Broadening the Reach of Cardiac Rehabilitation to Rural and Remote Australia

The multiple linear regression model: to predict peak metabolic equivalents and peak oxygen pulse in patients with coronary artery disease after percutaneous coronary intervention

Background

The clinical indicators of patients with coronary artery disease (CAD) often affect their prognosis. Cardiopulmonary Exercise Testing (CPET) can effectively evaluate the cardiopulmonary ability of CAD patients. The objective of this research was to explore the correlation between some clinical indicators and peak metabolic equivalents (peak METs) and peak oxygen pulse (O2Ppeak) in patients with CAD. Regression equations were further constructed for indicators with significant correlations to predict peak METs and O2Ppeak.

Methods

152 CAD patients were recruited (M: F = 109:43, age = 64.47 ± 7.80 years, including 32 patients with chronic myocardial infarction, 46 with frailty, 93 with hypertension, and 48 with diabetes). All participants had blood biochemistry analysis, cardiac ultrasound, CPET and five time sit-to-stand (FTSTS) test. CPET was tested according to an incremental loading scheme of 10-15 w/min and peak METs, O2Ppeak were recorded. Stepwise multifactorial linear regression was used to determine which clinical variables should be adjusted to improve peak METs and O2Ppeak.

Results

Results of multifactorial linear regression showed 2 equations: peak METs = 6.768-0.116*BMI + 0.018*Hgb-0.026*age-0.005*Gensini score (Adjusted R2 = 0.301, F = 17.239, p < 0.001); O2Ppeak = -1.066 + 0.264*BMI + 0.049*Hgb-0.035*age (Adjusted R2 = 0.382, F = 32.106, p < 0.001).

Conclusion

BMI, Hgb, age and Gensini score can be used to predict peak METs and BMI, Hgb and age can be used to predict O2Ppeak in patients with CAD clinically. Thus, tailored exercise program should be prescribed for individual CAD patient undergoing cardiac rehabilitation and modifying clinical factors such as BMI, Hgb and Gensini score will help to improve their cardiorespiratory fitness and quality of life.

Exploring the delivery of phase II cardiac rehabilitation services in rural and remote Australia: a scoping review

Objective Phase II cardiac rehabilitation (CR) reduces cardiovascular risk factors, morbidity and mortality after a cardiac event. Traditional Australian CR programs are located in metropolitan areas and delivered by an expert, multidisciplinary team. Referral and uptake barriers for people living in rural and remote locations are significantly affected by geographical isolation. This scoping review aimed to explore how phase II CR services in rural and remote Australia are being delivered. Methods A scoping review was conducted to obtain all published literature relating to CR service delivery for people living in rural and remote Australia. A literature search of the following databases was performed in December 2021: Cumulative Index to Nursing and Allied Health Literature, Embase, the Physiotherapy Evidence Database, and PubMed. Results Six articles met the inclusion criteria. Study designs varied and included mixed methods, cross-sectional design and narrative review. Overall, literature relating to CR programs in rural and remote Australia was limited. Three themes were apparent: (1) barriers to the delivery of phase II CR in rural and remote Australia remain; (2) community centre-based programs do not reach all people in rural and remote Australia; and (3) alternative models of CR are underutilised. Conclusions Phase II CR programs in rural and remote Australia do not align with current recommendations for service delivery. The use of technology as a primary or adjunct model of delivery to support people living in rural and remote Australia needs to be further developed and implemented. Further research exploring barriers to the uptake of alternative models of CR delivery is recommended.

