Promoting cardiac rehabilitation program quality in low-resource settings: Needs assessment and evaluation of the International Council of Cardiovascular Prevention and Rehabilitation's registry quality improvement supports

BACKGROUND

Cardiac rehabilitation (CR) registries have the potential to support quality improvement (QImp). This study investigated the QImp needs of International CR Registry-participating programs and their evaluation of its' supports.

METHODS

ICRR offers comparative outcome dashboards and QImp sessions, among other features. In this qualitative study, ICRR data stewards from the 17 active on-boarded CR programs were invited to a focus group held in November 2023 via Teams; stewards not sufficiently-proficient in English were invited to provide written input. Deductive-thematic analysis using NVIVO was undertaken by 2 researchers; member-checking ensued.

RESULTS

Nine participated, and four provided input, from eight countries. Three themes emerged; saturation was achieved. First, QImp facilitators included training, institutional requirements, dedicated staff, resources in academic centres and ICRR features. Second, QImp barriers included staffing issues, the global nature of the ICRR, and structural challenges in low-resource settings. Finally, ICRR supports for QImp included didactic webinars, hearing from other programs, 1-1 support offered and assessing minimum Certification standards.

CONCLUSION

ICRR-participating programs are satisfied with QImp supports but encounter challenges, including related to language, staffing and other resources. CR registries should be leveraged and optimized to support CR programs to assess and improve their care quality.

Uptake and implementation of cardiac telerehabilitation: A systematic review of provider and system barriers and enablers

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.

A National Survey of Patient Data Capture, Management, Reporting Practice in Australian Cardiac Rehabilitation Programs

BACKGROUND

Lack of service data for cardiac rehabilitation limits understanding of program delivery, benchmarking and quality improvement. This study aimed to describe current practices, management, utilisation and engagement with quality indicators in Australian programs.

METHOD

Cardiac rehabilitation programs (n=396) were identified from national directories and networks. Program coordinators were surveyed on service data capture, management systems and adoption of published national quality indicators. Text responses were coded and classified. Logistic regression determined independent associates of the use of data for quality improvement.

RESULTS

A total of 319 (81%) coordinators completed the survey. Annual patient enrolments/programs were >200 (31.0%), 51-200 (46%) and ≤50 (23%). Most (79%) programs used an electronic system, alongside paper (63%) and/or another electronic system (19%), with 21% completely paper. While 84% knew of the national quality indicators, only 52% used them. Supplementary to patient care, data were used for reports to managers (57%) and funders (41%), to improve quality (56%), support funding (43%) and research (31%). Using data for quality improvement was more likely when enrolments where >200 (Odds ratio [OR] 3.83, 95% Confidence Interval [CI] 1.76-8.34) and less likely in Victoria (OR 0.24 95%, CI 0.08-0.77), New South Wales (OR 0.25 95%, CI 0.08-0.76) and Western Australia (OR 0.16 95%, CI 0.05-0.57).

CONCLUSIONS

The collection of service data for cardiac rehabilitation patient data and its justification is diverse, limiting our capacity to benchmark and drive clinical practice. The findings strengthen the case for a national low-burden approach to data capture for quality care.

Exercise Self-efficacy Improvements During Cardiac Rehabilitation: IMPACT OF SOCIAL DISPARITIES

PURPOSE

The objective of this study was to determine exercise self-efficacy improvements during cardiac rehabilitation (CR) and identify predictors of exercise self-efficacy change in CR participants.

METHODS

Patients with coronary heart disease at four metropolitan CR sites completed the Exercise Self-efficacy Scale at entry and completion. A general linear model identified independent predictors of change in exercise self-efficacy.

RESULTS

The mean age of patients (n = 194) was 65.9 ± 10.5 yr, and 81% were males. The majority (80%) were married or partnered, 76% were White, and 24% were from an ethnic minority background. Patients received CR in-person (n = 91, 47%) or remote-delivered (n = 103, 54%). Exercise self-efficacy mean scores improved significantly from 25.2 ± 5.8 at CR entry to 26.2 ± 6.3 points at completion ( P = .025). The majority of patients (59%) improved their self-efficacy scores, 34% worsened, and 7% had no change. Predictors of reduced exercise self-efficacy change were being from an ethnic minority (B =-2.96), not having a spouse/partner (B =-2.42), attending in-person CR (B =1.75), and having higher exercise self-efficacy at entry (B =-0.37) (adjusted R2 = 0.247).

