Evaluation of the Psychometric Properties of the Thai Version of the Cardiac Rehabilitation Barriers Scale

Background Cardiac telerehabilitation is proven to be equally safe and effective as center-based cardiac rehabilitation. Nevertheless, some real-world barriers significantly impact the adoption and successful implementation of cardiac rehabilitation as well as cardiac telerehabilitation. Purpose This study assesses willingness and actual participation in cardiac (tele)rehabilitation, examining key influencing factors (i.e. digital health readiness, health literacy, patients’ awareness). It explores the relation between digital health readiness and patients’ awareness concerning their intention to participate in cardiac telerehabilitation. Additionally, it investigates the relation between intention and actual participation in cardiac rehabilitation, considering the impact of health literacy and patients’ awareness. Methods In this prospective single-center survey study, patients with cardiovascular disease were asked to fill in questionnaires. Digital health readiness was measured by Digital health readiness questionnaire (DHRQ), and health literacy was assessed with the Health Literacy Scale (HLS-EU). Patients' awareness of their cardiovascular disease was determined by the accuracy of their understanding of their specific cardiovascular condition. Results A total of 72 patients (mean age 62.7 ± 13.3; 33.3% is women) were included in this survey. 81.7% and 50% patients have respectively the intention to participate in cardiac rehabilitation and telerehabilitation. Additionally, 50,7% patients actually participated cardiac rehabilitation. There is a negative correlation between age and digital health readiness (r = -0.05, p < 0.001)/learnability ( r= -0.26, P = 0.025). There is no correlation between digital health readiness (r= 0.011, P= 0.931) and patients’ awareness with the intention to participate in cardiac telerehabilitation (r = -0.045, P = 0.733). Furthermore, there is also no correlation between health literacy (r = 0.196, P= 0.123) and patients’ awareness (r = 0.002, P = 0.086) with the intention to participate in cardiac rehabilitation. Lastly, no correlation between health literacy and actual participation in cardiac rehabilitation is detected (r = -0.115, P = 0.375), but it has been established that there is a relationship between patients’ awareness and actual participation in cardiac rehabilitation (r = -0.266, P = 0.033). Conclusion Cardiovascular patients express a moderate intention to participate in cardiac terehabilitation, and there is no relation between digital health readiness and this intention, suggesting that digital health readiness is not a barrier to the willingness to participate cardiac telerehabilitation. Additionally, higher levels of patients’ awareness of their cardiovascular disease appears to result in increased engagement in cardiac rehabilitation program. However, further research is necessary to explore the barriers in participation to cardiac (tele)rehabilitation.

The rate of cardiac rehabilitation attendance at the Sarawak Heart Centre was identified as very low, and the reason has not been investigated. A scale is needed to identify barriers to participation in cardiac rehabilitation among patients with heart disease in Sarawak, Malaysia. The purposes of this study were to translate, adapt, and evaluate the Malay-language version of the Cardiac Rehabilitation Barriers Scale (CRBS) and to measure the psychometric properties of the Malay-version CRBS to justify its use in Sarawak. A forward and back-translation method was used. Content validity was assessed by three experts. Psychometric testing was conducted on a sample of 283 patients who were eligible to participate in cardiac rehabilitation. A construct validity test was performed using factor analysis. Cronbach's alpha was used to examine the internal consistency. The test-retest reliability was calculated using the intraclass correlation coefficient on 22 participants. Independent-samples t test and analysis of variance were conducted to assess the criterion validity. Mean scores for total barriers of the scale and each individual factor were compared among the different patient characteristics. The Malay-version CRBS showed an item level of content validity index of 1.00 for all of the items after improvements were made based on the experts' suggestions. The factor analysis, using principal component analysis with direct oblimin rotation, extracted four factors that differed from the original study. These four factors explained 52.50% of the cumulative percentage of variance. The Cronbach's alphas ranged from .74 to .81 for the obtained factors. Test-retest reliability was established using the intraclass correlation coefficient value of .78. Criterion validity was supported using the significant differences in the mean score for total barriers among educational level, driving distance, travel time to the hospital, and cardiac rehabilitation attendance. This study found the Malay-version CRBS to be a valid and reliable instrument. It may be used with inpatients to identify barriers to participation in cardiac rehabilitation to promote rehabilitation attendance and improve patient care.