Challenges in Managing Acute Cardiovascular Diseases and Follow Up Care in Rural Areas: A Narrative Review

This narrative review explores relevant literature that is related to the challenges in implementing evidence-based management for clinicians in rural and remote areas, while primarily focussing on management of acute coronary syndrome (ACS) and follow up care. A targeted literature search around rural/urban differences in the management of ACS, cardiovascular disease, and cardiac rehabilitation identified multiple issues that are related to access, including the ability to pay, transport and geographic distances, delays in patients seeking care, access to diagnostic testing, and timely treatment in an appropriate facility. Workforce shortages or lack of ready access to relevant expertise, cultural differences, and complexity that arises from comorbidities and from geographical isolation amplified diagnostic challenges. Given the urgency in management of ACS, rural clinicians must act quickly to achieve optimal patient outcomes. New technologies and quality improvement approaches enable better access to rapid diagnosis, as well as specialist input and care. Achieving an uptake of cardiac rehabilitation in rural and remote settings poses challenges that may reduce with the use of alternative models to centre-based rehabilitation and use of modern technologies. Expediting improvement in cardiovascular outcomes and reducing rural disparities requires system changes and that clinicians embrace attention to prevention, emergency management, and follow up care in rural contexts.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cardiac Rehabilitation in Australia: A Brief Survey of Program Characteristics

BACKGROUND

Defining cardiac rehabilitation (CR) program characteristics on a national level is crucial for decision-making on resource allocation and evaluation of service quality. Comprehensive surveys of CR programs have been conducted overseas, but, to date, no such profile had been conducted in Australia.

METHODS

A representative sample of 165 CR programs across Australia were asked to provide details on a range of program characteristics such as program location and size, program elements, and staffing profile.

RESULTS

Australian CR programs differ from their overseas counterparts in characteristics such as program length, number of sessions, number of specialities represented and extent of outreach.

CONCLUSIONS

The study findings point to a need for a routine comprehensive survey of CR programs throughout Australia.

Quality of life improvement with rehabilitation according to constitution of the World Health Organization for coronary artery bypass graft surgery patients: A descriptive review

This is a descriptive review focusing on trends of treatments required for postoperative coronary artery bypass graft surgery (CABG) patients to improve the quality of life (QOL).

METHODOLOGY

The sources of literary research to understand the concepts of coronary artery disease according to Indian scriptures are Ayurveda texts, Bhagavad Gita, Patanjali Yoga Sutra. The data was typed in Sanskrit using Devanagari script and explanation in English was given. As per new research techniques, surgery, physiotherapy rehabilitation and Yoga are serving CABG patient's medical and psychological health better. The World Health Organization (WHO) defines health as physical, mental and social well-being later redefined with additional terms like environmental and spiritual health. This definition is similar to the Panchakosha concept in Yoga and Pancha Mahabhutas in Ayurveda. In cases of emergency or passive treatment, medication serves as a better option for physical health. In circumstances where the person is able to move in daily activities (just after discharge), rehabilitation serves as a better option for physical, mental and social health. Travel and reactions to climatic change serve environmental health. Last strategy, belief, cultural and traditional methods with scientific background serves as the spiritual health. These step-wise treatments are required for CABG patients to get the overall health or QOL. However, surgery and physiotherapy rehabilitation are advanced as per modern era which serves physical, mental, and social health also, but environmental health and spiritual health have yet to be addressed. As an ancient system of medicine, Yoga combines physical, mental, social, environmental and spiritual practices and it should be added as treatment along with surgery and physiotherapy rehabilitation. If all of these therapies were in the treatment protocol for CABG surgery patients, we would observe the changes of QOL and fulfill the requirements of constitution of the WHO. Integrating concepts of Yoga, Ayurveda, modern rehabilitation, surgery and patient cooperation with lifestyle change are the key to QOL improvements after CABG.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

FINDINGS

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

DISCUSSION AND CONCLUSION

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

Structured telephone support or non-invasive telemonitoring for patients with heart failure

BACKGROUND

Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits.

SELECTION CRITERIA

We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age).

MAIN RESULTS

We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours.

AUTHORS' CONCLUSIONS

For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.

Patient perceptions of nurse mentors facilitating the Aussie Heart Guide: A home-based cardiac rehabilitation programme for rural patients

AIM

To explore and describe long-term thoughts and perceptions of the Aussie Heart Guide Programme including the role of the mentor, held by patients recovering from myocardial infarction.

DESIGN

A qualitative design.

METHODS

Thirteen patients recovering from myocardial infarction who were unable to attend a hospital-based or affiliated outpatient cardiac rehabilitation programme were interviewed by telephone at the completion of the programme and asked to describe the relationship with their assigned nurse mentor and their perception of the audiovisual used in the programme.