CONCLUSIONS

Confidence for self-directed exercise improves in most, but not all, patients during CR. Those at risk for poor improvement (ethnic minorities, single patients) may need extra or tailored support, and screening for exercise self-efficacy at CR entry and completion is recommended. Differences identified from CR delivery mode need exploration using robust methods to account for complex factors.

Online Health Information-Seeking Behaviours and eHealth Literacy among First-Generation Chinese Immigrants

Due to linguistic and cultural barriers, immigrants often have limited access to health information. Online health information is popular and accessible, but quality is questionable and its benefits dependent on an individual's eHealth literacy. This study examined online health information-seeking behaviours, eHealth literacy and its predictors among first-generation Chinese immigrants. A sample of 356 Chinese immigrants living in Australia completed an anonymous paper-based survey, including sociodemographic, clinical data, English proficiency, health literacy, online health information-seeking behaviours, and eHealth literacy. Linear regression models analyzed predictive factors of eHealth literacy. Participants were aged mean 59.3 years, female (68.3%), 53.1% completed university, and their English proficiency was rated fair/poor by 75.1%. Participants perceived online health information as useful (61.6%) and important (56.2%) to their health. Health information accessed was often related to lifestyle (61.2%), health resources (44.9%), diseases (36.0%), and medications (30.9%). Inadequate health literacy and eHealth literacy occurred in 48.3% and 44.9%, respectively. Age, number of technological devices used, education, and health status were independently associated with eHealth literacy. While most Chinese immigrants used online health information, many had inadequate eHealth literacy. Healthcare authorities and providers should support older immigrants, those with lower education and poorer health, and those less engaged with technology in online health information use by providing culturally and linguistically appropriate information, directing immigrants to credible websites, and involving them in health material development processes.

Nursing students' experiences of using flipcharts as a learning tool during the COVID-19 pandemic

BACKGROUND

Building mastery of clinical skills is essential for nursing students to ensure readiness for clinical placements. During the coronavirus disease (COVID-19) pandemic, limited face-to-face teaching and student access to campus facilities, along with the rapid adoption of online methods, increased the need to develop innovative teaching tools to support students.

OBJECTIVE

This study aimed to explore nursing student perceptions and experiences of using Flipcharts for learning clinical nursing skills during the COVID-19 pandemic.

DESIGN

This study used a qualitative descriptive design.

METHODS

Second-year nursing students were invited to participate at the end of the semester to share their experiences of using Flipcharts in their clinical simulation laboratory. A total of 12 nursing students participated in individual semi-structured interviews conducted between December 2020 and February 2021. Data were analysed using Braun and Clarke's six-step method of thematic analysis.

RESULTS

The findings of the study demonstrated that students considered Flipcharts to be beneficial in developing their clinical skills and were additionally valuable in supporting students with English as a second language. Three major themes were identified: the perceived value of Flipcharts during limited face-to-face teaching, the role of Flipcharts in supporting skills acquisition across learning domains, and the practicality and accessibility of this learning resource across different mediums.

CONCLUSION

Students perceived the use of Flipcharts to be valuable in achieving mastery of clinical skills during COVID-19. The students' experience of using Flipcharts was positive overall and found the learning tool practical and accessible in supplementing learning.

Cardiovascular Nursing and Climate Change: A Call to Action From the CSANZ Cardiovascular Nursing Council

This Call to Action aims to provide key considerations for cardiovascular nursing, related to climate and environmental impacts. Strategies to optimise nursing preparation, immediate response and adaptation to climate emergencies are crucial to ensure those at greatest risk, including First Nations peoples, are protected from potentially avoidable harm. Professionals who manage climate consequences must also understand the impact of their care on the root cause of the problem.

Health-related quality of life of Australians during the 2020 COVID-19 pandemic: a comparison with pre-pandemic data and factors associated with poor outcomes

PURPOSE

Compare the health-related quality of life (HRQL) of the Australian general population during the COVID-19 pandemic (2020) with pre-pandemic data (2015-2016) and identify pandemic-related and demographic factors associated with poorer HRQL.

