1
|
Pepera G, Antoniou V, Su JJ, Lin R, Batalik L. Comprehensive and personalized approach is a critical area for developing remote cardiac rehabilitation programs. World J Clin Cases 2024; 12:2009-2015. [PMID: 38680265 PMCID: PMC11045502 DOI: 10.12998/wjcc.v12.i12.2009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
In the evolving landscape of cardiac rehabilitation (CR), adopting digital technologies, including synchronous/real-time digital interventions and smart applications, has emerged as a transformative approach. These technologies offer real-time health data access, continuous vital sign monitoring, and personalized educational enhanced patient self-management and engagement. Despite their potential benefits, challenges and limitations exist, necessitating careful consideration. Synchronous/real-time digital CR involves remote, two-way audiovisual communication, addressing issues of accessibility and promoting home-based interventions. Smart applications extend beyond traditional healthcare, providing real-time health data and fostering patient empowerment. Wearable devices and mobile apps enable continuous monitoring, tracking of rehabilitation outcomes, and facilitate lifestyle modifications crucial for cardiac health maintenance. As digital CR progresses, ensuring patient access, equitable implementation, and addressing the digital divide becomes paramount. Artificial intelligence holds promise in the early detection of cardiac events and tailoring patient-specific CR programs. However, challenges such as digital literacy, data privacy, and security must be addressed to ensure inclusive implementation. Moreover, the shift toward digital CR raises concerns about cost, safety, and potential depersonalization of therapeutic relationships. A transformative shift towards technologically enabled CR necessitates further research, focusing not only on technological advancements but also on customization to meet diverse patient needs. Overcoming challenges related to cost, safety, data security, and potential depersonalization is crucial for the widespread adoption of digital CR. Future studies should explore integrating moral values into digital therapeutic relationships and ensure that digital CR is accessible, equitable, and seamlessly integrated into routine cardiac care. Theoretical frameworks that accommodate the dynamic quality of real-time monitoring and feedback feature of digital CR interventions should be considered to guide intervention development.
Collapse
Affiliation(s)
- Garyfallia Pepera
- Clinical Exercise Physiology and Rehabilitation Research Laboratory, Department of Physiotherapy, Faculty of Health Sciences, University of Thessaly, Lamia GR35100, Greece
| | - Varsamo Antoniou
- Clinical Exercise Physiology and Rehabilitation Research Laboratory, Department of Physiotherapy, Faculty of Health Sciences, University of Thessaly, Lamia GR35100, Greece
| | - Jing Jing Su
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong 999077, China
| | - Rose Lin
- University of Rochester School of Nursing, New York, NY 14602, United States
| | - Ladislav Batalik
- Department of Rehabilitation, University Hospital Brno, Brno 62500, Czech Republic
- Department of Public Health, Faculty of Medicine, Masaryk University, Brno 62500, Czech Republic
| |
Collapse
|
2
|
Ferrel-Yui D, Candelaria D, Pettersen TR, Gallagher R, Shi W. Uptake and implementation of cardiac telerehabilitation: A systematic review of provider and system barriers and enablers. Int J Med Inform 2024; 184:105346. [PMID: 38281451 DOI: 10.1016/j.ijmedinf.2024.105346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/20/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Cardiac telerehabilitation has demonstrated effectiveness for patient health outcomes, but uptake and implementation into practice have been limited and variable. While patient-level influences on uptake have been identified, little is known about provider- and system-level factors. AIMS To identify provider and system barriers and enablers to uptake and implementation of cardiac telerehabilitation. METHODS A systematic review was conducted, including a search of six databases (MEDLINE, Embase, CINAHL, Scopus, Web of Science, and PsycINFO) from 2000 to March 2023. Two reviewers independently screened eligible articles. Study quality was evaluated according to study design by the Critical Appraisal Skills Programme (CASP) checklist for qualitative data, the Appraisal Tool for Cross-sectional Studies (AXIS), and the Mixed Methods Appraisal Tool (MMAT) for mixed methods. Data were analysed using narrative synthesis. RESULTS Twenty eligible studies (total 1674 participants) were included. Perceived provider-level barriers included that cardiac telerehabilitation is resource intensive, inferior to centre-based delivery, and lack of staff preparation. Whereas provider-level enablers were having access to resources, adequate staff preparation, positive staff beliefs regarding cardiac telerehabilitation and positive team dynamics. System-level barriers related to unaligned policy, healthcare system and insurance structures, technology issues, lack of plans for implementation, and inadequate resources. System-level enablers included cost-effectiveness, technology availability, reliability, and adaptability, and adequate program development, implementation planning and leadership support. CONCLUSIONS Barriers and enablers at both provider and system levels must be recognised and addressed at the local context to ensure better uptake of cardiac telerehabilitation programs.
Collapse
Affiliation(s)
- Daniel Ferrel-Yui
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia
| | - Dion Candelaria
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia; The University of Sydney, Charles Perkins Centre, D17, John Hopkins Drive, Camperdown, New South Wales, 2050, Australia.
| | - Trond Røed Pettersen
- Haukeland University Hospital, Department of Heart Disease, Box 1400, 5021, Bergen, Norway
| | - Robyn Gallagher
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia; The University of Sydney, Charles Perkins Centre, D17, John Hopkins Drive, Camperdown, New South Wales, 2050, Australia
| | - Wendan Shi
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, D18, Western Avenue, Camperdown, New South Wales 2050, Australia; The University of Sydney, Charles Perkins Centre, D17, John Hopkins Drive, Camperdown, New South Wales, 2050, Australia; St George Hospital, Centre for Research in Nursing and Health, Gray Street, Kogarah, New South Wales 2217, Australia
| |
Collapse
|
3
|
DeLara DL, Pollack LM, Wall HK, Chang A, Schieb L, Matthews K, Stolp H, Pack QR, Casper M, Jackson SL. County-Level Cardiac Rehabilitation and Broadband Availability: Opportunities for Hybrid Care in the United States. J Cardiopulm Rehabil Prev 2024:01273116-990000000-00145. [PMID: 38669319 DOI: 10.1097/hcr.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
PURPOSE Cardiac rehabilitation (CR) improves patient outcomes and quality of life and can be provided virtually through hybrid CR. However, little is known about CR availability in conjunction with broadband access, a requirement for hybrid CR. This study examined the intersection of CR and broadband availability at the county level, nationwide. METHODS Data were gathered and analyzed in 2022 from the 2019 American Community Survey, the Centers for Medicare & Medicaid Services, and the Federal Communications Commission. Spatially adaptive floating catchments were used to calculate county-level percent CR availability among Medicare fee-for-service beneficiaries. Counties were categorized: by CR availability, whether lowest (ie, CR deserts), medium, or highest; and by broadband availability, whether CR deserts with majority-available broadband, or dual deserts. Results were stratified by state. County-level characteristics were examined for statistical significance by CR availability category. RESULTS Almost half of US adults (n = 116 325 976, 47.2%) lived in CR desert counties (1691 counties). Among adults in CR desert counties, 96.8% were in CR deserts with majority-available broadband (112 626 906). By state, the percentage of the adult population living in CR desert counties ranged from 3.2% (New Hampshire) to 100% (Hawaii and Washington, DC). Statistically significant differences in county CR availability existed by race/ethnicity, education, and income. CONCLUSIONS Almost half of US adults live in CR deserts. Given that up to 97% of adults living in CR deserts may have broadband access, implementation of hybrid CR programs that include a telehealth component could expand CR availability to as many as 113 million US adults.
