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Saensoda S, Pokpalagon P, Chaiviboontham S. The Effects of a Home-Based Cardiac Rehabilitation Program via the Line Application on Functional Capacity and Quality of Life Among Open-Heart Surgery Patients: A Quasi-Experimental Study. Healthcare (Basel) 2025; 13:1051. [PMID: 40361829 PMCID: PMC12071928 DOI: 10.3390/healthcare13091051] [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: 03/24/2025] [Revised: 04/15/2025] [Accepted: 04/18/2025] [Indexed: 05/15/2025] Open
Abstract
Background/Objectives: This study aims to investigate the effects of a home-based cardiac rehabilitation (HBCR) program via a LINE application on functional capacity and quality of life (QOL) in open-heart surgery patients. Methods: This study involved 54 open-heart surgery patients divided into a control group and an experimental group (27 intervention, 27 control) using pair matching. Participants in the intervention group participated in the HBCR program, while the control group received standard care. Orem's self-care theory was used as the conceptual framework. Functional capacity was measured via a six-minute walk test and the Duke Activity Status Index, while QOL was measured via the Thai version of the Short Form-36 Survey. Results: The findings from the study reveal that the patients who underwent open-heart surgery in the experimental group had significantly higher functional capacity compared to those in the control group (p < 0.05). Additionally, the overall QOL of the open-heart surgery patients in the experimental group was significantly better than that of the control group, alongside physical functioning, emotional roles, vitality, mental health, social functioning, and general health (p < 0.05). However, there were no significant differences between the two groups in terms of physical roles and bodily pain (p > 0.05). Conclusions: Using an HBCR program via the LINE application has the potential to enhance the at-home self-care ability of post-open-heart surgery patients, thus improving their functional capacity and QOL.
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Affiliation(s)
- Suteetida Saensoda
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (S.S.); (S.C.)
- Department of Nursing, Rajavithi Hospital, Bangkok 10400, Thailand
| | - Piyawan Pokpalagon
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (S.S.); (S.C.)
| | - Suchira Chaiviboontham
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (S.S.); (S.C.)
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MacEachern E, Quach J, Giacomantonio N, Theou O, Hillier T, Abel-Adegbite I, Gonzalez-Lara M, Kehler DS. Cardiac rehabilitation and frailty: a systematic review and meta-analysis. Eur J Prev Cardiol 2024; 31:1960-1976. [PMID: 39036978 DOI: 10.1093/eurjpc/zwae239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/05/2024] [Accepted: 07/21/2024] [Indexed: 07/23/2024]
Abstract
AIMS Frailty among cardiac rehabilitation (CR) participants is associated with worse health outcomes. However, no literature synthesis has quantified the relationship between frailty and CR outcomes. The purpose of this study was to examine frailty prevalence at CR admission, frailty changes during CR, and whether frailty is associated with adverse outcomes following CR. METHODS AND RESULTS We searched CINAHL, EMBASE, and MEDLINE for studies published from 2000 to 2023. Eligible studies included a validated frailty measure, published in English. Two reviewers independently screened articles and abstracted data. Outcome measures included admission frailty prevalence, frailty and physical function changes, and post-CR hospitalization and mortality. Observational and randomized trials were meta-analysed separately using inverse variance random-effects models. In total, 34 peer reviewed articles (26 observational, 8 randomized trials; 19 360 participants) were included. Admission frailty prevalence was 46% [95% CI 29-62%] and 40% [95% CI 28-52%] as measured by Frailty Index and Kihon Checklist (14 studies) and Frailty Phenotype (11 studies), respectively. Frailty improved following CR participation (standardized mean difference (SMD): 0.68, 95% CI 0.37-0.99; P < 0.0001; six studies). Meta-analysis of observational studies revealed higher admission frailty and increased participants' risk of all-cause mortality (hazard ratio: 9.24, 95% CI 2.93-29.16; P = 0.0001; four studies). Frailer participants at admission had worse physical health outcomes, but improved over the course of CR. CONCLUSION High variability in frailty tools and CR designs was observed, and randomized controlled trial contributions were limited. The prevalence of frailty is high in CR and is associated with greater mortality risk; however, CR improves frailty and physical health outcomes. REGISTRATION PROSPERO: CRD42022311765.
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Affiliation(s)
- Evan MacEachern
- School of Physiotherapy, Dalhousie University, 5869 University Ave, Dalhousie University Forrest Building, Room 402, PO Box 15000, Halifax, NS B3H 4R2, Canada
| | - Jack Quach
- Faculty of Health, Dalhousie University, 5868 College Street, Room 316, PO Box 15000, Halifax, NS B3H 4R2, Canada
| | | | - Olga Theou
- School of Physiotherapy, Dalhousie University, 5869 University Ave, Dalhousie University Forrest Building, Room 402, PO Box 15000, Halifax, NS B3H 4R2, Canada
- Faculty of Health, Dalhousie University, 5868 College Street, Room 316, PO Box 15000, Halifax, NS B3H 4R2, Canada
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Troy Hillier
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Ifedayo Abel-Adegbite
- Faculty of Health, Dalhousie University, 5868 College Street, Room 316, PO Box 15000, Halifax, NS B3H 4R2, Canada
| | - Mariana Gonzalez-Lara
- Faculty of Health, Dalhousie University, 5868 College Street, Room 316, PO Box 15000, Halifax, NS B3H 4R2, Canada
| | - Dustin Scott Kehler
- School of Physiotherapy, Dalhousie University, 5869 University Ave, Dalhousie University Forrest Building, Room 402, PO Box 15000, Halifax, NS B3H 4R2, Canada
- Faculty of Health, Dalhousie University, 5868 College Street, Room 316, PO Box 15000, Halifax, NS B3H 4R2, Canada
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Grace SL, Ghanbari M, da Cruz MMA, Vanderlei LCM, Ghisi GLDM. Psychometric validation of the Cardiac Rehabilitation Barriers Scale Revised (CRBS-R) for hybrid delivery. BMJ Open 2024; 14:e090261. [PMID: 39414267 PMCID: PMC11481153 DOI: 10.1136/bmjopen-2024-090261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 09/23/2024] [Indexed: 10/18/2024] Open
Abstract
OBJECTIVE To test the measurement properties of the revised version of the English Cardiac Rehabilitation Barriers Scale (CRBS-R), suitable for hybrid delivery, structural validity, internal reliability, as well as face, cross-cultural, construct and criterion validity were assessed. DESIGN Cross-sectional study, where participants completed an online survey via Qualtrics (2023-2024). SETTING Multicentre, with cardiac rehabilitation (CR) programmes recruiting patients globally; most patients stemmed from a hybrid programme in Iran and supervised programme in Brazil. PARTICIPANTS Participants include inpatients or outpatients with a cardiovascular diagnosis or procedure that is indicated for participation in CR. MEASURES In addition to sociodemographic and CR use items, the 21-item CRBS-R was administered. It assesses multilevel barriers and was revised based on a literature review. Responses range from 1 to 5, with higher scores indicating greater barriers. RESULTS 235 patients participated from all 6 WHO regions. Items were rated as highly applicable, and open-ended responses revealing no key barriers were omitted, supporting face and cross-cultural validity. Cronbach's α for the total CRBS-R was 0.82. Principal components analysis resulted in the extraction of 4 components, which collectively accounted for 60.5% of the variance and were all internally consistent. Construct validity was supported by associations of total CRBS scores with work status (p=0.04), exercise history (p=0.01) and social support (p=0.03). Total CRBS-R scores were significantly lower in patients who were referred and enrolled versus those who were not (both p≤0.01), confirming criterion validity. CONCLUSIONS The CRBS-R is a reliable and valid scale comprising four subscales, applicable to hybrid CR across diverse settings. It can serve as a valuable tool to support identification of patient's CR barriers, to optimise secondary prevention utilisation globally.
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Affiliation(s)
- Sherry L Grace
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Mahdieh Ghanbari
- Yazd Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | | | - Gabriela Lima de Melo Ghisi
- KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Department pf Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Höppchen I, Wurhofer D, Meschtscherjakov A, Smeddinck JD, Kulnik ST. Targeting behavioral factors with digital health and shared decision-making to promote cardiac rehabilitation-a narrative review. Front Digit Health 2024; 6:1324544. [PMID: 38463944 PMCID: PMC10920294 DOI: 10.3389/fdgth.2024.1324544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/13/2024] [Indexed: 03/12/2024] Open
Abstract
Cardiac rehabilitation (CR) represents an important steppingstone for many cardiac patients into a more heart-healthy lifestyle to prevent premature death and improve quality of life years. However, CR is underutilized worldwide. In order to support the development of targeted digital health interventions, this narrative review (I) provides understandings of factors influencing CR utilization from a behavioral perspective, (II) discusses the potential of digital health technologies (DHTs) to address barriers and reinforce facilitators to CR, and (III) outlines how DHTs could incorporate shared decision-making to support CR utilization. A narrative search of reviews in Web of Science and PubMed was conducted to summarize evidence on factors influencing CR utilization. The factors were grouped according to the Behaviour Change Wheel. Patients' Capability for participating in CR is influenced by their disease knowledge, awareness of the benefits of CR, information received, and interactions with healthcare professionals (HCP). The Opportunity to attend CR is impacted by healthcare system factors such as referral processes and HCPs' awareness, as well as personal resources including logistical challenges and comorbidities. Patients' Motivation to engage in CR is affected by emotions, factors such as gender, age, self-perception of fitness and control over the cardiac condition, as well as peer comparisons. Based on behavioral factors, this review identified intervention functions that could support an increase of CR uptake: Future DHTs aiming to support CR utilization may benefit from incorporating information for patients and HCP education, enabling disease management and collaboration along the patient pathway, and enhancing social support from relatives and peers. To conclude, considerations are made how future innovations could incorporate such functions.
