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Ferrel-Yui D, Candelaria D, Pettersen TR, Gallagher R, Shi W. Uptake and implementation of cardiac telerehabilitation: A systematic review of provider and system barriers and enablers. Int J Med Inform 2024; 184:105346. [PMID: 38281451 DOI: 10.1016/j.ijmedinf.2024.105346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/20/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Cardiac telerehabilitation has demonstrated effectiveness for patient health outcomes, but uptake and implementation into practice have been limited and variable. While patient-level influences on uptake have been identified, little is known about provider- and system-level factors. AIMS To identify provider and system barriers and enablers to uptake and implementation of cardiac telerehabilitation. METHODS A systematic review was conducted, including a search of six databases (MEDLINE, Embase, CINAHL, Scopus, Web of Science, and PsycINFO) from 2000 to March 2023. Two reviewers independently screened eligible articles. Study quality was evaluated according to study design by the Critical Appraisal Skills Programme (CASP) checklist for qualitative data, the Appraisal Tool for Cross-sectional Studies (AXIS), and the Mixed Methods Appraisal Tool (MMAT) for mixed methods. Data were analysed using narrative synthesis. RESULTS Twenty eligible studies (total 1674 participants) were included. Perceived provider-level barriers included that cardiac telerehabilitation is resource intensive, inferior to centre-based delivery, and lack of staff preparation. Whereas provider-level enablers were having access to resources, adequate staff preparation, positive staff beliefs regarding cardiac telerehabilitation and positive team dynamics. System-level barriers related to unaligned policy, healthcare system and insurance structures, technology issues, lack of plans for implementation, and inadequate resources. System-level enablers included cost-effectiveness, technology availability, reliability, and adaptability, and adequate program development, implementation planning and leadership support. CONCLUSIONS Barriers and enablers at both provider and system levels must be recognised and addressed at the local context to ensure better uptake of cardiac telerehabilitation programs.
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Affiliation(s)
- Daniel Ferrel-Yui
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia
| | - Dion Candelaria
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia; The University of Sydney, Charles Perkins Centre, D17, John Hopkins Drive, Camperdown, New South Wales, 2050, Australia.
| | - Trond Røed Pettersen
- Haukeland University Hospital, Department of Heart Disease, Box 1400, 5021, Bergen, Norway
| | - Robyn Gallagher
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia; The University of Sydney, Charles Perkins Centre, D17, John Hopkins Drive, Camperdown, New South Wales, 2050, Australia
| | - Wendan Shi
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia; The University of Sydney, Charles Perkins Centre, D17, John Hopkins Drive, Camperdown, New South Wales, 2050, Australia; St George Hospital, Centre for Research in Nursing and Health, Gray Street, Kogarah, New South Wales 2217, Australia
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Hammad Jafri S, Qureshi R, Ho TTT, Chung HE, Ngamdu KS, Medbury E, Ursillo J, Robitaille J, Wu WC. Home Based Cardiac Rehabilitation Participation Among Patients With Heart Failure. Curr Probl Cardiol 2023; 48:102013. [PMID: 37544630 DOI: 10.1016/j.cpcardiol.2023.102013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Patients with Heart Failure (HF) have significant morbidity and mortality. Home Based Cardiac Rehabilitation (HBCR) is a form of Cardiac Rehabilitation (CR) which has been proven beneficial for the patients with cardiovascular disease; However, cardiovascular outcomes in patients with HF who was referred to HBCR is not known. METHODS A retrospective study of 188 patients with HF (HFrEF or heart failure with reduced ejection fraction and HFpEF or heart failure with preserved ejection fraction) referred to HBCR at Veterans Affairs Medical Center (VAMC) from November 2017 to March 2020. We used the outcomes of patients with HF who attended HBCR and compared with the outcomes of patients who did not attend HBCR (Non-HBCR) from 3 months after starting HBCR till 12 months. Primary outcome was composite of all-cause mortality and cardiovascular hospitalizations. Secondary outcomes were all-cause mortality, cardiovascular hospitalizations and all-cause hospitalization, separately. We used cox proportional methods to calculate hazard ratios (HR) and 95% CI. We adjusted for imbalanced characteristics at baseline: age, smoking, PCI and CABG status. In subgroup analysis, we compared HFrEF and HFpEF patients who have completed HBCR and compared differences of their outcomes (weight, blood pressure, cholesterol, LDL, HDL, triglycerides, HbA1C, 6 Minutes walking test, duke score and PHQ-9) pre- and post-HBCR. RESULTS Mean age of the patients was 72 year and 98% were male. Out of 188 patients total, 11 patients were excluded for the main analysis as their outcomes occurred within first 90 days of HBCR enrollment, 105/177 (59%) patients attended HBCR while 72/177 (41%) patients did not attend HBCR and 93/105 (89%) patients have completed HBCR. The primary outcome occurred in 14 patients (13.3%) in the HBCR group and 19 patients (26.4%) in the Non-HBCR group (adjusted HR=0.32, CI 0.15-0.68). There was no difference in cardiovascular hospitalization among two groups, however patients in HBCR group have lower all-cause hospitalizations and all-cause death, separately. After HBCR completion, all outcomes (weight, blood pressure, cholesterol, LDL, HDL, triglycerides, HbA1C, 6 Minutes walking test, duke score and PHQ-9) have improved in both HFrEF and HFpEF group. CONCLUSION Patients with HF who have completed HBCR have a lower risk of all-cause mortality, all cause hospitalization separately and lower risk of combined all-cause mortality and cardiovascular hospitalization. Patients with HFrEF and HFpEF have equal degree of improvement after completing HBCR when compared with each other. HBCR is an ideal opportunity for patients with HF who cannot attend center-based CR and also for patients with HFpEF since CR is not approved for those patients.
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Affiliation(s)
- S Hammad Jafri
- Providence Veterans Affairs Medical Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI.
| | - Reema Qureshi
- Alpert Medical School, Brown University, Providence, RI
| | | | - Hojune E Chung
- Providence Veterans Affairs Medical Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
| | - Kyari Sumayin Ngamdu
- Providence Veterans Affairs Medical Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
| | | | | | | | - Wen-Chih Wu
- Providence Veterans Affairs Medical Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
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Matsuoka A, Mizutani T, Kaji Y, Yaguchi-Saito A, Odawara M, Saito J, Fujimori M, Uchitomi Y, Shimazu T. Barriers and facilitators to implementing geriatric assessment in daily oncology practice in Japan: A qualitative study using an implementation framework. J Geriatr Oncol 2023; 14:101625. [PMID: 37708801 DOI: 10.1016/j.jgo.2023.101625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/19/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Various guidelines recommend geriatric assessment (GA) for older adults with cancer, but it is not widely implemented in daily practice. This study uses an implementation framework to comprehensively and systematically identify multi-level barriers and facilitators to implementing GA in daily oncology practice. MATERIALS AND METHODS We conducted 16 semi-structured interviews with healthcare providers in 10 designated cancer hospitals in Japan, using purposive and convenience sampling. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of interview data following a deductive content analysis approach with consensual qualitative research methods. After coding the interview data, ratings were assigned to each CFIR construct for each case, reflecting the valence and strength of each construct relative to implementation success. Then, those constructs that appeared to distinguish between high-implementation hospitals (HI) where GA is routinely performed in daily practice and low-implementation hospitals (LI) where GA is performed only for research purposes or not at all were explored. RESULTS Of the 24 CFIR constructs assessed in the interviews, 15 strongly distinguished between HI and LI. In HI, GA was self-administered (Adaptability), or administered via a mobile app with interpretation (Design Quality and Packaging). In HI, healthcare providers were strongly aware of the urgent need to change practice for older adults (Tension for Change) and recognized that GA was compatible with existing workflow as part of their jobs (Compatibility), whereas in LI, they did not realize the need to change practice, and dismissed GA as an extra burden on their heavy workload. In HI, usefulness of GA was widely recognized by healthcare providers (Knowledge & Beliefs about the Intervention), GA had a high priority (Relative Priority) and had strong support from hospital directors, managers, and nursing chiefs (Leadership Engagement), and multiple stakeholders were successfully engaged, including nurses (Key Stakeholders), peer doctors (Opinion Leaders), and those who drive implementation of GA (Champions). DISCUSSION These findings suggest that successful implementation of GA should focus on not only individual beliefs about the usefulness of GA and the complexity of GA itself, but also organizational factors related to hospitals and the engagement of multiple stakeholders.
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Affiliation(s)
- Ayumu Matsuoka
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Tomonori Mizutani
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yuki Kaji
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Akiko Yaguchi-Saito
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan; Faculty of Human Sciences, Tokiwa University, Ibaraki, Japan
| | - Miyuki Odawara
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Junko Saito
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Maiko Fujimori
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Yosuke Uchitomi
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Taichi Shimazu
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan.