Uptake and Effectiveness of Outpatient vs. Residential Cardiac Rehabilitation After Myocardial Infarction: A Nationwide Analysis

Barriers to Intake Assessment in Women Referred for Cardiac Rehabilitation

Trends and predictors of cardiac rehabilitation referrals and participation in patients undergoing elective percutaneous coronary intervention

To examine the effectiveness of cardiac rehabilitation on health status following coronary artery bypass surgery. A prospective cohort study of patients having coronary artery bypass surgery at 14 centers in the state of Washington. Baseline clinical and demographic data were collected, as was information from the Rand Short Form, 36 (SF-36), the Seattle Angina Questionnaire, and other questions regarding health status before surgery and at 6 and 12 months after surgery. In the 12-month follow-up survey, subjects were asked to complete questions pertaining to their participation in postdischarge cardiac rehabilitation programs. A total of 947 subjects from 13 centers received 1-year follow-up surveys, with 75% responding. Of these, 691 (95%) answered questions about participation in cardiac rehabilitation programs. SF-36 and Seattle Angina Questionnaire scores improved significantly after surgery for both cardiac rehabilitation participants and nonparticipants. Although more than 90% of subjects who participated in the cardiac rehabilitation programs stated that they were beneficial, for eight SF-36 domains and five Seattle Angina Questionnaire domains, no significant associations were found with participation in cardiac rehabilitation. When the participation status was defined as only those participants who completed at least 8 weeks of cardiac rehabilitation, only 1 of 13 health status domains favored cardiac rehabilitation. Responses to a series of questions about perceptions of change in general and cardiac-specific health did not differ among participants and nonparticipants. Although patients report favorable impressions of cardiac rehabilitation after coronary artery bypass surgery, it does not appear to provide a measurable benefit in self-reported health status beyond that achieved from the revascularization procedure itself.

Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017–2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6–10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39–2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.

Referral and participation in cardiac rehabilitation of patients following acute coronary syndrome; lessons learned

Introduction: Cardiac rehabilitation is a guideline-recommended therapy for patients after acute myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass surgery (CABG). However, participation in cardiac rehabilitation is notoriously poor. Evaluating variation in health care delivery can help to identify best practices that improve quality of care more broadly. Therefore, we sought to examine regional variation in the percent of patients who participate in cardiac rehabilitation across the United States. Methods: We used ICD-9 codes from Medicare and Veterans Health Administration (VHA) data to identify patients hospitalized for MI, PCI, or CABG between 1/1/2007 and 12/31/2009 (in a 5% Medicare sample) or 10/1/2006 and 9/30/2011 (in VHA). After excluding patients who died within 30 days of hospitalization, we calculated the percent of patients who participated in one or more outpatient visits for cardiac rehabilitation (CPT code 93797 or 93798) during the 12 months after hospitalization. We then compared the percent of patients who participated in cardiac rehabilitation by state. Hawaii and Alaska were excluded from the analysis because they do not have VHA inpatient facilities. Results: Overall participation in cardiac rehabilitation was 20% (13,435/67,115) in Medicare and 8% (3,955/47,051) in VHA. Similar regional variation was observed, with the North-Central United States having the highest participation in both health care systems (Figure). Within Medicare, participation in cardiac rehabilitation ranged from 10% (Nevada) to 52% (Nebraska). Within VHA, participation ranged from 0 (Delaware, New Jersey) to 30% (Nebraska). Conclusion: Similar regional variation in participation in cardiac rehabilitation was observed in two separate health care systems. Nebraska had the highest rate of participation in both Medicare and VHA populations. Further study of reasons for regional variation and differences in regional variation in these populations may reveal opportunities for improving delivery of cardiac rehabilitation.

