Cardiac Rehabilitation Barriers Research Articles

Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries

ObjectiveDespite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes. MethodsThis retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use. ResultsOverall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001). ConclusionsIdentifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

The Translation, Culture-Adaptation and Psychometric Evaluation of the Cardiac Rehabilitation Barriers Scale Among Chinese Older Population.

This study aimed to translate and cross-culturally adapt the cardiac rehabilitation barriers scale to the Chinese, and examine its reliability and validity among the older population. An approach comprising translation, cultural adaptation, reliability, and validity examination in the Chinese version was conducted in two hospitals in Jilin, China. The t-tests were used to compare the sex differences between each item. Participants included Chinese individuals >60 who were eligible for the cardiac rehabilitation program. In total, 325 participants completed the questionnaire with an average age of 61.23 ± 9.68 years. The item-total correlations were 0.432 to 0.678. Factor analysis of CRBS-C (Kaiser Meyer Olkin = 0.867, Bartlett's test p = 0.000) revealed four factors: logistical factors, comorbidities/functional status, perceived need/healthcare factors, and work/time conflict. The confirmatory factor analysis (CFA) indicated a good model fit (χ2/df = 1.84, RMSEA = 0.051, CFI = 0.953, TLI = 0.945, SRMR=0.046). Cronbach's alpha was 0.88 for the scale, ranging from 0.801 to 0.88 for each item, which indicates the internal reliability was acceptable. The Chinese version of the CRRS has acceptable reliability and validity in the Chinese elderly population.

Barriers to cardiac rehabilitation and patient perceptions on the usage of technologies in cardiac rehabilitation: Across-sectional study.

The study aimed to identify factors associated with participation in Phase II cardiac rehabilitation and to assess patient perceptions towards the usage of technologies in cardiac rehabilitation. Despite efforts to promote utilisation of cardiac rehabilitation (CR), participation among patients remains unsatisfactory. Little is known of patient decision to participate Phase II CR in a multi-ethnic country. A cross-sectional study design. A consecutive sampling of 240 patients with coronary heart disease completed Coronary Artery Disease Education Questionnaire (CADE-Q) II, Hospital Anxiety and Depression Scale (HADS), Multidimensional Scale of Perceived Social Support (MSPSS) and Cardiac Rehabilitation Barriers Scale (CRBS). Seventy per cent of patients (mean age 60.5 [SD = 10.6] years, 80.8% male) participated in phase II cardiac rehabilitation. Self-driving to cardiac rehabilitation centres, higher barriers in perceived need/health care and logistical factors were significantly associated with decreased odds of participation. Patients with more barriers from comorbidities/functional status, higher perceived social support from friends, and anxiety were more likely to participate. Chinese and Indians were less likely to participate when compared with Malays. More than 80% of patients used both home and mobile broadband internet, and 72.9% of them would accept the usage of technologies, especially educational videos, instant messenger, and video calls to partially replace the face-to-face, centre-based cardiac rehabilitation approach. Several barriers were associated with non-participation in phase II cardiac rehabilitation. With the high perceived acceptance of technology usage in cardiac rehabilitation, home-based and hybrid cardiac rehabilitation may represent potential solutions to improve participation. By addressing the barriers to cardiac rehabilitation, patients are more likely to be ready to adopt health behaviour changes and adhere to the cardiac rehabilitation programme. The high perceived acceptance of using technologies in cardiac rehabilitation may provide insights into new delivery models that can improve and overcome barriers to participation.

Women’s Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation’s First Global Assessment

BackgroundCardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women’s greatest barriers according to enrollment status. MethodsIn this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated. ResultsParticipants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women’s barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5). ConclusionsCR barriers—men’s and women’s—vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women’s barriers in particular.