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Affiliation(s)
- Isabel Höppchen
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- Department of Artificial Intelligence and Human Interfaces, Human Computer Interaction Division, Paris Lodron University of Salzburg, Salzburg, Austria
| | - Daniela Wurhofer
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
| | - Alexander Meschtscherjakov
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- Department of Artificial Intelligence and Human Interfaces, Human Computer Interaction Division, Paris Lodron University of Salzburg, Salzburg, Austria
| | - Jan David Smeddinck
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
| | - Stefan Tino Kulnik
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
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Wills WB, Athilingam P, Beckie TM. Exercise-based cardiac rehabilitation in women with heart failure: a review of enrollment, adherence, and outcomes. Heart Fail Rev 2023; 28:1251-1266. [PMID: 37059937 DOI: 10.1007/s10741-023-10306-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 04/16/2023]
Abstract
Exercise-based cardiac rehabilitation (CR) is an evidence-based recommendation for patients with stable heart failure (HF). Less clear is how effective exercise-based CR is for women with HF. The aim of this review was to synthesize the evidence for the effects of exercise-based CR on mortality, hospitalizations, exercise capacity, and quality of life (QOL) among women with HF. We identified 18 studies comprising 4917 patients, of which 1714 were women. The interventions evaluated consisted of various combinations of supervised in-hospital and out-patient sessions as well as home-based programs that included aerobic (walking, treadmill, bicycle) and resistance training. The interventions ranged from 12 to 54 weeks, with a frequency of 2-7 sessions per week, lasting from 30 to 105 min per session. Because of a paucity of sex-specific analyses of the outcomes, it was not possible to draw conclusions for women. There was limited evidence for mortality benefit for men or women participating in exercise-based CR. There was more substantial evidence for reductions in hospitalizations for the participants. Generally, exercise training improved exercise capacity. The effects of exercise-based CR on QOL were mixed with most studies favoring CR at 3 months but not at 4, 5, and 12 months. Moreover, generally, the physical dimension of QOL but not the mental dimensions improved. Recommendations for future research to reduce the gap in knowledge about the effects of exercise-based CR for women are offered.
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Affiliation(s)
- Walter B Wills
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC Box 22, Tampa, FL, 33612, USA
| | - Ponrathi Athilingam
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC Box 22, Tampa, FL, 33612, USA
| | - Theresa M Beckie
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC Box 22, Tampa, FL, 33612, USA.
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Ghisi GLDM, Kim WS, Cha S, Aljehani R, Cruz MMA, Vanderlei LCM, Pepera G, Liu X, Xu Z, Maskhulia L, Venturini E, Chuang HJ, Pereira DG, Trevizan PF, Kouidi E, Batalik L, Ghanbari Firoozabadi M, Burazor I, Jiandani MP, Zhang L, Tourkmani N, Grace SL. Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment. Can J Cardiol 2023; 39:S375-S383. [PMID: 37747380 DOI: 10.1016/j.cjca.2023.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women's greatest barriers according to enrollment status. METHODS In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated. RESULTS Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women's barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5). CONCLUSIONS CR barriers-men's and women's-vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women's barriers in particular.
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Affiliation(s)
- Gabriela Lima de Melo Ghisi
- KITE - Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Won-Seok Kim
- Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Seungwoo Cha
- Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Raghdah Aljehani
- Rehabilitation Department, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Mayara Moura Alves Cruz
- São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
| | | | - Garyfallia Pepera
- Department of Physiotherapy, Faculty of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Xia Liu
- Chengdu Wanda UPMC Hospital, Chengdu, China
| | - Zhimin Xu
- Shanghai Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lela Maskhulia
- TSMU Sports Medicine and Rehabilitation Clinical Centre, Cardiac Rehabilitation, Tbilisi, Georgia
| | - Elio Venturini
- Department of Cardiac Rehabilitation, Cecina Hospital, Cecina, Italy
| | - Hung-Jui Chuang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Danielle Gomes Pereira
- Graduate Program in Rehabilitation Sciences, Department of Physical Therapy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Patricia Fernandes Trevizan
- Graduate Program in Rehabilitation Sciences, Department of Physical Therapy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Department of Physical Education and Sports Science, Thessaloniki, Greece
| | - Ladislav Batalik
- Department of Rehabilitation, University Hospital Brno, Brno, Czech Repub
| | - Mahdieh Ghanbari Firoozabadi
- Yazd Cardiovascular Research Center, Non-Communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Ivana Burazor
- Institute for Cardiovascular Diseases "Dedinje" and Belgrade University, Faculty of Medicine, Belgrade, Serbia
| | | | - Ling Zhang
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Nidal Tourkmani
- Rehabilitation Clinic "Mons. G. Calaciura," Biancavilla, Catania, Italy; "Gibiino" Cardiovascular Diagnostic Center, Catania, Italy
| | - Sherry L Grace
- KITE - Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; Faculty of Health, York University, Toronto, Ontario, Canada.
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7
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Regan EW, Fritz SL. Key participant characteristics influencing completion of a phase II cardiac rehabilitation program: A cross-sectional analysis. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 33:100314. [PMID: 38510555 PMCID: PMC10946023 DOI: 10.1016/j.ahjo.2023.100314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 03/22/2024]
Abstract
Study objective Cardiac rehabilitation (CR) programs are effective at reducing cardiovascular disease risk factors, yet programs in the United States (US) have poor participation and completion. The current study evaluates characteristics related to completion and drop-out for CR participants. Design A cross-sectional study design compared participants who completed the program (finishers) and those did not finish (non-finishers). Variables were compared to determine differences between the dichotomous groups included demographic data, initial six-minute walk test, Zung Depression Index, and Quality of Life Measure (QLM). Logistical regression using variables with differences between groups determined impact on program completion. Setting Phase two outpatient hospital based cardiac rehabilitation program. Participants Ninety-seven participants were part of the sample; 61 completed the program, and 36 dropped out. Main outcome measure Completion of CR. Results Ninety-seven participants are included; 61 (63 %) were finishers and 36 (37 %) were non-finishers. Finishers were older, had a higher proportion of females and Medicare insurance recipients, had lower depression scores, and reported higher quality of life. Results of the final logistic regression revealed finishers were more likely to have Medicare (odds ratio (OR) = 5.215, confidence interval (CI) 1.897-14.338), be female (OR = 4.597, 95 % CI 1.532-13.795) and have higher QLM Family Sub scores (OR = 1.129, 95 % CI 1.023-1.246). The model correctly classified 71.9 % of cases. Conclusion The analysis highlights Medicare insurance and family support are associated with program completion. Interventions to increase family and social support, and to provide financial assistance for those with financial burden through lack of insurance or high co-pays may increase cardiac rehabilitation completion rates.
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Affiliation(s)
- Elizabeth W. Regan
- Department of Exercise Science, University of South Carolina, Columbia, SC, United States of America
| | - Stacy L. Fritz
- Department of Exercise Science, University of South Carolina, Columbia, SC, United States of America
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Loureiro Diaz J, Foster LD, Surendran PJ, Jacob P, Ibrahim O, Gupta P. Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program. BMJ Open Qual 2023; 12:bmjoq-2022-002202. [PMID: 37257915 DOI: 10.1136/bmjoq-2022-002202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies had shown safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR. A multidisciplinary team reviewed various alternative models for delivery and decided to implement a hybrid CRP2 exercise programme (HCRP2-EP) to ensure continuation of our patient care. Our aim was to enrol in the HCRP2-EP 70% of all eligible patients by 30 September 2020. Institute for Health Care Improvement's collaborative model was adopted. Multiple plan-do-study-act cycles were used to test change ideas. The outcomes of the project were analysed using standard run chart rules to detect the changes in outcomes over time. This project was implemented from March 2020, and the male patients enrolled between August 2020 and April 2021, with sustained monthly median enrolment above target of 70% throughout. As for our secondary outcome, 75.8% of the male patients who completed HCRP2-EP showed a meaningful change in peak exercise capacity of ≥10% (mean change 17%±6%). There were no major adverse events reported, and the median Patient Satisfaction Score was 96% well above the institutional target of 90%. This shows a well-designed quality improvement programme is an appropriate strategy for implementing HCRP2-EP in a clinical setting, and HCRP2-EP is a feasible, effective and safe intervention in eligible male patients with cardiovascular disease.
