Proposal of quality indicators for cardiac rehabilitation after acute coronary syndrome in Japan: a modified Delphi method and practice test

Association between Rapid Dementia Screening Test score and clinical events in elderly patients with cardiovascular disease: a retrospective cohort study

AIMS

Cognitive decline is prevalent among patients with cardiovascular disease (CVD). Cognitive measurement has been considered as a standard assessment for secondary prevention; however, standard cognitive tests are sometimes infeasible due to time constraints. This study aimed to examine the association between the Rapid Dementia Screening Test (RDST), a brief screening tool for cognitive function, and clinical events in elderly patients with CVD.

METHODS AND RESULTS

This retrospective cohort study included 140 hospitalized patients with CVD who participated in inpatient cardiac rehabilitation (median age, 75 years; male, 67%). Cognitive function for each patient was assessed using the RDST and Montreal Cognitive Assessment (MoCA), a standard test of mild cognitive impairment. The clinical events assessed as outcomes included all-cause mortality and unplanned rehospitalization. Receiver-operating characteristic (ROC) curve analysis showed similar predictive accuracy for the study outcome (P = 0.337) between the RDST [area under the curve, 0.651; 95% confidence interval (CI), 0.559-0.743] and MoCA (0.625; 0.530-0.720). The ROC analysis identified a cut-off value of 9 points for the RDST (sensitivity, 77.8%; specificity, 50.5%). Patients with RDST ≤9 showed a poor survival rate compared with those with ≥10 points (log-rank test, P = 0.002; hazard ratio, 2.94, 95% CI, 1.46-5.94). This result was consistent even after adjusting for potential confounders.

CONCLUSION

The RDST was associated with clinical events in elderly patients with CVD and its predictive capability was comparable with that of MoCA, a standard cognitive test. The RDST may be useful in CVD as an alternative screening tool for cognitive decline.

A nationwide survey on participation in cardiac rehabilitation among patients with coronary heart disease using health claims data in Japan

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.

Performance Measures for Short-Term Cardiac Rehabilitation in Patients of Working Age: Results of the Prospective Observational Multicenter Registry OutCaRe

Objective

To determine immediate performance measures for short-term, multicomponent cardiac rehabilitation (CR) in clinical routine in patients of working age, taking into account cardiovascular risk factors, physical performance, social medicine, and subjective health parameters and to explore the underlying dimensionality.

Design

Prospective observational multicenter register study in 12 rehabilitation centers throughout Germany.

Setting

Comprehensive 3-week CR.

Participants

Patients (N=1586) ≤65 years of age (mean 53.8±7.3y, 77.1% men) in CR (May 2017-May 2018).

Interventions

Not applicable.

Main Outcome Measures

Feasibility, defined by data availability for ≥85% of patients (CR admission and discharge), and modifiability based on pre-post comparison (statistical significance, with P value<.01; standardized effect size≥.35; change by ≥5% points in categorical variables). In addition, latent factors were identified using an exploratory factor analysis (EFA).

Results

Based on feasibility and modifiability criteria, smoking behavior, lifestyle change behavior, blood pressure, endurance training load, depression in Patient Health Questionnaire-9 (PHQ-9), the 5-item World Health Organization Well-Being Index (WHO-5), physical and mental health and pain scale of the indicators of rehabilitation status-24 (IRES-24), and self-assessed health prognosis proved to be suitable performance measures. As a result of the EFA, 2 solid factors were identified: (1) subjective mental health including PHQ-9, WHO-5, mental health (IRES-24), mental quality of life, and anxiety and (2) physical health including physical quality of life, physical health and pain scale of IRES-24, and self-assessed occupational prognosis. A third factor represents the blood pressure.

Conclusions

We provide a small set of performance measures, that are essentially based on 3 latent factors (subjective mental health, physical health, blood pressure). These performance measures can represent immediate success of comprehensive CR and be applied easily in clinical practice.

Quality indicators for cardiac rehabilitation after myocardial infarction in China: a consensus panel and practice test

OBJECTIVES

Cardiac rehabilitation (CR) improves outcomes after myocardial infarction (MI), but it is underused in China. The purpose of this study was to develop a set of quality indicators (QIs) to improve clinical practices and to confirm the measurability and performance of the developed QIs for CR in Chinese patients after MI.

DESIGN AND SETTING

The QIs were developed by a Chinese expert consensus panel during in-person meetings. The five QIs most in need of improvement were selected using a national questionnaire. Finally, the completion rate and feasibility of the QIs were verified in a group of MI survivors at university hospitals in China.

PARTICIPANTS

Seventeen professionals participated in the consensus panel, 89 personnel in the field of CR participated in the national questionnaire and 165 MI survivors participated in the practice test.