RESULTS

Three themes emerged; assisting me to cope, supporting me and my family and tailoring the programme to my needs. Patients were satisfied with the programme and appreciative of the supportive and caring relationships provided by mentors during their hospitalization through to their discharge from the programme.

Alternative models of cardiac rehabilitation: a systematic review

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

Chronic obstructive pulmonary disease self-management activation research trial (COPD-SMART): design and methods

BACKGROUND

Treatment of COPD requires multiple pharmacological and non-pharmacological intervention strategies. One target is physical inactivity because it leads to disability and contributes to poor physical and mental health. Unfortunately, less than 1% of eligible patients have access to gold-standard pulmonary rehabilitation.

METHODS

A single-site parallel group randomized trial was designed to determine if a self-management lifestyle physical activity intervention would improve physical functioning and dyspnea. During the first six weeks after enrollment patients receive COPD self-management education delivered by a health coach using a workbook and weekly telephone calls. Patients are then randomized to usual care or the physical activity intervention. The 20 week physical activity intervention is delivered by the health coach using a workbook supported by alternating one-on-one telephone counseling and computer assisted telephone calls. Theoretical foundations include social cognitive theory and the transtheoretical model.

RESULTS

Primary outcomes include change in Chronic Respiratory Questionnaire (CRQ) dyspnea domain and 6-minute walk distance measured at 6-, 12-, and 18-months after randomization. Secondary outcomes include other CRQ domains (fatigue, emotion, and mastery), SF-12, and health care utilization. Other measures include process outcomes and clinical characteristics.

CONCLUSIONS

This theory driven self-management lifestyle physical activity intervention is designed to reach patients unable to complete center-based pulmonary rehabilitation. Results will advance knowledge and methods for dissemination of a potentially cost-effective program for patients with COPD.

Home-based rehabilitation enhances daily physical activity and motor skill in children who have undergone the Fontan procedure

This randomized trial compared physical activity enhancing exercise prescription and education programs in 61 children (36 male) with single-ventricle physiology after Fontan. After Fontan, children are less active than recommended for optimal health. They are often geographically dispersed and unable to attend weekday programs. Participants, 5.9-11.7 years of age who were status 5.3 years post-Fontan, received 12-month, parent-delivered home programs to enhance physical activity, motor skill, fitness, and activity attitudes. Daily moderate-to-vigorous physical activity (MVPA) was measured at baseline and again at 6, 12, and 24 months. Secondary outcomes were gross motor skill, fitness, and activity attitudes. Gross motor skill (p = .01) was significantly greater at the end of the 2-year study period for both intervention groups combined. MVPA at 2 years was significantly greater (p = .03) than the predicted decrease with age. Spring season (85 ± 25 min), male sex (69 ± 21 min), greater baseline activity (0.3 ± 0.1 min/baseline minute), and better gross motor skill (1.1 ± 0.4 min/percentile) increased weekly MVPA in a multivariable repeated-measures regression model adjusted for intervention, maturation during the 2-year study, sex, season, and baseline activity. Benefits were not influenced by type of rehabilitation, compliance, or rural/urban location. Home-based, pediatric physical activity rehabilitation enhances physical activity, gross motor skill, exercise capacity, and physical fitness among preadolescent children after Fontan regardless of rural/urban location. Prescribed education and exercise programs are similarly effective for providing the important health benefits of daily physical activity. Enhanced gross motor skill is associated with increased MVPA despite exercise capacity limitations after Fontan. Rehabilitation attenuates the expected decrease in MVPA with age.

Understanding the landscape: promoting health for rural individuals after tertiary level cardiac revascularization

PURPOSE

The purpose of this pilot study was to describe the needs and experiences of rural individuals commuting to an urban center for percutaneous coronary intervention (PCI).

METHODS

Data were analyzed from a "Patient Adherence and Satisfaction Survey" conducted by telephone as part of a quality improvement focus, and supplemented with in-depth semi-structured interviews with rural patients following PCI.

