Cardiac Rehabilitation Enrollment Research Articles

Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries.

Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting. Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers. A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge. A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.

A novel referral strategy to enhance the enrollment of patients with heart failure in cardiac rehabilitation: A feasibility study.

Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well-documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure. This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15-20 min face-to-face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi-structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate. Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety-one percent data completeness was achieved. The intervention was well-accepted by patients and health care professionals. The enrollment rate reached 79%. The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full-scale trial. The novel referral strategy was well-accepted, and enrollment rate approached an acceptable level.

Anxiety Predicts Worse Cardiorespiratory Fitness Outcomes in Cardiac Rehabilitation for Lower Socioeconomic Status Patients.

The purpose of this study was to show that patients in cardiac rehabilitation (CR) with lower socioeconomic status (SES) have worse clinical profiles and higher rates of psychiatric difficulties and they have lower cardiorespiratory fitness (CRF) improvements from CR than their counterparts with higher SES. Improvement in CRF during CR predicts better long-term health outcomes. Research suggests that higher anxiety impairs CRF in structured exercise regimes and is overrepresented among patients with lower SES. However, no study has determined whether this relationship holds true in CR. This study is a secondary analysis of a randomized controlled trial to improve CR attendance among patients with lower SES. Anxiety (ASEBA ASR; Achenbach System of Empirically Based Assessment, Adult Self Report) and CRF measures (metabolic equivalent tasks [METs peak ]) were collected prior to CR enrollment and 4 mo later. Regression was used to examine the association of anxiety with CRF at 4 mo while controlling for other demographic and clinical characteristics. Eight-eight participants were included in the analyses, 31% of whom had clinically significant levels of anxiety ( T ≥ 63). Higher anxiety significantly predicted lower exit CRF when controlling for baseline CRF, age, sex, qualifying diagnosis, and number of CR sessions attended ( β =-.05, P = .04). Patients with clinically significant levels of anxiety could be expected to lose >0.65 METs peak in improvement. The results from this study suggest that anxiety, which is overrepresented in populations with lower SES, is associated with less CRF improvement across the duration of CR. The effect size was clinically meaningful and calls for future research on addressing psychological factor in CR.

Lower cardiac rehabilitation enrolment occurs in acute coronary syndrome patients who report low levels of physical activity at four weeks post-event: A prospective observational study using physical activity tracker data

BackgroundPhysical activity (PA) and cardiac rehabilitation (CR) attendance are important for recovery and prognosis following acute coronary syndrome (ACS). However, PA patterns early post-ACS are not well known. ObjectivesInvestigate the level of PA at 4-weeks post-ACS and any potential associations with CR enrolment. MethodsWe recruited patients admitted for ACS from cardiac wards and clinics at two hospital sites in Sydney, Australia. PA data were collected using wearable activity trackers worn at 4-weeks post-ACS, and CR enrolment was self-reported. ResultsParticipants (n = 61) were aged 66.7 ± 10.3 years, 74 % male, 61 % were married or partnered, and 33 % were diagnosed with ST-elevation myocardial infarction. Patients engaged in 7514±3355 steps per day and 44.6 ± 37.5 min of moderate-to-vigorous physical activity (MVPA). Patients who enrolled in CR exhibited higher daily step counts (p = 0.044), MVPA minutes (p = 0.001), and were more likely to meet PA guidelines. ACS patients who engaged in higher levels of MVPA were more likely to enrol in CR (odds ratio [OR] 1.46; 95 % confidence interval [CI] 1.08, 1.98). CR enrolment was also positively associated with being married or in an intimate partnership (OR 9.93; 95 % CI 1.83, 53.85) and absence of depressive symptoms (OR 11.86; 95 % CI 1.91, 73.74). ConclusionLower CR enrolment rates were observed among less physically active patients at 4-weeks post-ACS. However, each 10 min increment in MVPA increased the odds of CR enrolment by 46 %. Future research should explore strategies to target this inactive and high-risk group, given the potential for a large prognostic gain with CR participation.