Introduction: Cardiac rehabilitation (CR) participation reduces the likelihood of major adverse cardiovascular events (MACE), but is limited by structural factors, including race or ethnicity and annual income. We investigated (1) associations between CR participation and MACE, and (2) how structural disadvantage modifies this association, focusing on the intersection between race or ethnicity and household income. Hypotheses: We hypothesized that (1) CR participation would be inversely associated with MACE, and (2) this association would attenuate differences in MACE by race or ethnicity, as well as by household income. Methods: We identified 212,744 individuals with a CR-qualifying event between 1/1/16 and 12/31/20 in Optum’s de-identified Clinformatics® Data Mart database. We evaluated associations between CR sessions attended (0 to 36) and MACE (cardiac arrest, heart failure, myocardial infarction, or stroke hospitalizations) using a proportional hazards model for recurrent events, and assessed the three-way interaction between CR participation, race or ethnicity, and household income. Results: We included 212,744 individuals (age 70.8±11.3 years; 37.8% female sex; 71.9% White race) of whom 26.0% attended ≥1 CR sessions. Overall, we observed a dose-response association between CR participation and MACE. After adjustment, those who did not attend CR were 2.9 times as likely to experience MACE as those who attended ≥36 sessions (95% CI: 2.71, 3.03, P <0.0001), for whom there were no significant differences by race or ethnicity ( Figure ). Associations between CR participation and MACE were similar both across race or ethnicity and by household income ( P , interaction=0.28). Conclusion: Greater CR participation is associated with lower risk of MACE, regardless of (1) race or ethnicity and (2) household income. Because participation in CR remains low, particularly in socially disadvantaged populations, interventions to promote use of CR are critical to reduce disparities in cardiovascular outcomes.

ObjectiveTo investigate factors associated with enrollment and participation in cardiac rehabilitation (CR) in Korea.MethodsPatients admitted to four university hospitals with acute coronary syndrome between June 2014 and May 2016 were enrolled. The Cardiac Rehabilitation Barriers Scale (CRBS) made of 21-item questionnaire and divided in four subdomains was administered during admission. CRBS items used a 5-point Likert scale and ≥2.5 was considered as a barrier. Differences between CR non-attender and CR attender, or CR non-enroller and CR enroller in subscale and each items of CRBS were examined using the chi-square test.ResultsThe CR participation rate in four hospitals was 31% (170 of the 552). Logistical factors (odds ratio [OR]=7.61; 95% confidence interval [CI], 4.62–12.55) and comorbidities/functional status (OR=6.60; 95% CI, 3.95–11.01) were identified as a barrier to CR enrollment in the subdomain analysis. Among patients who were enrolled (agreed to participate in CR during admission), only work/time conflict was a significant barrier to CR participation (OR=2.17; 95% CI, 1.29–3.66).ConclusionDiverse barriers to CR participation were identified in patients with acute coronary syndrome. Providing the tailored model for CR according to the individual patient's barrier could improve the CR utilization. Further multicenter study with large sample size including other CR indication is required.

Cardiac rehabilitation after myocardial infarction in the community

Introduction: The effect of the COVID-19 pandemic on availability of and participation in cardiac rehabilitation (CR) participation is unknown. Methods: We used Medicare Fee-for-Service claims, American Hospital Association surveys, and Rural Urban Commuting Area codes to evaluate CR center availability and CR participation (01/2019-12/21). Results: Medicare beneficiaries participated in a mean ± SD of 56,898 ± 2,046 CR sessions per month from 01/2019 - 02/2020. Immediately after the announcement of the public health emergency in 03/2020, CR sessions declined by 93% (to 3,989 sessions in 04/2020) (Figure). The monthly CR sessions recovered gradually through 12/21, but CR participation remained 17% lower than pre-pandemic levels (54,730 ± 2,340 sessions/month in Q1 2019 vs. 45,209 ± 326 sessions/month in Q4 2021, p<0.01). Prior to the pandemic, Medicare beneficiaries received CR at 2,631 ± 8 CR centers. Only 688 centers were in operation in 04/2020 (a 74% decline from pre-pandemic levels), with slow and incomplete recovery in the following months. The number of CR centers in 12/2021 was 5% lower than pre-pandemic levels (2,620 ± 6 centers available in Q1 2019 vs. 2,485 ± 8 centers available in Q4 2021, p <0.01). Ownership status (private/not for profit, private/for profit and public/municipal), teaching status affiliation (major, minor and none), and location (metro, micro and rural) were not associated with post-pandemic CR center availability. Conclusions: The COVID-19 pandemic has been associated with persistent declines in the availability of CR centers and participation in CR sessions among Medicare beneficiaries. Future studies should examine the impact of these closures on health outcomes and equity. Meeting the Million Hearts Initiative’s goal of equitably increasing CR participation will require scalable innovation in CR financing and delivery.