Collapse
Affiliation(s)
- David L DeLara
- Author Affiliations: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia (Mr DeLara, Drs Pollack, Casper, and Jackson, and Mss Wall, Chang, Schieb, and Stolp); Office of the Associate Director for Policy and Strategy, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Matthews); ASRT Inc, Smyrna, Georgia (Ms Stolp); and Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, Massachusetts (Dr Pack)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Maxwell WD, Fierke KK, Zumach GM. Outcomes of a "virtual think tank" to establish collaborative leadership initiative plans ("CLIPs"). Explor Res Clin Soc Pharm 2024; 13:100409. [PMID: 38317647 PMCID: PMC10839148 DOI: 10.1016/j.rcsop.2024.100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/05/2024] [Accepted: 01/17/2024] [Indexed: 02/07/2024] Open
Abstract
Goal The American Association of Colleges of Pharmacy (AACP) Leadership Development Special Interest Group (LD SIG) held a one-hour "Virtual Think Tank" (VTT) interactive session in 2020 for pharmacy educators interested in leadership development. The purpose of this study was to evaluate the quantitative and qualitative outcomes of this VTT. Methods VTT attendees worked together in small groups created based on pre-selected common interest areas related to leadership development to create collaborative leadership initiative plans (CLIPs), which were ideas for new collaborative scholarly or programmatic initiatives. Principal findings Quantitative outcomes of this VTT included statistically significant increases in positive perceptions toward the organization hosting the VTT regarding networking, scholarly collaboration, educational collaboration, and professional service opportunities, as well as significant improvements in attitudes regarding engagement with the sponsoring organization. Additionally, 18.4% of VTT attendees continued communicating with CLIP groups post-VTT and 13.2% of respondents indicated that they successfully implemented the CLIP ideas that were generated during the VTT. Qualitative outcomes included findings that the two most commonly encountered barriers were insufficient traction of the initial idea and lack of time (41.9% (n = 13) for both). Other barriers included lack of alignment with priorities at 12.9% (n = 4). Practical applications This leadership VTT for pharmacy academicians led to development and implementation of important scholarly and programmatic outcomes, and fostered cross-institutional partnerships. Findings from this study evaluating a VTT provide a framework of expectations for other organizations seeking to implement a similar initiative.
Collapse
Affiliation(s)
- Whitney D. Maxwell
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, 715 Sumter Street, Columbia, SC 29208, United States of America
| | - Kerry K. Fierke
- Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, 232 Life Science, 1110 Kirby Drive, Duluth, MN 55812-3003, United States of America
| | - Gregory M. Zumach
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center College of Pharmacy, 986120 Nebraska Medical CenterOmaha, NE 68198-6120, United States of America
| |
Collapse
|
5
|
Platz K, Metzger M, Cavanagh C, Park L, Howie-Esquivel J. Initiating and Continuing Long-Term Exercise in Heart Failure: A Qualitative Analysis From the GEtting iNTo Light Exercise-Heart Failure Study. J Cardiovasc Nurs 2024:00005082-990000000-00170. [PMID: 38411493 DOI: 10.1097/jcn.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Exercise is a class 1A recommendation to improve the lives of patients with heart failure, yet less than one-third adhere to physical activity guidelines, and less than 3% attend cardiac rehabilitation. OBJECTIVE The aim of this study was to determine the effect of gentle nonaerobic exercise on initial and long-term adherence in patients with heart failure. METHODS We used a qualitative descriptive approach with qualitative content analysis to analyze previously recorded interview data collected as part of the 6-month GEtting iNTo Light Exercise-Heart Failure study and looked for trends in responses among our sample. Thematic statements, representing salient aspects of the participants' experiences, were created and supported by illustrative excerpts from the data. RESULTS Twenty-two interviews were analyzed. Eight participants had ≥80% adherence, and the remaining 14 participants were super-adherers (>100% adherence). Super-adherers tended to be male and 65 years or older, and have no exercise for 3 months before the study, a body mass index ≥ 30, and poor to good Kansas City Cardiomyopathy Questionnaire scores. Participants initially enrolled because they saw the program as an opportunity to improve a health issue and to exercise. Long-term adherence was facilitated by convenience, individualization, experiencing psychological and physical improvements, and peer fellowship. CONCLUSIONS The GEtting iNTo Light Exercise-Heart Failure study that used home-based gentle nonaerobic exercise had 64% of participants come more than was asked. It is imperative that clinicians incorporate what participants with heart failure have directly stated is important for their initiation and long-term adherence to exercise so that we can work toward bridging sedentary patients to the full exercise guidelines to reduce morbidity and mortality.
Collapse
|
6
|
Forouzandeh F, Alexander K, Forman D, Kirkpatrick JN, Rich MW, Zieman S, Wenger NK. Cardiovascular Disease in the Older Adult: Where Are We 4 Decades Later? JACC Adv 2024; 3:100820. [PMID: 38435451 PMCID: PMC10906817 DOI: 10.1016/j.jacadv.2023.100820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
The 1986 Bethesda Conference on Cardiovascular Disease (CVD) in the Elderly, co-chaired by Drs. Nanette Wenger, Frank Marcus, and Robert O'Rourke, delineated the anticipated social, political, ethical, economic and technological impact of an aging population on the incidence, prevalence, and management of CVD in the US and worldwide. In the ensuing 4 decades, older patients have come to comprise an increasingly large proportion of the CVD population, and there has been an explosion of research in all aspects of CVD affecting older adults. Correspondingly, Geriatric Cardiology is now an established field within cardiovascular medicine. In this communication, we provide a focused update on intersections between CVD and geriatrics from basic science to clinical practice, a review of major advances in diagnosis and treatment of older adults with CVD, and a preview of future research directions in the still evolving field of geriatric cardiology.
