguese adult population. A cross-sectional study was conducted on people without disabilities. Sociodemographic (age and sex), anthropometric (weight, height, and body mass index), smoking status, and physical activity (using the brief physical activity assessment tool) data were collected. Participants performed two repetitions of the IST and the best test was used to establish the reference equation with a forward stepwise multiple regression. An analysis comparing the results from the reference equation with the actual values was conducted with the Wilcoxon test. A total of 155 adult volunteers were recruited (60.6% female, 47.8 ± 19.7 years), and the reference equation was as follows: steps in IST = 475.52 - (4.68 × age years) + (30.5 × sex), where male = 1 and female = 0, and r² = 60%. No significant differences were observed between the values performed and those obtained by the equation (p = 0.984). The established equation demonstrated that age and sex were the determinant variables for the variability of the results.

Efficacy of Phase II Remote Home Rehabilitation in Patients with Acute Myocardial Infarction after Percutaneous Coronary Intervention

Objective

To assess the efficacy of home-based cardiac rehabilitation and traditional outpatient rehabilitation in stage II after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI).

Methods

From September 2019 to March 2020, 80 AMI patients in Cangzhou Central Hospital were randomly assigned to one of the two groups: the control group or the observation group, 40 cases in each group. The control group received old-fashioned outpatient rehabilitation treatment, and the study group received long-distance family rehabilitation nursing intervention. The blood pressure, examination results, compliance, satisfaction evaluation, incidence of cardiac events, heart rate, quality of life score, and 6-minute walking test were compared between the two groups.

Results

There were no deaths in both groups. There were significant differences in heart failure, unstable angina pectoris, unplanned readmission rate, walking compliance, and 6-minute walking test at 6 months after discharge (P < 0.05). There were substantial variances in left ventricular discharge portion, low-density lipoprotein, medication compliance, satisfaction, and quality of life (P < 0.05); there was substantial inconsistency in the 6-minute walking test concerning the two groups afterwards discharge for 3 months (P < 0.05).

Conclusion

Home rehabilitation is a new home cardiac rehabilitation model with high efficiency, convenience, and whole process monitoring and barrier-free follow-up management. It can effectively improve the cardiac function, workout patience and worth of life expectancy of victims with AMI, improve their self-management awareness and rehabilitation compliance, reduce the risk of cardiac events, and have a positive impact on the prognosis and rehabilitation of patients with AMI.

Organization of rehabilitation services in randomized controlled trials - which factors influence functional outcome? A systematic review

Objective

To identify factors related to the organization of rehabilitation services that may influence patients’ functional outcome and make recommendations for categories to be used in the reporting of rehabilitation interventions.

Data Sources

A systematic review based on a search in MEDLINE indexed journals (MEDLINE [OVID], Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials) until June 2019.

Study Selection

In total 8587 candidate randomized controlled trials reporting on organizational factors of multidisciplinary rehabilitation interventions and their associations with functional outcome. An additional 1534 trials were identified from June 2019 to March 2021. Data Extraction: Quality evaluation was conducted by 2 independent researchers. The organizational factors were classified according to the International Classification for Service Organization in Health-related Rehabilitation 2.0.

Data Synthesis

In total 80 articles fulfilled the inclusion criteria. There was a great heterogeneity in the terminology and reporting of service organization across all studies. Aspects of Settings including the Mode of Service Delivery was the most explicitly analyzed organizational category (44 studies). The importance of the integration of rehabilitation in the inpatient services was supported. Furthermore, several studies documented a lack of difference in outcome between outpatient vs inpatient service delivery. Patient Centeredness, Integration of Care, and Time and Intensity factors were also analyzed, but heterogeneity of interventions in these studies prohibited aggregation of results.

Conclusions

Settings and in particular the way the services were delivered to the users influenced functional outcome. Hence, it should be compulsory to include a standardized reporting of aspects of service delivery in clinical trials. We would also advise further standardization in the description of organizational factors in rehabilitation interventions to build knowledge of effective service organization.

Participant exercise attendance in community-based, bridging, and hospital-based cardiac rehabilitation: a retrospective case control study

Background

A paucity of studies have investigated participant attendance in community-based and hybrid cardiac rehabilitation programs in the Canadian setting. We compared exercise-session attendance of community-based, bridging (hospital plus community-based), and hospital-based participants who attended a high-volume cardiac rehabilitation program in Alberta, Canada.

