Factors Associated With Referral to Outpatient Cardiac Rehabilitation Services

Outcomes of a smartphone-based application with live health-coaching post-percutaneous coronary intervention

Background

The interval between inpatient hospitalization for symptomatic coronary artery disease (CAD) and post-discharge office consultation is a vulnerable period for adverse events.

Methods

Content was customized on a smartphone app-based platform for hospitalized patients receiving percutaneous coronary intervention (PCI) which included education, tracking, reminders and live health coaches. We conducted a single-arm open-label pilot study of the app at two academic medical centers in a single health system, with subjects enrolled 02/2018–05/2019 and 1:3 propensity-matched historical controls from 01/2015–12/2017. To evaluate feasibility and efficacy, we assessed 30-day hospital readmission (primary), outpatient cardiovascular follow-up, and cardiac rehabilitation (CR) enrollment as recorded in the health system. Outcomes were assessed by Cox Proportional Hazards model.

Findings

118 of 324 eligible (36·4%) 21–85 year-old patients who underwent PCI for symptomatic CAD who owned a smartphone or tablet enrolled. Mean age was 62.5 (9·7) years, 87 (73·7%) were male, 40 of 118 (33·9%) had type 2 diabetes mellitus, 68 (57·6%) enrolled underwent PCI for MI and 59 (50·0%) had previously known CAD; demographics were similar among matched historical controls. No significant difference existed in all-cause readmission within 30 days (8·5% app vs 9·6% control, ARR -1.1% absolute difference, 95% CI -7·1–4·8, p = 0·699) or 90 days (16·1% app vs 19·5% control, p = 0.394). Rates of both 90-day CR enrollment (HR 1·99, 95% CI 1·30–3·06) and 1-month cardiovascular follow up (HR 1·83, 95% CI 1·43–2·34) were greater with the app. Weekly engagement at 30- and 90-days, as measured by percentage of weeks with at least one day of completion of tasks, was mean (SD) 73·5% (33·9%) and 63·5% (40·3%). Spearman correlation analyses indicated similar engagement across age, sex, and cardiovascular risk factors.

Interpretations

A post-PCI smartphone app with live health coaches yielded similarly high engagement across demographics and safely increased attendance in cardiac rehabilitation. Larger prospective randomized controlled trials are necessary to test whether this app improves cardiovascular outcomes following PCI.

Funding

National Institutes of Health, Boston Scientific.

Clinical trial registration

NCT03416920 (https://clinicaltrials.gov/ct2/show/NCT03416920).

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes: a randomized controlled trial

BACKGROUND

There are well-documented treatment gaps in secondary prevention of coronary heart disease with a lack of clearly defined strategies to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps.

OBJECTIVES

The primary goal of this study was to assess whether a smartphone-based, early cardiac rehabilitation program improved exercise capacity in patients with ACS.

METHODS

A total of 206 patients with ACS across six tertiary Australian hospitals were included in this randomized controlled trial. Participants were randomized to usual care (UC; including referral to traditional cardiac rehabilitation), with or without an adjunctive smartphone-based cardiac rehabilitation program (S-CRP) upon hospital discharge. The primary endpoint was change in exercise capacity, measured by the change in 6-minute walk test distance at 8 weeks when compared to baseline, between groups. Secondary endpoints included uptake and adherence to cardiac rehabilitation, changes in cardiac risk factors, psychological well-being and quality of life status.

RESULTS

Of the 168 patients with complete follow-up (age 56 ± 10 years; 16% females), 83 were in the S-CRP. At 8-week follow-up, the S-CRP group had a clinically significant improvement in 6-minute walk test distance (Δ117 ± 76 vs. Δ91 ± 110 m; P = 0.02). Patients in the S-CRP were more likely to participate (87% vs. 51%, P < 0.001) and adhere (72% vs. 22%, P < 0.001) to a cardiac rehabilitation program. Compared to UC, patients receiving S-CRP had similar smoking cessation rates, LDL-cholesterol levels, blood pressure reduction, depression, anxiety and quality of life measures (all P = NS).

CONCLUSION

In patients with ACS, a S-CRP, as an adjunct to UC improved exercise capacity at 8 weeks in addition to participation and adherence to cardiac rehabilitation (Australian New Zealand Clinical Trials Registry; ACTRN12616000426482).