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Affiliation(s)
- Javier Loureiro Diaz
- Cardiac Rehabilitation Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Liam David Foster
- Cardiac Rehabilitation Department, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - Prasobh Jacob
- Cardiac Rehabilitation Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Omar Ibrahim
- Cardiac Rehabilitation Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Poonam Gupta
- Performance Improvement Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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9
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Lalande K, Bouchard K, Tulloch H. Cardiac rehabilitation: One size does not fit all. Int J Cardiol 2023; 379:134-135. [PMID: 36907455 DOI: 10.1016/j.ijcard.2023.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Affiliation(s)
- K Lalande
- University of Ottawa Heart Institute, Ottawa, Canada,.
| | - K Bouchard
- University of Ottawa Heart Institute, Ottawa, Canada,; University of Ottawa, Ottawa, Canada
| | - H Tulloch
- University of Ottawa Heart Institute, Ottawa, Canada,; University of Ottawa, Ottawa, Canada
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10
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Ozemek C, Arena R, Rouleau CR, Campbell TS, Hauer T, Wilton SB, Stone J, Laddu D, Williamson TM, Liu H, Chirico D, Austford LD, Aggarwal S. Long-Term Maintenance of Cardiorespiratory Fitness Gains After Cardiac Rehabilitation Reduces Mortality Risk in Patients With Multimorbidity. J Cardiopulm Rehabil Prev 2023; 43:109-114. [PMID: 36203224 DOI: 10.1097/hcr.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
PURPOSE The objective of this study was to characterize the impact of multimorbidity and cardiorespiratory fitness (CRF) on mortality in patients completing cardiac rehabilitation (CR). METHODS This cohort study included data from patients with a history of cardiovascular disease (CVD) completing a 12-wk CR program between January 1996 and March 2016, with follow-up through March 2017. Patients were stratified by the presence of multimorbidity, which was defined as having a diagnosis of ≥2 noncommunicable diseases (NCDs). Cox regression analyses were used to evaluate the effects of multimorbidity and CRF on mortality in patients completing CR. Symptom-limited exercise tests were completed at baseline, immediately following CR (12 wk), with a subgroup completing another test at 1-yr follow-up. Peak metabolic equivalents (METs) were determined from treadmill speed and grade. RESULTS Of the 8320 patients (61 ± 10 yr, 82% male) included in the analyses, 5713 (69%) patients only had CVD diagnosis, 2232 (27%) had CVD+1 NCD, and 375 (4%) had CVD+≥2 NCDs. Peak METs at baseline (7.8 ± 2.0, 6.9 ± 2.0, 6.1 ± 1.9 METs), change in peak METs immediately following CR (0.98 ± 0.98, 0.83 ± 0.95, 0.76 ± 0.95 METs), and change in peak METs 1 yr after CR (0.98 ± 1.27, 0.75 ± 1.17, 0.36 ± 1.24 METs) were different ( P < .001) among the subgroups. Peak METs at 12 wk and the presence of coexisting conditions were each predictors ( P < .001) of mortality. Improvements in CRF by ≥0.5 METS from baseline to 1-yr follow-up among patients with or without multimorbidity were associated with lower mortality rates. CONCLUSION Increasing CRF by ≥0.5 METs improves survival regardless of multimorbidity status.
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Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago (Drs Ozemek, Arena, and Laddu); TotalCardiology Research Network, Calgary, Canada (Drs Arena, Rouleau, Campbell, Wilton, Stone, Chirico, and Aggarwal and Ms Austford); TotalCardiology™ Rehabilitation, Calgary, Canada (Drs Rouleau and Aggarwal and Ms Hauer); Departments of Psychology (Drs Rouleau, Campbell, and Aggarwal and Ms Williamson), Community Health Sciences (Dr Liu), and Kinesiology (Dr Chirico), University of Calgary, Calgary, Canada; and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada (Drs Wilton, Stone, and Liu)
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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: 68] [Impact Index Per Article: 34.0] [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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Ghisi GLDM, Marzolini S, Price J, Beckie TM, Mamataz T, Naheed A, Grace SL. Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline. Can J Cardiol 2022; 38:1786-1798. [PMID: 36085185 DOI: 10.1016/j.cjca.2022.06.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 12/14/2022] Open
Abstract
Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.
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Affiliation(s)
- Gabriela Lima de Melo Ghisi
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Susan Marzolini
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; Faculty of Health, York University, Toronto, Ontario, Canada
| | | | - Theresa M Beckie
- College of Nursing, Division of Cardiovascular Sciences, University of South Florida, Tampa, Florida, USA; College of Medicine, Division of Cardiovascular Sciences, University of South Florida, Tampa, Florida, USA
| | - Taslima Mamataz
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; Faculty of Health, York University, Toronto, Ontario, Canada
| | - Aliya Naheed
- Initiative for Non-Communicable Diseases, Health System and Population Studies Division, International Centre for Diarrheal Diseases Research Bangladesh, Dhaka, Bangladesh
| | - Sherry L Grace
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; Faculty of Health, York University, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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13
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Racette SB, Park LK, Rashdi ST, Montgomery K, McKenzie KM, Deych E, Graham C, Das N, Fogarty TM, Van Zandt A, Carson T, Durbin D, Jonagan J, Rich MW, de las Fuentes L, Peterson LR. Benefits of the First Pritikin Outpatient Intensive Cardiac Rehabilitation Program. J Cardiopulm Rehabil Prev 2022; 42:449-455. [PMID: 35861951 PMCID: PMC9643589 DOI: 10.1097/hcr.0000000000000700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Intensive cardiac rehabilitation (ICR) is a comprehensive, medically supervised exercise treatment program covered by Medicare for patients with approved cardiac diagnoses. The aim of this study was to determine the benefits of the first Pritikin outpatient ICR program. METHODS This retrospective analysis included patients referred to ICR or traditional cardiac rehabilitation (CR) during the first 7 yr (2013-2019) at the first facility to implement Pritikin ICR. Intensive cardiac rehabilitation is composed of 36 education sessions on nutrition, exercise, and a healthy mindset, in addition to 36 monitored exercise sessions that comprise traditional CR. Assessments included anthropometrics (weight, body mass index, and waist circumference), dietary patterns, physical function (6-min walk test, [6MWT] Short Physical Performance Battery [SPPB: balance, 4-m walk, chair rise], handgrip strength), and health-related quality of life (Dartmouth COOP, 36-item Short Form Survey). Baseline and follow-up measures were compared within and between groups. RESULTS A total of 1963 patients enrolled (1507 ICR, 456 CR, 66.1 ± 11.4 yr, 68% male, 82% overweight or obese); 1141 completed the program (58%). The ICR patients completed 22 exercise and 18 education sessions in 9.6 wk; CR patients completed 19 exercise sessions in 10.3 wk. ICR resulted in improvements ( P < .001 pre vs post) in all anthropometric measures, dietary patterns, 6MWT distance, all SPPB components, grip strength, and health-related quality of life. The improvements in anthropometrics and dietary patterns were greater in ICR than in CR. CONCLUSIONS The Pritikin outpatient ICR program promoted improvements in several cardiovascular health indices. Critical next steps are to assess long-term health outcomes after ICR, including cardiac events and mortality.
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Affiliation(s)
- Susan B. Racette
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Lauren K. Park
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Serene T. Rashdi
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Kristin Montgomery
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Kristin M. McKenzie
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Elena Deych
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Christopher Graham
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Nikhil Das
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Taylor M. Fogarty
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Alexandria Van Zandt
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Tessa Carson
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Dotti Durbin
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Jennifer Jonagan
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Michael W. Rich
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Lisa de las Fuentes
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
| | - Linda R. Peterson
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Park, Fogarty, and Van Zandt); Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Drs Racette, Rich, de las Fuentes, and Peterson, Mss Rashdi, Montgomery, McKenzie, and Deych, and Mr Das); Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri (Mr Graham); and Barnes-Jewish Hospital, BJC HealthCare, St Louis, Missouri (Mss Carson, Durbin, and Jonagan)
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14
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Miralles-Resurreccion KV, Grace SL, Cuenza LR. Trends in cardiac rehabilitation enrollment post-coronary artery bypass grafting upon implementation of automatic referral in Southeast Asia: A retrospective cohort study. J Cardiovasc Thorac Res 2022; 14:84-89. [PMID: 35935385 PMCID: PMC9339729 DOI: 10.34172/jcvtr.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cardiac rehabilitation (CR) is an effective but underutilized intervention. Strategies have been identified to increase its use, but there is paucity of data testing them in low-resource settings. We sought to determine the effect of automatic referral post-coronary artery bypass graft (CABG) surgery on CR enrollment.
Methods: This is a retrospective cohort study assessing cardiac patients referred to CR at a tertiary center in Southeast Asia from 2013 to 2019. The paper-based pathway was introduced at the end of 2012. The checklist with automatic CR referral on the third day post-operation prompted a nurse to educate the patient about CR, initiate phase 1 and encourage enrollment in phase 2. Patients who were not eligible for the pathway for administrative or clinical reasons were referred at the discretion of the attending physician (i.e., usual care). Enrollment was defined as attendance at≥1 CR visit. Results: Of 4792 patients referred during the study period, 394 enrolled in CR. Significantly more patients referred automatically enrolled compared to usual care (225 [11.8%] vs. 169 [5.8%]; OR=2.2, 95% CI=1.8-2.7), with increases up to 23.4% enrollment in 2014 (vs. average enrollment rate of 5.9% under usual referral). Patients who enrolled following automatic referral were significantly younger and more often employed (both P<0.001); no other differences were observed. Conclusion: In a lower-resource, Southeast Asian setting, automatic CR referral is associated with over two times greater enrollment in phase 2 CR, although efforts to maintain this effect are required.
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Affiliation(s)
| | - Sherry L. Grace
- York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada
| | - Lucky R. Cuenza
- Section of Cardiac Rehabilitation, Philippine Heart Center, Quezon City, Philippines
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15
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Mamataz T, Ghisi GL, Pakosh M, Grace SL. Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis. Maturitas 2022; 160:32-60. [PMID: 35550706 DOI: 10.1016/j.maturitas.2022.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/08/2021] [Accepted: 01/18/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost. METHODS Medline, PubMed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception through to May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. "Women-focused" CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women's preferences. No studies were excluded on the basis of outcome. Two independent reviewers rated citations for potential inclusion, and one extracted data, including on quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied. RESULTS 3498 unique citations were identified, of which 28 studies (52 papers) were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with "usual care" comparisons. Compared to "active comparison" group, women-focused CR had no meaningful additional effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence) and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as scores on seven of the eight SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported a favorable economic impact and another reported reduced sick days. CONCLUSIONS Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed. PROSPERO REGISTRATION CRD42020189760.
