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Ogmundsdottir Michelsen H, Henriksson P, Wallert J, Back M, Sjolin I, Schlyter M, Hagstrom E, Kiessling A, Held C, Hag E, Nilsson L, Schiopu A, Zaman MJ, Leosdottir M. Organizational and patient-level predictors for reaching key risk factor targets in cardiac rehabilitation after myocardial infarction – the perfect-CR study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2538] [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: 11/12/2022] Open
Abstract
Abstract
Background
The benefits of specific cardiac rehabilitation (CR) programme components on patient outcomes after myocardial infarction (MI) remain unclear, as does their relative predictive strength compared to patient-level predictors.
Purpose
To identify CR organizational and patient-level predictors for reaching risk factor targets at one-year post-MI.
Methods
This was an observational survey- and registry-based study. Data on CR organization at all 78 CR centres in Sweden was collected in 2016 and merged with individual patient data from nationwide registries (n=7549, median age 64 years, 24% females). Cross-validation resampled orthogonal partial least squares discriminant analysis identified predictors for reaching treatment targets for low-density lipoprotein-cholesterol (LDL-C<1.8 mmol/L), blood pressure (BP<140/90 mmHg) and smoking abstinence (yes/no). Predictors with Variables of Importance for the Projection (VIP) value >0.8 and 95% confidence intervals (CI) excluding zero, were considered meaningful.
Results
Of the 71 analysed organizational variables, 36 were identified as meaningful predictors for reaching LDL-C and 35 for BP targets (Figure 1). The strongest predictors (VIP [95% CI]) for LDL-C and BP were: offering psychosocial management at initial CR assessment 2.09 [1.70–2.49]; 2.34 [1.90–2.78], having a CR team psychologist 1.59 [1.28–1.91]; 2.00 [1.46–2.55], having extended CR centre opening hours 2.17 [1.95–2.40]; 1.51 [1.03–2.00], staff reporting satisfaction with CR centre facilities 1.55 [1.07–2.04]; 1.96 [1.64–2.28], having a medical director 1.71 [1.45–1.97]; 1.47 [1.07–1.87], nurses using protocols for antihypertensive and/or lipid lowering medication adjustment 1.58 [1.35–1.81]; 1.56 [1.03–2.08], having operational team meetings 1.36 [1.08–1.64]; 1.34 [0.99–1.70], and using audit data for quality improvement 1.00 [0.79–1.20]; 1.27 [0.99–1.56]. Offering pre-exercise-based CR (exCR) assessment and different modes of exCR were predictors for reaching both targets. The strongest patient-level predictor of reaching LDL-C target was low baseline LDL-C 3.90 [3.25–4.56], and for BP it was having no history of hypertension 2.93 [2.74–3.12]. Second, participation in exCR was the strongest predictor for both outcomes 1.60 [0.83–2.37]; 1.50 [1.15–1.86]. For smoking abstinence, 5 organizational variables were identified as meaningful predictors, the strongest being prescription of varenicline by the centre physicians 1.98 [0.13–3.84] (Figure 2). The strongest patient-level predictors were exCR participation 2.51 [2.24–2.79] and socioeconomic status variables e.g., income 1.67 [1.28–2.06], living with partner 1.47 [0.84–2.09] and education 0.80 [0.48–1.12].
Conclusion
The study identified multiple CR organizational and patient-level predictors for reaching key risk factor targets one-year post-MI. The results might contribute to defining the optimal composition of comprehensive CR programmes.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) The Swedish Research Council for Health, Working Life and Welfare (FORTE)2) The Swedish Heart and Lung Foundation (Hjärt Lung Fonden)
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Affiliation(s)
| | - P Henriksson
- Karolinska Institute, Department of Clinical Sciences Danderyd Hospital, Stockholm, Sweden
| | - J Wallert
- Karolinska Institute, Centre for Psychiatry Research, Department of Clinical Neuroscience, Stockholm, Sweden
| | - M Back
- Sahlgrenska University Hospital, Department of Occupational therapy and Physiotherapy, Gothenburg, Sweden
| | - I Sjolin
- Skane University Hospital, Department of Cardiology, Malmo, Sweden
| | - M Schlyter
- Skane University Hospital, Department of Cardiology, Malmo, Sweden
| | - E Hagstrom
- Uppsala University, Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - A Kiessling
- Karolinska Institute, Department of Clinical Sciences Danderyd Hospital, Stockholm, Sweden
| | - C Held
- Uppsala University, Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - E Hag
- Ryhov County Hospital, Department of Internal Medicine, Jonkoping, Sweden
| | - L Nilsson
- Linkoping University, Department of Health Medicine and Caring Sciences, Linkoping, Sweden
| | - A Schiopu
- Lund University, Department of Clinical Sciences, Malmo, Sweden
| | - M J Zaman
- James Paget Hospitals, Department of Cardiology, Norfolk, United Kingdom
| | - M Leosdottir
- Skane University Hospital, Department of Cardiology, Malmo, Sweden
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Leosdottir M, Warjerstam S, Ogmundsdottir Michelsen H, Schlyter M, Hag E, Wallert J, Larsson M. Improving smoking cessation after myocardial infarction by systematically implementing evidence-based treatment methods: a prospective observational cohort study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1409] [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: 11/14/2022] Open
Abstract
Abstract
Background
For smokers who suffer a myocardial infarction (MI), smoking cessation is the most effective measure to reduce recurrent event risk. Still, evidence-based treatment methods for aiding smoking cessation post-MI are underused.