Collapse
Affiliation(s)
- Farshad Forouzandeh
- University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Karen Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Daniel Forman
- Department of Medicine (Divisions of Geriatrics and Cardiology), University of Pittsburgh, and the Pittsburgh Geriatrics, Research, Education, and Clinical Center (GRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - James N Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| | - Michael W Rich
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Susan Zieman
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health, Bethesda, MD
| | - Nanette K Wenger
- Department of Medicine (Division of Cardiology), Emory University School of Medicine, Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, GA
| |
Collapse
|
7
|
Isakadze N, Kim CH, Marvel FA, Ding J, MacFarlane Z, Gao Y, Spaulding EM, Stewart KJ, Nimbalkar M, Bush A, Broderick A, Gallagher J, Molello N, Commodore-Mensah Y, Michos ED, Dunn P, Hanley DF, McBee N, Martin SS, Mathews L. Rationale and Design of the mTECH-Rehab Randomized Controlled Trial: Impact of a Mobile Technology Enabled Corrie Cardiac Rehabilitation Program on Functional Status and Cardiovascular Health. J Am Heart Assoc 2024; 13:e030654. [PMID: 38226511 PMCID: PMC10926786 DOI: 10.1161/jaha.123.030654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 12/01/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is an evidence-based, guideline-recommended intervention for patients recovering from a cardiac event, surgery or procedure that improves morbidity, mortality, and functional status. CR is traditionally provided in-center, which limits access and engagement, most notably among underrepresented racial and ethnic groups due to barriers including cost, scheduling, and transportation access. This study is designed to evaluate the Corrie Hybrid CR, a technology-based, multicomponent health equity-focused intervention as an alternative to traditional in-center CR among patients recovering from a cardiac event, surgery, or procedure compared with usual care alone. METHODS The mTECH-Rehab (Impact of a Mobile Technology Enabled Corrie CR Program) trial will randomize 200 patients who either have diagnosis of myocardial infarction or who undergo coronary artery bypass grafting surgery, percutaneous coronary intervention, heart valve repair, or replacement presenting to 4 hospitals in a large academic health system in Maryland, United States, to the Corrie Hybrid CR program combined with usual care CR (intervention group) or usual care CR alone (control group) in a parallel arm, randomized controlled trial. The Corrie Hybrid CR program leverages 5 components: (1) a patient-facing mobile application that encourages behavior change, patient empowerment, and engagement with guideline-directed therapy; (2) Food and Drug Administration-approved smart devices that collect health metrics; (3) 2 upfront in-center CR sessions to facilitate personalization, self-efficacy, and evaluation for the safety of home exercise, followed by a combination of in-center and home-based sessions per participant preference; (4) a clinician dashboard to track health data; and (5) weekly virtual coaching sessions delivered over 12 weeks for education, encouragement, and risk factor modification. The primary outcome is the mean difference between the intervention versus control groups in distance walked on the 6-minute walk test (ie, functional capacity) at 12 weeks post randomization. Key secondary and exploratory outcomes include improvement in a composite cardiovascular health metric, CR engagement, quality of life, health factors (including low-density lipoprotein-cholesterol, hemoglobin A1c, weight, diet, smoking cessation, blood pressure), and psychosocial factors. Approval for the study was granted by the local institutional review board. Results of the trial will be published once data collection and analysis have been completed. CONCLUSIONS The Corrie Hybrid CR program has the potential to improve functional status, cardiovascular health, and CR engagement and advance equity in access to cardiac rehabilitation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05238103.
Collapse
Affiliation(s)
- Nino Isakadze
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Chang H Kim
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Francoise A Marvel
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Jie Ding
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Zane MacFarlane
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Yumin Gao
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Erin M Spaulding
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
- Johns Hopkins University School of Nursing Baltimore MD USA
- Welch Center for Prevention, Epidemiology, and Clinical Research Johns Hopkins University Baltimore MD USA
| | - Kerry J Stewart
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
| | - Mansi Nimbalkar
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
| | - Alexandra Bush
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
| | - Ashley Broderick
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
| | - Jeanmarie Gallagher
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
| | - Nancy Molello
- Johns Hopkins Center for Health Equity Baltimore MD USA
| | - Yvonne Commodore-Mensah
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
- Johns Hopkins University School of Nursing Baltimore MD USA
- Johns Hopkins Center for Health Equity Baltimore MD USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
| | - Patrick Dunn
- Center for Health Technology and Innovation, American Heart Association Dallas TX USA
- Department of Neurology Johns Hopkins University School of Medicine Baltimore MD USA
| | - Daniel F Hanley
- Department of Neurology Johns Hopkins University School of Medicine Baltimore MD USA
- Division of Neurosurgery, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD USA
- Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD USA
| | - Nichol McBee
- Ginsburg Institute for Health Equity, Nemours Children's Health Orlando FL USA
- Department of Neurology Johns Hopkins University School of Medicine Baltimore MD USA
| | - Seth S Martin
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
- Johns Hopkins Center for Health Equity Baltimore MD USA
| | - Lena Mathews
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center) Baltimore MD USA
- Johns Hopkins Center for Health Equity Baltimore MD USA
- Welch Center for Prevention, Epidemiology, and Clinical Research Johns Hopkins University Baltimore MD USA
| |
Collapse
|
8
|
Atluri N, Mishra SR, Anderson T, Stevens R, Edwards A, Luff E, Nallamothu BK, Golbus JR. Acceptability of a Text Message-Based Mobile Health Intervention to Promote Physical Activity in Cardiac Rehabilitation Enrollees: A Qualitative Substudy of Participant Perspectives. J Am Heart Assoc 2024; 13:e030807. [PMID: 38226512 PMCID: PMC10926792 DOI: 10.1161/jaha.123.030807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/08/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Mobile health (mHealth) interventions have the potential to deliver longitudinal support to users outside of episodic clinical encounters. We performed a qualitative substudy to assess the acceptability of a text message-based mHealth intervention designed to increase and sustain physical activity in cardiac rehabilitation enrollees. METHODS AND RESULTS Semistructured interviews were conducted with intervention arm participants of a randomized controlled trial delivered to low- and moderate-risk cardiac rehabilitation enrollees. Interviews explored participants' interaction with the mobile application, reflections on tailored text messages, integration with cardiac rehabilitation, and opportunities for improvement. Transcripts were thematically analyzed using an iteratively developed codebook. Sample size consisted of 17 participants with mean age of 65.7 (SD 8.2) years; 29% were women, 29% had low functional capacity, and 12% were non-White. Four themes emerged from interviews: engagement, health impact, personalization, and future directions. Participants engaged meaningfully with the mHealth intervention, finding it beneficial in promoting increased physical activity. However, participants desired greater personalization to their individual health goals, fitness levels, and real-time environment. Generally, those with lower functional capacity and less experience with exercise were more likely to view the intervention positively. Finally, participants identified future directions for the intervention including better incorporation of exercise physiologists and social support systems. CONCLUSIONS Cardiac rehabilitation enrollees viewed a text message-based mHealth intervention favorably, suggesting the potentially high usefulness of mHealth technologies in this population. Addressing participant-identified needs on increased user customization and inclusion of clinical and social support is crucial to enhancing the effectiveness of future mHealth interventions. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04587882.