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Affiliation(s)
| | - Gabriela Lm Ghisi
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Maureen Pakosh
- Library & Information Services, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Toronto, ON, Canada; KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
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16
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Rodrigues GDF, Vieira DDR, Ruschel PP, Seelig C, Coronel C, Barbiero SM. Interdisciplinary Group Intervention on Nutritional Profile, Quality of Life, and Stress During Cardiopulmonary Rehabilitation: A Randomized Clinical Trial. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20200295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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17
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Heald FA, de Araújo Pio CS, Liu X, Theurel FR, Pavy B, Grace SL. Evaluation of an Online Course in 5 Languages for Inpatient Cardiac Care Providers on Promoting Cardiac Rehabilitation: REACH, EFFECTS, AND SATISFACTION. J Cardiopulm Rehabil Prev 2022; 42:103-108. [PMID: 34793364 DOI: 10.1097/hcr.0000000000000619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Evidence proves that health care providers should promote cardiac rehabilitation (CR) to patients face-to-face to increase CR enrollment. An online course was designed to promote this at the bedside; it is evaluated herein in terms of reach, effect on knowledge, attitudes, discussion self-efficacy and practices, and satisfaction. METHODS Design was observational, one-group pre- and post-test. Some demographics were requested from learners taking all language versions of the 20-min course: English, Portuguese, French, Spanish, and simplified Chinese, available at: https://globalcardiacrehab.com/CR-Utilization. Investigator-generated items in the pre- and post-test and evaluation survey administered using Google Forms were based on Kirkpatrick's training evaluation model. RESULTS The course was initiated by 522 learners from 33 of 203 (16%) countries; most commonly female (n = 341, 65%) nurses (n = 180, 34%) from high-income countries (n = 259, 57%) completing the English (n = 296, 57%) and Chinese (n = 108, 21%) versions. A total of 414 (79%) learners completed the post-test and 302 (58%) completed the evaluation. Median CR attitudes were 5 of 5 on the Likert scale at pre-test, suggesting some selection bias. Mean CR knowledge ([7.22 ± 2.14]/10), discussion self-efficacy ([3.86 ± 0.85]/5), and practice ([4.13 ± 1.11]/5) significantly improved after completion of the course (all P < .001). Satisfaction was high regardless of language version ([4.44 ± 0.64]/5; P = .593). CONCLUSIONS This free, open-access course is effective in increasing CR knowledge, self-efficacy, and encouragement practices among participating inpatient cardiac providers, with high satisfaction. While testing impact on actual CR use is needed, it should be more broadly disseminated to increase reach, in an effort to increase patient enrollment in CR, to reduce morbidity and mortality.
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Affiliation(s)
- Fiorella A Heald
- Faculty of Health, York University, Toronto, Ontario, Canada (Drs Heald and Grace); KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Ontario, Canada (Drs Heald, Santiago de Araújo Pio, Rivera Theurel, and Grace); School of Nursing, Shanghai Jiao Tong University, Shanghai, China (Ms Liu); Department of Cardiac Rehabilitation, Hospital Loire-Vendée-Océan, Machecoul, France (Dr Pavy); and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada (Dr Grace)
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18
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Rangel-Cubillos DM, Vega-Silva AV, Corzo-Vargas YF, Molano-Tordecilla MC, Peñuela-Arévalo YP, Lagos-Peña KM, Jácome-Hortúa AM, Villamizar-Jaimes CJ, Grace SL, Dutra de Souza HC, Angarita-Fonseca A, Sánchez-Delgado JC. Examining Facilitators and Barriers to Cardiac Rehabilitation Adherence in a Low-Resource Setting in Latin America from Multiple Perspectives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19041911. [PMID: 35206100 PMCID: PMC8872241 DOI: 10.3390/ijerph19041911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 01/27/2023]
Abstract
Cardiac rehabilitation (CR) is under-used, particularly in low-resource settings. There are few studies of barriers and facilitators to CR adherence in these settings, particularly considering multiple perspectives. In this multiple-method study, a cross-sectional survey including the Cardiac Rehabilitation Barriers Scale (each item scored on a five-point Likert scale) was administered to patients treated between February and July, 2019, in three CR centers in Colombia. A random subsample of 50 participants was invited to a focus group, along with an accompanying relative. Physiotherapists from the programs were invited to an interview, with a similar interview guide. Audio-recordings were transcribed and analyzed using interpretive description. A total of 210 patients completed the survey, and 9 patients, together with 3 of their relatives and 3 physiotherapists, were interviewed. The greatest barriers identified were costs (mean = 2.8 ± 1.6), distance (2.6 ± 1.6) and transportation (2.5 ± 1.6); the logistical subscale was highest. Six themes were identified, pertaining to well-being, life roles, weather, financial factors, healthcare professionals and health system factors. The main facilitators were encouragement from physiotherapists, relatives and other patients. The development of hybrid programs where patients transition from supervised to unsupervised sessions when appropriate should be considered, if health insurers were to reimburse them. Programs should consider the implications regarding policies of family inclusion.
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Affiliation(s)
- Diana Marcela Rangel-Cubillos
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | - Andrea Vanessa Vega-Silva
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | - Yully Fernanda Corzo-Vargas
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | - Maria Camila Molano-Tordecilla
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | - Yesica Paola Peñuela-Arévalo
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | - Karen Mayerly Lagos-Peña
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | - Adriana Marcela Jácome-Hortúa
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
| | | | - Sherry L. Grace
- Faculty of Health, York University, Toronto, ON M3J 1P3, Canada;
- KITE-Toronto Rehab Institute, & Director of Cardiac Rehabilitation Research, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON M4G 1R7, Canada
| | - Hugo Celso Dutra de Souza
- Laboratory of Physiology and Cardiovascular Physioterapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
- Correspondence: (H.C.D.d.S.); or (J.C.S.-D.)
| | - Adriana Angarita-Fonseca
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
- Université du Québec en Abitibi-Témiscamingue, Rouyn Noranda, QC J9X 5E4, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montreal, QC H2X 0A9, Canada
| | - Juan Carlos Sánchez-Delgado
- Universidad de Santander, Facultad de Ciencias Médicas y de la Salud, Bucaramanga 680003, Colombia; (D.M.R.-C.); (A.V.V.-S.); (Y.F.C.-V.); (M.C.M.-T.); (Y.P.P.-A.); (K.M.L.-P.); (A.M.J.-H.); (A.A.-F.)
- Laboratory of Physiology and Cardiovascular Physioterapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
- Grupo de Investigación Ser Cultura y Movimiento, Universidad Santo Tomás-Bucaramanga, Santander 680001, Colombia
- Correspondence: (H.C.D.d.S.); or (J.C.S.-D.)
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Heald FA, Marzolini S, Colella TJF, Oh P, Nijhawan R, Grace SL. Profile of women choosing mixed-sex, women-only, and home-based cardiac rehabilitation models and impact on utilization. Women Health 2022; 62:98-107. [DOI: 10.1080/03630242.2021.2023247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Fiorella A. Heald
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Susan Marzolini
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tracey J. F. Colella
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Paul Oh
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rajni Nijhawan
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sherry L. Grace
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Borges GLB, da Cruz MMA, Ricci-Vitor AL, da Silva PF, Grace SL, Vanderlei LCM. Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study. SAO PAULO MED J 2022; 140:108-114. [PMID: 35043870 PMCID: PMC9623829 DOI: 10.1590/1516-3180.2020.0782.r1.31052021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/31/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges. OBJECTIVE To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence. DESIGN AND SETTING Observational, cross-sectional study in public and private CR programs offered in Brazil. METHODS Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale. RESULTS From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012). CONCLUSION Publicly funded programs need to be tailored to meet their patients' requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.
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Affiliation(s)
- Giovanna Lombardi Bonini Borges
- PT. Physiotherapist, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
| | - Mayara Moura Alves da Cruz
- PT, MSc. Physiotherapist and Doctoral Student, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
| | - Ana Laura Ricci-Vitor
- PT, PhD. Professor, Escola Superior de Saúde Egas Moniz (ESSEM), Egas Moniz - Cooperativa de Ensino Superior (CRL), Almada, Setúbal, Portugal.
| | - Paula Fernanda da Silva
- PT. Physiotherapist and Master's Student, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
| | - Sherry Lynn Grace
- PhD, CRFC. Professor, Faculty of Health, York University, Toronto, Ontario, Canada; and Senior Scientist, KITE & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Luiz Carlos Marques Vanderlei
- PhD. Professor, Department of Physiotherapy, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil.
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21
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Pogosova NV, Badtieva VA, Ovchinnikova AI, Sokolova OY. [New treatments and technologies in cardiac rehabilitation programs]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2022; 99:50-57. [PMID: 35700376 DOI: 10.17116/kurort20229903150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The article presents a review of literature data reflecting the relevance and modern views on the effectiveness and expediency of using various options for rehabilitation programs for cardiovascular diseases. The issues of the history of the development of cardiac rehabilitation both abroad and in Russia are consecrated. The article also presents alternative models for conducting cardiac rehabilitation, in particular, using remote and telemedicine technologies. The widespread use of smartphones and high-speed Internet access contributed to the further introduction and use of telemedicine technologies in cardiac rehabilitation. The article discusses the possibilities of telerehabilitation of cardiological patients and shows its comparable effectiveness with traditional cardiac rehabilitation.
