In the modern era of percutaneous coronary intervention: Is cardiac rehabilitation engagement purely a patient or a service level decision?

Knowledge and Prevalence of Risk Factors for Coronary Artery Disease in Patients after Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

Background: Percutaneous coronary intervention (PCI) is associated with a short hospital stay and fast recovery. However, it might be related to insufficient implementation of lifestyle changes after the procedure. Conversely, coronary artery bypass grafting (CABG) is a highly invasive technique that requires a prolonged hospital stay and long rehabilitation with more opportunities for education. This study aimed to evaluate the impact of CABG on adherence to lifestyle modifications and knowledge about coronary artery disease (CAD) in comparison with PCI. We also evaluated the level of education and tried to define groups of patients that might require targeted education. Methods: Data was collected using a self-designed 56-item questionnaire. Questions assessed the knowledge of CAD risk factors and the level of their control. Results: The study group consisted of 155 consecutive patients admitted to the Cardiology Department. Patients with a history of PCI (68%) (at least 8 weeks before) were included in the prior-PCI group, and patients with previous surgical revascularization (also at least 8 weeks before) were assigned to the prior-CABG group (32%). The knowledge score was higher in the prior-CABG group. The median (IQR) results in the prior-PCI vs. prior-CABG group were, respectively: 20 (12–24) vs. 22 (19–25) [points, per 31 max.]; p = 0.01. Similar results were obtained in the level of risk control (prior-PCI vs. prior-CABG, respectively: 6 (4–7) vs. 7 (6–8) [points, per 15 max.]; p = 0.002). Conclusions: The method of treatment of CAD might impact the implementation of lifestyle modifications after the procedure. More effort is required to improve secondary prevention, especially in PCI patients.

To what extent are comorbidity profiles associated with referral and uptake to cardiac rehabilitation

INTRODUCTION

Given the high proportion of comorbidities in patients with coronary heart disease (CHD) and low participation rates in cardiac rehabilitation (CR), a better understanding of how comorbidity interacts with the CR pathway is needed. We investigated associations between comorbidity profiles and referral and uptake in everyday clinical CR across UK.

METHOD

Patients (≥18 years) diagnosed with a CHD between 1st of January 2014 and 31st of December 2019 registered in the National Audit of Cardiac Rehabilitation (NACR) database were eligible. Self-reported comorbidities from 15 disease categories were conceptualized into similar or dissimilar based on overall related pathophysiologic profile and care management as CHD. Regression models were conducted with four comorbidity profiles; similar conditions, dissimilar conditions, similar and dissimilar and no comorbidity.

RESULTS

399,348 (61.8%) patients were eligible for referral from 198 programmes. The majority were males (70%), mean age of 67 (±12 SD) years. A non-significant association was found between comorbidity profiles and referral. Odds ratios (OR) for CR uptake were higher in patients with dissimilar (OR = 1.38 (95% CI 1.26-1.54)) and dissimilar and similar comorbidities profiles (OR = 1.35 (95% CI 1.21-1.43)) compared to patients with similar comorbidities. No significant differences in uptake were found between patients with similar comorbidities and those without comorbidities (OR = 0.985 (95% CI 0.854-1.125).

CONCLUSION

Using routine practice data, comorbidity profiles were not significantly associated with CR referral suggesting equality in referral. Dissimilar comorbidity profiles were associated with uptake. To increase the likelihood of starting CR, services should consider developing tailored participation strategies that include comorbidity profiles.

The Impact of Socio-environmental Barriers on the Process of Engagement in Cardiac Rehabilitation Programs

Cardiac rehabilitation (CR) is a multi-disciplinary intervention designed to stabilise, slow, or reverse CVD, restore health following a cardiac event and facilitate the prevention of further events. The Model of Therapeutic Engagement (MTE) is a comprehensive conceptual model for explaining the process of engagement in rehabilitation. Of concern is that the role of socio-environmental factors is absent from explaining individual engagement in the MTE. There is also a lack of prospective studies investigating the impact of socio-environmental barriers on engagement in CR programs over time. This study aimed to expand the MTE, by illuminating the role of socio-environmental barriers in a three-stage process of engagement in CR programs. A prospective study was conducted, with 217 individuals recruited from the Cardiology Ward in the Gold Coast University Hospital (GCUH) and the Robina Cardiac Rehabilitation Centre. The collected data were examined using a structural equation model that added socio-environmental factors into the MTE, using multi-group analyses. In this study, we found that socio-environmental factors were not associated with intention to engage in the CR program, but were related to actual attendance and maintenance of participation in CR programs. Knowing how these socio-environmental barriers affect the process of engagement at different stages may help to tailor more accessible CR programs for the population.