Methods

Exercise sessions attended and participant characteristics were collected and analyzed from 230 records of patients who attended cardiac rehabilitation between 2016 and 2019. Community-based (n = 74) and bridging (n = 41) program participants were age- and sex-matched in a 1:1 ratio to hospital-based participants. The number of exercise sessions attended was compared among program groups, between female and male patients, and for patients with vs without cardiac surgery. The percentage of exercise sessions attended was also compared among program groups.

Results

Bridging participants attended the greatest number of exercise sessions (median = 10.0 sessions) and demonstrated a significantly higher percentage of sessions attended (91%, 25th and 75th percentile interquartile range [IQR] = 64, 100%) than matched hospital participants (median = 6.0 sessions; 63%, 25, 75 IQR = 13, 94%; P = 0.01). Percentage of sessions attended did not differ for bridging and community-based participants (P = 0.30). Exercise-session attendance was similar for community-based participants (median = 6.0 sessions; 75%, 25, 75 IQR = 38%, 88%) vs their hospital matches (median = 6.0 sessions; 81%, 25, 75 IQR = 38%, 100%; P ≥ 0.37), as well as for female vs male patients (median = 7.0 sessions for both sexes; P = 0.66), and for surgical vs nonsurgical patients (median = 7.0 sessions; P = 0.48). Female patients in the bridging program attended significantly more exercise sessions in the community, compared with male patients in the bridging program (P = 0.02).

Conclusions

Bridging participants attended the most exercise sessions overall and demonstrated a higher percentage attendance than hospital-based participants. These results suggest that a hybrid program consisting of hospital and community-based exercise was favourable for exercise-session attendance. Given modern approaches to de-medicalize cardiac rehabilitation, our findings further support the provision of community program offerings, without detriment to patient session attendance.

Effect of Different Endurance Training Protocols During Cardiac Rehabilitation on Quality of Life

BACKGROUND

This study aimed to assess the effect of different types of endurance training during outpatient cardiac rehabilitation on patients' health-related quality of life (HRQL).

METHODS

The MacNew Heart Disease HRQL questionnaire and the Hospital Anxiety and Depression Scale were used to assess changes in HRQL in 66 patients before and after 6 weeks of cardiac rehabilitation. Patients were randomized to 1 of 3 types of supervised endurance training: continuous endurance training, high-intensity interval training, and pyramid training. Two-way analysis of variance for repeated measure and chi-square test were used to analyze changes before and after rehabilitation.

RESULTS

Attendance rate during the 6 weeks of exercise training was 99.2%. Physical work capacity increased from 136.1 to 165.5 watts (+22.9%; P < .001), and there were no statistical differences between training protocols. Fully completed questionnaires at both time points were available in 46 patients (73.9%; 61.3±11.6 years, 34 males, 12 females). Regardless of the type of supervised endurance training, there was significant improvement during rehabilitation in each of the categories of the MacNew questionnaire (ie, emotion, physical, social, global; all P < .05) and the Hospital Anxiety and Depression Scale (anxiety: P = .05; depression: P = .032), without significant differences between protocols.

CONCLUSIONS

All 3 types of endurance training led to significant and well comparable increases in physical work capacity, which was associated with an increase in HRQL independent of the type of training. Our findings support further individualization of training regimes, which could possibly lead to better compliance during life-long home-based exercise training.

Cardiac rehabilitation and its essential role in the secondary prevention of cardiovascular diseases

Cardiovascular diseases are the most common causes of mortality worldwide. They are frequently the reasons for patient hospitalization, their incapability for work, and disability. These diseases represent a significant socio-economic burden affecting the medical system as well as patients and their families. It has been demonstrated that the etiopathogenesis of cardiovascular diseases is significantly affected by lifestyle, and so modification of the latter is an essential component of both primary and secondary prevention. Cardiac rehabilitation (CR) represents an efficient secondary prevention model that is especially based on the positive effect of regular physical activity. This review presents an overview of basic information on CR with a focus on current trends, such as the issue of the various training modalities, utilization, and barriers to it or the use of telemedicine technologies. Appropriate attention should be devoted to these domains, as CR continues evolving as an effective and readily available intervention in the future.