Collapse
Affiliation(s)
- Namratha Atluri
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Sonali R. Mishra
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Theresa Anderson
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Rachel Stevens
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Angel Edwards
- Department of PharmacyUniversity of MichiganAnn ArborMIUSA
| | - Evan Luff
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Brahmajee K. Nallamothu
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP)University of MichiganAnn ArborMIUSA
- The Center for Clinical Management and Research, Ann Arbor VA Medical CenterAnn ArborMIUSA
| | - Jessica R. Golbus
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- The Center for Clinical Management and Research, Ann Arbor VA Medical CenterAnn ArborMIUSA
| |
Collapse
|
9
|
Nabutovsky I, Breitner D, Heller A, Levine Y, Moreno M, Scheinowitz M, Levin C, Klempfner R. Home-Based Cardiac Rehabilitation Among Patients Unwilling to Participate in Hospital-Based Programs. J Cardiopulm Rehabil Prev 2024; 44:33-39. [PMID: 37220026 DOI: 10.1097/hcr.0000000000000796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE Asynchronous home-based cardiac rehabilitation (HBCR) is a viable alternative to center-based cardiac rehabilitation (CBCR). However, to achieve significant functional improvement, a high level of adherence and activity must be achieved. The effectiveness of HBCR among patients who actively avoid CBCR has not been effectively investigated. This study aimed to investigate the effectiveness of the HBCR program among patients unwilling to participate in CBCR. METHODS A randomized prospective study enrolled 45 participants to a 6-mo HBCR program and the remaining 24 were allocated to regular care. Both groups were digitally monitored for physical activity (PA) and self-reported outcomes. Change in peak oxygen uptake (VO 2peak ), the primary study outcome, was measured by the cardiopulmonary exercise test, immediately before program start and 4 mo thereafter. RESULTS The study included 69 patients, 81% men, aged 55.9 ±12 yr, enrolled in a 6-mo HBCR program to follow a myocardial infarction (25.4%) or coronary interventions (41.3%), heart failure hospitalization (29%), or heart transplantation (10%). Weekly aerobic exercise totaled a median of 193.2 (110.2-251.5) min (129% of set exercise goal), of which 112 (70-150) min was in the heart rate zone recommended by the exercise physiologist.After 4 mo, VO 2peak improved by 10.2% in the intervention group versus -2.7% in the control group (+2.46 ± 2.67 vs -0.72 ± 3.02 mL/kg/min; P < .001). CONCLUSION The monthly PA of patients in the HBCR versus conventional CBCR group were well within guideline recommendations, showing a significant improvement in cardiorespiratory fitness. Risk level, age, and lack of motivation at the beginning of the program did not prevent achieving goals and maintaining adherence.
Collapse
Affiliation(s)
- Irene Nabutovsky
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nabutovsky and Klempfner, Messrs Breitner and Levine, and Ms Heller); Cardiac Prevention and Rehabilitation Institute, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel (Drs Nabutovsky and Klempfner and Ms Moreno); Department of Biomedical Engineering, Faculty of Engineering, Sylvan Adams Sports Institute, School for Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Hashomer, Israel (Dr Scheinowitz); and Faculty of School of Life and Health Sciences, The Jerusalem College of Technology, Jerusalem, Israel (Dr Levin)
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Oehler AC, Holmstrand EC, Zhou L, Harzand A, Vathsangam H, Kendall K, Gabriel G, Murali S. Cost Analysis of Remote Cardiac Rehabilitation Compared With Facility-Based Cardiac Rehabilitation for Coronary Artery Disease. Am J Cardiol 2024; 210:266-272. [PMID: 37973439 DOI: 10.1016/j.amjcard.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/14/2023] [Indexed: 11/19/2023]
Abstract
Remote cardiac rehabilitation (RCR) represents a promising, noninferior alternative to facility-based cardiac rehabilitation (FBCR). The comparable cost of RCR in US populations has yet to be extensively studied. The purpose of this prospective, patient-selected study of traditional FBCR versus a third-party asynchronous RCR platform was to assess whether RCR can be administered at a comparable cost and clinical efficacy to FBCR. Adult insured patients were eligible for enrollment after an admission for a coronary heart disease event. Patients selected either FBCR or Movn RCR, a 12-week telehealth intervention using an app-based platform and internet-capable medical devices. Clinical demographics, intervention adherence, cost-effectiveness, and hospitalizations at 1-year after enrollment were assessed from the Highmark claims database after propensity matching between groups. A total of 260 patients were included and 171 of those eligible (65.8%) received at least 1 cardiac rehabilitation session and half of the patients chose Movn RCR. The propensity matching produced a sample of 41 matched pairs. Movn RCR led to a faster enrollment and higher completion rates (80% vs 50%). The total medical costs were similar between Movn RCR and FBCR, although tended toward cost savings with Movn RCR ($10,574/patient). The cost of cardiac rehabilitation was lower in those enrolled in Movn RCR ($1,377/patient, p = 0.002). The all-cause and cardiovascular-related hospitalizations or emergency department visits in the year after enrollment in both groups were similar. In conclusion, this pragmatic study of patients after a coronary heart disease event led to equivalent total medical costs and lower intervention costs for an asynchronous RCR platform than traditional FBCR while maintaining similar clinically important outcomes.
Collapse
Affiliation(s)
- Andrew C Oehler
- Allegheny Health Network Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | | | - Lulu Zhou
- Evaluation Analytics, Highmark Health, Pittsburgh, Pennsylvania
| | | | - Harshvardhan Vathsangam
- Movn Health, Irvine, California; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kellee Kendall
- VITAL Innovation Program, Highmark Health, Pittsburgh, Pennsylvania
| | - George Gabriel
- Allegheny Health Network Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Srinivas Murali
- Allegheny Health Network Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| |
Collapse
|
11
|
Child CE, Kelly ML, Sizelove H, Garvin M, Guilliams J, Kim P, Cai HD, Luo S, McQuade KJ, Swenson ER, Wise AT, Lynch YT, Ho LA, Brown MB. A remote monitoring-enabled home exercise prescription for patients with interstitial lung disease at risk for exercise-induced desaturation. Respir Med 2023; 218:107397. [PMID: 37640274 DOI: 10.1016/j.rmed.2023.107397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/11/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
RATIONALE Alternatives to center-based pulmonary rehabilitation are needed to improve patient access to this important therapy. A critical challenge to overcome is how to maximize safety of unsupervised exercise for at-risk patients. We investigated if a novel remote monitoring-enabled mobile health (mHealth) program is safe, feasible, and effective for patients who experience exercise-induced hemoglobin desaturation. METHODS An interstitial lung disease (ILD) commonly associated with pronounced exercise desaturation was investigated - the rare, female-predominant ILD lymphangioleiomyomatosis (LAM). Over a 12-week program, hemoglobin saturation (SpO2) was continuously recorded during all home exercise sessions. Intervention effects were assessed with 6-min walk test (6MWT), maximal cardiopulmonary exercise test (CPET), lower extremity computerized dynamometry, pulmonary function tests, and health-related quality of life (QoL) surveys. Safety was assessed by blood biomarkers of systemic inflammation and cardiac wall stress, and incidence of adverse events. RESULTS Fifteen LAM patients enrolled and 14 completed the intervention, with high adherence to aerobic (87 ± 15%) and strength (87 ± 12%) training components. An innovative characterization of exercise training SpO2 revealed that while mild-to-moderate desaturation was common during home workouts, participants were able to self-adjust exercise intensity and supplemental oxygen levels to maintain recommended exercise parameters. Significant improvements included 6MWT distance (+36 ± 34 m, p = 0.003), CPET time (p = 0.04), muscular endurance (p = 0.008), QoL (p = 0.009 to 0.03), and fatigue (p = 0.001 to 0.03). Patient acceptability and satisfaction indicators were high, blood biomarkers remained stable (p > 0.05), and no study-related adverse events occurred. CONCLUSION A remote monitoring-enabled home exercise program is a safe, feasible, and effective approach even for patients who experience exercise desaturation.