Sex differences in cardiac rehabilitation barriers among non-enrollees in the context of lower gender equality: a cross-sectional study

BackgroundDespite the benefits of cardiac rehabilitation (CR), it remains under-utilized, particularly by women. This study compared CR barriers between non-enrolling men and women in Iran, which has among the lowest gender equality globally.MethodsIn this cross-sectional study, CR barriers were assessed via phone interview in phase II non-attenders from March 2017 to February 2018 with the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P). T-tests were used to compare scores, with each of 18 barriers scored out of 5, between men and women.Results357 (33.9%) of the sample of 1053 were women, and they were older, less educated and less often employed than men. Total mean CRBS scores were significantly greater in women (2.37 ± 0.37) than men (2.29 ± 0.35; effect size[ES] = 0.08, confidence interval[CI]: 0.03–0.13; p < 0.001). The top CR barriers among women were cost (3.35; ES = 0.40, CI:0.23–0.56; P < 0.001), transportation problems (3.24; ES = 0.41, CI:0.25–0.58; P < 0.001), distance (3.21; ES = 0.31, CI:0.15–0.48; P < 0.001), comorbidities (2.97; ES = 0.49, CI:0.34–0.64; P < 0.001), low energy (2.41; ES = 0.29, CI:0.18–0.41; P < 0.001), finding exercise as tiring or painful (2.22; ES = 0.11, CI:0.02–0.21; P = 0.018), and older age (2.27; ES = 0.18, CI:0.07–0.28; P = 0.001). Men rated “already exercise at home or in community” (2.69; ES = 0.23, CI:0.1–0.36; P = 0.001), time constraints (2.18; ES = 0.15, CI:0.07–0.23; P < 0.001) and work responsibilities (2.24; ES = 0.16, CI:0.07–0.25; P = 0.001) as greater CR barriers than women.ConclusionWomen had greater barriers to CR participation than men. CR programs should be modified to address women’s needs. Home-based CR tailored to women’s exercise needs and preferences should be considered.

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers.

Cardiac rehabilitation (CR) utilization is low, particularly in Arabic-speaking countries. This study aimed to translate and psychometrically validate the CR Barriers Scale in Arabic (CRBS-A), as well as strategies to mitigate them. The CRBS was translated by two bilingual health professionals independently, followed by back-translation. Next, 19 healthcare providers, followed by 19 patients rated the face and content validity (CV) of the pre-final versions, providing input to improve cross-cultural applicability. Then, 207 patients from Saudi Arabia and Jordan completed the CRBS-A, and factor structure, internal consistency, construct, and criterion validity were assessed. Helpfulness of mitigation strategies was also assessed. For experts, item and scale CV indices were 0.8-1.0 and 0.9, respectively. For patients, item clarity and mitigation helpfulness scores were 4.5 ± 0.1 and 4.3 ± 0.1/5, respectively. Minor edits were made. For the test of structural validity, four factors were extracted: time conflicts/lack of perceived need and excuses; preference to self-manage; logistical problems; and health system issues and comorbidities. Total CRBS-A α was 0.90. Construct validity was supported by a trend for an association of total CRBS with financial insecurity regarding healthcare. Total CRBS-A scores were significantly lower in patients who were referred to CR (2.8 ± 0.6) vs. those who were not (3.6 ± 0.8), confirming criterion validity (p = 0.04). Mitigation strategies were considered very helpful (mean = 4.2 ± 0.8/5). The CRBS-A is reliable and valid. It can support identification of top barriers to CR participation at multiple levels, and then strategies for mitigating them can be implemented.

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Greek Version of the Cardiac Rehabilitation Barriers Scale (CRBS-GR): What Are the Barriers in South-East Europe?