Quantifying the impact of delayed delivery of cardiac rehabilitation on patients' health

Background

Despite its role as an effective intervention to improve the long-term health of patients with cardiovascular disease and existence of national guidelines on timeliness, many health services still fail to offer cardiac rehabilitation in a timely manner after referral. The impact of this failure on patient health and the additional burden on healthcare providers in an English setting is quantified in this article.

Methods

Two logistic regressions are conducted, using the British Heart Foundation National Audit of Cardiac Rehabilitation dataset, to estimate the impact of delayed cardiac rehabilitation initiation on the level of uptake and completion. The results of these regressions are applied to a decision model to estimate the long-term implications of these factors on patient health and National Health Service expenditure.

Results

We demonstrate that the failure of 43.6% of patients in England to start cardiac rehabilitation within the recommended timeframe results in a 15.3% reduction in uptake, and 7.4% in completion. These combine to cause an average lifetime loss of 0.08 years of life expectancy per person. Scaled up to an annual cohort this implies 10,753 patients not taking up cardiac rehabilitation due to the delay, equating to a loss of 3936 years of life expectancy. We estimate that an additional £12.3 million of National Health Service funding could be invested to alleviate the current delay.

Conclusions

The current delay in many patients starting cardiac rehabilitation is causing quantifiable and avoidable harm to their long-term health; policy and research must now look at both supply and demand solutions in tackling this issue.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.

Objectives

To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.

Methods

For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).

Results

A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.

Future work

Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Improving cardiac rehabilitation uptake: Potential health gains by socioeconomic status

BACKGROUND

Globally, cardiac rehabilitation (CR) is recommended as soon as possible after admission from an acute myocardial infarction (MI) or revascularisation. However, uptake is consistently poor internationally, ranging from 10% to 60%. The low level of uptake is compounded by variation across different socioeconomic groups. Policy recommendations continue to focus on increasing uptake and addressing inequalities in participation; however, to date, there is a paucity of economic evidence evaluating higher CR participation rates and their relevance to socioeconomic inequality.

METHODS

This study constructed a de-novo cost-effectiveness model of CR, utilising the results from the latest Cochrane review and national CR audit data. We explore the role of socioeconomic status by incorporating key deprivation parameters and determine the population health gains associated with achieving an uptake target of 65%.

RESULTS

We find that the low cost of CR and the potential for reductions in subsequent MI and revascularisation rates combine to make it a highly cost-effective intervention. While CR is less cost-effective for more deprived groups, the lower level of uptake in these groups makes the potential health gains, from achieving the target, greater. Using England as a model, we estimate the expenditure that could be justified while maintaining the cost-effectiveness of CR at £68.4 m per year.

CONCLUSIONS

Increasing CR uptake is cost-effective and can also be implemented to reduce known socioeconomic inequalities. Using an estimation of potential population health gains and justifiable expenditure, we have produced tools with which policymakers and commissioners can encourage greater utilisation of CR services.

Determinants of walking fitness in patients with heart failure attending cardiac rehabilitation

Introduction

Patients with heart failure (HF) attending cardiac rehabilitation (CR) benefit in terms of improved quality of life, physical fitness and reduced hospital admissions. Too few patients with HF attend CR and little data exist on the characteristics of those who do especially in respect of physical fitness. This study evaluates the extent by which clinical and demographic factors determine walking fitness in patients with a primary diagnosis of HF.

Methods

Clinical data from the British Heart Foundation National Audit of Cardiac Rehabilitation identified 1519 patients with HF who completed an incremental shuttle walk test (ISWT). Stepwise regression accounting for age, gender and multiple potential confounders assessed their contribution to total walking distance.

Results

Mean age was 64.5 (SD 12.70) years with a range of ISWT distances across gender and associated comorbidities from 215 to 282 m. Walking distance reduced by 4.9 m for each year increase in age above mean age (p<0.001). After accounting for confounders, females walked 42.1 m less than males (p≤ 0.001). Pulmonary disease and the existence of depression was associated with a 39.3 and 52.2 m reduction in walking distance, respectively. Body mass index >30 was associated with 28.5 m reduction in walking distance (p<0.001). HF severity failed to improve the regression model fit or achieve significance in the analysis.

Conclusions

Age, gender and the presence of pulmonary disease or depression were highly significant factors in predicting walking fitness in patients with HF. The study also produced a set of reference values based on these four factors to aid the interpretation of walking fitness in patients with HF.

Factors associated with acute depressive symptoms in patients with comorbid depression attending cardiac rehabilitation

Background

The literature suggests that comorbid depression, defined in this paper as a history of depression prior to a cardiovascular event, has an impact on later onset depression as well as constituting increased risk of mortality and adverse cardiac events. However, which factors are associated with depression, specifically in patients with comorbid depression, is unclear. Therefore, this paper investigates the factors associated with depression in patients with comorbid depression attending cardiac rehabilitation (CR).