Collapse
Affiliation(s)
- Claire E Child
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Morgan L Kelly
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Haley Sizelove
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Marissa Garvin
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Julia Guilliams
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Paul Kim
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Haotian D Cai
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - SiWei Luo
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Kevin J McQuade
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Erik R Swenson
- Medical Service, VA Puget Sound Health Care System, USA; University of Washington, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - Amanda T Wise
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| | - Ylinne T Lynch
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - Lawrence A Ho
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - Mary Beth Brown
- University of Washington, Department of Rehabilitation Medicine, Division of Physical Therapy, USA.
| |
Collapse
|
12
|
Abstract
Given the under-utilisation of cardiac rehabilitation despite its benefits, there has been a shift towards alternative delivery models. The recent coronavirus disease 2019 (COVID-19) pandemic has accelerated this shift, leading to a growing interest in home-based cardiac rehabilitation including telerehabilitation. There is increasing evidence to support cardiac telerehabilitation, with studies generally demonstrating comparable outcomes and potential cost-benefits. This review aims to provide a synopsis of the current evidence on home-based cardiac rehabilitation with a focus on telerehabilitation and practical considerations.
Collapse
Affiliation(s)
- Rita Hwang
- Department of Physiotherapy, Princess Alexandra Hospital, Metro South Health, Ipswich Road, Woolloongabba, QLD 4102, Brisbane, Australia.
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
- School of Allied Health Sciences and Menzies Health Institute, Griffith University, Gold Coast, Australia.
| | - Elise M Gane
- Department of Physiotherapy, Princess Alexandra Hospital, Metro South Health, Ipswich Road, Woolloongabba, QLD 4102, Brisbane, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia
| | - Norman R Morris
- School of Allied Health Sciences and Menzies Health Institute, Griffith University, Gold Coast, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Metro North Health, Brisbane, Australia
| |
Collapse
|
13
|
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: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
14
|
Bauer TM, Yaser JM, Daramola T, Mansour AI, Ailawadi G, Pagani FD, Theurer P, Likosky DS, Keteyian SJ, Thompson MP. Cardiac Rehabilitation Reduces 2-Year Mortality After Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 116:1099-1105. [PMID: 37392993 PMCID: PMC11007662 DOI: 10.1016/j.athoracsur.2023.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 05/12/2023] [Accepted: 05/30/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is a supervised outpatient exercise and risk reduction program offered to patients who have undergone coronary revascularization procedures. Multiple professional societal guidelines support the use of CR after coronary artery bypass grafting (CABG) based on studies in combined percutaneous coronary intervention and CABG populations with surrogate outcomes. This statewide analysis of patients undergoing CABG evaluated the relationship between CR use and long-term mortality. METHODS Medicare fee-for-service claims were linked to surgical data for patients discharged alive after isolated CABG from January 1, 2015, through September 30, 2019. Outpatient facility claims were used to identify any CR use within 1 year of discharge. Death within 2 years of discharge was the primary outcome. Mixed-effects logistic regression was used to predict CR use, adjusting for a variety of comorbidities. Unadjusted and inverse probability treatment weighting (IPTW) were used to compare 2-year mortality among CR users vs nonusers. RESULTS A total of 3848 of 6412 patients (60.0%) were enrolled in CR for an average of 23.2 (SD, 12.0) sessions, with 770 of 6412 (12.0%) completing all recommended 36 sessions. Logistic regression identified increasing age, discharge to home (vs extended care facility), and shorter length of stay as predictors of postdischarge CR use (P < .05). Unadjusted and IPTW analyses showed significant reduction in 2-year mortality in CR users compared with CR nonusers (unadjusted: 9.4% reduction; 95% CI, 10.8%-7.9%; P < .001; IPTW: -4.8% reduction; 95% CI, 6.0%-3.5%; P < .001). CONCLUSIONS These data suggest that CR use is associated with lower 2-year mortality. Future quality initiatives should consider identifying and addressing root causes of poor CR enrollment and completion.
Collapse
Affiliation(s)
- Tyler M Bauer
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Patricia Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Steven J Keteyian
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; Division of Cardiovascular Medicine, Henry Ford Health, Detroit, Michigan
| | - Michael P Thompson
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Value Collaborative, Ann Arbor, Michigan.
| |
Collapse
|
15
|
Khong A, Liu N, Giancaterino S, Junker M, Labiak R, Cortez-Toledo E, Fausto AGB, Andrade H, Chen C, López JE. Medical Disruptions During Center-Based Cardiac Rehabilitation: A Necessary Appraisal for the Development of Emerging Remote and Virtual Care Models. J Cardiopulm Rehabil Prev 2023; 43:329-337. [PMID: 36811521 DOI: 10.1097/hcr.0000000000000771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE The purpose of this study is to show that with remote and virtual cardiac rehabilitation (CR) care models rapidly emerging, CR core components must be maintained to prioritize safety and effectiveness. Currently, there is a paucity of data on medical disruptions in phase 2 center-based CR (cCR). This study aimed to characterize the frequency and types of unplanned medical disruptions. METHODS We reviewed 5038 consecutive sessions from 251 patients enrolled in cCR program from October 2018 to September 2021. Quantification of events was normalized to sessions to control for multiple disruptions that occurred to a single patient. A multivariate logistical regression model was used to predict comorbid risk factors for disruptions. RESULTS Fifty percent of patients experienced one or more disruptions during cCR. Glycemic events (71%) and blood pressure (12%) abnormalities accounted for most of these while symptomatic arrhythmias (8%) and chest pain (7%) were less frequent. Sixty-six percent of events occurred within the first 12 wk. The regression model showed that a diagnosis of diabetes mellitus was the strongest predictor for disruptions (OR = 2.66: 95% CI, 1.57-4.52; P < .0001). CONCLUSIONS Medical disruptions were frequent during cCR, with glycemic events being most common and occurring early. A diagnosis of diabetes mellitus was a strong independent risk factor for events. This appraisal suggests that patients living with diabetes mellitus, particularly those on insulin, need to be the highest priority for monitoring and planning and suggests that a hybrid care model may be beneficial in this population.