Cardiac Rehabilitation (CR) is a secondary prevention intervention proven to improve quality of life, yet with low participation. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess multi-level barriers to participation. This study aimed at the translation, and cross-cultural adaptation of the CRBS into the Greek language (CRBS-GR), followed by psychometric validation. Some 110 post-angioplasty patients with coronary artery disease (88.2% men, age 65.3 ± 10.2 years) answered the CRBS-GR. Factor analysis was performed to obtain the CRBS-GR subscales/factors. The internal consistency and 3-week test-retest reliability was evaluated using Cronbach's alpha (α) and intraclass correlation coefficient (ICC), respectively. Construct validity was tested via convergent and divergent validity. Concurrent validity was assessed with the Hospital Anxiety and Depression Scale (HADS). Translation and adaptation resulted in 21 items similar to the original version. Face validity and acceptability were supported. Construct validity assessment revealed four subscales/factors, with acceptable overall reliability (α = 0.70) and subscale internal consistency for all but one factor (α range = 0.56-0.74). The 3-week test-retest reliability was 0.96. Concurrent validity assessment demonstrated a small to moderate correlation of the CRBS-GR with the HADS. The greatest barriers were the distance from the rehabilitation center, the costs, the lack of information about CR, and already exercising at home. The CRBS-GR is a reliable and valid tool for identifying CR barriers among Greek-speaking patients.

Clinical Determinants and Barriers to Cardiac Rehabilitation Enrollment of Patients with Heart Failure with Reduced Ejection Fraction: A Single-Center Study in Portugal.

Despite cardiac rehabilitation (CR) being a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF), it is still underused. This study investigated the clinical determinants and barriers to enrollment in a CR program for HFrEF patients. We conducted a cohort study using the Cardiac Rehabilitation Barriers Scale (CRBS) to assess the reason for non-enrollment. Of 214 HFrEF patients, 65% had not been enrolled in CR. Patients not enrolled in CR programs were older (63 vs. 58 years; p < 0.01) and were more likely to have chronic obstructive pulmonary disease (COPD) (20% vs. 5%; p < 0.01). Patients enrolled in CR were more likely to be treated with sacubitril/valsartan (34% vs. 19%; p = 0.01), mineralocorticoid receptor antagonists (84% vs. 72%; p = 0.04), an implantable cardioverter defibrillator (ICD) (41% vs. 20%; p < 0.01), and cardiac resynchronization therapy (21% vs. 10%; p = 0.03). Multivariate analysis revealed that age (adjusted OR 1.04; 95% CI 1.01–1.07), higher education level (adjusted OR 3.31; 95% CI 1.63–6.70), stroke (adjusted OR 3.29; 95% CI 1.06–10.27), COPD (adjusted OR 4.82; 95% CI 1.53–15.16), and no ICD status (adjusted OR 2.68; 95% CI 1.36–5.26) were independently associated with CR non-enrollment. The main reasons for not being enrolled in CR were no medical referral (31%), concomitant medical problems (28%), patient refusal (11%), and geographical distance to the hospital (9%). Despite the relatively high proportion (35%) of HFrEF patients who underwent CR, the enrollment rate can be further improved. Innovative multi-level strategies addressing physicians’ awareness, patients’ comorbidities, and geographical issues should be pursued.

Cardiac Rehabilitation Completion Study: Barriers and Potential Solutions.

Cardiac Rehabilitation Completion Study: Barriers and Potential Solutions.

Barriers and facilitators to participating in cardiac rehabilitation and physical activity: A cross-sectional survey.