Abstract 18530: Associations Among Self-Reported and Physiologic Sleep Measurements and Fatigue in Adults Following Major Cardiac Events

Background: Insufficient sleep contributes to fatigue and cardiometabolic disorders. Current sleep measures vary in accuracy, with weak correlations between self-report and physiologic measures. Developing reliably associated self-report and physiologic sleep measures can optimize data collection methods. Purpose: Investigate correlations between self-reported and physiologic sleep measures in cardiac rehabilitation patients and determine associations with fatigue. Methods: Participants (N = 25, 58% male, 89% non-Hispanic white, mean age = 61 years) recruited from cardiac rehabilitation centers participated in a three-arm RCT. Inclusion criteria were experiencing a myocardial infarction or revascularization procedure, enrollment in cardiac rehabilitation, and experiencing depression or anxiety. Participants without complete sleep measures were excluded. Data was collected at baseline, 3-, and 6-months. Sleep was measured over 8 days with an investigator-developed self-report diary and an ActiGraph GT9X Link accelerometer. ActiGraphs collected data with a 30Hz sampling rate and were scored using the autodetected sleep periods to determine total sleep time. Mean daily minutes of sleep were calculated from self-report and ActiGraph data. Participants also completed a demographics survey and Fatigue Severity Scale. Statistical methods included Pearson correlation coefficients with 95% confidence intervals (CI) estimated with Fisher's r-to-z transformation. Results: Results showed self-reported and ActiGraph measured sleep were highly correlated (r = 0.889, [95% CI 0.812, 0.935], p < 0.001). Fatigue was not correlated with self-reported (r = 0.074, [95% CI -0.206, 0.342] p = 0.607) or ActiGraph measured sleep (r = 0.150, [95% CI -0.131, 0.408] p = 0.295). Even though the finding was non-significant, the correlation between fatigue and ActiGraph measured sleep was larger than self-reported sleep. Conclusion: Accurate sleep measures are essential to inform future research and interventions. Unlike past work, this investigator-developed, self-report measure was strongly correlated with the physiologic measure. Researchers should consider reliability when selecting sleep measures.

Abstract 18081: Using Evidence-Based Strategies, Including Coverage of Home-Based Cardiac Rehabilitation, to Increase Participation in Cardiac Rehabilitation - A Community Health Plan’s Experience

Introduction: Barriers to referral, enrollment and participation in cardiac rehabilitation (CR) contribute to low rates of completion despite known benefits. Barriers are system, provider and patient related. We sought to examine the impact a non-integrated community health plan can have on addressing these barriers, given the absence of formal studies evaluating its impact. Hypothesis: Implementing evidence-based strategies would increase CR participation. Methods: Between October 2019-October 2022, The Capital District Physicians’ Health Plan (CDPHP) developed and implemented an enhanced cardiac rehabilitation initiative (ECRI) to increase CR rates using evidence-based strategies. CDPHP: 1) eliminated patient cost-share, 2) covered home-based cardiac rehabilitation (HBCR), 3) implemented physician valued-based incentives, 4) presented metrics to providers, 5) educated providers and patients, and 6) dedicated staff to facilitating enrollment. CR rates were evaluated between Q2 2021 and Q2 2022. Results: Time from ECRI program conception to implementation was 18 months. Enrollment in HBCR went from 4% (19/485) (Q2, 2021) to 7.8% (33/422) (Q2, 2022). Enrollment in center-based cardiac rehab (CBCR) went from 11% (53/485) to 11.4% (48/422) respectively. Total enrollment in CR increased from 14.8% (72/485) to 19.2% (81/422). Conclusions: The ECRI created a call-to-action among providers to address modifiable barriers such as patient identification for CR and referral and enrollment processes. The introduction of HBCR increased CR rates and were additive to CBCR rates, suggesting the introduction of HBCR can increase CR rates and not displace CBCR. Increasing CR engagement and amplifying the results found in this demonstration, requires coordinated effort from all stakeholders-cardiology providers, hospitals, CR providers and health plans.

Abstract 15107: Dramatic Impact of a Liaison-Mediated Referral Strategy on Cardiac Rehabilitation Participation After Percutaneous Coronary Intervention: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