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Beatty AL, Beckie TM, Dodson J, Goldstein CM, Hughes JW, Kraus WE, Martin SS, Olson TP, Pack QR, Stolp H, Thomas RJ, Wu WC, Franklin BA. A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities. Circulation 2023; 147:254-266. [PMID: 36649394 PMCID: PMC9988237 DOI: 10.1161/circulationaha.122.061046] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.
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Affiliation(s)
- Alexis L Beatty
- Department of Epidemiology and Biostatistics (A.L.B.), University of California, San Francisco.,Department of Medicine, Division of Cardiology (A.L.B.), University of California, San Francisco
| | - Theresa M Beckie
- College of Nursing (T.M.B.), University of South Florida, Tampa.,College of Medicine, Division of Cardiovascular Sciences (T.M.B.), University of South Florida, Tampa
| | - John Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine (J.D.), New York University School of Medicine, New York.,Department of Population Health (J.D.), New York University School of Medicine, New York
| | - Carly M Goldstein
- The Weight Control and Diabetes Research Center, the Miriam Hospital, Providence, RI (C.M.G.).,Department of Psychiatry and Human Behavior, The Warren Alpert Medical School (C.M.G.), Brown University, Providence, RI
| | - Joel W Hughes
- Department of Psychological Sciences, Kent State University, OH (J.W.H.)
| | - William E Kraus
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC (W.E.K.)
| | - Seth S Martin
- Department of Medicine, Division of Cardiology, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (S.S.M.)
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic, Rochester, MN (T.P.O., R.J.T.)
| | - Quinn R Pack
- Department of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield (Q.R.P.)
| | - Haley Stolp
- ASRT, Inc, Atlanta, GA (H.S.).,Centers for Disease Control and Prevention, Atlanta, GA (H.S.)
| | - Randal J Thomas
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic, Rochester, MN (T.P.O., R.J.T.)
| | - Wen-Chih Wu
- Lifespan Cardiovascular Institute (W.-C.W.), Brown University, Providence, RI.,Division of Cardiology, Providence VA Medical Center, RI (W.-C.W.)
| | - Barry A Franklin
- William Beaumont Hospital, Royal Oak, MI (B.A.F.).,Oakland University William Beaumont School of Medicine, Rochester, MI (B.A.F.)
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Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2022; 42:338-346. [PMID: 35420563 DOI: 10.1097/hcr.0000000000000688] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Cardiac rehabilitation (CR) is evolving to include both in-person and virtual delivery. Our objective was to compare, in CR patients, the association of in-person, hybrid, and virtual CR with change in performance on the 6-min walk test (6MWT) between enrollment and completion. METHODS Patients enrolled in CR between October 22, 2019, and May 10, 2021, were categorized into in-person, hybrid, or virtual groups by number of in-person and virtual visits. All patients received individualized exercise training and health behavior counseling. Cardiac rehabilitation was delivered to patients in the hybrid and virtual cohorts using synchronous video exercise and/or asynchronous telephone visits. Measurements at CR enrollment and completion included the 6MWT, blood pressure (BP), depression, anxiety, waist-to-hip ratio, and cardiac self-efficacy. RESULTS Of 187 CR patients, 37/97 (38.1%) were in-person patients and 58/90 (64.4%) were hybrid/virtual patients ( P = .001). Compared to in-person (51.5 ± 59.4 m) improvement in the 6MWT was similar in hybrid (63.4 ± 55.6; P = .46) and virtual (63.2 ± 59.6; P = .55) compared with in-person (51.5 ± 59.4). Hybrid and virtual patients experienced similar improvements in BP control and anxiety. Virtual patients experienced less improvement in depression symptoms. There were no statistically significant changes in waist-to-hip ratio or cardiac self-efficacy. Qualitative themes included the adaptability of virtual CR, importance of relationships between patients and CR staff, and need for training and organizational adjustments to adopt virtual CR. CONCLUSIONS Hybrid and virtual CR were associated with similar improvements in functional capacity to in-person. Virtual and hybrid CR have the potential to expand availability without compromising outcomes.