Cardiovascular rehabilitation in patients aged 70-year-old or older: benefits on functional capacity, physical activity and metabolic profile in younger vs. older patients

Background

The benefits of exercise-based cardiac rehabilitation (EBCR) programs in post-acute myocardial infarction (AMI) patients have been demonstrated. Our aim was to assess the impact of EBCR in ≥ 70-years-old vs. younger post-AMI patients.

Methods

We retrospectively evaluated patients who underwent a supervised EBCR protocol, twice a week during 6-12 weeks. We evaluated changes in several outcomes based on pre- and post-CRP assessments.

Results

Of a total of 1607 patients, 333 (21%) were ≥ 70-years-old. After the EBCR, an overall improvement on functional capacity, daily physical activity, lipid profile, body mass index, glycated hemoglobin (HbA1c), N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-reactive protein was observed in both younger and older patients (P < 0.05). Older patients showed a smaller benefit on the increment of daily physical activity and lipid profile improvement, but a larger reduction in NT-pro-BNP. In the multivariate analysis, only improvements on daily physical activity and HbA1c were dependent on age.

Conclusion

As their younger counterparts, older patients, significantly improved functional capacity, metabolic parameters and level of daily physical activity after EBCR.

Efficacy of Smartphone-Based Secondary Preventive Strategies in Coronary Artery Disease

Background:

Cardiac rehabilitation programs provide a comprehensive framework for the institution of secondary preventive measures. Smartphone technology can provide a platform for the delivery of such programs and is a promising alternative to hospital-based services. However, there is limited evidence to date supporting this approach. Accordingly, we performed a systematic review and meta-analysis examining smartphone-based secondary prevention programs to traditional cardiac rehabilitation in patients with established coronary artery disease to ascertain the feasibility and effectiveness of these interventions.

Methods:

A systematic search of PubMed, MEDLINE, EMBASE, and the Cochrane Library was conducted. A meta-analysis was performed using a random-effects model with the outcomes of interest being 6-minute walk test (6MWT) distance, systolic blood pressure, low-density lipoprotein (LDL) cholesterol, and body mass index (BMI).

Results:

A total of 8 studies with 1120 patients across 5 countries were included in the quantitative analysis. Follow-up ranged from 6 weeks to 12 months. Five studies examined all patients post acute coronary syndrome, 2 studies examined only patients undergoing percutaneous coronary intervention, and 1 study examined all patients with a diagnosis of coronary artery disease, independent of intervention. Exercise capacity, as measured by the 6MWT, was significantly greater in the smartphone group (20.10 meters, 95% confidence interval [CI] 7.44-33.97; P < .001; I² = 45.58). There was no significant difference in BMI reduction, systolic blood pressure, or LDL cholesterol levels between groups (P value for all > .05).

Conclusion:

Publicly available smartphone-based cardiac rehabilitation programs are a convenient and easily disseminated intervention which show merit in exercise promotion in patients with established coronary artery disease. Further research is required to establish the clinical significance of recent findings favoring their use.

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol

BACKGROUND

There are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS.

METHODS

We have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone's accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations.

DISCUSSION

This randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention.

TRIAL REGISTRATION

The trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482 .

Does cardiac rehabilitation favour the young over the old?

BACKGROUND

Although cardiac rehabilitation (CR) is a proven intervention in reducing cardiovascular mortality and morbidity there is concern that CR programme delivery may not yield comparable outcomes across age groups.

PURPOSE

This study sought to determine if the outcomes achieved after completing CR were influenced by age in patients with coronary heart disease.

METHOD

Patients were stratified into 2 age groups: young (18-65 years) and elderly (>65 years). Pre-CR and post-CR assessments were used to compute changes in 9 CR outcomes (body mass index (BMI), waist size, hyperlipidaemia, hypertension, smoking, walking fitness, physical activity, anxiety and depression). Pearson's χ(2) test was used to examine the association between the age groups and outcome. Data was extracted from the UK National Audit from July 2010 to June 2015.