METHODS

Participants were quota sampled from an online panel by four regions (defined by active COVID-19 case numbers); then by age and sex. Participants completed an online survey about their HRQL [EORTC QLQ-C30 questionnaire and General Health Question (GHQ)], demographic characteristics, and the impact of the pandemic on daily life. HRQL scores were compared to a 2015-2016 reference sample using independent t-tests, adjusted for multiple testing. Associations between 22 pre-specified factors (pandemic-related and demographic) and 15 QLQ-C30 domains and GHQ, were assessed with multiple regressions.

RESULTS

Most domains were statistically significantly worse for the 2020 sample (n = 1898) compared to the reference sample (n = 1979), except fatigue and pain. Differences were largest for the youngest group (18-29 years) for cognitive functioning, nausea, diarrhoea, and financial difficulties. Emotional functioning was worse for 2020 participants aged 18-59, but not for those 60 +. All models were statistically significant at p < .001; the most variance was explained for emotional functioning, QLQ-C30 global health/QOL, nausea/vomiting, GHQ, and financial difficulties. Generally, increased workload, negative COVID-19 impacts, COVID-19-related worries, and negative attitudes towards public health order compliance were associated with poorer HRQL outcomes.

CONCLUSION

During the COVID-19 pandemic, Australians reported poorer HRQL relative to a pre-pandemic sample. Risk factors for poor HRQL outcomes included greater negative pandemic-related impacts, poorer compliance attitudes, and younger age.

TRIAL REGISTRATION

ANZCTR number is: ACTRN12621001240831. Web address of your trial: https://www.anzctr.org.au/ACTRN12621001240831.aspx . Date submitted: 26/08/2021 2:56:53 PM. Date registered: 14/09/2021 9:40:31 AM. Registered by: Margaret-Ann Tait. Principal Investigator: Madeleine King.

Mortality, morbidity, and cardiovascular risk factor outcomes from cardiac rehabilitation, in ethnic minorities: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Abstract

Background

Cardiac rehabilitation (CR) is a secondary prevention intervention for coronary heart disease that has well-established efficacy in reducing mortality, morbidity, and cardiovascular risk factors. However, outcomes from CR are known to differ between population groups, with ethnic minorities reported to have health outcome disparities. However, there is no synthesis of these CR outcomes for ethnic minority populations.

Purpose

The main purpose of this study was to evaluate the impact of CR on rates of mortality, morbidity, and important cardiovascular risk factor outcomes including exercise performance, exercise capacity, low-density lipoproteins, cholesterol levels, body mass index, weight, waist circumference and systolic blood pressure, within ethnic minority groups.

Methods

Four electronic databases (Medline, EMBASE, CINAHL, Scopus) were searched from February to September 2021, for studies that reported CR outcomes of ethnic minorities. Potential papers were independently screened by two reviewers, and discrepancies were resolved by a third reviewer. Data was extracted from the studies using an electronic data extraction form. Meta-analyses for eligible studies were performed using Revman 5.4. Risk of bias were assessed using the Cochrane Tool.

Results

Across 13 studies (n = 132,109 participants), the 10,494 participants of ethnic minority groups achieved significant improvements in mortality, morbidity, and most cardiovascular risk factor outcomes including exercise performance, exercise capacity, body mass index, waist circumference, and systolic blood pressure. However, while ethnic minority groups achieved equivalent outcomes from CR for exercise performance and low-density lipoproteins, some outcomes were worse (exercise capacity, body mass index, waist circumference, systolic blood pressure). In addition, minority participants had greater reductions in cholesterol levels.

Conclusion

Ethnic minority groups achieve important improvements in mortality, morbidity, and cardiovascular risk factor outcomes from CR, although to a lesser extent than majority groups. Therefore, this information can be used to support efforts to improve participation in CR and prompt changes to the delivery of CR services for ethnic minority participants.

OUP accepted manuscript

Aims

Enforced suspension and reduction of in-person cardiac rehabilitation (CR) services during the coronavirus disease-19 (COVID-19) pandemic restrictions required rapid implementation of remote delivery methods, thus enabling a cohort comparison of in-person vs. remote-delivered CR participants. This study aimed to examine the health-related quality of life (HRQL) outcomes and patient experiences comparing these delivery modes.