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Keteyian SJ, Jackson SL, Chang A, Brawner CA, Wall HK, Forman DE, Sukul D, Ritchey MD, Sperling LS. Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE. J Cardiopulm Rehabil Prev 2022; 42:235-245. [PMID: 35135961 PMCID: PMC10865223 DOI: 10.1097/hcr.0000000000000675] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence. METHODS We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type. RESULTS In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States. CONCLUSIONS The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.
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Affiliation(s)
- Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | | | - Anping Chang
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Clinton A. Brawner
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | | | - Daniel E. Forman
- Divisions of Geriatrics and Cardiology, University of Pittsburgh and the VA Pittsburgh GRECC, Pittsburgh, PA
| | - Devraj Sukul
- Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, MI
| | | | - Laurence S. Sperling
- Centers for Disease Control and Prevention, Atlanta, GA
- Emory University School of Medicine, Center for Heart Disease Prevention, Atlanta, GA
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Drwal KR, Hurst D, Wakefield BJ. Effectiveness of a Home-Based Pulmonary Rehabilitation Program in Veterans. Telemed J E Health 2022. [PMID: 35584256 DOI: 10.1089/tmj.2022.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: This study examined the effectiveness and safety of a home-based pulmonary rehabilitation (HBPR) program in Veterans. Methods: Patients were evaluated from five Veteran Affairs facilities that enrolled in the 12-week program. Pre- to postchanges were completed on clinical outcomes using paired t-tests and the Wilcoxon signed rank sum test. Descriptive statistics were used for patient demographics, emergency room visits, and hospitalizations. Results: Two hundred eighty-five patients with a mean age of 69.6 ± 8.3 years enrolled in the HBPR program from October 2018 to March 2020. There was a 62% (n = 176) completion rate of both pre- and post assessments. Significant improvements were detected after completion of the HBPR program in dyspnea (modified Medical Research Council: 3.1 ± 1.1 vs. 1.9 ± 1.1; p < 0.0001); exercise capacity (six-minute walk distance: 263.1 m ± 96.6 m vs. 311.0 m ± 103.6 m; p < 0.0001; Duke Activity Status Index: 13.8 ± 9.6 vs. 20.0 ± 12.7; p < 0.0001; self-reported steps per day: 1514.5 ± 1360.4 vs. 3033.8 ± 2716.2; p < 0.0001); depression (patient health questionnaire-9: 8.3 ± 5.7 vs. 6.4 ± 5.1); nutrition habits (rate your plate, heart: 45.3 ± 9.0 vs. 48.9 ± 9.2; p < 0.0001); multicomponent assessment tools (BODE Index: 5.1 ± 2.5 vs. 3.4 ± 2.4; p < 0.0001), GOLD ABCD Assessment: p < 0.0009); and quality of life (chronic obstructive pulmonary disease assessment test: 25.4 ± 7.7 vs. 18.7 ± 8.5; p < 0.0001). No adverse events were reported due to participation in HBPR. Conclusions: The HBPR program is a safe and effective model and provides an additional option to address the gap in pulmonary rehabilitation access and utilization in the Veterans Affairs.
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Affiliation(s)
- Kariann R Drwal
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Delanie Hurst
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Bonnie J Wakefield
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
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Keteyian SJ, Ades PA, Beatty AL, Gavic-Ott A, Hines S, Lui K, Schopfer DW, Thomas RJ, Sperling LS. A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE. J Cardiopulm Rehabil Prev 2022; 42:1-9. [PMID: 34433760 DOI: 10.1097/hcr.0000000000000634] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR. REVIEW METHODS To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations. SUMMARY A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.
