How cardiac rehabilitation is being influenced by changes in health-care delivery

An evaluation of training responses using self-regulation in a residential rehabilitation program

BACKGROUND

The efficacy of exercise training for patients with cardiovascular disease is well established. Given recent changes in reimbursement patterns for cardiac rehabilitation and therefore a greater need for self-monitoring, home programs, and the like, a need exists to determine the capability of patients to regulate their own exercise intensity and assess the efficacy of self-regulated exercise. This study assessed the training responses of a group instructed to train at an intensity they perceived as "somewhat hard," and compared their responses to standardized methods of exercise prescription.

METHODS

A total of 78 patients (86% male; mean age, 56 +/- 10 years; mean ejection fraction, 64% +/- 12%) referred to a residential rehabilitation program after myocardial infarction or bypass surgery were randomized to three different groups, for which exercise intensity was prescribed using different methods. For group 1, 70% of heart rate reserve was maintained using precise, continuous electronic heart rate-controlled resistance on a cycle ergometer. Group 2 gauged their own exercise intensity according to a level they perceived as "somewhat hard" (13 on the Borg scale) and were given no feedback in terms of heart rate or work rate. For group 3, exercise intensity was determined using both objective (heart rate reserve and work rate targeted to 60% to 80% of maximal exercise) and subjective (Borg scale 12 to 14) indices. The subjects exercised daily for 1 month. Training frequency, duration, and mode were equivalent between the groups.

RESULTS

The exercise capacity of the three groups was increased significantly after the training period: 33.7% in group 1, 22.9% in group 2, and 31.2% in group 3 (P <.005 for all). Other measures of the training response also were similar between the groups, including a significant increase in work rate at a perceived exertion of 13 and maximal watts achieved. The magnitude of the training response was not different between the groups. There were no complications during training.

CONCLUSIONS

The training response was similar between the three methods used to monitor exercise intensity. Thus, patients are able to gauge their own exercise intensity reasonably when instructed to exercise at a perceived exertion of 13. This suggests that close heart rate monitoring may not always be necessary for many stable patients with cardiovascular disease to achieve the benefits of a rehabilitation program.

Utilisation of outpatient cardiac rehabilitation in Queensland

OBJECTIVES

To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs.

DESIGN AND SETTING

Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs.

PARTICIPANTS

Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private).

MAIN OUTCOME MEASURES

Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance.

RESULTS

15 186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality.

CONCLUSION

There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.

Program participation and physical activity maintenance after cardiac rehabilitation

This study examined exercise maintenance among patients after completing cardiac rehabilitation. Subjects were men and women who had completed a Phase II Cardiac Rehabilitation Program approximately 12 months previously. Subjects were classified according to whether they had (a) never participated in a Phase III program (G-I) (N = 37), (b) enrolled and completed a Phase III program (G-II) (N = 30), or (c) were currently enrolled in a Phase III maintenance program (G-III) (N = 33). Subjects were significantly more likely to be participating in regular exercise if they had participated in a Phase III program (p < .05). Individuals in G-II and G-III engaged in more minutes of physical activity per week and were more likely to meet recommended levels of physical activity compared to G-1 subjects. G-1 individuals who had longer Phase II programs were more likely to maintain their exercise habits following graduation (p < .05). Results suggest that Phase III maintenance programs and longer Phase II participation improved exercise maintenance following rehabilitation.

Is brisk walking an adequate aerobic training stimulus for cardiac patients?

Walking is the most common aerobic training modality utilized in cardiac rehabilitation programs. However, it remains unclear whether or not brisk walking is of a sufficient intensity to improve aerobic fitness in this population. In this study, we investigated whether men and women with coronary artery disease can achieve an exercise intensity that is sufficient to induce a training effect, ie, a training heart rate (THR), defined as >/= 70% of measured maximal heart rate (HRmax), via brisk walking on a flat surface. One hundred forty-two outpatient volunteers from the William Beaumont Hospital Cardiac Rehabilitation Program (Royal Oak, MI) and the University of Wisconsin-La Crosse Exercise and Health Program (La Crosse, WI) were asked to walk one mile as briskly as possible on measured tracks. Heart rate was monitored throughout the walk via radiotelemetry. The percentage of patients within each gender and phase of rehabilitation who attained a THR were assessed using peak or symptom-limited exercise testing to determine the HRmax. All of the women and 90% of the men achieved a THR, averaging 85 +/- 8% and 79 +/- 10% of HRmax, respectively (mean +/- SD). There was no difference in the percentage of phase II or phase III cardiac rehabilitation program patients who achieved a THR. These findings suggest that brisk walking is of a sufficient intensity to elicit a THR in all but the most highly fit patients with coronary disease. Thus, physicians and allied health professionals can prescribe brisk walking on a flat surface to their cardiac patients with confidence that this intensity will achieve cardiorespiratory and health benefits.

Women and cardiac rehabilitation: accessibility issues and policy recommendations

The purpose of this study was to identify whether certain factors related to accessibility can predict women's participation in cardiac rehabilitation (CR). This cross-sectional comparative study used a convenience sample of 370 women cardiac patients who were treated and discharged between April 1, 1995, and September 30, 1995. A self-report instrument and medical record reviews were used to collect data at five hospitals and four CR centers in three midsized cities in northeastern Ohio. Differences between participants and nonparticipants were examined on the groups of variables. Logistic regression showed women's participation in CR to be overwhelmingly determined by physician referral (odds ratio [OR] = 0.000), which was more likely to occur if the patient had CR insurance (OR = 0.73). The probability of compliance with a referral in women with CR insurance and no history of coronary heart disease (CHD) was .89; with no insurance and a history of CHD, the probability of participation was .37. Participation was associated with level of education, coronary artery bypass surgery, and available transportation. We recommend the promotion and encouragement of the use of Clinical Practice Guidelines by physicians, and lower cost and more accessible approaches to CR, such as contracting with managed care, home rehabilitation, and community-based programs.

Personal perceptions and women's participation in cardiac rehabilitation

The purpose of this study was to determine whether there were differences in personal perceptions between women who participated in cardiac rehabilitation (CR) and women who did not. This cross-sectional study used a convenience sample of 370 female patients who had been treated and discharged between April 1, 1995, and September 30, 1995. Three standardized scales, a self-report instrument, and medical records reviews were used to collect data at five hospitals and four CR centers in three midsized northeastern Ohio cities. Differences in personal perception and demographic variables between participants and nonparticipants were examined. Education, history of coronary heart disease (CHD), and specific cardiac diagnoses showed statistically significant differences between the groups. Logistic regression tested the model for participation. No variable or group of variables was found to predict CR participation in this sample of women. All cardiac patients need information about CR. Patients with less education, a history of CHD, and a diagnosis of stable angina need special instructions and closer follow-up.