FINDINGS

Both urban and rural patients after PCI experienced few complications, had made some attempts to reduce tobacco usage, and were highly satisfied with explanations of their treatment and their overall treatment experience. Patients in rural settings were more likely to experience chest pain at least rarely following their surgery than people in urban settings (P < .05). Data on participation in cardiac rehabilitation (CR) showed no significant differences between urban and rural dwellers. Four themes emerged from the interviews: standards of care during treatment; transportation; local resources and community support; and lifestyle changes. Although patients were highly satisfied with standards of care during acute treatment, there were unmet needs in relation to transportation and lifestyle changes.

CONCLUSION

Transitions between rural communities and urban centers and rural adaptations of secondary prevention programs require more attention in health service delivery. Further research is required to better understand potential variations in chest pain patterns between urban and rural residents.

Development and feasibility of a smartphone, ECG and GPS based system for remotely monitoring exercise in cardiac rehabilitation

BACKGROUND

Despite its efficacy and cost-effectiveness, exercise-based cardiac rehabilitation is undertaken by less than one-third of clinically eligible cardiac patients in every country for which data is available. Reasons for non-participation include the unavailability of hospital-based rehabilitation programs, or excessive travel time and distance. For this reason, there have been calls for the development of more flexible alternatives.

METHODOLOGY AND PRINCIPAL FINDINGS

We developed a system to enable walking-based cardiac rehabilitation in which the patient's single-lead ECG, heart rate, GPS-based speed and location are transmitted by a programmed smartphone to a secure server for real-time monitoring by a qualified exercise scientist. The feasibility of this approach was evaluated in 134 remotely-monitored exercise assessment and exercise sessions in cardiac patients unable to undertake hospital-based rehabilitation. Completion rates, rates of technical problems, detection of ECG changes, pre- and post-intervention six minute walk test (6 MWT), cardiac depression and Quality of Life (QOL) were key measures. The system was rated as easy and quick to use. It allowed participants to complete six weeks of exercise-based rehabilitation near their homes, worksites, or when travelling. The majority of sessions were completed without any technical problems, although periodic signal loss in areas of poor coverage was an occasional limitation. Several exercise and post-exercise ECG changes were detected. Participants showed improvements comparable to those reported for hospital-based programs, walking significantly further on the post-intervention 6 MWT, 637 m (95% CI: 565-726), than on the pre-test, 524 m (95% CI: 420-655), and reporting significantly reduced levels of cardiac depression and significantly improved physical health-related QOL.

CONCLUSIONS AND SIGNIFICANCE

The system provided a feasible and very flexible alternative form of supervised cardiac rehabilitation for those unable to access hospital-based programs, with the potential to address a well-recognised deficiency in health care provision in many countries. Future research should assess its longer-term efficacy, cost-effectiveness and safety in larger samples representing the spectrum of cardiac morbidity and severity.

Geographic issues in cardiac rehabilitation utilization: a narrative review

OBJECTIVE

The purpose of this study was to review the current evidence regarding the relationship between geographic indicators and cardiac rehabilitation (CR) utilization among coronary heart disease (CHD) patients.

RESULTS

Seventeen articles were identified for inclusion, where nine studies assessed rurality, 10 studies assessed travel time/distance, and two of these studies assessed both. Nine of the 17 studies (52.9%) showed a significant negative relationship between geographic barrier and CR use. Four of the 17 studies (23.5%) showed a null relationship, while four studies (23.5%) showed mixed findings. Inconsistent findings identified appeared to be related to restricted geographic range, regional density, and socioeconomic status.

CONCLUSIONS

Overall, 52.9% of the identified studies reported a significant negative relationship between geographic indicators and CR utilization. This relationship appeared to be particularly consistent in North American and Australian settings, but somewhat less so in the United Kingdom where there is greater population density and availability of public transport.

Structured telephone support or telemonitoring programmes for patients with chronic heart failure

BACKGROUND

Specialised disease management programmes for chronic heart failure (CHF) improve survival, quality of life and reduce healthcare utilisation. The overall efficacy of structured telephone support or telemonitoring as an individual component of a CHF disease management strategy remains inconclusive.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or telemonitoring compared to standard practice for patients with CHF in order to quantify the effects of these interventions over and above usual care for these patients.