Background: While cardiac rehabilitation (CR) improves outcomes after percutaneous coronary intervention (PCI) it remains underutilized. A liaison-mediated referral, where a healthcare professional explains CR’s benefits and places a referral before discharge, may promote CR use. Hypothesis: We hypothesize a liaison-mediated CR referral is associated with greater CR participation after PCI. Methods: This was a retrospective cohort study of patients who underwent PCI across 48 hospitals in Michigan between January 2021 and April 2022 and were referred to CR before discharge. Clinical registry data was linked to Medicare and commercial claims to identify the primary outcome of CR participation, defined as attending ≥1 CR session within 90 days of discharge from the index PCI admission. Bayesian hierarchical logistic regression modeling was used to compare CR participation between patients with and without a liaison referral, adjusting for patient characteristics. Cox-proportional hazard modeling was used to compare days elapsed between discharge and first CR session between liaison cohorts. Results: Among 9,023 patients referred to CR after PCI, 4,323 (47.9%) underwent a liaison referral and 3,390 (37.6%) attended ≥1 CR session within 90 days of discharge. The liaison and non-liaison cohorts had a mean age of 69.3 vs 69.4 years, and 68.3% vs 68.4% were male, respectively. The liaison cohort had a higher unadjusted 90-day CR participation rate compared with the non-liaison cohort (Figure). After adjustment, the liaison cohort had a significantly higher odds of attending ≥1 CR session and a shorter delay in attending the first session compared with the non-liaison cohort (28 vs 33 days, p<0.001) (Figure). Conclusion: A liaison-mediated CR referral is associated with higher odds of post-PCI CR participation and may mitigate delays in CR enrollment. This may be an effective referral strategy to improve CR participation rates and patient outcomes after PCI.

Abstract 16761: Preprocedural Frailty is Associated With Lower Cardiac Rehabilitation Use Despite Greater Benefit

Introduction: Increased frailty before cardiovascular procedures is associated with poorer outcomes. While underutilized, cardiac rehabilitation (CR) is guideline-recommended for patients undergoing cardiovascular procedures and may help mitigate frailty through individualized, monitored exercise and risk factor reduction. Research Question/Hypothesis: Evaluate the relationship between preprocedural frailty, CR use, and one-year mortality. Methods: Medicare fee-for-service claims data were queried for patients who underwent inpatient percutaneous or surgical revascularization or aortic valve replacement between July 2016 and December 2018. Patients were stratified into quartiles (Q1 through Q4) using the validated claims-based frailty index. CR use was defined as attending any CR session within one year of discharge. Unadjusted and adjusted logistic regression was used to compare CR use across increasing frailty quartiles, and inverse probability treatment weighting was used to evaluate the effect of CR on one-year mortality across frailty quartiles. Results: Overall CR enrollment among the 570,851 beneficiaries was 35.3%; increasing frailty was associated with decreased CR use (unadjusted: frailty Q1: 48.3% vs Q4: 20.6%, p<0.001; adjusted OR: 0.61, p<0.001). Unadjusted one-year mortality was lower among CR users as opposed to non-users (2.7% vs 14.6%). After weighted adjustment, the absolute reduction in mortality associated with CR use was greater among frailer patients (Q4: -12.2%) relative to less frail patients (Q1: -2.9%) (Figure). Significant interaction effects between CR use and frailty quartiles indicated stronger associations of CR on mortality among more frail patients. Conclusions: Preprocedural frailty was associated with lower CR use despite greater absolute benefits on one-year mortality. Increasing CR enrollment in frail patients may enhance outcomes after cardiac interventions.

Race or ethnicity and education in cardiac rehabilitation enrollment

BackgroundAlthough cardiac rehabilitation (CR) has established benefits for cardiovascular health, it remains significantly underutilized, with substantial differences in participation related to factors such as educational attainment (EA), race, and ethnicity. We studied a geographically and racially diverse cohort of insured individuals in a health claims database to (1) evaluate differences in CR participation by EA and race or ethnicity and (2) assess how EA modifies associations between race or ethnicity and CR participation. MethodsWe conducted a retrospective cohort study of individuals identified in Optum's de-identified Clinformatics® database between 1/1/2016 and 12/31/2019. Eligible individuals included those aged ≥18 years with a hospitalization for an incident CR-qualifying diagnosis. We calculated incidence rates of CR enrollment by EA and race or ethnicity, as well as associations of EA and race or ethnicity with CR enrollment, and evaluated interaction between EA and race or ethnicity with respect to CR participation. ResultsWe identified 171,297 individuals eligible for CR with a mean ± SD age of 70.4 ± 11.6 years; 37.4 % were female, and 68.3 % had >high school education. We observed a dose-response association between EA and rate of participation in CR. After adjustment, compared to White individuals, the odds of attending CR was 24 % lower for Asian individuals [95 % confidence interval (CI): 17 %, 30 %], 13 % lower for Black individuals (95 % CI: 9 %, 17 %), and 32 % lower for Hispanic individuals (95 % CI: 28 %, 35 %), all p < 0.0001. However, Black individuals with ≥bachelor's degree had a similar odds of CR enrollment as White individuals with ≥bachelor's degree (odds ratio 1.01, 95 % CI: 0.85, 1.20, p = 0.95). ConclusionsEA was positively associated with CR enrollment across racial and ethnic groups. Higher EA might partially attenuate racial and ethnic differences in CR participation, but significant disparities persist. Our findings support increased attention to individuals with limited education to improve CR enrollment.