Methods

This observational study used routinely collected data from the British Heart Foundation National Audit of Cardiac Rehabilitation for the time period between April 2012 and March 2017. CR participants with comorbid depression were selected as the study population. An independent t-test and chi-square test were used to compare the association between acute depression symptoms and baseline characteristics in this population.

Results

A total of 2715 CR patients with comorbid depression were analysed. Characteristics associated with acute depressive symptoms in patients with comorbid depression were found to be: young age (MD: 2.71, 95% CI 1.91, 3.50), increased number of comorbidities (MD: -0.50, 95% CI -0.66, − 0.34), increased weight (MD: -1.94, 95% CI -3.35, − 0.52), high BMI (MD: -1.94, 95% CI -3.35, − 0.52), HADS anxiety (MD: -5.17, 95% CI -5.47, − 4.87), comorbid anxiety (52.4%, p <  0.001), physical inactivity (150 min moderate physical activity a week and 75 min vigorous exercise a week; 27.5%, p <  0.001; 5.6%, p <  0.001 respectively), smoking (12.7%, p <  0.001), and being less likely to be partnered (63.6%, p <  0.001).

Conclusion

The study demonstrated the association between a variety of clinical and socio-demographic factors and depression. The findings of the research indicated that, at CR baseline assessment, caution must be taken with patients with comorbid depression, specifically those with higher level depressive symptoms at the start of rehabilitation. Furthermore, their multi-comorbid condition must also be taken into account. Patients with higher depression symptoms and comorbid depression scored five points higher on the HADS anxiety scale in comparison to patients with lower level depression symptoms at the start of CR, which demonstrated that anxiety and depression are interrelated and present together.

Does the mode of delivery in routine cardiac rehabilitation have an association with cardiovascular risk factor outcomes?

Aims

Cardiac rehabilitation is one of the most cost-effective interventions for patients with cardiovascular disease. Worldwide supervised group-based cardiac rehabilitation is the dominant mode of delivery followed by facilitated self-managed (FSM), which is emerging as part of a cardiac rehabilitation menu. Modern research evidence, using trials and well-resourced interventions, suggests FSM is comparable to supervised rehabilitation in its outcomes for patients; however, this is yet to be established using routine clinical practice data.

Methods

Including 81,626 patients from routine clinical data in the National Audit of Cardiac Rehabilitation, this observational study investigated whether mode of delivery, supervised or FSM, was associated with similar cardiac rehabilitation outcomes. Hierarchical regression models included patient and service covariates such as age, gender, cardiac rehabilitation duration and programme staff type.

Results

The results showed 85% of the population received supervised cardiac rehabilitation. The FSM group were significantly older, female and predominantly in lower socioeconomic groups. The results showed that all patients on average benefit from cardiac rehabilitation, independently of mode of delivery, across all risk factors. Additional benefit of 13% and 11.4% increased likelihood of achieving the target state for physical activity and body mass index respectively when using FSM approaches.

Conclusion

This is the first study to investigate traditional cardiovascular risk factors with cardiac rehabilitation mode of delivery using routine clinical data. Both modes of delivery were associated with comparable statistically significant positive outcomes. Despite having equivalent outcomes, FSM cardiac rehabilitation continues to be underutilised, with less than 20% of patients receiving this mode of delivery in the UK.

Gender differences in the factors predicting initial engagement at cardiac rehabilitation

Objective

To determine whether there are gender differences in the factors that predict attendance at the initial cardiac rehabilitation baseline assessment (CR engagement) after referral.

Methods

Using data from the National Audit of Cardiac Rehabilitation, we analysed data on 95 638 patients referred to CR following a cardiovascular diagnosis/treatment between 2013 and 2016. Eighteen factors that have been shown in previous research to be important predictors of CR participation were investigated and grouped into four categories: sociodemographic factors, cardiac risk factors, patient medical status and service-level factors. Logistic binary regression models were built for male patients and female patients, assessing the likelihood for CR engagement. Each included predictors such as age, number of comorbidities and social deprivation score.

Results

There were no important differences in the factors that predict the likelihood of CR engagement in men and women. Seven factors associated with a reduced probability of CR engagement, and eight factors associated with increased probability, were identified. Fourteen of the 15 factors identified as predicting the likelihood for engagement/non-engagement were the same for both men and women. Increasing age, being South Asian or non-white ethnicity (other than Black) and being single were all associated with a reduced likelihood of attending an initial CR baseline assessment in both men and women. Male patients with diabetes were 11% less likely to engage with CR; however, there was no significant association in women. Results showed that the overwhelmingly important determinant of CR engagement observed in both men and women was receiving an invitation to attend an assessment session (OR 4.223 men/4.033women; p<0.05).

Conclusions

Consideration of gender differences in predictors of CR uptake should probably be more nuanced and informed by the stage of the patient care pathway.