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Affiliation(s)
- Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan (Dr Keteyian); University of Vermont Larner College of Medicine, Burlington (Dr Ades); Department of Epidemiology and Biostatistics and Division of Cardiology, University of California San Francisco, San Francisco (Dr Beatty), Northwest Community Healthcare, Arlington Heights, Illinois (Ms Gavic-Ott); Abt Associates, Rockville, Maryland (Dr Hines); Advocate for Action, LLC, Gainesville, GA (Ms Lui); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland (Dr Schopfer); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (Dr Thomas); and Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia (Dr Sperling)
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Harzand A, Weidman AC, Rayl KR, Adesanya A, Holmstrand E, Fitzpatrick N, Vathsangam H, Murali S. Retrospective Analysis and Forecasted Economic Impact of a Virtual Cardiac Rehabilitation Program in a Third-Party Payer Environment. Front Digit Health 2021; 3:678009. [PMID: 34901923 PMCID: PMC8653769 DOI: 10.3389/fdgth.2021.678009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Participation in cardiac rehabilitation (CR) is recommended for all patients with coronary artery disease (CAD) following hospitalization for acute coronary syndrome or stenting. Yet, few patients participate due to the inconvenience and high cost of attending a facility-based program, factors which have been magnified during the ongoing COVID pandemic. Based on a retrospective analysis of CR utilization and cost in a third-party payer environment, we forecasted the potential clinical and economic benefits of delivering a home-based, virtual CR program, with the goal of guiding future implementation efforts to expand CR access. Methods: We performed a retrospective cohort study using insurance claims data from a large, third-party payer in the state of Pennsylvania. Primary diagnostic and procedural codes were used to identify patients admitted for CAD between October 1, 2016, and September 30, 2018. Rates of enrollment in facility-based CR, as well as all-cause and cardiovascular hospital readmission and associated costs, were calculated during the 12-months following discharge. Results: Only 37% of the 7,264 identified eligible insured patients enrolled in a facility-based CR program within 12 months, incurring a mean delivery cost of $2,922 per participating patient. The 12-month all-cause readmission rate among these patients was 24%, compared to 31% among patients who did not participate in CR. Furthermore, among those readmitted, CR patients were readmitted less frequently than non-CR patients within this time period. The average per-patient cost from hospital readmissions was $30,814 per annum. Based on these trends, we forecasted that adoption of virtual CR among patients who previously declined CR would result in an annual cost savings between $1 and $9 million in the third-party healthcare system from a combination of increased overall CR enrollment and fewer hospital readmissions among new HBCR participants. Conclusions: Among insured patients eligible for CR in a third-party payer environment, implementation of a home-based virtual CR program is forecasted to yield significant cost savings through a combination of increased CR participation and a consequent reduction in downstream healthcare utilization.
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Affiliation(s)
- Arash Harzand
- Emory University School of Medicine, Atlanta, GA, United States
| | - Aaron C Weidman
- VITAL Innovation, Highmark Health, Pittsburgh, PA, United States
| | - Kenneth R Rayl
- VITAL Innovation, Highmark Health, Pittsburgh, PA, United States
| | | | | | | | | | - Srinivas Murali
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, United States
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Jafri SH, Imran TF, Medbury E, Ursillo J, Ahmad K, Imran H, Drwal K, Wu WC. Cardiovascular Outcomes of Patients Referred to Home Based Cardiac Rehabilitation. Heart Lung 2021; 52:1-7. [PMID: 34801771 PMCID: PMC8600943 DOI: 10.1016/j.hrtlng.2021.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/19/2022]
Abstract
Background Home Based Cardiac Rehabilitation (HBCR) has been considered a reasonable alternative to Center-based Cardiac Rehabilitation (CBCR) in patients with established cardiovascular disease, especially in the midst of COVID-19 pandemic. However, the long-term cardiovascular outcomes of patients referred to HBCR remains unknown. Objectives To compare outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR). Methods We performed a retrospective study of 269 patients referred to HBCR at Providence Veterans Affairs Medical Center (PVAMC). From November 2017 to March 2020, 427 patients were eligible and referred for Cardiac Rehabilitation (CR) at PVAMC. Of total patients, 158 patients were referred to CBCR and 269 patients to HBCR based on patient and/or clinician preference. The analysis of outcomes was focused on HBCR patients. We compared outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR) from 3 to 12 months of the referral date. HBCR consisted of face-to-face entry exam with exercise prescription, weekly phone calls for education and exercise monitoring, with adjustments where applicable, for 12-weeks and an exit exam. Primary outcome was composite of all-cause mortality and hospitalizations. Secondary outcomes were all-cause hospitalization, all-cause mortality and cardiovascular hospitalizations, separately. We used cox proportional methods to calculate hazard ratios (HR) and 95% CI. We adjusted for imbalanced characteristics at baseline: smoking, left ventricular ejection fraction and CABG status. Results A total of 269 patients (mean age: 72, 98% Male) were referred to HBCR, however, only 157 (58%) patients attended HBCR. The primary outcome occurred in 30 patients (19.1%) in the HBCR group and 30 patients (30%) in the Non-HBCR group (adjusted HR=0.56, CI 0.33-0.95, P=.03). All-cause mortality occurred in 6.4% of patients in the HBCR group and 13% patients in the Non-HBCR group 3 to 12 months after HBCR referral (adjusted HR=0.43, CI 0.18-1.0, P= .05). There was no difference in cardiovascular hospitalizations (HBCR: 5.7% vs Non-HBCR: 10%, adjusted HR 0.57, CI 0.22-1.4, P= .23) or all cause hospitalizations at 3 to 12 months between the groups (HBCR: 12.7% vs Non-HBCR: 21%, adjusted HR 0.53, CI 0.28-1.01, P= .05). Conclusion Completion of HBCR among referred patients was associated with a lower risk of the combined all-cause mortality and all-cause hospitalizations up to 12 months. Based on the outcomes, HBCR is a reasonable option that can improve access to CR for patients who are not candidates of or cannot attend CBCR. Randomized-controlled studies are needed to confirm these findings.