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Affiliation(s)
- N V Pogosova
- National Medical Research Center of Cardiology, Moscow, Russia
| | - V A Badtieva
- Moscow Scientific-Practical Center of Medical Rehabilitation, Restorative and Sports Medicine, Moscow, Russia
| | - A I Ovchinnikova
- Moscow Scientific-Practical Center of Medical Rehabilitation, Restorative and Sports Medicine, Moscow, Russia
| | - O Yu Sokolova
- National Medical Research Center of Cardiology, Moscow, Russia
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22
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Heald FA, Marzolini S, Colella TJF, Oh P, Nijhawan R, Grace SL. Women's outcomes following mixed-sex, women-only, and home-based cardiac rehabilitation participation and comparison by sex. BMC Womens Health 2021; 21:413. [PMID: 34911506 PMCID: PMC8672337 DOI: 10.1186/s12905-021-01553-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/26/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite women's greater need for cardiac rehabilitation (CR), they are less likely to utilize it. Innovative CR models have been developed to better meet women's needs, yet there is little controlled, comparative data assessing the effects of these models for women. This study compared outcomes in women electing to participate in mixed-sex, women-only, or home-based CR, and a matched sample of men. METHODS In this retrospective study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017 and July 2019 were analyzed; clinical outcomes comprised cardiorespiratory fitness, risk factors and psychosocial well-being. These were assessed at intake and post-6-month program and analyzed using general linear mixed models. RESULTS There were 1181 patients (727 women [74.7% mixed, 22.0% women-only, 3.3% home-based]; 454 age and diagnosis-matched men) who initiated CR; Cardiorespiratory fitness among women was higher at initiation of mixed-sex than women-only (METs 5.1 ± 1.5 vs 4.6 ± 1.3; P = .007), but no other outcome differences were observed. 428 (58.9%) women completed the programs, with few women retained in the home-based model limiting comparisons. There were significant improvements in high-density lipoprotein cholesterol (P = .001) and quality of life (P = .001), and lower depressive symptoms (P = .030) as well as waist circumference (P = .001) with mixed-sex only. VO2peak was significantly higher at discharge in mixed-sex than women-only (estimate = 1.67, standard error = 0.63, 95% confidence interval = 0.43-2.91). CONCLUSION Participation in non-gender-tailored women-only CR was not advantageous as expected. More research is needed, particularly including women participating in home-based programs.
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Affiliation(s)
- Fiorella A Heald
- Faculty of Health, York University, Bethune 368, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Susan Marzolini
- Faculty of Health, York University, Bethune 368, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tracey J F Colella
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Paul Oh
- Faculty of Health, York University, Bethune 368, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Rajni Nijhawan
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Bethune 368, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada.
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada.
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23
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Ohtera S, Kato G, Ueshima H, Mori Y, Nakatani Y, Ozasa N, Nakayama T, Kuroda T. A nationwide survey on participation in cardiac rehabilitation among patients with coronary heart disease using health claims data in Japan. Sci Rep 2021; 11:20096. [PMID: 34635704 PMCID: PMC8505519 DOI: 10.1038/s41598-021-99516-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/22/2021] [Indexed: 11/09/2022] Open
Abstract
Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017-2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6-10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39-2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.
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Affiliation(s)
- Shosuke Ohtera
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.,Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6 Minami, Wako-shi, Saitama, 351-0197, Japan
| | - Genta Kato
- Solutions Center for Health Insurance Claims, Kyoto University Hospital, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Hiroaki Ueshima
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yukiko Mori
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuka Nakatani
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Neiko Ozasa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Tomohiro Kuroda
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Mamataz T, Ghisi GLM, Pakosh M, Grace SL. Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review. BMC Cardiovasc Disord 2021; 21:459. [PMID: 34556036 PMCID: PMC8458788 DOI: 10.1186/s12872-021-02267-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/15/2021] [Indexed: 12/28/2022] Open
Abstract
Background Women do not participate in cardiac rehabilitation (CR) to the same degree as men; women-focused CR may address this. This systematic review investigated the: (1) nature, (2) availability, as well as (3a) utilization of, and (b) satisfaction with women-focused CR. Methods Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception to May 2020. Primary studies of any design were included. Adult females with any cardiac diseases, participating in women-focused CR (i.e., program or sessions included ≥ 50% females, or was 1-1 and tailored to women’s needs) were considered. Two authors rated citations for inclusion. One extracted data, including study quality rated as per the Mixed-Methods Assessment Tool (MMAT), which was checked independently by a second author. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guideline. Results 3498 unique citations were identified, with 28 studies (53 papers) included (3697 women; ≥ 10 countries). Globally, women-focused CR is offered by 40.9% of countries that have CR, with 32.1% of programs in those countries offering it. Thirteen (46.4%) studies offered women-focused sessions (vs. full program), 17 (60.7%) were women-only, and 11 (39.3%) had gender-tailoring. Five (17.9%) programs offered alternate forms of exercise, and 17 (60.7%) focused on psychosocial aspects. With regard to utilization, women-focused CR cannot be offered as frequently, so could be less accessible. Adherence may be greater with gender-tailored CR, and completion effects are not known. Satisfaction was assessed in 1 trial, and results were equivocal. Conclusions Women-focused CR involves tailoring of content, mode and/or sex composition. Availability is limited. Effects on utilization require further study. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02267-0.
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Affiliation(s)
- Taslima Mamataz
- Faculty of Health, York University, Bethune 368, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada.,KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gabriela L M Ghisi
- KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Maureen Pakosh
- Library & Information Services, Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Bethune 368, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada. .,Peter Munk Cardiac Centre, KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada.
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25
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Lee JJ, Ko JY, Lee S. An observational study substantiating the statistical significance of cardiopulmonary exercise with laboratory tests during the acute and subacute phases of center and home-based cardiac rehabilitation. Medicine (Baltimore) 2021; 100:e26861. [PMID: 34397862 PMCID: PMC8341314 DOI: 10.1097/md.0000000000026861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/04/2023] Open
Abstract
Cardiac rehabilitation (CR) can improve clinical indicators in patients with cardiovascular diseases. The literature reports a 20% reduction in all-cause mortality and a 27% reduction in heart-disease mortality following CR. Although its clinical efficacy has been established, there is uncertainty whether center-based (CBCR) is more effective than home-based (HBCR) programs in acute and subacute phases. We aimed to verify significant differences in their effectiveness for the improvement of cardiopulmonary function by analyzing cardiopulmonary exercise (CPX) with laboratory tests following both CR programs.A single-center cohort study of 37 patients, recently diagnosed with underlying cardiovascular diseases, underwent CBCR(18) and HBCR(19). CBCR group performed a supervised exercise regimen at the CR center, for 1 hour, 2 to 3 days a week, for a total of 12 to18 weeks. HBCR group completed a self-monitored exercise program at home under the same guidelines as CBCR. Participants were evaluated by CPX with laboratory tests at 1- and 6-month, following the respective programs.There was no statistical significance in clinical characteristics and laboratory findings. Pre-post treatment comparison showed significant improvement in VO2/kg, minute ventilation/carbon dioxide production slope, breathing reserve, tidal volume (VT), heart rate recovery, oxygen consumption per heart rate, low-density lipoprotein (LDL), LDL/HDL ratio, total cholesterol, ejection fraction (EF) (P < .05). CBCR approach showed greater improvement with significance in VO2/kg, metabolic equivalents, and EF on between groups analysis (P < .05).The time effect of CPX test and laboratory data showed improvement in cardiopulmonary function and serum indicators for both groups. VO2/kg, metabolic equivalents, and EF were among the variables that showed significant differences between groups. In the acute and subacute phases of 1 to 6 months, the CBCR group showed a greater cardiac output improvement than the HBCR group.
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Abstract
PURPOSE OF REVIEW Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. RECENT FINDINGS ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.
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Affiliation(s)
- Sherry L Grace
- Faculty of Health, York University, 4700 Keele Street, Toronto, Canada. .,KITE-Toronto Rehabilitation Institute, Toronto, ON, Canada. .,Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Kornelia Kotseva
- National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland.,Imperial College Healthcare NHS Trust, London, UK
| | - Mary A Whooley
- US Department of Veterans Affairs Quality Enhancement Research Initiative, San Francisco, USA.,University of California, San Francisco, USA
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27
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Liu X, Fowokan A, Grace SL, Ding B, Meng S, Chen X, Xia Y, Zhang Y. Translation, Cross-Cultural Adaptation, and Psychometric Validation of the Chinese/Mandarin Cardiac Rehabilitation Barriers Scale (CRBS-C/M). Rehabil Res Pract 2021; 2021:5511426. [PMID: 34239731 PMCID: PMC8233091 DOI: 10.1155/2021/5511426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Cardiovascular diseases are among the leading causes of morbidity in China and around the world. Cardiac rehabilitation (CR) effectively mitigates this burden; however, utilization is low. CR barriers in China have not been well characterized; this study sought to translate, cross-culturally adapt, and psychometrically validate the CR Barriers Scale in Chinese/Mandarin (CRBS-C/M). METHODS Independent translations of the 21-item CRBS were conducted by two bilingual health professionals, followed by back-translation. A Delphi process was undertaken with five experts to consider the semantics and cross-cultural relevance of the items. Following finalization, 380 cardiac patients from 11 hospitals in Shanghai were administered a validation survey including the translated CRBS. Following exploratory and confirmatory factor analysis, internal consistency was assessed. Validity was tested through assessing the association of the CRBS-C/M with the CR Information Awareness Questionnaire. RESULTS Items were refined and finalized. Factor analysis of CRBS-C/M (Kaiser Meyer Olkin = 0.867, Bartlett's test p < 0.001) revealed five factors: perceived CR need, external logistical factors, time conflicts, program and health system-level factors, and comorbidities/lack of vitality; Cronbach's alpha (α) of the subscales ranged from 0.67 to 0.82. The mean total CRBS score was significantly lower in patients who participated in CR compared with those who did not, demonstrating criterion validity (2.35 ± 0.71 vs. 3.08 ± 0.55; p < 0.001). Construct validity was supported by the significant associations between total CRBS scores and CR awareness, sex, living situation, city size, income, diagnosis/procedure, disease severity, and several risk factors (all p < 0.05). CONCLUSIONS CRBS-C/M is reliable and valid, so barriers can be identified and mitigated in Mandarin-speaking patients.
