Cardiac rehabilitation services in Denmark: Still room for expansion

A comprehensive review: role of smokeless tobacco consumption as a risk factor for diabetes mellitus

The extensive use of smokeless tobacco and the worldwide occurrence of diabetes mellitus (DM) poses significant public health obstacles. A comprehensive review of the literature was undertaken to assess epidemiological research, clinical trials, and meta-analyses that examine the link between smokeless tobacco use and DM. The key results indicate that the biological constituents of smokeless tobacco may interfere with the process of glucose metabolism and lead to an increase in insulin resistance. An association between consumption levels and diabetes risk is evident, with higher levels of usage being positively correlated with an increased chance of developing diabetes. Smokeless tobacco usage is identified as a significant risk factor for DM. This highlights the need to implement focused public health initiatives and policies aimed at decreasing the usage of smokeless tobacco and its influence on the incidence of diabetes. Future research should prioritize elucidating the processes behind this correlation and developing efficacious preventative methods to mitigate the worldwide burden of diabetes.

Cardiac rehabilitation for patients with heart failure: association with readmission and mortality risk

AIMS

To examine the temporal trends and factors associated with national cardiac rehabilitation (CR) referral and compare the risk of hospital readmission and mortality in those referred for CR versus no referral.

METHODS AND RESULTS

This cohort study includes all adult patients alive 120 days from incident heart failure (HF) identified by the Danish Heart Failure Registry (n = 33 257) between 2010 and 2018. Multivariable logistic regression models were used to assess the association between CR referral and patient factors and acute all-cause hospital readmission and mortality at 1 year following HF admission. Overall, 46.7% of HF patients were referred to CR, increasing from 31.7% in 2010 to 52.2% in 2018. Several factors were associated with lower odds of CR referral: male sex [odds ratio (OR): 0.85; 95% confidence interval: 0.80-0.89], older age, unemployment, retirement, living alone, non-Danish ethnic origin, low educational level, New York Heart Association (NYHA) class IV vs. I (OR: 0.75; 0.60-0.95), left ventricular ejection fraction >40%, and comorbidity (stroke, chronic kidney disease, atrial fibrillation/flutter, and diabetes). Myocardial infarction, arthritis, coronary artery bypass grafting, percutaneous coronary intervention, valvular surgery, NYHA class II, and use of angiotensin-converting enzyme inhibitors were associated with higher odds of CR referral. CR referral was associated with lower risk of acute all-cause readmission (OR: 0.92; 0.87-0.97) and all-cause mortality (OR: 0.65; 0.58-0.72).

CONCLUSION

Although increased over time, only one in two HF patients in Denmark were referred to CR in 2018. Strategies are needed to reduce referral disparities, focusing on subgroups of patients at highest risk of non-referral.

What are the prevalence and predictors of psychosocial healthcare among patients with heart disease? A nationwide population-based cohort study

OBJECTIVES

Psychosocial healthcare is recommended, but little is known about how patients perceive the level of care and whether subgroups of patients experience less psychosocial healthcare than others. We examined the prevalence of patient-reported psychosocial healthcare and factors predicting patient-reported lack of psychosocial healthcare among patients with heart disease.

DESIGN

A cohort study.

SETTING

Denmark, nationwide.

PARTICIPANTS

A registry-based random sample of 5000 patients with incident heart disease in 2013.

MEASURES

Patient-reported psychosocial healthcare was obtained from a survey and potential predictors before disease onset from registries. We used multivariable logistic regression analysis to determine predictors of patient-reported lack of care.

RESULTS

We received responses from 56%; 40% reported lacking information on psychosocial aspects, 51% lacking psychosocial rehabilitation and support and 32% reported lacking both types of psychosocial healthcare. The type of heart disease was the strongest predictor of patient-reported lack of psychosocial healthcare, especially among patients with atrial fibrillation (OR: 3.11-3.98). Older age (OR: 1.48-2.05), female gender (OR: 1.27-1.53) and no contact with general practitioner (OR: 1.47-1.84) also predicted patient-reported lack of psychosocial healthcare. Patients outside the labour force (OR: 1.29) and living in the capital region (OR: 1.50) more frequently reported lacking psychosocial rehabilitation and support, and patients with recent (OR: 1.63) or past (OR: 1.33) anxiety or depression and severe comorbidities (OR: 1.34) more frequently reported lacking both types of psychosocial healthcare.