Purpose
To compare the odds of smoking cessation at two-months post-MI before and after implementing a set of pre-specified routines for optimization of evidence-based treatment methods for smoking cessation, with start during admission.
Methods
Structured routines for early smoking cessation counselling and treatment optimization were implemented at six cardiac rehabilitation (CR) centres in Sweden. The routines included CR nurses providing current smokers hospitalized for acute MI with short consultation, written material, and optimal dosage of nicotine replacement therapy during admission, increasing early prescription of varenicline for eligible patients, and contacting the patients by telephone 3–5 days after discharge, after which usual care CR follow-up commenced. Centres were also encouraged to strive for continuity in nurse-patient care. Patient data was retrieved from the SWEDEHEART registry and medical records. Using logistic regression, we compared the odds for smoking cessation at two-months post-MI for currently smoking patients admitted with MI (a) before (n=188, median age 60 years, 23% females) and (b) after (n=195, median age 60 years, 29% females) routine implementation. Secondary outcomes included adherence to implemented routines and the association of each routine with smoking cessation odds at two-months.
Results
In total, 159 (85%) and 179 (92%) of enrolled patients attended the two-month CR follow-up, before and after implementation of the new routines. After implementation, a significantly larger proportion of patients (65% vs 54%) were abstinent from smoking at two-months (crude OR 1.60 [1.04–2.48], p=0.034) (Figure 1). Including only those counselled during admission (n=89), 74% (vs 54%) were abstinent at two-months (crude OR 2.50 [1.42–4.41], p=0.002). After the new routine implementation patients were counselled more frequently during admission (50% vs 6%, p<0.001), prescribed varenicline at discharge or during follow-up (23% vs 7%, p<0.001), and contacted by telephone during the first week post-discharge (18% vs 2%, p<0.001), compared to before implementation. Crude and adjusted associations between each routine and smoking cessation at two-months are shown in Table 1. Entering all routines into the regression model simultaneously, being prescribed varenicline before discharge or during follow-up had the strongest independent association with smoking abstinence at two-months (adjusted OR 4.09 [1.68–10.00], p=0.002).
Conclusion
Our results support that readily available methods for aiding smoking cessation can be implemented effectively in routine practice, with possible beneficial effects on smoking cessation for the high-risk group of smoking MI patients.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The Swedish Heart and Lung AssociationPfizer AB
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Affiliation(s)
- M Leosdottir
- Skane University Hospital, Dept of Cardiology, Malmo, Sweden
| | - S Warjerstam
- Skane University Hospital, Dept of Cardiology, Malmo, Sweden
| | | | - M Schlyter
- Skane University Hospital, Dept of Cardiology, Malmo, Sweden
| | - E Hag
- Ryhov County Hospital, Dept of Internal Medicine, Jonkoping, Sweden
| | - J Wallert
- Karolinska Institute, Dept of Clinical Neuroscience, Stockholm, Sweden
| | - M Larsson
- Orebro University Hospital, The Heart, Lung and Physiology Clinic, Orebro, Sweden
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Gorelik Y, Hag E, Hananya T, Leiba R, Chowers Y, Half EE. Volume of fluid consumption during preparation for colonoscopy is possibly the single most important determinant of bowel preparation adequacy. Ann Gastroenterol 2021; 34:705-712. [PMID: 34475742 PMCID: PMC8375653 DOI: 10.20524/aog.2021.0642] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/29/2020] [Indexed: 12/05/2022] Open
Abstract
Background The effectiveness and safety of colonoscopy are directly dependent on the quality of bowel preparation. Multiple risk factors for inadequate bowel preparation (IBP) have been identified; however, IBP is still reported in 20-30% of cases in most studies. We aimed to identify modifiable predictors of the adequacy of bowel preparation using sodium picosulfate, and to recommend easily modifiable parameters to increase the success rate of colonoscopies. Methods This was a single-center observational study of adult outpatients referred for an elective colonoscopy. Patients were interviewed prior to colonoscopy; volume of liquids consumed was calculated as number of 200-mL cups showed to the patient. Additional information, including medical history, diagnoses and regular medications, was procured from patients’ medical records. Univariate and multivariate regression analyses were performed to identify factors significantly associated with IBP in a subgroup analysis of high-risk patients. Results The rate of IBP in 1172 subjects was 19.4%. This rate decreased as fluid consumption increased, with a further drop associated with shorter intervals from end of preparation to colonoscopy. Drinking < 1.4 L significantly increased the risk of IBP (odds ratio [OR] 3.62, 95% confidence interval [CI] 2.65-4.95), while drinking ≥2 L was associated with adequate preparation (OR 0.09, 95%CI 0-0.42). These associations were stronger in high-risk individuals. Conclusion Greater fluid intake and short interval to colonoscopy are easily modifiable parameters that can substantially reduce the rate of IBP, especially among high-risk individuals.