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Affiliation(s)
- Xia Liu
- Shanghai Jiao Tong University School of Nursing, Shanghai, China
| | - Adeleke Fowokan
- KITE & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sherry L. Grace
- KITE & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Biao Ding
- Shanghai Sixth People's Hospital, Shanghai, China
| | - Shu Meng
- Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiu Chen
- Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yinghua Xia
- Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yaqing Zhang
- Shanghai Jiao Tong University School of Nursing, Shanghai, China
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28
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Buckley JP. The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management. Disabil Rehabil 2021; 43:3515-3522. [PMID: 33989103 DOI: 10.1080/09638288.2021.1921062] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM This paper aims to demonstrate how the rationale and delivery of cardiac rehabilitation (CR), in those countries with long term established standards of practice, has changed over the past eight decades. METHODS A narrative report based on the evolution of key published guidelines, systematic reviews and medical policies since the 1940s. RESULTS Case reports of the value of exercise in cardiac disease can be dated back to 1772. Formative groundwork for exercise-based CR was published between 1940 and 1970. However, it was not until the late 1980s that a large enough data set of controlled trials was available to show significant reductions in premature all-cause and cardiac mortality. Since the mid 1990s, cardiac mortality has been greatly reduced due to enhanced public health, emergency care and more sensitive diagnostic techniques and aggressive treatments. As a result, there appears to be an associated reduced potency of CR to affect mortality. New rationales for why, how and where CR is delivered have emerged including: adapting to a longer surviving ageing multi-morbid population, where healthcare cost savings and quality of life have become increasingly important. CONCLUSIONS In light of these results, an emerging focus for CR, and in some cases "pre-habilitation", is that of a chronic disability management programme increasingly delivered in community and home settings. Within this delivery model, the use of remote personalised technologies is now emerging, especially with new needs accelerated by the pandemic of COVID-19. IMPLICATIONS FOR REHABILITATIONWith continued advances in medical science and better long term survival, the nature of cardiac rehabilitation has evolved over the past eight decades. It was originally an exercise-focused intervention on short term recovery and reducing cardiac and all-cause mortality, to now being one part of a multi-factor lifestyle, behavioural, and medical chronic disease management programme.Throughout history, the important influence of psycho-social well-being and human behaviour has, however, always been of key importance to patients.The location of rehabilitation can now be suited to patient need, both medically and socially, where the same components can be delivered in either a traditional outpatient clinic, community settings, at home and more recently all of these being supported or augmented with the advent of mobile technology.
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Affiliation(s)
- John P Buckley
- Centre for Active Living, University Centre Shrewsbury/University of Chester, Chester, UK
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da Cruz MMA, Ricci-Vitor AL, Borges GLB, da Silva PF, Turri-Silva N, Takahashi C, Grace SL, Vanderlei LCM. A Randomized, Controlled, Crossover Trial of Virtual Reality in Maintenance Cardiovascular Rehabilitation in a Low-Resource Setting: Impact on Adherence, Motivation, and Engagement. Phys Ther 2021; 101:6146373. [PMID: 33625515 DOI: 10.1093/ptj/pzab071] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 11/26/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the effects of adding virtual reality (VR) to maintenance cardiac rehabilitation (CR); it was hypothesized VR would increase adherence, motivation, and engagement. METHODS This study was a randomized, 1:1 concealed-allocation, single-blinded, 2 parallel-arm, crossover trial. Blinded assessments were undertaken at baseline (midprogram), 12 weeks, and 24 weeks after baseline. The setting was a single CR program of unlimited duration in Brazil. Participants were patients with cardiovascular diseases or risk factors who had been in the program for 3 months or longer. The CR program consisted of 3 supervised exercise sessions per week. In the VR arm, participants had 1 VR session of the 3 per week during the initial 12 weeks of the trial; this was withdrawn the subsequent 12 weeks. Measures were program adherence (% of 3 sessions/week over 12 weeks, ascertained in all participants), motivation (Behavioral Regulation in Exercise Questionnaire 3), and engagement (User Engagement Scale, adapted; vigor, dedication, and absorption subscales); all 3 were primary outcomes. RESULTS Sixty-one (83.6%) patients were randomly assigned (n = 30 to CR + VR); 54 (88.5%) were retained at 12 and 24 weeks. At baseline, participants had been in CR on average 7 years and had high engagement and motivation. CR + VR resulted in a significant increase in adherence at 12 weeks (baseline = 72.87%; 12 weeks = 82.80%), with significant reductions at 24 weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time. There was a significant effect for arm, with significantly higher adherence in the CR + VR arm than usual CR at 12 weeks (73.51%). Motivation decreased significantly from baseline to 12 weeks (4.32 [SD = 0.37] vs 4.02 [SD = 0.76]) and significantly increased from 12 to 24 weeks in the CR + VR arm (4.37 [SD = 0.36]). Absorption was significantly lower at 12 weeks in the CR + VR arm (6.79 [SD = 0.37] vs 6.20 [SD = 1.01]). CONCLUSION Although VR increased program adherence, interspersing it with usual CR sessions actually decreased patient motivation and absorption. IMPACT Supplementing a maintenance CR program with VR using "exergames" resulted in significantly greater adherence (8% increase or 3 of 36 sessions), and this was quite a robust effect given it was extinguished with the removal of VR. However, contrary to the hypotheses, offering 1 session of VR per week and 2 of usual CR exercise was related to lower motivation and absorption, which has implications for how clinicians design programs for this patient population.
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Affiliation(s)
- Mayara Moura Alves da Cruz
- Department of Physiotherapy, São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
| | - Ana Laura Ricci-Vitor
- Department of Physiotherapy, São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
| | - Giovanna Lombardi Bonini Borges
- Department of Physiotherapy, São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
| | - Paula Fernanda da Silva
- Department of Physiotherapy, São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
| | | | - Carolina Takahashi
- Department of Physiotherapy, São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
| | - Sherry L Grace
- Department of Physiotherapy, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Luiz Carlos Marques Vanderlei
- Department of Physiotherapy, São Paulo State University (UNESP), School of Technology and Sciences, Presidente Prudente, Brazil
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Regan EW, Handlery R, Stewart JC, Pearson JL, Wilcox S, Fritz S. Feasibility of integrating survivors of stroke into cardiac rehabilitation: A mixed methods pilot study. PLoS One 2021; 16:e0247178. [PMID: 33780477 PMCID: PMC8007047 DOI: 10.1371/journal.pone.0247178] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 02/02/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Survivors of stroke are often deconditioned and have limited opportunities for exercise post-rehabilitation. Cardiac Rehabilitation (CR), a structured exercise program offered post-cardiac event in the United States (U.S.), may provide an opportunity for continued exercise. The purpose of this study was to examine the feasibility of integrating survivors of stroke into an existing, hospital-based CR program through an assessment of (1) recruitment, uptake and retention, (2) adherence and fidelity, (3) acceptability and (4) safety. METHODS A mixed methods design combined a single group, pre-post design, pilot feasibility study with an imbedded qualitative inquiry. Survivors of stroke were recruited into a standard 12-week, 36 visit CR program. RESULTS Fifty-three survivors were referred, 29 started and 24 completed the program. Program uptake rate was 55% and completion rate was 83%. Eleven completers and one non-completer participated in the qualitative interviews. Program completers attended an average of 25.25 (SD 5.82) sessions with an average of 38.93 (SD 5.64) exercise minutes per session while reaching targeted rate of perceived exertion levels. Qualitative themes included perceived benefits of an individualized program in a group setting, positive interactions with qualified staff, opportunities for socialization, and regular monitoring and staff attentiveness promoting feelings of safety. CONCLUSIONS Survivors of stroke were able to meet Medicare standard dosage (frequency and session duration) and rate of perceived intensity goals, and perceived the program as needed regardless of their mobility limitations or previous exercise experience. Primary challenges included managing referrals and uptake. Results support feasibility and benefit for survivors to integrate into U.S. CR programs.