RESULTS

A total of 203 012 young patients (55.1±7.9 years, 78% male) and 262 813 elderly patients (76.1±6.9 years, 63.9% male) were analysed. Young patients had a better ratio of improvement across a wide range of risk factors in particular smoking cessation (OR=3.3, p<0.001) while elderly patients had a better ratio of improvement in body shape risk factors BMI (OR=1.3, p<0.001), waist size in women (OR=1.3, p=0.016).

CONCLUSIONS

Age is a significant predictor of outcomes following CR. While elderly patients achieve better outcomes in body shape risk factors, younger patients clearly achieve better outcomes across a wider range of risk factors in particular smoking cessation.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people.

METHODS

Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people.

RESULTS

Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services.

CONCLUSION

The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.

Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis

AIMS

To assess the effectiveness of home-based cardiac rehabilitation (CR) for heart failure compared to either usual medical care (i.e. no CR) or centre-based CR on mortality, morbidity, exercise capacity, health-related quality of life, drop out, adherence rates, and costs.

METHODS

Randomised controlled trials were initially identified from previous systematic reviews of CR. We undertook updated literature searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Library to December 2015. A total of 19 trials with median follow up of 3months were included - 17 comparisons of home-based CR to usual care (995 patients) and four comparing home and centre-based CR (295 patients).

RESULTS

Compared to usual care, home-based CR improved VO2max (mean difference: 1.6ml/kg/min, 0.8 to 2.4) and total Minnesota Living with Quality of Life score (-3.3, -7.5 to 1.0), with no difference in mortality, hospitalisation or study drop out. Outcomes and costs were similar between home-based and centre-based CR with the exception of higher levels of trial completion in the home-based group (relative risk: 1.2, 1.0 to 1.3).

CONCLUSIONS

Home-based CR results in short-term improvements in exercise capacity and health-related quality of life of heart failure patients compared to usual care. The magnitude of outcome improvement is similar to centre-based CR. Home-based CR appears to be safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR for heart failure as an evidence-based alternative to the traditional centre-based model of provision.

Cardiac rehabilitation: beginning at the bedside

PURPOSE

Despite well-documented positive benefits, cardiac rehabilitation (CR) is an underutilized resource for patients following a cardiac event or intervention. Bias in the CR referral process has led to programs designed to ensure that all eligible patients receive a referral. The purpose of the current investigation was to describe the implementation of a nurse-delivered automatic bedside referral process and to examine the effectiveness on referral and intake rates for CR.

METHODS

In 2007, an automatic CR referral system was implemented at the University of Ottawa Heart Institute. A nurse-delivered automatic bedside referral process was implemented in 2008. A CR nurse screened all inpatient charts, discussed CR benefits and program options with patients, triaged the patient to the appropriate program, and facilitated booking of the CR intake appointment. Data were analyzed to determine the effectiveness of this approach.

RESULTS

Only 15.5% to 19.7% of eligible patients participated in CR program prior to 2006. Implementation of an automatic referral process increased participation to 26.7%. The nurse-delivered bedside automatic referral process increased participation to 32.6%. The proportion of patients receiving CR referrals almost tripled following the implementation of the nurse-delivered referral process from 26.7% in 2003 to 79.0% in 2008.

CONCLUSIONS

A nurse-delivered automatic bedside referral process had a positive impact on both referral and intake to CR. Future challenges for CR programs will be to ensure optimal participation in programs, while managing the growth associated with increased rates of involvement.

Effect of exercise-based cardiac rehabilitation on ejection fraction in coronary artery disease patients: a randomized controlled trial

BACKGROUND

Exercise training as a part of cardiac rehabilitation aims to restore patient with heart disease to health. However, left ventricular ejection fraction (LVEF) is clinically used as a predictor of long-term prognosis in coronary artery disease (CAD) patients, there is a scarcity of data on the effectiveness of exercise-based cardiac rehabilitation on LVEF.

OBJECTIVE

To investigate the effectiveness of exercise-based cardiac rehabilitation on LVEF in early post-event CAD patients.

PATIENTS AND METHODS

In a single blinded, randomized controlled trial, post-coronary event CAD patients from the age group of 35-75 years, surgically (Coronary artery bypass graft or percutaneous coronary angioplasty) or conservatively treated, were recruited from Golsar Hospital, Iran. Exclusion criteria were high-risk group (AACVPR-99) patients and contraindications to exercise testing and training. Forty-two patients were randomized either into Study or Control. The study group underwent a 12-week structured individually tailored exercise program either in the form of Center-based (CExs) or Home-based (HExs) according to the ACSM-2005 guidelines. The control group only received the usual cardiac care without any exercise training. LVEF was measured before and after 12 weeks of exercise training for all three groups. Differences between and within groups were analyzed using the general linear model, two-way repeated measures at alfa=0.05.