Community-Based Cardiac Rehabilitation Conducted in a Public Health Center in South Korea: A Preliminary Study

OBJECTIVE

To evaluate the safety and effectiveness of the community-based cardiac rehabilitation (CBCR) program that we had developed.

METHODS

Individuals aged >40 years with cardiovascular disease or its risk factors who were residing in a rural area were recruited as study subjects. The CBCR program, which consisted of 10 education sessions and 20 weeks of customized exercises (twice a week), was conducted in a public health center for 22 weeks. Comprehensive outcomes including body weight, blood glucose level, and 6-minute walk distance (6MWD) were measured at baseline, 11th week, and completion. Furthermore, the outcomes of young-old (65-74 years) and old-old (≥75 years) female subjects were compared.

RESULTS

Of 31 subjects, 21 completed the program (completion rate, 67.7%). No adverse events were observed, and none of the subjects discontinued the exercise program because of chest pain, dyspnea, and increased blood pressure. Body weight and blood glucose level were significantly decreased, and 6MWD was significantly increased following program implementation (p<0.05). Both young-old and old-old women exhibited an improvement in blood glucose level and 6MWD test (p<0.05).

CONCLUSION

We reported the results of the first attempted CBCR in South Korea that was implemented without adverse events during the entire program. Improved aerobic exercise ability and reduced risk factors in all participants were observed. These improvements were also achieved by older adults aged ≥75 years.

The effect of participating in MedEx Wellness, a community-based chronic disease exercise rehabilitation programme, on physical, clinical and psychological health: A study protocol for a cohort trial

Background

Community-based exercise rehabilitation programmes for chronic disease are an effective alternative to traditional hospital-based programmes. MedEx Wellness is a novel community-based exercise rehabilitation programme that integrates a range of chronic diseases. The aim of this trial was to investigate the effect of participating in MedEx Wellness on physical, clinical and psychological health.

Methods

A prospective cohort study was conducted. Participants were recruited at induction to the MedEx Wellness programme following referral from healthcare professionals. Participants underwent a baseline assessment before commencing the exercise programme and repeat assessments at 3, 6 and 12 months. The primary outcome was cardiorespiratory fitness (6 minute- time trial) at 12 months. Secondary outcomes included health-related quality of life (EuroQoL-5D, Satisfaction with Life Scale, Warwick Edinburgh Mental Wellbeing Scale, Patient Health Questionnaire8, Functional Assessment of Cancer Therapy Questionnaire), free living activity behavior (accelerometer) and healthcare utilization (recall questionnaire). Tertiary outcomes included blood pressure (24 h), biomarkers (lipids, glucose and C-reactive protein), other components of physical fitness, including strength (handgrip test, sit-to-stand test), flexibility (sit-and-reach test), body composition (body mass index and waist-to-hip ratio), and falls risk (timed up and go test), and claudication time (incremental treadmill walking test), cognitive function, including attention (Attention Network Task), memory (Luck & Vogel Visual Working Memory Task) and cognitive reserve. Exploratory outcomes included psychosocial determinants of physical activity (self-efficacy, social support, intentions).

Discussion

This trial will evaluate whether participation in the MedEx Wellness programme has positive effects on physical, clinical and psychological health in individuals with a range of chronic diseases.

Trial registration

ISRCTN Registry ISRCTN10351412.

Impact of Community-Based Cardiac Rehabilitation on Clinical Parameters of Patients with Cardiovascular Diseases

BACKGROUND

Cardiac rehabilitation (CR) programmes have been shown to improve patient outcomes, but vary widely in their components. The impact of Singapore's CR programme on clinical outcomes is currently not known.

OBJECTIVE

To evaluate the effects of a community-based CR programme on important clinical parameters in patients with cardiovascular disease in Singapore.

METHOD

A retrospective cohort study was conducted. Cardiovascular patients who had completed a hospital-based CR programme were included. Patients who continued with community-based CR (n = 94) during the period of 2009-2013 were compared with patients who received regular care (n = 157). Changes in clinical and physical examination parameters between baseline and one-year post follow-up were analyzed. Within-group differences were compared using the paired t-test, while multivariate linear regression was used to compare the changes in the various parameters between the intervention and control groups. The primary outcome measure was low density lipoprotein (LDL) levels.