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Affiliation(s)
- Elizabeth W. Regan
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, United States of America
| | - Reed Handlery
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, United States of America
| | - Jill C. Stewart
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, United States of America
| | - Joseph L. Pearson
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
| | - Sara Wilcox
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, United States of America
| | - Stacy Fritz
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, United States of America
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Winnige P, Vysoky R, Dosbaba F, Batalik L. Cardiac rehabilitation and its essential role in the secondary prevention of cardiovascular diseases. World J Clin Cases 2021; 9:1761-1784. [PMID: 33748226 PMCID: PMC7953385 DOI: 10.12998/wjcc.v9.i8.1761] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/18/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases are the most common causes of mortality worldwide. They are frequently the reasons for patient hospitalization, their incapability for work, and disability. These diseases represent a significant socio-economic burden affecting the medical system as well as patients and their families. It has been demonstrated that the etiopathogenesis of cardiovascular diseases is significantly affected by lifestyle, and so modification of the latter is an essential component of both primary and secondary prevention. Cardiac rehabilitation (CR) represents an efficient secondary prevention model that is especially based on the positive effect of regular physical activity. This review presents an overview of basic information on CR with a focus on current trends, such as the issue of the various training modalities, utilization, and barriers to it or the use of telemedicine technologies. Appropriate attention should be devoted to these domains, as CR continues evolving as an effective and readily available intervention in the future.
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Affiliation(s)
- Petr Winnige
- Department of Public Health, Faculty of Medicine, Masaryk University, Czech Republic, Brno 62500, Jihomoravsky, Czech Republic
- Department of Rehabilitation, University Hospital Brno, Brno 62500, Czech Republic
| | - Robert Vysoky
- Department of Public Health, Faculty of Medicine, Masaryk University, Czech Republic, Brno 62500, Jihomoravsky, Czech Republic
- Department of Health Promotion, Faculty of Sports Studies, Masaryk University, Brno 62500, Jihomoravsky, Czech Republic
| | - Filip Dosbaba
- Department of Rehabilitation, University Hospital Brno, Brno 62500, Czech Republic
| | - Ladislav Batalik
- Department of Rehabilitation, University Hospital Brno, Brno 62500, Czech Republic
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Regan EW, Handlery R, Stewart JC, Pearson JL, Wilcox S, Fritz S. Integrating Survivors of Stroke Into Exercise-Based Cardiac Rehabilitation Improves Endurance and Functional Strength. J Am Heart Assoc 2021; 10:e017907. [PMID: 33499647 PMCID: PMC7955427 DOI: 10.1161/jaha.120.017907] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Cardiac rehabilitation (CR) is a structured exercise program prevalent in the United States for people with cardiovascular disease that has been shown to increase cardiovascular endurance and improve quality of life. Despite similar cardiovascular risk factors, stroke is not among the covered diagnoses for CR. The purpose of this study was to examine the participant impact of integrating survivors of stroke into the exercise portion of an existing hospital‐based CR program through measures of physical function and other health impacts and through qualitative evaluation of participant perception. Methods and Results Subacute and chronic survivors of stroke were integrated into a standard 12‐week, 3 sessions per week, exercise‐based CR program. A total of 29 began the program, 24 completed the program, and 18 were available for 6‐month follow‐up. Quantitative measures were compared preprogram with postprogram with t‐test or equivalent, and preprogram with postprogram to 6‐month follow‐up with ANOVA or equivalent. Semistructured interviews were completed with 11 participants postprogram. Exercise‐based CR had significant impacts on cardiovascular endurance preprogram to postprogram, with maintenance at 6‐month follow‐up. The participants improved on the 6‐minute walk test on average by 61.92 m(95% CI, 33.99–89.84 m), and maximum metabolic equivalents improved by a median of 3.6 (interquartile range, 2.35). Five times sit to stand (functional strength) improved preprogram to postprogram by a median of 2.85 s (interquartile range, 4.03 s). Qualitative findings highlight additional health improvements. Most participants (83% [15/18]) reported continued exercise at follow‐up. Conclusions Exercise‐based CR has the potential to improve cardiovascular endurance, health status, and quality of life for survivors of stroke. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03706105.
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Affiliation(s)
| | - Reed Handlery
- Exercise Science University of South Carolina Columbia SC
| | - Jill C Stewart
- Exercise Science University of South Carolina Columbia SC
| | - Joseph L Pearson
- Health Promotion, Education and Behavior University of South Carolina Columbia SC
| | - Sara Wilcox
- Exercise Science University of South Carolina Columbia SC
| | - Stacy Fritz
- Exercise Science University of South Carolina Columbia SC
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More Evidence of Comprehensive Cardiac Rehabilitation Benefits, Even for All-Cause Mortality: Need to Increase Use Worldwide. Can J Cardiol 2021; 37:19-21. [DOI: 10.1016/j.cjca.2020.02.087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 01/13/2023] Open
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Lion A, Tchicaya A, Theisen D, Delagardelle C. Association between a national public health campaign for physical activity for patients with chronic diseases and the participation in Phase III cardiac rehabilitation in Luxembourg. IJC HEART & VASCULATURE 2020; 32:100691. [PMID: 33364335 PMCID: PMC7753148 DOI: 10.1016/j.ijcha.2020.100691] [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: 08/12/2020] [Revised: 11/18/2020] [Accepted: 11/28/2020] [Indexed: 11/30/2022]
Abstract
National public health campaign may increase participation to Phase III cardiac rehabilitation. National public health campaign increases visibility of a website displaying the Phase III cardiac rehabilitation. A more integrated and synergized strategic approach may help to sensitize the patients.
Background A 2-stage national campaign promoting physical activity for patients with chronic diseases (including cardiovascular disease) was implemented in the Grand-Duchy of Luxembourg in 2018. The first stage consisted of national TV and radio advertisements broadcasted from June 15, 2018 to July 29, 2018. The second stage was a promotional mail sent to all medical doctors on September 3, 2018. This study investigated the association between this campaign and the participation of cardiac patients in Phase III cardiac rehabilitation as well as the visibility of a dedicated website (www.sport-sante.lu). Methods The daily numbers of participants in the classes of the Phase III cardiac rehabilitation and the visits on www.sport-sante.lu were collected from January 1, 2016 to December 31, 2018. Segmented regression analysis was used to assess the association between the promotional campaign and the participation in the Phase III cardiac rehabilitation as well as the website visibility. Results The baseline participation rate, which was 30 participants/day, increased temporarily by 11 (p = 0.0267) and 18 (p = 0.0030) participants/day after the first and second stages of the campaign, respectively. The baseline visit rate on www.sport-sante.lu, which was 12 visits/day, increased temporarily by 20 (p < 0.0001) and 15 (p = 0.0002) visits/day after the first and second stages of the campaign, respectively. Conclusions The national public health campaign was associated with a limited increased participation in the Phase III cardiac rehabilitation and the website visibility. However, no conclusion can be drawn about causality due to the long and difficult process from health promotion to patient’s behavior change.
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Affiliation(s)
- Alexis Lion
- Fédération Luxembourgeoise des Associations de Sport de Santé, L-1445 Strassen, Luxembourg.,Association Luxembourgeoise des Groupes Sportifs pour Cardiaques, L-1445 Strassen, Luxembourg.,Luxembourg Institute of Research in Orthopedics, Sports Medicine and Science, L-1460 Luxembourg, Luxembourg
| | - Anastase Tchicaya
- Luxembourg Institute of Socio-Economic Research, Department Living Conditions, L-4366 Esch-sur-Alzette, Luxembourg
| | - Daniel Theisen
- ALAN Maladies Rares Luxembourg, L-4959 Bascharage, Luxembourg
| | - Charles Delagardelle
- Fédération Luxembourgeoise des Associations de Sport de Santé, L-1445 Strassen, Luxembourg.,Association Luxembourgeoise des Groupes Sportifs pour Cardiaques, L-1445 Strassen, Luxembourg.,Luxembourg Institute of Research in Orthopedics, Sports Medicine and Science, L-1460 Luxembourg, Luxembourg.,Department of Cardiology, Centre Hospitalier du Luxembourg, L-1210 Luxembourg, Luxembourg
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Chia KSW, Brown K, Kotlyar E, Wong PKK, Faux SG, Shiner CT. 'Tired, afraid, breathless … .' An international survey of the exercise experience for people living with pulmonary hypertension. Pulm Circ 2020; 10:2045894020968023. [PMID: 33240490 PMCID: PMC7675876 DOI: 10.1177/2045894020968023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/30/2020] [Indexed: 12/21/2022] Open
Abstract
Patients with pulmonary hypertension are more sedentary than the general population, but attitudes and experiences that may influence their exercise behaviour remain poorly understood. This study identified patterns of behaviour, attitudes towards exercise, barriers and enablers of exercise for people living with pulmonary hypertension. Accessibility of rehabilitation services from a patient perspective was also explored. A voluntary, international survey of people living with pulmonary hypertension was conducted, with mixed quantitative and qualitative data collection. Data from 187 participants in 19 countries were included in the analyses. In total, 52% (95/183) of people with pulmonary hypertension reported that they attempted to engage in regular physical activity. This was less than the proportion who did so prior to diagnosis (61%, 112/184, p = 0.006) and was accompanied by uncertainty and anxiety about exercise. In total, 63% (113/180) of the cohort reported experiencing previous adverse events while exercising, which was associated with a greater likelihood of ongoing exercise concerns and anxiety. Fear, frustration and uncertainty about exercise were noted as common barriers to engaging in exercise with pulmonary hypertension. Other barriers to exercise included intrinsic factors such as debilitating breathlessness and fatigue, and external factors such as cost and access to appropriate services. Most respondents (76%, 128/169) did not have access to a multi-disciplinary rehabilitation service, although an overwhelming majority (92%, 159/172) reported that this would be helpful. Respondents rated education; a supervised, structured exercise programme; and psychology input as the most important components of a multi-disciplinary rehabilitation service for pulmonary hypertension. Health professionals must work together with consumers to co-design rehabilitation services that will facilitate exercise and increased activity for people living with pulmonary hypertension.