RESULTS

Mean age of the subjects was 60.5 ± 8.9 years. There was a significant increase in LVEF in the study (46.9 ± 5.9 to 61.5 ± 5.3) group compared with the control (47.9 ± 7.0 to 47.6 ± 6.9) group (P=0.001). There was no significant difference in changes in LVEF between the HExs and CExs groups (P=1.0).

CONCLUSION

A 12-week early (within 1 month post-discharge) structured individually tailored exercise training could significantly improve LVEF in post-event CAD patients.

A prospective examination of disease management program use by complex cardiac outpatients

BACKGROUND

The use of disease management programs (DMPs) by patients with cardiovascular disease (CVD) is associated with improved outcomes. Although rates of cardiac rehabilitation (CR) use are well established, less is known about other DMPs. The objectives of this study were to describe the degree of DMP utilization by CVD outpatients, and examine factors related to use.

METHODS

This study represents a secondary analysis of a larger prospective cohort study. In hospital, 2635 CVD inpatients from 11 hospitals in Ontario Canada completed a survey that assessed factors affecting DMP utilization. One year later, 1803 participants completed a mailed survey that assessed DMP utilization.

RESULTS

One thousand seventy-three (59.5%) participants reported using at least 1 DMP. Overall, 951 (52.7%) reported participating in cardiac rehabilitation, and among participants with a comorbid indication, 212 (41.2%) reported attending a diabetes education centre, 28 (25.9%) attended stroke rehabilitation, 35 (12.9%) used a heart failure clinic, and 13 (11.7%) attended a smoking cessation program. A multinomial logistic regression analysis showed that compared with no DMP use, participants that attended 1 or multiple programs were younger, married, diagnosed with a myocardial infarction, less likely to have had a percutaneous coronary intervention and had higher perceptions of personal control over their heart condition. There were few differences between participants that used 1 vs multiple DMPs, however, having diabetes or comorbid stroke significantly increased the likelihood of multiple DMP use.

CONCLUSIONS

Approximately 40% of CVD outpatients do not access DMPs. An integrated approach to vascular disease management appears warranted.

Exercise in elderly patients with chronic heart failure in primary care: effects on physical capacity and health-related quality of life

INTRODUCTION

Chronic heart failure (CHF) limits exercise capacity which influences physical fitness and health-related quality of life (HRQoL).

AIM

The aim was to determine the effects on physical capacity and HRQoL of an exercise programme in elderly patients with CHF in primary care.

METHODS

An exercise intervention was conducted as a prospective, longitudinal and controlled clinical study in primary care in elderly patients with CHF. Endurance exercise and resistance training were conducted as group-training at the primary care centre and as home training. Follow-up on physical capacity and HRQoL was done at 3, 6 and 12months.

RESULTS

Exercise significantly improved muscle endurance in the intervention group (n=29, mean age 76.2years) compared to the control group (n=31, mean age 74.4years) at all follow-ups except for shoulder flexion right at 12months (shoulder abduction p=0.006, p=0.048, p=0.029; shoulder flexion right p=0.002, p=0.032, p=0.585; shoulder flexion left p=0.000, p=0.046, p=0.004). Six minute walk test improved in the intervention group at 3months (p=0.013) compared to the control group. HRQoL measured by EQ5D-VAS significantly improved in the intervention group at 3 and 12months (p=0.016 and p=0.034) and SF-36, general health (p=0.048) and physical component scale (p=0.026) significantly improved at 3months compared to the control group.

CONCLUSION

This study shows that exercise conducted in groups in primary care and in the patients' homes could be used in elderly patients with CHF. The combination of endurance exercise and resistance training has positive effects on physical capacity. However, the minor effects in HRQoL need further verification in a study with a larger study population.

Association between Participation in Outpatient Cardiac Rehabilitation and Self-Reported Receipt of Lifestyle Advice from a Healthcare Provider: Results of a Population-Based Cross-Sectional Survey

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events.