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Affiliation(s)
- S Hammad Jafri
- Providence Veterans Affairs Medical Center, Providence, RI; Miriam Hospital Cardiac Rehabilitation Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
| | - Tasnim F Imran
- Providence Veterans Affairs Medical Center, Providence, RI; Miriam Hospital Cardiac Rehabilitation Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
| | | | | | - Khansa Ahmad
- Providence Veterans Affairs Medical Center, Providence, RI; Miriam Hospital Cardiac Rehabilitation Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
| | - Hafiz Imran
- Providence Veterans Affairs Medical Center, Providence, RI; Miriam Hospital Cardiac Rehabilitation Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI
| | - Kariann Drwal
- Iowa City VA Healthcare System, Veterans Rural Health Resource Center-Central Region, VA Office of Rural Health, Iowa City, Iowa
| | - Wen-Chih Wu
- Providence Veterans Affairs Medical Center, Providence, RI; Miriam Hospital Cardiac Rehabilitation Center, Providence, RI; Alpert Medical School, Brown University, Providence, RI.
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11
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Beatty AL, Brown TM, Corbett M, Diersing D, Keteyian SJ, Mola A, Stolp H, Wall HK, Sperling LS. Million Hearts Cardiac Rehabilitation Think Tank: Accelerating New Care Models. Circ Cardiovasc Qual Outcomes 2021; 14:e008215. [PMID: 34587751 PMCID: PMC10088365 DOI: 10.1161/circoutcomes.121.008215] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This article describes the October 2020 proceedings of the Million Hearts Cardiac Rehabilitation Think Tank: Accelerating New Care Models, convened with representatives from professional organizations, cardiac rehabilitation (CR) programs, academic institutions, federal agencies, payers, and patient representative groups. As CR delivery evolves, terminology is evolving to reflect not where activities occur (eg, center, home) but how CR is delivered: in-person synchronous, synchronous with real-time audiovisual communication (virtual), or asynchronous (remote). Patients and CR staff may interact through ≥1 delivery modes. Though new models may change how CR is delivered and who can access CR, new models should not change what is delivered-a multidisciplinary program addressing CR core components. During the coronavirus disease 2019 (COVID-19) public health emergency, Medicare issued waivers to allow virtual CR; it is unclear whether these waivers will become permanent policy post-public health emergency. Given CR underuse and disparities in delivery, new models must equitably address patient and health system contributors to disparities. Strategies for implementing new CR care models address safety, exercise prescription, monitoring, and education. The available evidence supports the efficacy and safety of new CR care models. Still, additional research should study diverse populations, impact on patient-centered outcomes, effect on long-term outcomes and health care utilization, and implementation in diverse settings. CR is evolving to include in-person synchronous, virtual, and remote modes of delivery; there is significant enthusiasm for implementing new care models and learning how new care models can broaden access to CR, improve patient outcomes, and address health inequities.
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Affiliation(s)
- Alexis L Beatty
- Department of Epidemiology and Biostatistics, Medicine, UCSF, San Francisco, CA (A.L.B.)
| | - Todd M Brown
- Department of Medicine, University of Alabama, Birmingham (T.M.B.)
| | - Mollie Corbett
- American Association of Cardiovascular and Pulmonary Rehabilitation, Chicago, IL (M.C.)
| | - Dean Diersing
- Physical Medicine and Rehabilitation, UMC Health System, Lubbock, TX (D.D.)