Methods and results

Participants across four metropolitan CR sites receiving in-person (December 2019 to March 2020) or remote-delivered (April to October 2020) programmes were assessed for HRQL (Short Form-12) at CR entry and completion. A General Linear Model was used to adjust for baseline group differences and qualitative interviews to explore patient experiences. Participants (n = 194) had a mean age of 65.94 (SD 10.45) years, 80.9% males. Diagnoses included elective percutaneous coronary intervention (40.2%), myocardial infarction (33.5%), and coronary artery bypass grafting (26.3%). Remote-delivered CR wait times were shorter than in-person [median 14 (interquartile range, IQR 10–21) vs. 25 (IQR 16–38) days, P < 0.001], but participation by ethnic minorities was lower (13.6% vs. 35.2%, P < 0.001). Remote-delivered CR participants had equivalent benefits to in-person in all HRQL domains but more improvements than in-person in Mental Health, both domain [mean difference (MD) 3.56, 95% confidence interval (CI) 1.28, 5.82] and composite (MD 2.37, 95% CI 0.15, 4.58). From qualitative interviews (n = 16), patients valued in-person CR for direct exercise supervision and group interactions, and remote-delivered for convenience and flexibility (negotiable contact times).

Conclusion

Remote-delivered CR implemented during COVID-19 had equivalent, sometimes better, HRQL outcomes than in-person, and shorter wait times. Participation by minority groups in remote-delivered modes are lower. Further research is needed to evaluate other patient outcomes.

Remote delivery of cardiac rehabilitation can achieve equivalent health-related quality of life outcomes to in-person methods in patients with coronary heart disease: a multi-site study

Funding Acknowledgements

Type of funding sources: None.

Background In-person exercise-based cardiac rehabilitation (CR) has well-established benefits for health-related quality of life (HRQL) for patients with coronary heart disease (CHD). During COVID-19 pandemic restrictions, remote delivery replaced in-person CR, but the impact on HRQL is unclear. This study addresses this gap.

Methods Consecutive patients commencing CR at four sites in one Local Health District in Sydney were recruited (n = 194), recruited from December 2019 to October 2020. Remote delivery from March 2020 created a natural comparison group to in-person CR. HRQL was measured at CR entry and completion using the SF-12v2 and linear regression was used for analyses.

Results Participants were aged mean 65.94 (SD 10.45) years, were 80.9% male and diagnoses included elective PCI (37.9%), CABG (26.7%), and MI (34.9%) either with PCI (23.6%) or alone (11.3%). Participants received remote (n = 103, 53.1%) or in-person (n = 91, 46.9%; ≥ assessment + 2 sessions) CR, with more completions for in-person (75.8% vs 63.1%, p=.03). Remote participants were more likely to be white than ethnic minority (35.2% vs 13.6% p&lt;.001), however, there were no differences in baseline HRQL for delivery group after adjustment.

HRQL improved from CR entry to completion regardless of delivery mode (adjusted). Most improvements occurred in physical function (SMD 6.37, 95% CI 4.81,7.92), role physical (SMD 5.72, 95% CI 4.29. 7.16) and physical component (SMD 5.77 95% CI 4.43, 7.12) scores. Least improvement occurred in mental component scores (SMD 1.65, 95%CI .53, 2.78).

Conclusion Remotely delivered CR provides comparable HRQL outcomes to in-person delivery, thus providing a promising alternative. Data are needed on cost-effectiveness, as well as staff and patient preferences.

Womens health-related quality of life substantially improves with tailored cardiac rehabilitation: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Women have poorer outcomes from coronary heart disease (CHD) compared to men and participation in exercise-based cardiac rehabilitation (EBCR) offers an opportunity for improvement. However, synthesised evidence for women-specific patient-reported outcomes are often lacking. We aimed to synthesise HRQL outcomes from EBCR in women with CHD.

Methods

Four electronic databases (PUBMED, CINAHL, SCOPUS and Cochrane) were searched for studies reporting HRQL using validated measures in women attending EBCR. Two reviewers independently screened papers and extracted data. Random effects model (RevMan v5.4) was used for analysis.

Results

Eleven studies (1292 women participants) were included: six observational, three randomised controlled trials, and two quasi-experimental design. Seven studies were included in the meta-analyses. EBCR participation was associated with HRQL benefits in several domains of the Short-Form (SF-12 or 36). Improvements were greatest in Role Physical (MD 19.09 95% CI 2.37, 35.81), Physical Functioning (MD 10.43, 95% CI 2.60, 18.27) and Vitality (MD 9.59, 95% CI 0.31, 18.86). When tailored components were added to traditional EBCR, gains in HRQL were also observed, specifically in Bodily Pain (MD 9.82, 95% CI 4.43, 15.21), Role Physical (MD 8.48, 95% CI 1.31, 9.97), Vitality (MD 8.17, 95% CI 3.79, 12.55), General Health (MD 5.64, 95% CI 1.31, 9.97), and Physical Function (MD 5.61, 95% CI 0.83, 10.40) domains.