The Canadian Heart Health Strategy and Action Plan: Cardiac rehabilitation as an exemplar of chronic disease management

BACKGROUND

In October 2006, federal funding was announced for the development of a national strategy to fight cardiovascular disease (CVD) in Canada. The comprehensive, independent, stakeholder-driven Canadian Heart Health Strategy and Action Plan (CHHS-AP) was delivered to the Minister of Health on February 24, 2009.

OBJECTIVES

The mandate of CHHS-AP Theme Working Group (TWG) 6 was to identify the optimal chronic disease management model that incorporated timely access to rehabilitation services and end-of-life planning and care. The purpose of the present paper was to provide an overview of worldwide approaches to CVD and cardiac rehabilitation (CR) strategies and recommendations for CR care in Canada, within the context of the well-known Chronic Care Model (CCM). A separate paper will address end-of-life issues in CVD.

METHODS

TWG 6 was composed of content representatives, primary care representatives and patients. Input in the area of Aboriginal and indigenous cardiovascular health was obtained through individual expert consultation. Information germane to the present paper was gathered from international literature and best practice guidelines. The CCM principles were discussed and agreed on by all. Prioritization of recommendations and overall messaging was discussed and decided on within the entire TWG. The full TWG report was presented to the CHHS-AP Steering Committee and was used to inform the recommendations of the CHHS-AP.

RESULTS

Specific actionable recommendations for CR are made in accordance with the key principles of the CCM.

CONCLUSIONS

The present CR blueprint, as part of the CHHS-AP, will be a first step toward reducing the health care burden of CVD in Canada.

Equity of access to cardiac rehabilitation: the role of system factors

Background

When patient selection processes determine who can and cannot use healthcare there can be inequalities and inequities in individuals' opportunities to benefit. This paper evaluates the influence of a hospital selection process on opportunities to access outpatient cardiac rehabilitation (CR).

Methods

A secondary data analysis was conducted on a cohort of inpatients (n = 2,375) who were all eligible for invitation to an Australian CR program. Eligibility was determined by hospital discharge diagnosis codes. Only invited patients could attend. Logistic regression analysis tested the extent to which individual patient characteristics were statistically significantly associated with the outcome 'invitation' after adjusting for cardiac disease and other factors.

Results

Less than half of the eligible patients were invited to the CR program. After allowing for known factors that may have justified not being selected, there was bias towards inviting males, younger patients, married patients, and patients who nominated English as their preferred language.

Conclusions

Health service managers typically monitor service utilisation patterns as indicators of access but often pay little attention to ways in which locally determined system factors influence access to care. The paper shows how a hospital selection process can unreasonably influence patients' opportunities to benefit from an evidence-based healthcare program.

Using non-linear decomposition to explain the discriminatory effects of male-female differentials in access to care: a cardiac rehabilitation case study

This paper demonstrates the use of non-linear decomposition for identifying discrimination in referral to a cardiac rehabilitation (CR) program. The application is important because the methods are not commonly applied in this context. A secondary data analysis was conducted on a cohort of 2375 patients eligible for referral (as defined) to an Australian hospital outpatient CR program (1 July 1996 to 31 December 2000) on the basis of inpatient discharge diagnosis codes. Data from a population-based disease register were linked to hospital inpatient statistics and CR program records. Cohort selection was established in accordance with first register recorded hospital separations having specified cardiac inpatient diagnoses for which CR was recommended. Using the existing literature as a guide, multivariate logistic regression methods tested the strength of statistical association between independent variables (or 'endowments') and CR referral. Compared with males, females had 40% fewer odds of being referred. Non-linear decomposition was performed as a post-logistic regression technique to show the extent to which the sex-based inequality in referral (as defined here) was due to group characteristics (the relative distribution of endowments) compared with other influences not adjusted for in the model. The results showed that approximately 18% of the male-female inequality in referral was not explained by group characteristics, and on this basis was 'discriminatory'. The extent to which individual endowments contributed to the explained part of the inequality was also of interest. The methods offer potentially useful tools for informing researchers, policy makers, clinicians and others about unfair discriminatory processes that influence access to health and social services.