Lower Cardiac Rehabilitation Enrolment Occurs in Acute Coronary Syndrome Patients who have Less Physical Activity: A Prospective Observational Study Using Wearable Activity Tracker Data

Lower Cardiac Rehabilitation Enrolment Occurs in Acute Coronary Syndrome Patients who have Less Physical Activity: A Prospective Observational Study Using Wearable Activity Tracker Data

Individualized exercise prescription and cardiac rehabilitation following a spontaneous coronary artery dissection or aortic dissection.

Prescribed aerobic-based exercise training is a low-risk fundamental component of cardiac rehabilitation (CR). Secondary prevention therapeutic strategies following a spontaneous coronary artery dissection (SCAD) or aortic dissection (AD) should include CR. Current exercise guidance for post-dissection patients recommends fundamental training components including target heart rate zones are not warranted. Omitting fundamental elements from exercise prescriptions risks safety and makes it challenging for both clinicians and patients to understand and implement recommendations in real-world practice. We review the principles of exercise prescription for CR, focusing on translating guidelines and evidence from well-studied high-risk CR populations to support the recommendation that exercise testing and individualized exercise prescription are important for patients following a dissection. When patients self-perceive exercise intensity there is a tendency to underestimate intensities within metabolic domains that should be strictly avoided during routine exercise training following a dissection. However, exercise testing associated with CR enrolment has gained support and has not been linked to adverse events in optimally medicated post-dissection patients. Graded heart rate and blood pressure responses recorded throughout exercise testing provide key information for developing an exercise prescription. An exercise prescription that is reflective of medical history, medications, and cardiorespiratory fitness optimizes patient safety and yields improvements in blood pressure control and cardiorespiratory fitness, among other benefits. This clinical practice and education article demonstrates how to develop and manage a CR exercise prescription for post-acute dissection patients that can be safe and effective for maintaining blood pressure control and improving cardiorespiratory fitness pre-post CR.

Abstract 12019: Educational Attainment is Associated With Cardiac Rehabilitation Enrollment

Introduction: Cardiac rehabilitation (CR) remains significantly underutilized. We examined the association of educational attainment (EA) with CR enrollment in a health claims database, hypothesizing that individuals with lower EA would be less likely to participate in CR. Methods: We employed an administrative database (Optum de-identified Clinformatics® Data Mart) to select individuals with incident events indicating CR eligibility from 2016-2018. We collected demographics (age, sex, race and ethnicity); comorbid conditions (hypertension, diabetes, stroke and those defined by the Elixhauser Comorbidity Index); household income; and CR qualifying event. In multivariable-adjusted logistic regression, we related EA (≤high school diploma; &gt;high school diploma and &lt;bachelor’s degree; ≥bachelor’s degree) to CR enrollment. We examined the association of EA and CR enrollment by race or ethnicity strata. Results: In 121,598 individuals eligible for CR, those with lower EA had lower odds of CR participation. Individuals with ≤high school diploma had 39% lower odds (95% Confidence Interval [CI] (35-42%) of enrolling in CR compared to those with ≥bachelor’s degree. The association of lower odds of CR enrollment with lower levels of EA persisted across racial and ethnic strata ( Figure ). Black individuals with ≥bachelor’s degree had similar odds of CR enrollment as White individuals with the same level of education (Odds Ratio [OR] 0.95, 95% CI 0.77-1.17). Hispanic (OR 0.26, 95% CI 0.23-0.28) and Asian individuals with ≤high school diploma (OR 0.25, 95% CI 0.19-0.33) had the lowest odds of CR enrollment compared with White individuals with ≥bachelor’s degree. Conclusions: We identified associations between EA and CR enrollment persisting across racial and ethnic strata. Our findings support increased attention to individuals with limited education to improve CR enrollment.

Abstract 13536: Cardiac Rehabilitation Enrollment Among Medicare Beneficiaries: Surgical Hospitals Play a Critical Role!