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Affiliation(s)
- Karen S W Chia
- Department of Rehabilitation, St Vincent's Hospital Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Karen Brown
- Department of Cardiology, St Vincent's Hospital Sydney, NSW, Australia
| | - Eugene Kotlyar
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Cardiology, St Vincent's Hospital Sydney, NSW, Australia
| | - Peter K K Wong
- Department of Rheumatology, Western Sydney Local Health District, Westmead, NSW, Australia.,UNSW Rural Clinical School, Coffs Harbour, NSW, Australia
| | - Steven G Faux
- Department of Rehabilitation, St Vincent's Hospital Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christine T Shiner
- Department of Rehabilitation, St Vincent's Hospital Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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Driscoll A, Hinde S, Harrison A, Bojke L, Doherty P. Estimating the health loss due to poor engagement with cardiac rehabilitation in Australia. Int J Cardiol 2020; 317:7-12. [PMID: 32376418 DOI: 10.1016/j.ijcard.2020.04.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/07/2020] [Accepted: 04/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac rehabilitation (CR) programs are effective in reducing cardiovascular mortality and readmissions. However, most patients are denied the benefits of CR due to low referral rates. Of those patients referred, commencement rates vary from 28.4% to 60%. This paper quantifies the scale of health loss in Australia due to poor engagement with the program, and estimates how much public funding can be justifiably reallocated to address the problem. METHODS Economic decision modelling was undertaken to estimate the expected lifetime health loss and costs to Medicare. Key parameters were derived from Australian databases, CR registries and meta-analyses. Population health gains associated with uptake rates of 60%, and 85% were calculated. RESULTS CR was associated with a 99.9% probability of being cost-effective, even at a cost-effectiveness threshold lower than conventionally applied. Importantly, an average of 0.52 years of life expectancy are lost due to national uptake being below 60% achieved in some best performing programs in Australia, equivalent to 0.28 quality adjusted life years. The analysis indicates that $12.9 million/year could be justifiably reallocated from public funds to achieve a national uptake rate of 60%, while maintaining cost-effectiveness of CR due to the large health gains that would be expected. CONCLUSION CR is a cost-effective service for patients with coronary heart disease. In Australia, less than a third of patients commence CR, potentially resulting in avoidable patient harm. Additional investment in CR is vital and should be a national priority as the health gains for patients far outweigh the costs.
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Affiliation(s)
- A Driscoll
- Deakin University, School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, VIC 3220, Australia.; Austin Health, Dept of Cardiology, Studley Rd, Heidelberg, VIC 3081, Australia.
| | - S Hinde
- University of York, Centrefor Health Economics, Alcuin A Block, Heslington, York, YO105DD, UK
| | - A Harrison
- University of York, Department of Health Sciences, Seebohm Rowntree Building, Heslington, York YO105DD, UK
| | - L Bojke
- University of York, Centrefor Health Economics, Alcuin A Block, Heslington, York, YO105DD, UK
| | - P Doherty
- University of York, Department of Health Sciences, Seebohm Rowntree Building, Heslington, York YO105DD, UK
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Ghanbari-Firoozabadi M, Mirzaei M, Vafaii Nasab M, Grace SL, Okati-Aliabad H, Madadizadeh F, Dadras H, Amrolahi N, Entezari M, Sadrbafghi SM. Cross-cultural adaptation and psychometric validation of the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P). BMJ Open 2020; 10:e034552. [PMID: 32565454 PMCID: PMC7311040 DOI: 10.1136/bmjopen-2019-034552] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES This study aimed to translate, cross-culturally adapt and psychometrically validate a Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P) and to identify the main barriers in an Iranian setting. SETTING Afshar cardiac rehabilitation (CR) centre, affiliated with the Yazd University of Medical Sciences, in the centre of Iran. DESIGN This was a multimethod study, culminating in a cross-sectional survey. PARTICIPANTS Inpatient CR graduates who did not attend their initial outpatient CR appointment. METHOD The 21-item CRBS was translated and cross-culturally adapted in accordance with best practices; an expert panel considered the items and previous non-attending patients were interviewed via phone to refine the scale. Next, structural validity was assessed; participants were invited to complete the CRBS on the phone between March 2017 and February 2018. Using exploratory factor analysis (EFA) with principal component analysis extraction and oblique rotation. Second, confirmatory factor analysis (CFA) was used to verify the results; several goodness-of-fit indices were considered. The internal consistency and 3-week test-retest reliability of the scale (5% subsample) were evaluated using Cronbach's α and intraclass correlation (ICC), respectively. RESULTS Face, content and cross-cultural validity were established by the experts and patients (n=50). One thousand and one hundred (40.7%) of the 2700 patients completed the CRBS-P. Structural validity was established by EFA (Bartlett's test p<0.001; =0.759) and confirmed by the CFA; a four-factor solution with 18 items accounting for 61.256% of variance had the best fit (χ2/df=3.206, root mean square error of approximation=0.061 and Comparative Fit Index=0.959). The internal consistency and test-retest reliability (n=42) of the scale were acceptable (ICC=0.743 95% CI (0.502 to 0.868); overall α=0.797). The top barriers were not knowing about CR, cost and lack of encouragement from physicians. CONCLUSION The four-factor, 18-item CRBS-P had good psychometric properties, and hence can be reliably and validly used to measure CR barriers in Iran and other Persian-speaking populations.
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Affiliation(s)
| | - Masoud Mirzaei
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Sherry L Grace
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Hassan Okati-Aliabad
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Farzan Madadizadeh
- Research Center of Prevention and Epidemiology of Non-Communicable Disease, Departments of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hakimeh Dadras
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Najmeh Amrolahi
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohamadmehdi Entezari
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation. Glob Heart 2020; 15:28. [PMID: 32489801 PMCID: PMC7218762 DOI: 10.5334/gh.783] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Cardiac rehabilitation (CR) is recommended in clinical practice guidelines for comprehensive secondary prevention. While India has a high burden of cardiovascular diseases (CVD), availability and nature of services delivered there is unknown. In this study, we undertook secondary analysis of the Indian data from the global CR audit and survey, conducted by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR). Methods In this cross-sectional study, an online survey was administered to CR programs, identified in India by CR champions and through snowball sampling. CR density was computed using Global Burden of Disease study ischemic heart disease (IHD) incidence estimates. Results Twenty-three centres were identified, of which 18 (78.3%) responded, from 3 southern states. There was only one spot for every 360 IHD patients/year, with 3,304,474 more CR spaces needed each year. Most programs accepted guideline-indicated patients, and most of these patients paid out-of-pocket for services. Programs were delivered by a multidisciplinary team, including physicians, physiotherapists, among others. Programs were very comprehensive. Apart from exercise training, which was offered across all centers, some centers also offered yoga therapy. Top barriers to delivery were lack of patient referral and financial resources. Conclusions Of all countries in ICCPR's global audit, the greatest need for CR exists in India, particularly in the North. Programs must be financially supported by government, and healthcare providers trained to deliver it to increase capacity. Where CR did exist, it was generally delivered in accordance with guideline recommendations. Tobacco cessation interventions should be universally offered.
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Wakefield BJ, Drwal K, Paez M, Grover S, Franciscus C, Reisinger HS, Kaboli PJ, El Accaoui R. Creating and disseminating a home-based cardiac rehabilitation program: experience from the Veterans Health Administration. BMC Cardiovasc Disord 2019; 19:242. [PMID: 31694570 PMCID: PMC6833278 DOI: 10.1186/s12872-019-1224-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 10/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) programs provide significant benefit for people with cardiovascular disease. Despite these benefits, such services are not universally available. We designed and evaluated a national home-based CR (HBCR) program in the Veterans Health Administration (VHA). The primary aim of the study was to examine barriers and facilitators associated with site-level implementation of HBCR. METHODS This study used a convergent parallel mixed-methods design with qualitative data to analyze the process of implementation, quantitative data to determine low and high uptake of the HBCR program, and the integration of the two to determine which facilitators and barriers were associated with adoption. Data were drawn from 16 VHA facilities, and included semi-structured interviews with multiple stakeholders, document analysis, and quantitative analysis of CR program attendance codes. Qualitative data were analyzed using the Consolidated Framework for Implementation Research codes including three years of document analysis and 22 interviews. RESULTS Comparing high and low uptake programs, readiness for implementation (leadership engagement, available resources, and access to knowledge and information), planning, and engaging champions and opinion leaders were key to success. High uptake sites were more likely to seek information from the external facilitator, compared to low uptake sites. There were few adaptations to the design of the program at individual sites. CONCLUSION Consistent and supportive leadership, both clinical and administrative, are critical elements to getting HBCR programs up and running and sustaining programs over time. All sites in this study had external funding to develop their program, but high adopters both made better use of those resources and were able to leverage existing resources in the setting. These data will inform broader policy regarding use of HBCR services.
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Affiliation(s)
- Bonnie J Wakefield
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA. .,The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.
| | - Kariann Drwal
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Monica Paez
- The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Sara Grover
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Carrie Franciscus
- The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Heather Schacht Reisinger
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Peter J Kaboli
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Ramzi El Accaoui
- The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
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