Cardiovascular diseases show high incidence and prevalence in Brazil; however, participation in Cardiac Rehabilitation (CR) is limited and has been poorly investigated in the country. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess the barriers to participation and adherence to CR. To translate, cross-culturally adapt and psychometrically validate CRBS to Brazilian Portuguese. Two independent initial translations were performed. After the reverse translation, both versions were reviewed by a committee. The new version was tested in 173 patients with coronary artery disease (48 women, mean age = 63 years). Of these, 139 (80.3%) participated in CR. Internal consistency was assessed by Cronbach's alpha, test-retest reliability by intraclass correlation coefficient (ICC) and construct validity by factor analysis. T-tests were used to assess criterion validity between participants and non-participants in CR. The applied test results were evaluated regarding patient characteristics (gender, age, health status and educational level). The Brazilian Portuguese version of the CRBS had Cronbach's alpha of 0.88, ICC of 0.68 and disclosed five factors, most of which showed to be internally consistent and all were defined by the items. The mean score for patients in CR was 1.29 (SD = 0.27) and 2.36 for ambulatory patients (SD = 0.50) (p <0.001). Criterion validity was also supported by significant differences in total scores by gender, age and educational level. The Brazilian Portuguese version of CRBS has shown adequate validity and reliability, which supports its use in future studies.

Introduction: Despite the benefits of Cardiac Rehabilitation (CR), local and national CR referral and participation rates remain low when compared to established cardiovascular therapies, especially amongst racial/ethnic groups. Objectives: This study investigated the effects of the implementation of a CR program and electronic order set (EOS) in a large health system on CR referral and participation rates among a diverse group of patients with Coronary Heart Disease (CHD). Methods: A total of 360 patients from UCSD Health who presented with ACS were prospectively evaluated during initial hospitalization and 6- and 12-weeks post-discharge. The multivariable logistic regression model assessed referral and participation rates by week 1 and -12 post-discharge, adjusting for gender, age, race, ethnicity, geography, and referring physician subspecialty. Results: UCSD CR program implementation led referral rates to increase at week 1 (Pre- 38.6% and Post-54.9%, p = 0.003) and week-12 (Pre- 54.1% and Post- 59.8%, p = 0.386). Post-CR referrals were more likely at week-1 (OR: 1.93, 95% CI 1.27-2.95) and week-12 (OR: 1.26, 95% CI 0.79-2.00). EOS implementation increased referral rates at week-1 (Pre- 40.3% and Post- 58.7%, p &lt; 0.001) and week-12 (Pre- 54.9% and Post- 60.4%, p = 0.394) with referrals more likely at week-1 (OR: 2.1, 95% CI 1.35-3.29) and week-12 (OR: 1.25, 95% CI 0.795-1.98). Participation in CR following EOS was more likely at both week-1 and week-12. Multivariable analysis revealed disparities in referral based on race, geographic location, and referring physician subspecialty. Conclusion: A CR program and EOS implementation were shown to increase referral rates with long-term potential for increasing referral and participation rates. Condensed abstract: This prospective study investigated the implementation of a Cardiac Rehabilitation (CR) program and Electronic Order Set (EOS) within the same health system on CR referral and participation rates. 360 patients with ACS were evaluated over 12 weeks. UCSD CR program and EOS implementation led referral rates to increase at week-1 and -12. CR participation was more likely to increase at week-1 and -12 following EOS. Multivariable analysis revealed disparities in referrals disproportionally affecting racial and ethnic minority groups and rural communities. CR and EOS implementation may increase CR referral rates for diverse patients with CHD.