Conclusion

Women attending EBCR achieve clinically meaningful improvements in multiple areas of HRQL, and additional benefits were seen when strategies tailored to their needs and preferences were included. Future research should focus on promoting EBCR uptake in women.

Human connection: a valuable element for health-related quality of life outcomes in cardiac rehabilitation during COVID-19

Funding Acknowledgements

Type of funding sources: None.

Background The COVID-19 pandemic restrictions have pivoted in-person cardiac rehabilitation (CR) to remote delivery via telehealth. Patient perceptions on their CR participation in these models can guide CR coordinators improve program elements.

Purpose To qualitatively explore patient perceptions and experiences on how CR influenced their health-related quality of life (HRQL).

Methods A purposive sample of 16 patients were recruited, ensuring representation from four participating CR sites, gender, age, and mode of CR delivery. Semi-structured telephone or video interviews were conducted at six months following CR completion. Interviews were audio-recorded, transcribed verbatim and analysed using Braun and Clarke’s six-step thematic analysis.

Results Perceptions and experiences of patients were positive overall and similar between the two models. Three main themes were identified: value of human connection, benefits of exercise and need for more individualised approaches, and importance of telehealth as an adjunct to in-person CR. Patients have expressed the value of interacting with health care professionals and socialising with peers in similar circumstances; and the absence of these interactions was palpable to those who attended telehealth. Exercises were beneficial but needed to be tailored to individual capabilities and preferences. Telehealth offered convenience and was generally accepted. However, telehealth should be complementary and not a replacement to in-person CR. 

Conclusions Meaningful personal interactions with health care providers and other CR participants are most appreciated by patients in both in-person and telehealth models. Exercises are perceived to be more beneficial when individualised. Long-term outcomes from alternative CR delivery models should be evaluated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thalidomide increases thrombin generation in multiple myeloma patients

7602

Background: Numerous reports have demonstrated that the clinical use of thalidomide (THAL) carries a risk for deep venous thrombosis. Only limited investigations into the causative mechanisms for this complication have been conducted. Thrombin generation is a global measurement of hyper or hypocoagulability that has not been used to examine the hypercoagulable state caused by THAL. The aim of this study was to determine if THAL affects thrombin generation in patients with multiple myeloma (MM). Methods: MM patients on and off THAL were recruited. Patients were considered to be “on THAL” if they had been taking the medication for at least three months and “off THAL” if they had not been taking the medication for at least three months. Coagulation tubes of blood containing 3.2% sodium citrate were drawn from each patient. Platelet poor plasma was prepared from these specimens using standard technique. The samples were snap frozen at -70 C and stored until analysis. Thrombin generation was measured using the Calibrated Automated Thrombogram as described by Hemker(Pathophysiol Haemo Thromb 2003;33:4–15) using a microplate fluorometer, the Fluoroskan Ascent from Thermo Electron and the Thrombinoscope software package. The endogenous thrombin potential or ETP (area under the thrombin generation curve) and peak thrombin generation (the maximum release of thrombin per unit of time) were the variables of interest for this study. Results: Twenty seven patients were recruited. Five were excluded from analysis because they were on warfarin or enoxaparin. The normal ETP in females is 1803 ± 241 nM*min and in males is 1745 ± 259 nM *min. Normal peak thrombin generation in females is 318.5 ± 52.9 nM and in males is 293.4 ± 48.5 nM. The t-test was used to compare subjects to normal values.Peak thrombin generation was significantly increased in the 9 subjects taking THAL, 374 ± 10.6 nM (p<0.001) and in the 13 subjects not taking THAL, 352 ± 14.7 nM (p=0.009) when compared to normal values. The ETP was not significantly increased 1818 ± 10.7 nM*min (p=0.69) in subjects not taking THAL. However, ETP was increased in subjects taking THAL, 1939± 90 nM*min and showed a trend toward statistical significance (p=0.10). Conclusions: Thalidomide therapy increases thrombin generation significantly in patients with MM.

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