RESULTS

Patients in the intervention group had significant lowering of LDL (2.5 to 2.2 mmol/L, p<0.01), while the control group's LDL increased (2.2 to 2.4 mmol/L, p<0.01). The intervention group had greater improvements in LDL (-0.3 vs. +0.2 mmol/L, p<0.01), triglycerides (-0.1 vs. +0.1 mmol/L, p=0.01), total cholesterol (-0.3 vs. +0.3 mmol/L, p<0.01), fasting blood glucose (-0.5 vs. +0.3 mmol/L, p<0.01), systolic blood pressure (-3.2 vs. +5 mmHg, p<0.01) and diastolic blood pressure (-2.6 vs. +2.8 mmHg, p<0.01).

CONCLUSION

The community-based CR programme in Singapore is associated with improvements in several cardiovascular clinical parameters and may be of benefit to cardiovascular patients.

Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement

Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.

Mobile clinics for women's and children's health

BACKGROUND

The accessibility of health services is an important factor that affects the health outcomes of populations. A mobile clinic provides a wide range of services but in most countries the main focus is on health services for women and children. It is anticipated that improvement of the accessibility of health services via mobile clinics will improve women's and children's health.

OBJECTIVES

To evaluate the impact of mobile clinic services on women's and children's health.

SEARCH METHODS

For related systematic reviews, we searched the Database of Abstracts of Reviews of Effectiveness (DARE), CRD; Health Technology Assessment Database (HTA), CRD; NHS Economic Evaluation Database (NHS EED), CRD (searched 20 February 2014).For primary studies, we searched ISI Web of Science, for studies that have cited the included studies in this review (searched 18 January 2016); WHO ICTRP, and ClinicalTrials.gov (searched 23 May 2016); Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.cochranelibrary.com (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 7 April 2015); MEDLINE, OvidSP (searched 7 April 2015); Embase, OvidSP (searched 7 April 2015); CINAHL, EbscoHost (searched 7 April 2015); Global Health, OvidSP (searched 8 April 2015); POPLINE, K4Health (searched 8 April 2015); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (searched 8 April 2015); Global Health Library, WHO (searched 8 April 2015); PAHO, VHL (searched 8 April 2015); WHOLIS, WHO (searched 8 April 2015); LILACS, VHL (searched 9 April 2015).

SELECTION CRITERIA

We included individual- and cluster-randomised controlled trials (RCTs) and non-RCTs. We included controlled before-and-after (CBA) studies provided they had at least two intervention sites and two control sites. Also, we included interrupted time series (ITS) studies if there was a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention. We defined the intervention of a mobile clinic as a clinic vehicle with a healthcare provider (with or without a nurse) and a driver that visited areas on a regular basis. The participants were women (18 years or older) and children (under the age of 18 years) in low-, middle-, and high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of studies identified by the search strategy, extracted data from the included studies using a specially-designed data extraction form based on the Cochrane EPOC Group data collection checklist, and assessed full-text articles for eligibility. All authors performed analyses, 'Risk of bias' assessments, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Two cluster-RCTs met the inclusion criteria of this review. Both studies were conducted in the USA.One study tested whether offering onsite mobile mammography combined with health education was more effective at increasing breast cancer screening rates than offering health education only, including reminders to attend a static clinic for mammography. Women in the group offered mobile mammography and health education may be more likely to undergo mammography within three months of the intervention than those in the comparison group (55% versus 40%; odds ratio (OR) 1.83, 95% CI 1.22 to 2.74; low certainty evidence).A cost-effectiveness analysis of mammography at mobile versus static units found that the total cost per patient screened may be higher for mobile units than for static units. The incremental costs per patient screened for a mobile over a stationary unit were USD 61 and USD 45 for a mobile full digital unit and a mobile film unit respectively.The second study compared asthma outcomes for children aged two to six years who received asthma care from a mobile asthma clinic and children who received standard asthma care from the usual (static) primary provider. Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom-free days, urgent care use and caregiver-reported medication use compared to children who receive care from their usual primary care provider. All of the evidence was of low certainty.

AUTHORS' CONCLUSIONS

The paucity of evidence and the restricted range of contexts from which evidence is available make it difficult to draw conclusions on the impacts of mobile clinics on women's and children's health compared to static clinics. Further rigorous studies are needed in low-, middle-, and high-income countries to evaluate the impacts of mobile clinics on women's and children's health.