Collapse
Affiliation(s)
- Anthony Khong
- Department of Internal Medicine (Drs Khong and Liu) and Division of Cardiovascular Medicine (Drs Giancaterino, Chen, and López, Mss Junker, Labiak, Cortez-Toledo, and Fausto, and Mr Andrade), UC Davis Health, Davis, California
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
|
17
|
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Varghese MS, Song Y, Xu J, Dahabreh I, Beatty AL, Sperling LS, Fonarow GC, Keteyian SJ, Yeh RW, Wu WC, Kazi DS. Availability and Use of In-Person and Virtual Cardiac Rehabilitation Among US Medicare Beneficiaries: A Post-Pandemic Update. J Cardiopulm Rehabil Prev 2023; 43:301-303. [PMID: 37158994 PMCID: PMC10843522 DOI: 10.1097/hcr.0000000000000803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Merilyn S. Varghese
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Issa Dahabreh
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alexis L. Beatty
- Department of Epidemiology and Biostatistics, Division of Cardiology, Department of Medicine, University of California, San Francisco, CA
| | - Laurence S. Sperling
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Wen-Chih Wu
- Providence VA Medical Center and the Miriam Hospital Cardiovascular Rehabilitation Center, Providence, RI
- Department of Medicine, Epidemiology and Center for Global Cardiometabolic Health, Brown University, Providence, RI
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| |
Collapse
|
19
|
Oclaman JM, Murray ML, Grandis DJ, Beatty AL. The Association Between Mobile App Use and Change in Functional Capacity Among Cardiac Rehabilitation Participants: Cohort Study. JMIR Cardio 2023; 7:e44433. [PMID: 37184917 DOI: 10.2196/44433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/09/2023] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) is underused in the United States and globally, with participation disparities across gender, socioeconomic status, race, and ethnicities. The pandemic led to greater adoption of telehealth CR and mobile app use. OBJECTIVE Our primary objective was to estimate the association between CR mobile app use and change in functional capacity from enrollment to completion in patients participating in a CR program that offered in-person, hybrid, and telehealth CR. Our secondary objectives were to study the association between mobile app use and changes in blood pressure (BP) or program completion. METHODS We conducted a retrospective cohort study of participants enrolled in CR at an urban CR program in the United States. Participants were English speaking, at least 18 years of age, participated in the program between May 22, 2020, and May 21, 2022, and downloaded the CR mobile app. Mobile app use was quantified by number of exercise logs, vitals logs, and education material views. The primary outcome was change in functional capacity, measured by change in 6-minute walk distance (6MWD) from enrollment to completion. The secondary outcome was change in BP from enrollment to completion. We estimated associations using multivariable linear or logistic regression models adjusted for age, sex, race, ethnicity, socioeconomic status by ZIP code, insurance, and primary diagnosis for CR referral. RESULTS A total of 107 participants (mean age 62.9, SD 13.02 years; 90/107, 84.1% male; and 57/105, 53.3% self-declared as White Caucasian) used the mobile app and completed the CR program. Participants had a mean 64.0 (SD 54.1) meter increase in 6MWD between enrollment and completion (P<.001). From enrollment to completion, participants with an elevated BP at baseline (≥130/80 mmHg) experienced a significant decrease in BP (systolic BP -11.5 mmHg; P=.002 and diastolic BP -7.7 mmHg; P=.003). We found no significant association between total app interactions and change in 6MWD (coefficient -0.03, 95% CI -0.1 to 0.07; P=.59) or change in BP (systolic coefficient 0.002, 95% CI -0.03 to 0.03; P=.87 and diastolic coefficient -0.005, 95% CI -0.03 to 0.02; P=.65). There was no significant association between total exercise logs and change in 6MWD (coefficient 0.1, 95% CI -0.3 to 0.4; P=.57) or total BP logs and change in BP (systolic coefficient -0.02, 95% CI -0.1 to 0.06; P=.63 and diastolic coefficient -0.02, 95% CI -0.09 to 0.04; P=.50). There was no significant association between total app interactions and completion of CR (adjusted odds ratio 1.00, 95% CI 0.99-1.01; P=.44). CONCLUSIONS CR mobile app use as part of an in-person, hybrid, or telehealth CR program was not associated with greater improvement in functional capacity or BP or with program completion.
Collapse
Affiliation(s)
- Janah May Oclaman
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Michelle L Murray
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Donald J Grandis
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Alexis L Beatty
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
20
|
Beatty AL, Marcus GM. Time to Get Moving: Exercise for Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:466-467. [PMID: 37100530 DOI: 10.1016/j.jacep.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Alexis L Beatty
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA; Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Gregory M Marcus
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
| |
Collapse
|
21
|
Brown TM. Cardiac Rehabilitation Underutilization: The Need for Innovative Delivery. J Am Coll Cardiol 2023; 81:1061-1062. [PMID: 36922092 DOI: 10.1016/j.jacc.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Todd M Brown
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| |
Collapse
|
22
|
Abstract
PURPOSE Cardiac rehabilitation (CR) improves health outcomes and quality of life for patients with cardiovascular disease, yet only a quarter of eligible patients enroll. A myriad of CR models that use either an alternative location (ie, home-based) and/or an alternative exercise have been developed to overcome known attendance and physical limitation barriers; however, patient experiences with these models have not been systematically reviewed. Our aim is to review patient experiences with these models of CR. REVIEW METHODS We conducted a systematic review and thematic analysis of qualitative studies published between 2009 and January of 2022 from CINAHL, PubMed, Web of Science, and PsycINFO. SUMMARY Twenty-five studies were included, representing the perspectives of 487 individuals who participated in an alternative model of CR. Exercises included walking, tai chi, yoga, aquatic exercise, exergaming, chair-based exercises, aerobics, physical activity trackers, and individualized exercise plans. Nineteen of 25 studies used home-based models and two used live video. Twelve studies included patients with heart failure. Patient perspectives comprised three central themes: exercise benefits, exercise facilitators, and participation barriers. Some thematic categories were reported variably by particular model/study design (eg, home-based) than by others. All alternative models of CR were found to be physically, psychologically, and/or socially beneficial to patients. Participants described facilitators and barriers that were influential in the decision to initiate or continue exercise. These patient insights are critical for innovative delivery of CR that is appealing, accommodates physical limitations, and broadens access to improve health equity.
Collapse
|
23
|
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: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.)
| |
Collapse
|
24
|
Thompson MP, Yaser JM, Forrest A, Keteyian SJ, Sukul D. Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK. J Cardiopulm Rehabil Prev 2022; 42:E75-E81. [PMID: 35831233 PMCID: PMC10069950 DOI: 10.1097/hcr.0000000000000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation. METHODS Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement. RESULTS A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. CONCLUSIONS This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.