BACKGROUNDCardiovascular diseases (CVD) have been shown to be the greatest cause of death worldwide and rates continue to increase. It is recommended that CVD patients attend cardiac rehabilitation (CR) following a cardiac event to reduce mortality, improve recovery and positively influence behaviour around CVD risk factors. Despite the recognised benefits and international recommendations for exercise-based CR, uptake and attendance remain suboptimal. A greater understanding of CR barriers and facilitators is required, not least to inform service development. Through understanding current cardiac patients’ attitudes and opinions around CR and physical activity (PA) could inform patient-led improvements. Moreover, through understanding aspects of CR and PA that participants like/dislike could provide healthcare providers and policy makers with information around what elements to target in the future.AIMTo investigate participants’ attitudes and opinions around CR and PA.METHODSThis study employed a cross-sectional survey design on 567 cardiac patients. Cardiac patients who were referred for standard CR classes at a hospital in the Scottish Highlands, from May 2016 to May 2017 were sampled. As part of a larger survey, the current study analysed the free-text responses to 5 open-ended questions included within the wider survey. Questions were related to the participants’ experience of CR, reasons for non-attendance, ideas to increase attendance and their opinions on PA. Qualitative data were analysed using a 6-step, reflexive thematic analysis. RESULTSTwo main topic areas were explored: “Cardiac rehabilitation experience” and “physical activity”. Self-efficacy was increased as a result of attending CR due to exercising with similar individuals and the safe environment offered. Barriers ranged from age and health to distance and starting times of the classes which increased travel time and costs. Moreover, responses demonstrated a lack of information and communication around the classes. Respondents highlighted that the provision of more classes and classes being held out with working hours, in addition to a greater variety would increase attendance. In terms of PA, respondents viewed this as different to the CR experience. Responses demonstrated increased freedom when conducting PA with regards to the location, time and type of exercise conducted.CONCLUSIONChanges to the structure of CR may prove important in creating long term behaviour change after completing the rehabilitation programme.

Examining Facilitators and Barriers to Cardiac Rehabilitation Adherence in a Low-Resource Setting in Latin America from Multiple Perspectives.

Cardiac rehabilitation (CR) is under-used, particularly in low-resource settings. There are few studies of barriers and facilitators to CR adherence in these settings, particularly considering multiple perspectives. In this multiple-method study, a cross-sectional survey including the Cardiac Rehabilitation Barriers Scale (each item scored on a five-point Likert scale) was administered to patients treated between February and July, 2019, in three CR centers in Colombia. A random subsample of 50 participants was invited to a focus group, along with an accompanying relative. Physiotherapists from the programs were invited to an interview, with a similar interview guide. Audio-recordings were transcribed and analyzed using interpretive description. A total of 210 patients completed the survey, and 9 patients, together with 3 of their relatives and 3 physiotherapists, were interviewed. The greatest barriers identified were costs (mean = 2.8 ± 1.6), distance (2.6 ± 1.6) and transportation (2.5 ± 1.6); the logistical subscale was highest. Six themes were identified, pertaining to well-being, life roles, weather, financial factors, healthcare professionals and health system factors. The main facilitators were encouragement from physiotherapists, relatives and other patients. The development of hybrid programs where patients transition from supervised to unsupervised sessions when appropriate should be considered, if health insurers were to reimburse them. Programs should consider the implications regarding policies of family inclusion.

Prevalence of US Adults With Cardiovascular Disease Reporting Barriers to Clinician Office Visits: IMPLICATIONS FOR ACCESSIBLE MODELS FOR CARDIAC REHABILITATION.

Despite known health benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), only a quarter of eligible patients attend. Among CR barriers are physical (eg, walking) and in-person attendance limitations. The purpose of this study was to determine the prevalence of difficulty walking and dependence on another person to attend medical appointments among people with and without CVD using national survey data. We compared the prevalence of difficulty walking and difficulty attending medical appointments alone among adults with and without CVD using national survey data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2015-2019. We used logistic regression and Rao-Scott χ2 analysis while controlling for several social determinants of health as covariates. Of 2 212 973 respondents, 200 087 (9.04%) had CVD. The odds of individuals with CVD experiencing either difficulty walking or difficulty attending medical appointments alone were >3 times greater than the odds for individuals without CVD. In all adults with CVD, 42% reported difficulty walking and 20% reported dependence on another person to attend medical appointments. In all adults with CVD, 46% reported difficulty with one or both difficulties compared with 14% of adults without CVD. We estimate that 11.9 million Americans with self-reported CVD have difficulty walking, or are dependent on another person to attend medical appointments, or both. Alternative models of CR that adapt to these limitations are needed to increase attendance of CR so that all adults with CVD can improve their health outcomes.

Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study.

Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges. To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence. Observational, cross-sectional study in public and private CR programs offered in Brazil. Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale. From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012). Publicly funded programs need to be tailored to meet their patients' requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.

Validity and Reliability of the Cardiac Rehabilitation Barriers Scale in the Czech Republic (CRBS-CZE): Determination of Key Barriers in East-Central Europe.

Cardiovascular rehabilitation (CR) is an effective secondary preventive model of care. However, the use of CR is insufficient, and the reasons for this are not well-characterized in East-Central Europe. This prospective observational study psychometrically validated the recently translated Cardiac Rehabilitation Barriers Scale for the Czech language (CRBS-CZE) and identified the main CR barriers. Consecutive cardiac in/out-patients were approached from January 2020 for 18 months, of whom 186 (89.9%) consented. In addition to sociodemographic characteristics, participants completed the 21-item CRBS-CZE (response options 1–5, with higher scores representing greater barriers), and their CR utilization was tracked. Forty-five (24.2%) participants enrolled in CR, of whom 42 completed the CRBS a second time thereafter. Factor analysis revealed four factors, consistent with other CRBS translations. Internal reliability was acceptable for all but one factor (Cronbach’s alpha range = 0.44–0.77). Mean total barrier scores were significantly higher in non-enrollers (p < 0.001), decreased from first and second administration in these enrollers (p < 0.001), and were lower in CR completers (p < 0.001), supporting criterion validity. There were also significant differences in barrier scores by education, geography, tobacco use, among other variables, further supporting validity. The biggest barriers to enrolment were distance, work responsibilities, lack of time, transportation problems, and comorbidities; and the greatest barriers to adherence were distance and travel. Several items were considered irrelevant at first and second administration. Other barriers included wearing a mask during the COVID-19 pandemic. The study demonstrated sufficient validity and reliability of CRBS-CZE, which supports its use in future research.

Current Status of Cardiac Rehabilitation in the Regional Cardiocerebrovascular Centers in Korea.

Regional Cardiocerebrovascular Centers (RCCs)—a Korean government initiative—seek to reduce medical gaps across regions, and their cardiac rehabilitation (CR) programs are expected to model post-acute care for the Korean CR program. Accordingly, this study aimed to evaluate the current status of CR programs in the RCCs. We distributed surveys on the CR condition, activity, and barriers to 12 RCCs in different provinces. The results revealed significant gaps in the annual number of acute myocardial infarction admissions, and CR candidates, capacity, and density across the 12 RCCs. The CR capacity (50–500) and density (0.42–7.36) indicated particularly large gaps. Twelve RCCs had the necessary facilities, equipment and personnel for CR assessments and management, with high CR referral (97%) and patient education (78%) rates. However, the inpatient CR exercise training (56%) participation rate was inadequate, with much lower enrollment (47%) and adherence (17%) rates to the outpatient CR program and large differences across centers. Therefore, this study’s results will provide the evidence required to establish special national health strategies to overcome the CR barriers of patient, doctor/hospital, and policy factors for activating Korean CR programs.

Translation, Cross-Cultural Adaptation, and Psychometric Validation of the Chinese/Mandarin Cardiac Rehabilitation Barriers Scale (CRBS-C/M).