RESULTS

A review of 17 eligible articles generated 26 potential QIs, among which 17 were selected by the consensus panel after careful evaluation. The 17 QIs were divided into two domains: (1) improving participation and adherence and (2) CR process standardisation. Nationwide telephone and WeChat surveys identified the five QIs most in need of improvement. A multicenter practice test (n=165) revealed that the mean performance value of the proposed QIs was 43.9% (9.9%-86.1%) according to patients with post-MI.

CONCLUSIONS

The consensus panel identified a comprehensive set of QIs for CR in patients with post-MI. A nationwide questionnaire survey was used to identify the QIs that need immediate attention to improve the quality of CR. Although practice tests confirmed the measurability of the proposed QIs in clinical practice, the implementation of the QIs needs to be improved.

TRIAL REGISTRATION NUMBER

This study is part of a study registered in ClinicalTrials.gov (NCT03528382).

Cardiac Rehabilitation Quality Improvement: A NARRATIVE REVIEW

PURPOSE

Despite evidence of the effectiveness of cardiac rehabilitation (CR), there is wide variability in programs, which may impact their quality. The objectives of this review were to (1) evaluate the ways in which we measure CR quality internationally; (2) summarize what we know about CR quality and quality improvement; and (3) recommend potential ways to improve quality.

METHODS

For this narrative review, the literature was searched for CR quality indicators (QIs) available internationally and experts were also consulted. For the second objective, literature on CR quality was reviewed and data on available QIs were obtained from the Canadian Cardiac Rehabilitation Registry (CCRR). For the last objective, literature on health care quality improvement strategies that might apply in CR settings was reviewed.

RESULTS

CR QIs have been developed by American, Canadian, European, Australian, and Japanese CR associations. CR quality has only been audited across the United Kingdom, the Netherlands, and Canada. Twenty-seven QIs are assessed in the CCRR. CR quality was high for the following indicators: promoting physical activity post-program, assessing blood pressure, and communicating with primary care. Areas of low quality included provision of stress management, smoking cessation, incorporating the recommended elements in discharge summaries, and assessment of blood glucose. Recommended approaches to improve quality include patient and provider education, reminder systems, organizational change, and advocacy for improved CR reimbursement. An audit and feedback strategy alone is not successful.

CONCLUSIONS

Although not a lot is known about CR quality, gaps were identified. The quality improvement initiatives recommended herein require testing to ascertain whether quality can be improved.

The development of indicator measure for monitoring the quality of patient-centered care in China's tertiary hospitals

OBJECTIVE

To develop a set of structure and process indicators to evaluate tertiary hospitals' performance in the Healthcare Improvement Initiative, a national program with a goal to improve quality of patient-centered care.

METHODS

A modified Delphi technique, including literature review, multidisciplinary panel meeting and anonymous rating, was used to generate a set of indicators. A practice test involving both general and special hospitals was conducted to ensure the feasibility of data collection for these indicators.

RESULTS

62 indicators were generated by literature review. The panel review procedure involving 39 panelists with diverse backgrounds resulted in a total of 59 indicators, which included 40 qualitative indicators and 19 quantitative indicators. In the practice test, six quantitative indicators were found unfeasible. According to the suggestion of the experts in the hospital evaluation committee, three of those indicators were kept by adjusting their data collection methods, while other three ones were discarded.

DISCUSSION

A set of 56 structure and process indicators was developed to evaluate hospitals' performance in the implementation of the Healthcare Improvement Initiative, which could be used in both general and special tertiary hospitals. Results of the indicator measurement could present a panorama of the quality of patient-centered care in tertiary hospitals nation-wide, and inform health administrators of the ways to attain the goal of the Initiative.

Development of Quality Indicators for Cardiac Rehabilitation in Australia: A Modified Delphi Method and Pilot Test

BACKGROUND

International guidelines recommend cardiac rehabilitation (CR) for secondary prevention of cardiovascular disease, however, it is underutilised and the quality of content and delivery varies widely. Quality indicators (QIs) for CR are used internationally to measure clinical practice performance, but are lacking in the Australian context. This study reports the development of QIs for minimum dataset (MDS) for CR and the results of a pilot test for feasibility and applicability in clinical practice in Australia.

METHODS

A modified Delphi method was used to develop initial QIs which involved a consensus approach through a series of face-to-face and teleconference meetings of an expert multidisciplinary panel (n=8), supplemented by an environmental scan of the literature and a multi-site pilot test.

RESULTS

Eight (8) QIs were proposed and sent to CR clinicians (n=250) electronically to rate importance, current data collection status, and feasibility of future collection. The top six of these QIs were selected with an additional two key performance indicators from the New South Wales (NSW) Ministry of Health and two QIs from international registers for a draft MDS. The pilot test in 16 sites (938 patient cases) demonstrated median performance of 93% (IQR 47.1-100%). All 10 QIs were retained and one further QI related to diabetes was added for a final draft MDS.

CONCLUSIONS

The MDS of 11 QIs for CR provides an important foundation for collection of data to promote the quality of CR nationally and the opportunity to participate in international benchmarking.