Collapse
Affiliation(s)
- Michael P Thompson
- Section of Health Services Research and Quality, Department of Cardiac Surgery (Dr Thompson) and Division of Cardiovascular Medicine, Department of Internal Medicine (Dr Sukul), Michigan Medicine, Ann Arbor; Michigan Value Collaborative, Ann Arbor (Dr Thompson and Ms Yaser); Blue Cross Blue Shield of Michigan Cardiovascular Consortium, Ann Arbor (Ms Forrest and Dr Sukul); and Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan (Dr Keteyian)
| | | | | | | | | |
Collapse
|
25
|
Varghese MS, Beatty AL, Song Y, Xu J, Sperling LS, Fonarow GC, Keteyian SJ, McConeghy KW, Penko J, Yeh RW, Figueroa JF, Wu WC, Kazi DS. Cardiac Rehabilitation and the COVID-19 Pandemic: Persistent Declines in Cardiac Rehabilitation Participation and Access Among US Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2022; 15:e009618. [PMID: 36314139 PMCID: PMC9749950 DOI: 10.1161/circoutcomes.122.009618] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The impact of the COVID-19 pandemic on participation in and availability of cardiac rehabilitation (CR) is unknown. METHODS Among eligible Medicare fee-for-service beneficiaries, we evaluated, by month, the number of CR sessions attended per 100 000 beneficiaries, individuals eligible to initiate CR, and centers offering in-person CR between January 2019 and December 2021. We compared these outcomes between 2 periods: December 1, 2019 through February 28, 2020 (period 1, before declaration of the pandemic-related national emergency) and October 1, 2021 through December 31, 2021 (period 2, the latest period for which data are currently available). RESULTS In period 1, Medicare beneficiaries participated in (mean±SD) 895±84 CR sessions per 100 000 beneficiaries each month. After the national emergency was declared, CR participation sharply declined to 56 CR sessions per 100 000 beneficiaries in April 2020. CR participation recovered gradually through December 2021 but remained lower than prepandemic levels (period 2: 698±29 CR sessions per month per 100 000 beneficiaries, P=0.02). Declines in CR participation were most marked among dual Medicare and Medicaid enrollees and patients residing in rural areas or socially vulnerable communities. There was no statistically significant change in CR eligibility between the 2 periods. Compared with 2618±5 CR centers in period 1, there were 2464±7 in period 2 (P<0.01). Compared with CR centers that survived the pandemic, 220 CR centers that closed were more likely to be affiliated with public hospitals, located in rural areas, and serve the most socially vulnerable communities. CONCLUSIONS The COVID-19 pandemic was associated with a persistent decline in CR participation and the closure of CR centers, which disproportionately affected rural and low-income patients and the most socially vulnerable communities. Innovation in CR financing and delivery is urgently needed to equitably enhance CR participation among Medicare beneficiaries.
Collapse
Affiliation(s)
- Merilyn S. Varghese
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (M.S.V., Y.S., J.X., R.W.Y., D.S.K.).,Harvard Medical School, Boston, MA (M.S.V., R.W.Y., D.S.K.)
| | - Alexis L. Beatty
- Department of Epidemiology and Biostatistics, Division of Cardiology, Department of Medicine, University of California, San Francisco (A.B.)
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (M.S.V., Y.S., J.X., R.W.Y., D.S.K.)
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (M.S.V., Y.S., J.X., R.W.Y., D.S.K.)
| | - Laurence S. Sperling
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.S.S.)
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles (G.C.F.)
| | - Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Kevin W. McConeghy
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI (K.W.M.).,Center of Innovation Long-Term Services and Supports, Providence Veterans Administration Medical Center, RI (K.W.M.)
| | - Joanne Penko
- Department of Epidemiology and Biostatistics, University of California San Francisco (J.P.)
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (M.S.V., Y.S., J.X., R.W.Y., D.S.K.).,Harvard Medical School, Boston, MA (M.S.V., R.W.Y., D.S.K.)
| | - Jose F. Figueroa
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA (J.F.F.).,Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (J.F.F.)
| | - Wen-Chih Wu
- Providence VA Medical Center and the Miriam Hospital Cardiovascular Rehabilitation Center, RI (W.-C.W.).,Departments of Medicine, Epidemiology and Center for Global Cardiometabolic Health, Brown University, Providence, RI (W.-C.W.)
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (M.S.V., Y.S., J.X., R.W.Y., D.S.K.).,Harvard Medical School, Boston, MA (M.S.V., R.W.Y., D.S.K.)
| |
Collapse
|
26
|
Ganeshan S, Jackson H, Grandis DJ, Janke D, Murray ML, Valle V, Beatty AL. Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2022; 42:338-46. [PMID: 35420563 DOI: 10.1097/HCR.0000000000000688] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Cardiac rehabilitation (CR) is evolving to include both in-person and virtual delivery. Our objective was to compare, in CR patients, the association of in-person, hybrid, and virtual CR with change in performance on the 6-min walk test (6MWT) between enrollment and completion. METHODS Patients enrolled in CR between October 22, 2019, and May 10, 2021, were categorized into in-person, hybrid, or virtual groups by number of in-person and virtual visits. All patients received individualized exercise training and health behavior counseling. Cardiac rehabilitation was delivered to patients in the hybrid and virtual cohorts using synchronous video exercise and/or asynchronous telephone visits. Measurements at CR enrollment and completion included the 6MWT, blood pressure (BP), depression, anxiety, waist-to-hip ratio, and cardiac self-efficacy. RESULTS Of 187 CR patients, 37/97 (38.1%) were in-person patients and 58/90 (64.4%) were hybrid/virtual patients ( P = .001). Compared to in-person (51.5 ± 59.4 m) improvement in the 6MWT was similar in hybrid (63.4 ± 55.6; P = .46) and virtual (63.2 ± 59.6; P = .55) compared with in-person (51.5 ± 59.4). Hybrid and virtual patients experienced similar improvements in BP control and anxiety. Virtual patients experienced less improvement in depression symptoms. There were no statistically significant changes in waist-to-hip ratio or cardiac self-efficacy. Qualitative themes included the adaptability of virtual CR, importance of relationships between patients and CR staff, and need for training and organizational adjustments to adopt virtual CR. CONCLUSIONS Hybrid and virtual CR were associated with similar improvements in functional capacity to in-person. Virtual and hybrid CR have the potential to expand availability without compromising outcomes.