SEARCH STRATEGY

Databases (the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database (HTA) on The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED and Science Citation Index Expanded and Conference Citation Index on ISI Web of Knowledge) and various search engines were searched from 2006 to November 2008 to update a previously published non-Cochrane review. Bibliographies of relevant studies and systematic reviews and abstract conference proceedings were handsearched. No language limits were applied.

SELECTION CRITERIA

Only peer reviewed, published RCTs comparing structured telephone support or telemonitoring to usual care of CHF patients were included. Unpublished abstract data was included in sensitivity analyses. The intervention or usual care could not include a home visit or more than the usual (four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

Data were presented as risk ratio (RR) with 95% confidence intervals (CI). Primary outcomes included all-cause mortality, all-cause and CHF-related hospitalisations which were meta-analysed using fixed effects models. Other outcomes included length of stay, quality of life, acceptability and cost and these were described and tabulated.

MAIN RESULTS

Twenty-five studies and five published abstracts were included. Of the 25 full peer-reviewed studies meta-analysed, 16 evaluated structured telephone support (5613 participants), 11 evaluated telemonitoring (2710 participants), and two tested both interventions (included in counts). Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI 0.54 to 0.81, P < 0.0001) with structured telephone support demonstrating a non-significant positive effect (RR 0.88, 95% CI 0.76 to 1.01, P = 0.08). Both structured telephone support (RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001) and telemonitoring (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008) reduced CHF-related hospitalisations. For both interventions, several studies improved quality of life, reduced healthcare costs and were acceptable to patients. Improvements in prescribing, patient knowledge and self-care, and New York Heart Association (NYHA) functional class were observed.

AUTHORS' CONCLUSIONS

Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

Cardiac rehabilitation: Adding years to life and life to years

Abstract

Cardiac rehabilitation is an integral component of comprehensive cardiac care and is effective in reducing morbidity and mortality and improving quality of life. However, despite a 50-year-history and extensive evidence base attesting to its clinical and cost-effectiveness, including adding years to life and life to years, and exhortations that its implementation should be a key priority, the majority of cardiac patients do not receive rehabilitation. There is a comparative dearth of funding and wide variation in service provision, with a health care system that often fails to address issues such as sub-optimal referral, enrolment and completion, particularly amongst certain potential user groups that could benefit. This paper reviews these issues and suggests ways of overcoming the obstacles identified. It also highlights some of the knowledge gaps and areas that warrant further research.

Utilization of the internet to deliver cardiac rehabilitation at a distance: a pilot study

Less than 25% of eligible patients attend cardiac rehabilitation programs (CRP), with geographical proximity being a predominant barrier. Therefore, we undertook a pilot study to assess the feasibility and safety of using the Internet as a medium for delivery of an interactive "virtual" CRP (vCRP) to patients at a distance. Fifteen patients on the waiting list for a local hospital-based CRP were randomized to either an Internet-based vCRP or observational control. The vCRP consisted of on-line intake forms, one-on-one chat sessions with a nurse, dietitian, and exercise specialist, downloadable exercise heart rate monitoring, education and data monitoring of blood pressure, weight, and glucose. Participants were assessed for exercise capacity, risk factors, and lifestyle behaviors at baseline and at 12 weeks. Those in the vCRP logged onto the Internet-based CRP an average of 4.2 times per week. There were no adverse events in the vCRP participants. The vCRP group significantly improved their HDL-C, triglycerides, total cholesterol:HDL-C ratio, exercise capacity as assessed in metabolic equivalents, weekly physical activity, and exercise specific self-efficacy (p < 0.05). There were no significant improvements in the control group. Improvements in the vCRP group were similar to historical controls in a standard CRP. Feedback from exit interviews of the vCRP participants was unanimously positive. This Internet-based CRP resulted in clinically significant improvements in risk factors and exercise capacity similar to that of a standard CRP. The high user acceptance indicated that this program may have the potential to effectively manage patients who do not have access to traditional hospital-based CRP.