Objective Cardiovascular diseases are among the leading causes of morbidity in China and around the world. Cardiac rehabilitation (CR) effectively mitigates this burden; however, utilization is low. CR barriers in China have not been well characterized; this study sought to translate, cross-culturally adapt, and psychometrically validate the CR Barriers Scale in Chinese/Mandarin (CRBS-C/M). Methods Independent translations of the 21-item CRBS were conducted by two bilingual health professionals, followed by back-translation. A Delphi process was undertaken with five experts to consider the semantics and cross-cultural relevance of the items. Following finalization, 380 cardiac patients from 11 hospitals in Shanghai were administered a validation survey including the translated CRBS. Following exploratory and confirmatory factor analysis, internal consistency was assessed. Validity was tested through assessing the association of the CRBS-C/M with the CR Information Awareness Questionnaire. Results Items were refined and finalized. Factor analysis of CRBS-C/M (Kaiser Meyer Olkin = 0.867, Bartlett's test p < 0.001) revealed five factors: perceived CR need, external logistical factors, time conflicts, program and health system-level factors, and comorbidities/lack of vitality; Cronbach's alpha (α) of the subscales ranged from 0.67 to 0.82. The mean total CRBS score was significantly lower in patients who participated in CR compared with those who did not, demonstrating criterion validity (2.35 ± 0.71 vs. 3.08 ± 0.55; p < 0.001). Construct validity was supported by the significant associations between total CRBS scores and CR awareness, sex, living situation, city size, income, diagnosis/procedure, disease severity, and several risk factors (all p < 0.05). Conclusions CRBS-C/M is reliable and valid, so barriers can be identified and mitigated in Mandarin-speaking patients.

심부전 환자의 운동기반 심장재활

Heart failure is one of the common causes of morbidity, mortality, and socioeconomic burdens. Heart failure is treated by medications or assistive devices according to the current evidence-based guideline, thus the mortality due to heart failure is decreasing but the long-term mortality is still high and patients with heart failure show poor quality of life. Exercise-based cardiac rehabilitation (CR) along with optimal medical therapy can decrease hospital readmissions, long-term mortality and promote health-related quality of life. Therefore, exercise-based CR in heart failure is strongly recommended by international guidelines for heart failure. In Korea, the national medical insurance coverage for CR was started in 2017 but CR for heart failure is definitely underutilized. To promote CR in heart failure, health care professionals in CR providers should fully understand the benefits and clinical application of CR and can convince other medical staff or patients with heart failure based on their solid knowledge. In this narrative brief review for CR in heart failure, I will cover the following topics: 1) mechanisms of exercise-based CR on beneficial effects in heart failure, 2) clinical evidence of CR in heart failure, 3) exercise prescription in heart failure, 4) CR barriers and strategies to promote CR.

Barriers to completion of a novel pediatric cardiac rehabilitation program

IntroductionPediatric cardiac rehabilitation addresses physical and emotional challenges related to underlying heart disease. While the benefits of cardiac rehabilitation have largely been established, the challenges that patients and their families experience when participating in these programs have yet to be examined in detail. In this study, we evaluated the barriers that families face when asked to complete a structured cardiac rehabilitation program. ObjectivesThe objectives of this study were to measure the success of a novel pediatric cardiac rehabilitation program and to evaluate the barriers that families face when asked to complete a structured cardiac rehabilitation program. MethodsParents of patients referred for cardiac rehabilitation and who attended at least one session were recruited to participate in a phone survey regarding their experience using a published psychometric validation of the cardiac rehabilitation barriers scale. Results9 families participated in the study. 67% of patients were male and 3 patients completed the program in its entirety. Challenges associated with time, travel, and insufficient insurance coverage, were the highest rated barriers to completion of the rehabilitation program. Families universally enjoyed the program. 5 of 9 felt that the biggest positive of the experience was gaining an understanding of what exercise is safe. 3 of 9 stated that cardiac rehabilitation should be a standard component of therapy for all pediatric cardiology patients. ConclusionsPediatric cardiac rehabilitation is effective and liked by families. The barriers to completing a structured in-person program are difficulty getting to appointments due to time and travel and level of insurance coverage for the program. As such, ensuring insurance coverage and perhaps virtual rehab programs would be beneficial.