CONCLUSIONS

Many patients with heart disease reported lacking psychosocial healthcare. Importantly, patients who most need psychosocial healthcare are not those who report receiving it. Our results call for action to translate guidelines into clinical practice.

A Systematic Review and Meta-analysis on the Prevalence of Smoking Cessation in Cardiovascular Patients After Participating in Cardiac Rehabilitation

Smoking is the most important modifiable cardiovascular risk factor causes around approximately one of every 4 cardiovascular-related deaths worldwide. Cardiac rehabilitation (CR) is the standard way of management of heart diseases after myocardial infraction. This study aimed to determine the prevalence of cardiovascular patients' quit smoking after participation in CR. PubMed, EMBASE, Web of Science, Scopus, and google scholar were searched systematically. In total, 18 studies were analyzed. Results showed that the mean age of smokers' were 54.80 (52.06, 57.55), and of them 53 % (22%, 83%) quit smoking after participating in CR. Subgroup analysis showed that among type of CR the most effective one was the educational along with physical exercise (comprehensive CR) cause 99% (98%, 100%) smoking cessation (SC). Group-based methods with76% (57%, 94%) of quitters showed to be more effective than individual-based. It can be concluded that CR has been effective in terms of smoking cessation.

Are survivors of cardiac arrest provided with standard cardiac rehabilitation? - Results from a national survey of hospitals and municipalities in Denmark

AIM

To quantify the provision of standard cardiac rehabilitation to Danish survivors of cardiac arrest at a programme level, and to analyse whether organizational factors influenced the provision.

METHOD

We mapped the provision of cardiac rehabilitation core components to survivors of cardiac arrest and compared this with a reference group of patients after acute myocardial infarction using data from a cross-sectional programme-level survey among all hospitals (n = 34) and municipalities (n = 98) in Denmark. Organizational factors of potential importance to service provision were considered: health care region, size of catchment area/population, type of department/municipality and socioeconomic index.

RESULTS

Response rates for the provision of each core component of cardiac rehabilitation ranged from 64% to 98%. All hospitals and municipalities provided some aspect of cardiac rehabilitation to survivors of cardiac arrest. Across hospitals, provision of four core components of cardiac rehabilitation to survivors of cardiac arrest was lower compared with post acute myocardial infarction patients: patient education (relative risk (RR) = 0.45 (95% confidence interval (CI) 0.27 to 0.75)), exercise training (RR = 0.69 (95% CI 0.49 to 0.98)), screening for anxiety and depression (RR = 0.64 (95% CI 0.46 to 0.90) and nutritional counselling RR = 0.76 (95% CI 0.62 to 0.93)). No difference was found in the provision of core components across municipalities. Overall, the provision of cardiac rehabilitation to survivors of cardiac arrest was not affected by organizational factors.

CONCLUSION

This study indicates a need for future research to inform the development, adoption and implementation of equal access to all components of cardiac rehabilitation for survivors of cardiac arrest in Denmark.

Dietary interventions in cardiac rehabilitation - The gap between guidelines and clinical practice

BACKGROUND & AIMS

An unhealthy diet is a risk factor for ischemic heart disease (IHD) and therefore cardiac rehabilitation (CR) should include dietary interventions. In 2007, CR became a shared responsibility between Danish hospitals and municipalities. Later, a national clinical guideline including recommendations on dietary interventions was developed to facilitate implementation of CR. The aim of the present study is: 1) To describe provision of dietary interventions in CR for IHD patients in Denmark in 2013 and 2015 emphasizing differences between hospitals and municipalities, and 2) To evaluate the implementation of the national clinical guideline in clinical practice.

METHODS

A repeated nationwide cross-sectional electronic survey was carried out in 2013 and 2015. Participation was mandatory for all Danish hospital departments offering CR (n = 36), but voluntary for municipalities (n = 98) reaching response rates of 82% and 89% in 2013 and 2015, respectively. The electronic survey covered the core components of dietary interventions in CR as described in the national clinical guideline.

RESULTS

In 2015, 72% of municipalities provided dietary interventions. This proportion was significantly higher in hospitals (94%, p = 0.007). 26% and 38% of hospitals screened systematically for dietary intervention needs in 2013 and 2015, respectively. Corresponding results from municipalities were 26% and 29%. No significant differences were seen in clinical practice over time.

CONCLUSIONS

The results of this study identified a major gap between recommendations in the national clinical guideline and actual clinical practice on dietary interventions in CR in Danish hospitals and municipalities. The study confirmed that implementation of guidelines in clinical practice takes time and requires an intensive effort.

Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark

A politically initiated national clinical guideline was launched in Denmark in 2013 to improve quality and equality of cardiac rehabilitation (CR) services. The guideline is to be implemented in both hospital and community (municipality) settings due to shared responsibility for provision of CR services. Little is known about implementation outcomes of a guideline in these two settings. We aimed to study this by determining the extent to which Danish CR services in hospitals and municipalities adhered to national recommendations following the launch of the guideline. The study employed an observational, longitudinal design. Data were gathered by a questionnaire survey to compare CR services at baseline, measured in 2013 immediately before the guideline was launched, with CR services at a two-year follow up in 2015. All Danish hospital departments offering CR services (N = 36) and all municipalities (N = 98) were included. Data were analysed using inferential statistics. Hospitals reported improvement of both content and quality of CR services. Municipalities reported no change in content of services, and lower level of fulfilment of one quality aspect. The results suggest that the guideline had different impact in hospitals and municipalities and that the differences in content and quality of services between the two settings increased in the study period, thus contradicting the guideline´s aim of uniform, evidence-based content of CR services across settings.

A Review of Cardiac Rehabilitation Delivery Around the World

Herein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases. Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.

Global availability of cardiac rehabilitation

Cardiovascular disease (CVD) is the most-prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low-income and middle-income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost-effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient's functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under-used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high-income and 23% of LMICs (8.3% for low-income and 28.2% for middle-income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.

Availability and characteristics of cardiovascular rehabilitation programs in South America

PURPOSE

Cardiac rehabilitation (CR) programs decrease morbidity and mortality rates in patients with coronary artery disease, the leading cause of death in Latin America. This study was carried out to assess the characteristics and current level of CR program implementation in South America.

METHODS

We carried out a survey of CR programs that were identified using the directory of the South American Society of Cardiology and through an exhaustive search by the investigators.

RESULTS

We identified 160 CR programs in 9 of the 10 countries represented in the South American Society of Cardiology and 116 of those responded to our survey. On the basis of survey results from the responding programs, we estimate that the availability of CR programs in South America is extremely low, approximately 1 CR program for every 2 319 312 inhabitants. These CR programs provided services to a median of 180 patients per year (interquartile range, 60-400) and were most commonly led by cardiologists (84%) and physical therapists (72%). Phases I, II, III, and IV CR were offered in 49%, 91%, 89%, and 56% of the centers, respectively. The most commonly perceived barrier to participation in a CR program was lack of referral from the cardiologist or primary care physician, as reported by 70% of the CR program directors.

CONCLUSIONS

The number of CR programs in South America appears to be insufficient for a population with a high and growing burden of cardiovascular disease. In addition, there appears to be a significant need for standardization of CR program components and services in the region.

Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey

BACKGROUND

Cardiac rehabilitation (CR) programmes support patients to achieve professionally recommended cardiovascular prevention targets and thus good clinical status and improved quality of life and prognosis. Information on CR service delivery in Europe is sketchy.

DESIGN

Postal survey of national CR-related organizations in European countries.

METHODS

The European Cardiac Rehabilitation Inventory Survey assessed topics including national guidelines, legislation and funding mechanisms, phases of CR provided and characteristic of included patients.

RESULTS

Responses were available for 28 of 39 (72%) countries; 61% had national CR associations; 57% national professional guidelines. Most countries (86%) had phase I (acute inhospital) CR, but with differing service availability. Only 29% reported provision to more than 80% patients. Phase II was also available, but 15 countries reported provision levels below 30%. Almost half (46%) had national legislation regarding phase II CR; three-quarters had government funding. Phase III was less supported: although available in most countries, 11 could not provide estimates of numbers participating. Thirteen reported that all costs were met by patients.

CONCLUSION

Fewer than half of eligible cardiovascular patients benefit from CR in most European countries. Deficits include absent or inadequate legislation, funding, professional guidelines and information systems in many countries. Priorities for improvement include promoting national laws and guidelines specific for CR and increasing both CR programme participation rates and CR infrastructure. The European Association of Cardiovascular Prevention and Rehabilitation can have an important coordinating role in sharing expertise among national CR-related agencies. Ultimately, such cooperation can accelerate CR delivery to the benefit of cardiac patients across Europe.

Current status of cardiac rehabilitation in Latin America and the Caribbean

BACKGROUND

The prevalence of coronary artery disease (CAD) in Latin America is increasing and contributes importantly to the global burden of cardiovascular diseases. Advanced resources for the diagnosis and treatment of CAD are available in most of the region. However, preventive approaches such as cardiovascular rehabilitation programs (CVRP) may not be widely implemented.