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Affiliation(s)
- Yuri Gorelik
- Department of Internal Medicine D, Rambam Health Care Campus (Yuri Gorelik)
| | - Eisa Hag
- Gastroenterology Institute, Rambam Health Care Campus (Eisa Hag, Yehuda Chowers, Elizabeth E. Half)
| | - Tomer Hananya
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (Tomer Hananya, Yehuda Chowers, Elizabeth E. Half)
| | - Ronit Leiba
- Department of Epidemiology, Rambam Health Care Campus (Ronit Leiba), Haifa, Israel
| | - Yehuda Chowers
- Gastroenterology Institute, Rambam Health Care Campus (Eisa Hag, Yehuda Chowers, Elizabeth E. Half).,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (Tomer Hananya, Yehuda Chowers, Elizabeth E. Half)
| | - Elizabeth E Half
- Gastroenterology Institute, Rambam Health Care Campus (Eisa Hag, Yehuda Chowers, Elizabeth E. Half).,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (Tomer Hananya, Yehuda Chowers, Elizabeth E. Half)
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Schlyter M, Ogmundsdottir Michelsen H, Sjolin I, Hag E, Hagstrom E, Nilsson L, Kiessling A, Henriksson P, Held C, Schiopu A, Zaman MJ, Leosdottir M. 410Treatment targets for systolic blood pressure are more often reached at cardiac rehabilitation centres where nurses adjust blood pressure medication doses - the Perfect-CR study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M Schlyter
- Malmo University, Department of Clinical Sciences and Department of Cardiology, Lund University and Skane University H, Malmo, Sweden
| | - H Ogmundsdottir Michelsen
- Lund University and Skane University Hospital, Department of Clinical Sciences Malmo and Department of Cardiology, Malmo, Sweden
| | - I Sjolin
- Lund University and Skane University Hospital, Department of Clinical Sciences Malmo and Department of Cardiology, Malmo, Sweden
| | - E Hag
- Department of Internal Medicine, County hospital Ryhov, Jönköping, Sweden, Jönköping, Sweden
| | - E Hagstrom
- Uppsala University, Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - L Nilsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden, Linköping, Sweden
| | - A Kiessling
- Department of Clinical Sciences Danderyd Hospital and the Karolinska Institute, Stockholm, Sweden, Stockholm, Sweden
| | - P Henriksson
- Department of Clinical Sciences Danderyd Hospital and the Karolinska Institute, Stockholm, Sweden, Stockholm, Sweden
| | - C Held
- Uppsala University, Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - A Schiopu
- Lund University and Skane University Hospital, Department of Clinical Sciences Malmo and Department of Cardiology, Malmo, Sweden
| | - M J Zaman
- James Paget University Hospital, Department of Cardiology, Norfolk, United Kingdom
| | - M Leosdottir
- Lund University and Skane University Hospital, Department of Clinical Sciences Malmo and Department of Cardiology, Malmo, Sweden
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Ogmundsdottir Michelsen H, Hagstrom E, Sjolin I, Schlyter M, Kiessling A, Held C, Hag E, Nilsson L, Schiopu A, Zaman M, Leosdottir M. P4912Swedish cardiac rehabilitation programmes; a descriptive nationwide analysis - the perfect CR study. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p4912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Schlyter M, Ogmundsottir Michelsen H, Sjolin I, Hag E, Hagstrom E, Nilsson L, Kiessling A, Held C, Schiopu A, Zaman M, Leosdottir M. P2499Myocardial infarction patients more often reach treatment goals for low-density lipoprotein at centres where cardiac rehabilitation nurses adjust statins - the Perfect-CR study. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p2499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ogmundsdottir Michelsen H, Hagstrom E, Sjolin I, Schlyter M, Kiessling A, Held C, Hag E, Nilsson L, Schiopu A, Zaman M, Leosdottir M. P3429Correlations between components of cardiac rehabilitation and attaining risk factor goals after myocardial infarction - the Perfect-CR study. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p3429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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