Cardiac rehabilitation barriers in the Czech Republic: Determination of key barriers in East-Central Europe

Funding AcknowledgementsType of funding sources: Public grant(s) – National budget only. Main funding source(s): the Ministry of Health, Czech Republic - conceptual development of research organization (65269705)BackgroundCardiovascular diseases are leading causes of morbidity and mortality worldwide, including in Central Europe. Cardiac rehabilitation (CR) represents an efficient secondary prevention model, but it is highly underutilised. Barriers to CR in the Czech Republic (and in Central Europe) are not well-characterised, and therefore we present a study to define these barriers.PurposeThrough this study, a reliable and valid means of assessing patient"s CR barriers will be established. Results will be used to identify ways to help patients overcome barriers to CR and potentially contribute to improving CR utilisation in this region.MethodsThis is a multi-method study. First, in 2019, we professionally translated and cross-culturally validated the Cardiac Rehabilitation Barriers Scale to Czech (CRBS-CZE), and piloting it in 50 cardiac patients. A prospective study was undertaken to psychometrically-validate the CRBS-CZE, where patients eligible for phase II/outpatient CR were recruited. The internal reliability of the scale was assessed with Cronbach"s alpha.In total, 143 eligible patients (target of 200-300 patients) in the University Hospital Brno was approached from January 2020 for one year. Consenting participants were informed about the CR program and their sociodemographic (age, sex, highest educational attainment, work status, travel time), clinical characteristics (diagnosis, anthropometrics, blood pressure, lipids levels, diabetes), heart-healthy behaviours (level of physical activity, tobacco use, harmful use of alcohol), and the CRBS-CZE administered.Mean CRBS-CZE scores (21-items/barriers, five-point Likert scale) were analysed to determine key barriers in this setting. To test construct validity, differences in CRBS-CZE total scores were compared by patient characteristics outlined above, using a t-test and Pearson"s correlation. Patient"s enrollment, adherence, and completion of the CR program (% of 24 prescribed sessions attended) were tracked.Results (preliminary)The CRBS-CZE had good internal consistency (Cronbach’s alpha = .74). Mean total perceived barriers were significantly greater among non-enrollers (2.1, SD = .57) than CR enrollers (1.8, SD = .53), and among rural (2.2, SD = .54) than urban inhabitants (1.7, SD = .46) (p < .05). The long distance from CR facilities (mean commuting time about 50 mins), a little free time, and the transportation problems were identified as the greatest barriers. From all eligible patients, 19.6% entered and 10.5% completed the CR program. The mean completion rate was 70.6%. The main limitations of the study were a small number of participants and the COVID-19 pandemic.ConclusionThe CRBS-CZE has shown adequate validity and reliability, which supports its use in future studies. Results also point to suboptimal CR availability in the Czech Republic. This finding, especially in the pandemic situation, promotes the need for CR alternatives like home-based programs and telerehabilitation.

Reliability of the Scale of Barriers for Cardiac Rehabilitation in the Colombian Population

Cardiac rehabilitation is supported by the highest level of scientific evidence. However, less than 25% of those eligible to participate in a cardiac rehabilitation program initiate it; and of these, 50% drop out prematurely. A modified Spanish Cardiac Rehabilitation Barriers Scale (CRBS) has been translated, culturally adapted and validated in Colombia, however, the reliability remains to be evaluated. This study aimed to determine the internal consistency and test–retest reliability of the CRBS in a Colombian population. In total, 193 patients (67% men, average age = 65 ± 12 years) completed the scale twice, with an average of eight days between applications. Cronbach’s Alpha and intraclass correlation coefficients (ICC) were calculated. The internal consistency of the Colombian version of the CRBS was acceptable (Cronbach’s alpha = 0.84). The ICC of the CRBS was 0.69 (95% CI 0.61–0.76); 0.78 (95% CI 0.71–0.84) when the CRBS was completed by interview; and 0.47 (95% CI 0.21–0.67) when the CRBS was self-reported. The reliability of the interview version of the CRBS was substantial in the Colombian population; however, the reliability of the self-report version was lower. The use of this scale will allow developing strategies to increase participation and adherence to cardiac rehabilitation programs.