Collapse
|
27
|
Abstract
PURPOSE Exercise cardiac rehabilitation (CR) represents an evidence-based therapy for patients with heart failure with reduced ejection fraction (HFrEF) and this article provides a concise review of the relevant exercise testing and CR literature, including aspects unique to their care. CLINICAL CONSIDERATIONS A hallmark feature of HFrEF is exercise intolerance (eg, early-onset fatigue). Drug therapies for HFrEF target neurohormonal pathways to blunt negative remodeling of the cardiac architecture and restore favorable loading conditions. Guideline drug therapy includes β-adrenergic blocking agents; blockade of the renin-angiotensin system; aldosterone antagonism; sodium-glucose cotransport inhibition; and diuretics, as needed. EXERCISE TESTING AND TRAINING Various assessments are used to quantify exercise capacity in patients with HFrEF, including peak oxygen uptake measured during an exercise test and 6-min walk distance. The mechanisms responsible for the exercise intolerance include abnormalities in ( a ) central transport (chronotropic response, stroke volume) and ( b ) the diffusion/utilization of oxygen in skeletal muscles. Cardiac rehabilitation improves exercise capacity, intermediate physiologic measures (eg, endothelial function and sympathetic nervous system activity), health-related quality of life (HRQoL), and likely clinical outcomes. The prescription of exercise in patients with HFrEF is generally similar to that for other patients with cardiovascular disease; however, patients having undergone an advanced surgical therapy do present with features that require attention. SUMMARY Few patients with HFrEF enroll in CR and as such, many miss the derived benefits, including improved exercise capacity, a likely reduction in risk for subsequent clinical events (eg, rehospitalization), improved HRQoL, and adoption of disease management strategies.
Collapse
Affiliation(s)
- Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital and Medical Group, Detroit, Michigan
| | | |
Collapse
|
28
|
Jeganathan VS, Golbus JR, Gupta K, Luff E, Dempsey W, Boyden T, Rubenfire M, Mukherjee B, Klasnja P, Kheterpal S, Nallamothu BK. Virtual AppLication-supported Environment To INcrease Exercise (VALENTINE) during cardiac rehabilitation study: Rationale and design. Am Heart J 2022; 248:53-62. [PMID: 35235834 DOI: 10.1016/j.ahj.2022.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In-person, exercise-based cardiac rehabilitation improves physical activity and reduces morbidity and mortality for patients with cardiovascular disease. However, activity levels may not be optimized and decline over time after patients graduate from cardiac rehabilitation. Scalable interventions through mobile health (mHealth) technologies have the potential to augment activity levels and extend the benefits of cardiac rehabilitation. METHODS The VALENTINE Study is a prospective, randomized-controlled, remotely-administered trial designed to evaluate an mHealth intervention to supplement cardiac rehabilitation for low- and moderate-risk patients (ClinicalTrials.gov NCT04587882). Participants are randomized to the control or intervention arms of the study. Both groups receive a compatible smartwatch (Fitbit Versa 2 or Apple Watch 4) and usual care. Participants in the intervention arm of the study additionally receive a just-in-time adaptive intervention (JITAI) delivered as contextually tailored notifications promoting low-level physical activity and exercise throughout the day. In addition, they have access to activity tracking and goal setting through the mobile study application and receive weekly activity summaries via email. The primary outcome is change in 6-minute walk distance at 6-months and, secondarily, change in average daily step count. Exploratory analyses will examine the impact of notifications on immediate short-term smartwatch-measured step counts and exercise minutes. CONCLUSIONS The VALENTINE study leverages innovative techniques in behavioral and cardiovascular disease research and will make a significant contribution to our understanding of how to support patients using mHealth technologies to promote and sustain physical activity.
Collapse
Affiliation(s)
- V Swetha Jeganathan
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jessica R Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, MI.
| | - Kashvi Gupta
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO
| | - Evan Luff
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Walter Dempsey
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Thomas Boyden
- Division of Cardiovascular Diseases, Department of Internal Medicine, Spectrum Health, Grand Rapids, MI
| | - Melvyn Rubenfire
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Predrag Klasnja
- School of Information, University of Michigan, Ann Arbor, MI
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, MI; The Center for Clinical Management and Research, Ann Arbor VA Medical Center, Ann Arbor, MI
| |
Collapse
|
29
|
Golbus JR, Gupta K, Stevens R, Jeganathan VS, Luff E, Boyden T, Mukherjee B, Klasnja P, Kheterpal S, Kohnstamm S, Nallamothu BK. Understanding Baseline Physical Activity in Cardiac Rehabilitation Enrollees Using Mobile Health Technologies. Circ Cardiovasc Qual Outcomes 2022; 15:e009182. [PMID: 35559648 DOI: 10.1161/circoutcomes.122.009182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Baseline physical activity in patients when they initiate cardiac rehabilitation is poorly understood. We used mobile health (mHealth) technology to understand baseline physical activity of patients initiating cardiac rehabilitation within a clinical trial to potentially inform personalized care. Methods: The Virtual AppLication-Supported ENvironment To INcrease Exercise During Cardiac Rehabilitation Study (VALENTINE) Study is a prospective, randomized-controlled, remotely administered trial designed to evaluate an mHealth intervention to supplement cardiac rehabilitation for low and moderate risk patients. All participants receive a smartwatch and usual care. Baseline physical activity was assessed remotely after enrollment and included 1) 6-minute walk distance, 2) daily step count, and 3) daily exercise minutes, both over 7 days and for compliant days, defined by ≥8 hours of watch wear time. Multivariable linear regression identified patient-level features associated with these 3 measures of baseline physical activity. Results: From October 2020 to March 2022, 220 participants enrolled in the study. Participants are mostly White [184 (83.6%)]; 67 (30.5%) are female and 84 (38.2%) are ≥ 65 years old. Most participants enrolled in cardiac rehabilitation after percutaneous coronary intervention [105 (47.7%)] or coronary artery bypass surgery [39 (17.7 %)]. Clinical diagnoses include coronary artery disease (78.6%), heart failure (17.3%), and valve repair or replacement (26.4%). Baseline mean 6-minute walk distance was 489.6 (standard deviation [SD], 143.4) meters, daily step count was 6845 (SD, 3353), and exercise minutes was 37.5 (SD, 33.5). In a multivariable model, 6-minute walk distance was significantly associated with age and sex, but not cardiac rehabilitation indication. Sex but not age or cardiac rehabilitation indication was significantly associated with daily step count and exercise minutes. Conclusions: Baseline physical activity varies substantially in low and moderate risk patients enrolled in cardiac rehabilitation. Future studies are warranted to explore whether personalizing cardiac rehabilitation programs using mHealth technologies could optimize recovery. Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT04587882.
Collapse
Affiliation(s)
- Jessica R Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI; Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, MI
| | - Kashvi Gupta
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO
| | - Rachel Stevens
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI
| | - V Swetha Jeganathan
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI
| | - Evan Luff
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI
| | - Thomas Boyden
- Division of Cardiovascular Diseases, Department of Internal Medicine, Spectrum Health, MI
| | | | - Predrag Klasnja
- School of Information, University of Michigan, Ann Arbor, MI
| | | | - Sarah Kohnstamm
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI; Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, MI; The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI
| |
Collapse
|