Reframing the dilemma of poor attendance at cardiac rehabilitation: an exploration of ambivalence and the decisional balance

AIM

To discuss the problem of poor attendance at cardiac rehabilitation from the alternative perspective of patient ambivalence.

BACKGROUND

Evidence supports the benefits of cardiac rehabilitation as a means for secondary prevention of coronary heart disease, yet current literature continues to document poor attendance at these programmes. Whilst extrinsic factors, such as transportation and lack of physician support have been identified as barriers, patients who choose not to attend these programmes are often described as lacking motivation or being non-compliant. However, it is possible that non-attendance is the result of ambivalence - the experience of simultaneously wanting to and yet not wanting to, or the 'I want to, but I don't want to' dilemma.

DESIGN

Discussion paper.

METHOD

This discussion paper draws on the literature of ambivalence and decision-making theory to reframe the issue of poor attendance at cardiac rehabilitation.

CONCLUSIONS

This paper has demonstrated that the problem of poor attendance may be explained from the perspective of patient ambivalence and that using strategies such as the decisional balance may assist these individuals in exploring their ambivalence to engage in secondary prevention programmes.

RELEVANCE TO CLINICAL PRACTICE

Understanding the dynamics of ambivalence provides an alternative to thinking of patients as lacking motivation, being non-compliant, or even resistant. Helping patients to explore and resolve their ambivalence may be all that is needed to help them make a decision and move forward.

Exercise-based cardiac rehabilitation for very old patients (> or =75 years): focus on physical function

Older patients have high rates of physical function impairment and disability following a cardiac event. Exercise training has been shown to favorably affect such limitations, as well as cardiovascular risk factors, symptoms, and mortality post coronary event in middle-aged patients. Aerobic capacity, body strength, quality of life, and physical function are improved with exercise-based cardiac rehabilitation (CR) in patients older than 65 years. However, there have been relatively few studies of the effects of exercise-based CR on physical function recovery in the very old patients (> or =75 years), despite the continuous growth of this segment of the population. After hospitalization for a cardiac event, postacute inpatient CR serves as a bridge between acute care and independent home living for the most disabled older patients. It plays an important role in the physical recovery process, particularly after cardiac surgery. Exercise-based outpatient (phase II) CR, starting early after hospital discharge, is safe in very old patients and studies demonstrate that these patients derive similar benefits from CR, compared with younger patients, regarding physical function improvement. Older patients, however, are less likely than younger cardiac patients to participate in outpatient CR programs. There is a need to find protocols that could increase the referral and participation rates of the frailer and older cardiac patient to exercise-based CR.

Effect of an American Heart Association Get With the Guidelines program-based clinical pathway on referral and enrollment into cardiac rehabilitation after acute myocardial infarction

Cardiac rehabilitation (CR)/secondary prevention programs are an important part of patient care after acute myocardial infarction (AMI). However, only 10% to 15% of eligible patients enroll in such programs. The purpose of this study was to evaluate the effect of an American Heart Association Get With the Guidelines (GWTG)-based clinical pathway on referral and enrollment into CR after AMI. Patients (n = 780) admitted to a single center during an 18-month period with AMI and discharged to home were evaluated retrospectively for referral and enrollment into CR programs. A total of 714 patients (92%) were on the GWTG pathway; 392 (55%) were referred and 135 (19%) were enrolled into CR. Higher referral was associated with pathway use (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1 to 4.9, p = 0.03), percutaneous coronary intervention (OR 3.1, 95% CI 1.9 to 5.2, p <0.0001), and in-patient physical therapy consultation (OR 13, 95% CI 8.2 to 20.5, p <0.0001). Ethnicity did not affect referral, but was the only variable associated with lower enrollment. Hispanic and black patients had 92% (OR 0.08, 95% CI 0.01 to 0.55, p = 0.02) and 57% (OR 0.43, 95% CI 0.19 to 1.05, p = 0.06) lower odds to enroll compared with white patients, respectively. In conclusion, use of the American Heart Association GWTG pathway showed a significantly higher referral rate to CR after AMI than previously reported in the literature. Nonetheless, most referred patients did not enroll. Strategies to bridge the gap between referral and enrollment in CR should be incorporated into AMI clinical pathways, with special emphasis on increasing enrollment in ethnic minorities.