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Medical Group, Detroit, MI (S.J.K.)
| | - Ana Mola
- Department of Rehabilitation Medicine, NYU Langone Health, New York, NY (A.M.)
| | - Haley Stolp
- IHRC, Inc, Atlanta, GA (H.S.).,CDC, Atlanta, GA (H.S., H.K.W., L.S.S.)
| | | | - Laurence S Sperling
- CDC, Atlanta, GA (H.S., H.K.W., L.S.S.).,Emory Center for Heart Disease Prevention, Atlanta, GA (L.S.S.)
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12
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Drwal KR, Wakefield BJ, Forman DE, Wu WC, Haraldsson B, El Accaoui RN. Home-Based Cardiac Rehabilitation: EXPERIENCE FROM THE VETERANS AFFAIRS. J Cardiopulm Rehabil Prev 2021; 41:93-99. [PMID: 33647921 DOI: 10.1097/hcr.0000000000000594] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The conceptual utility of home-based cardiac rehabilitation (HBCR) is widely acknowledged. However, data substantiating its effectiveness and safety are limited. This study evaluated effectiveness and safety of the Veterans Affairs (VA) national HBCR program. METHODS Veterans completed a 12-wk HBCR program over 18 mo at 25 geographically dispersed VA hospitals. Pre- to post-changes were compared using paired t tests. Patient satisfaction and adverse events were also summarized descriptively. RESULTS Of the 923 Veterans with a mean age of 67.3 ± 10.6 yr enrolled in the HBCR program, 572 (62%) completed it. Findings included significant improvements in exercise capacity (6-min walk test distance: 355 vs 398 m; P < .05; Duke Activity Status Index: 27.1 vs 33.5; P < .05; self-reported steps/d: 3150 vs 4166; P < .05); depression measured by Patient Health Questionnaire (6.4 vs 4.9; P < .0001); cardiac self-efficacy (33.1 vs 39.2; P < .0001); body mass index (31.5 vs 31.1 kg/m2; P = .0001); and eating habits measured by Rate Your Plate, Heart (47.2 vs 51.1; P < .05). No safety issues were related to HBCR participation. Participants were highly satisfied. CONCLUSIONS The VA HBCR program demonstrates strong evidence of effectiveness and safety to a wide range of patients, including those with high clinical complexity and risk. HBCR provides an adjunct to site-based programs and access to cardiac rehabilitation. Additional research is needed to assess long-term effects, cost-effectiveness, and sustainability of the model.
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Affiliation(s)
- Kariann R Drwal
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City (Ms Drwal, Drs Wakefield and El Accaoui, and Mr Haraldsson); The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City (Ms Drwal, Dr Wakefield, and Mr Haraldsson); Sinclair School of Nursing, University of Missouri, Columbia (Dr Wakefield); VA Pittsburgh Healthcare System, Pittsburgh, Department of Medicine, University of Pittsburgh, Pittsburgh, and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Forman); Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, Cardiovascular Rehab Center, Miriam Hospital, Providence, and Alpert Medical School and School of Public Health, Brown University, Providence, Rhode Island (Dr Wu); and Division of Cardiovascular Medicine, University of Iowa, Iowa City (Dr El Accaoui)
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13
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Drwal KR, Forman DE, Wakefield BJ, El Accaoui RN. Cardiac Rehabilitation During COVID-19 Pandemic: Highlighting the Value of Home-Based Programs. Telemed J E Health 2020; 26:1322-1324. [PMID: 32552412 DOI: 10.1089/tmj.2020.0213] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cardiac rehabilitation (CR) is a class I treatment for cardiovascular disease, however, underutilization of these services remains. Home-based CR (HBCR) models have been implemented as a potential solution to addressing access barriers to CR services. Home-based models have been shown to be effective, however, there continues to be large variation of protocols and minimal evidence of effectiveness in higher risk populations. In addition, lack of reimbursement models has discouraged the widespread adoption of HBCR. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has been present due to decreased availability of on-site services. The COVID-19 pandemic presents a time to highlight the value and experiences of home-based models as clinicians search for ways to continue to provide care. Continued review and standardization of HBCR models are essential to provide care for a wider range of patients and circumstances.
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Affiliation(s)
- Kariann R Drwal
- VA Office of Rural Health, Veterans Rural Health Resource Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,The Comprehensive Access and Delivery Research and Evaluation Center Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Daniel E Forman
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bonnie J Wakefield
- VA Office of Rural Health, Veterans Rural Health Resource Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,The Comprehensive Access and Delivery Research and Evaluation Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
| | - Ramzi N El Accaoui
- VA Office of Rural Health, Veterans Rural Health Resource Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa, USA
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