METHODS

We carried out a telephone-based survey to hospitals sampled in a random and population-weighted fashion from a list of 202 centers with cardiac catheterization laboratories in Mexico, Central and South America, and the Caribbean. We collected information of availability of cardiac procedures and imaging techniques and also extensive data about the presence, characteristics, and quality measures of CVRP.

RESULTS

A total of 98 centers were contacted, and a complete survey was provided by 59 centers (60%) from 13 countries. Cardiovascular rehabilitation programs were available in only 56% of centers. There were no differences between centers with and without CVRP regarding type of hospital, availability of cardiac surgery, and annual volume of patients with myocardial infarction. Among centers with CVRP, 70% offered all phases of CVRP. The lack of CVRP was attributed to lack of qualified personnel in 41% of centers, financial constraints in 33%, and lack of physical space in 13%. All centers without CVRP performed cardiac surgery and percutaneous interventions.

CONCLUSIONS

Despite the presence of state-of-the-art technology for the diagnosis and treatment of CAD, availability of CVRP, a less expensive yet effective tool for the treatment of CAD, appears to be limited in Latin America and the Caribbean.

Use of statins and beta-blockers after acute myocardial infarction according to income and education

OBJECTIVE

To study the initiation of and long-term refill persistency with statins and beta-blockers after acute myocardial infarction (AMI) according to income and education.

DESIGN AND SETTING

Linkage of individuals through national registers of hospitalisations, drug dispensation, income and education.

PARTICIPANTS

30 078 patients aged 30-74 years surviving first hospitalisation for AMI in Denmark between 1995 and 2001.

MAIN OUTCOME MEASURES

Initiation of statin or beta-blocker treatment (out-patient claim of prescriptions within 6 months of discharge) and refill persistency (first break in treatment lasting at least 90 days, and re-initiation of treatment after a break).

RESULTS

When simultaneously estimating the effect of income and education on initiation of treatment, the effect of education attenuated and a clear income gradient remained for both drugs. Among patients aged 30-64 years, high income (adjusted hazard ratio (HR) 1.27; 95% confidence interval (CI) 1.19-1.35) and medium income (HR 1.13; 95% CI 1.06-1.20) was associated with initiation of statin treatment compared with low income. The risk of break in statin treatment was lower for patients with high (HR 0.73; 95% CI 0.66-0.82) and medium (HR 0.82; 95% CI 0.74-0.92) income compared with low income, whereas there was a trend in the opposite direction concerning a break in beta-blocker treatment. There was no gradient in re-initiation of treatment.

CONCLUSION

Patients with low compared with high income less frequently initiated preventive treatment post-AMI, had worse long-term persistency with statins, but tended to have better persistency with beta-blockers. Low income by itself seems not to be associated with poor long-term refill persistency post-AMI.

A randomized clinical trial of hospital-based, comprehensive cardiac rehabilitation versus usual care for patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease (the DANREHAB trial)--design, intervention, and population

BACKGROUND

Current guidelines broadly recommend comprehensive cardiac rehabilitation (CR), although evidence for this is still limited. It is not known whether evidence from before 1995 is still valid.

STUDY DESIGN

The DANish Cardiac ReHABilitation (DANREHAB) trial was designed as a centrally randomized clinical trial to clarify whether hospital-based comprehensive CR is superior to usual care for patients with congestive heart failure, ischemic heart disease, or high risk for ischemic heart disease. A combined primary outcome measure included total mortality, myocardial infarction, or readmissions due to heart disease based on linkage to public registries. The CR was an individually tailored, multidisciplinary program (6 weeks of intensive CR and 12 months of follow-up) including patient education, exercise training, dietary counseling, smoking cessation, psychosocial support, risk factor management, and clinical assessment.

STUDY POPULATION

Of 5060 discharged patients, 1614 (32%) were eligible for the trial and 770 patients were randomized (47% of those eligible). Participants were younger (P < .001) and had less comorbidity than nonparticipants (P < .03).

CONCLUSION

Our trial shows that a large-scale, centrally randomized clinical trial on comprehensive CR can be conducted among a broadly defined patient group, but reaching the stipulated number of 1800 patients was difficult. Although the study included relatively many women and older people, elderly patients and patients with high comorbidity were underrepresented, which may influence the external validity.