Older adults' use of postacute and cardiac rehabilitation services after hospitalization for a cardiac event

The purpose of this study was to describe older patients' use of postacute care (PAC) and outpatient cardiac rehabilitation (CR) services after a cardiac event and to describe the differences between older adults who use these services and those who do not. Under a longitudinal descriptive design, data were collected during hospitalization for a cardiac event, 3 and 6 weeks later, and 4 and 6 months later Of the 60 older adults in the sample, 73% used PAC after discharge. Older adults discharged home without PAC services had fewer complications and were less depressed than those who used PAC. Older adults discharged to a skilled nursing facility had poorer physical function both before the cardiac event and during hospitalization. Twenty-five percent participated in outpatient CR. Older adults who went to CR were male, had better physical function, and did not live alone. Understanding the use of PAC and CR services will help with discharge planning and customizing PAC and CR services for older adults to optimize cardiac recovery. The integration of CR principles into PAC may be an opportunity to enhance recovery for older adults, especially because only a small percentage of older adults attend CR.

Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation

The Canadian Cardiovascular Society formed an Access to Care Working Group ('Working Group') in the spring of 2004. The mandate of the group was to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The present commentary presents the rationale for benchmarks for cardiac rehabilitation (CR) services. The Working Group's search for evidence included: a full literature review of the efficacy of CR, and the factors affecting access and referral to CR; a review of existing guidelines for access to CR; and a national survey of 14 CR programs across Canada undertaken in May 2005 to solicit information on referral to, and wait times for, CR. The Working Group also reviewed the results of The Ontario Cardiac Rehabilitation Pilot Project (2002) undertaken by the Cardiac Care Network of Ontario, which reported the average and median wait times for CR. Some international agencies have formulated their own guidelines relating to the optimal wait time for the onset of CR. However, due to the limited amount of supporting literature, these guidelines have generally been formed as consensus statements. The Canadian national survey showed that few programs had guidelines for individual programs. The Cardiac Care Network of Ontario pilot project reported that the average and median times from a cardiac event to the intake into CR were 99 and 70 days, respectively. The national survey of sampled CR programs also revealed quite remarkable differences across programs in terms of the length of time between first contact to first attendance and to commencement of exercise. Programs that required a stress test before program initiation had the longest wait for exercise initiation. Some patients need to be seen within a very short time frame to prevent a marked deterioration in their medical or psychological state. In some cases, early intervention and advocacy may reduce the risk of loss of employment. Or, there may be profound disturbances in the patient's family as a result of the cardiac event. For other patient groups, preferable wait times vary from one to 30 days, and acceptable wait times vary from seven to 60 days. All cardiovascular disease patients require core aspects of CR services. Patients who would derive benefit from formal CR programs should be provided the opportunity, given the proven efficacy and cost effectiveness of CR.

Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review

BACKGROUND

Despite the documented efficacy of cardiac rehabilitation (CR), a minority of patients with diagnosed coronary artery disease are referred. Although referral is a necessary step in the promotion of CR uptake, little is known about its determinants.

PURPOSE

The objective of this paper was to systematically review the available literature on factors predicting referral of patients to CR to appraise both their relative impact and consistency across studies.

METHODS

Studies were identified by searching MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials. Search terms were "myocardial infarction," "acute myocardial infarction," "coronary artery disease," combined with "rehabilitation," "cardiac rehabilitation," "secondary prevention," "exercise training," "referral," and/or "consultation." Forty-five studies were identified and independently assessed by 2 reviewers using predetermined eligibility criteria.

RESULTS

Ten published observational studies (1999-2004) including 30,333 coronary artery disease patients were selected. Determinants of referral to CR were grouped as sociodemographic, health status, and health care system factors. Major predictors were English speaking (RR 9.56, 95% CI 2.18-41.93), prior myocardial infarction (RR 2.73, 95% CI 1.69-4.42), being admitted to hospitals providing CR (RR 5.35, 95% CI 4.04-7.10), and having insurance coverage (RR 2.94, 95% CI 1.13-7.66).

CONCLUSION

This review highlights disparities in referral to CR and reveals a treatment gap in the secondary prevention of cardiovascular disease. Precise estimates of the impact of all factors on referral are not possible, but some hierarchies and potential priorities for action are evident.