Introduction: Hospitalization for myocardial infarction (MI), percutaneous coronary intervention (PCI), or cardiac surgery [coronary artery bypass surgery (CABG) or valve surgery] represents a key opportunity to refer and recruit eligible patients to cardiac rehabilitation (CR.) However, little is known about how hospitals influence CR enrollment at the national level. Methods: Using Medicare fee-for-service claims from 2017, we identified all patients with a principal discharge diagnosis of MI, PCI, CABG, or valve surgery. We defined CR enrollment as attending ≥ 1 session within 90 days and calculated hospital-specific CR enrollment rates. To assure stability of our statistical results, we limited our sample to hospitals where cardiac surgery was performed, and then examined the association between patient demographics, procedures, comorbidities, and hospital characteristics on CR enrollment using mixed effects hierarchical logistic regression. We calculated the median odds ratio (MOR) to estimate the extent to which the hospital where a patient was cared for influenced their chance of enrolling in CR. Results: At 3,420 hospitals, we identified a total of 264,970 eligible patients (age 77 ± 8 yrs., 58% male, 85% white, 39% surgical), of which 25% attended CR. While a minority (38%) of hospitals performed cardiac surgery - these hospitals cared for the vast majority (92%) of all eligible patients. At these hospitals, the median CR enrollment rate was low (22%) and varied 10-fold across hospitals at the 10 th and 90 th percentiles (3%, 42%). After multivariable adjustment, the factors most associated with CR enrollment were having cardiac surgery or undergoing PCI (OR 5.8, 2.6 vs. MI respectively), advancing age (OR 0.77 per 5-year increase), low socioeconomic status (OR 0.33), smoking (OR 0.59), or living in the Midwest (OR 2.3 vs. South), p &lt;0.001 for all. The hospital MOR was 2.1, similar in effect size to PCI or Midwest location. Conclusions: In this large national study of older adults, participation rates in CR were low, and the hospital where patients receive their care was strongly associated with CR enrollment. As surgical hospitals care for the majority of all eligible patients, they appear to be the most logical place to focus improvement efforts.

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.

Clinical determinants and barriers to cardiac rehabilitation enrolment of patients with heart failure with reduced ejection fraction

Abstract Introduction Cardiac rehabilitation (CR) is a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF). Despite the robust evidence supporting its safety and benefits, there is an incomplete understanding of the reasons of the underutilization of CR programs in HFrEF. These reasons are complex and probably encompass healthcare system- and patient-level barriers. Purpose To study the clinical determinants and barriers to enrolment in a CR program for HFrEF patients. Methods We conducted a study of consecutive heart failure patients followed at a dedicated HFrEF cardiology clinic from January 2019 to April 2021. Patients were divided according to previous enrolment in CR program. Data were collected from electronic health records, and in case of missing data patients were asked by telephone about the reason for not participating in CR using a structured and validated questionnaire for this purpose. Results Of 228 patients with HFrEF, 60% had not been enrolled in a CR program; they were older (63 vs 58 years; p&amp;lt;0.01) and more likely to have comorbidities such as hypertension (56% vs 41%; p=0.03) or concomitant chronic obstructive pulmonary disease (20% vs 8%; p=0.01). Conversely, patients enrolled in CR programs were more likely to have a previous history of acute myocardial infarction (34% vs 20%; p=0.02). Regarding heart failure-related clinical features (NYHA functional class, LVEF, ICD/CRT), we did not find any significant differences between groups. The main reasons for not being enrolled in CR programs were: no medical referral (31%), concomitant medical problems (27%) such as musculoskeletal problems, patient refusal (11%) and geographical distance to the hospital (9%). Conclusion Despite the high proportion (40%) of HFrEF patients who underwent CR program compared to previous studies, the enrolment to CR can be further improved. The main barriers are related to health professionals (no referral), healthcare system (geographical distance to the hospital) and patients (concomitant noncardiac problems). Innovative strategies should target these factors to increase the delivery of CR program in HFrEF. Funding Acknowledgement Type of funding sources: None.

Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK.

Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation. Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement. A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.

Weight Loss and Its Predictors During Participation in Cardiac Rehabilitation

We aimed to assess the prevalence and magnitude of clinically meaningful weight loss among cardiac rehabilitation (CR) participants who were overweight or obese and identify its predictors. We analyzed subjects with body mass index (BMI) ≥25 who were enrolled in a 12-week CR outpatient program from January 1, 2015, to December 31, 2019, and had paired pre- and post-CR weight data. Patients who lost 3% or more of their body weight by the end of the program were compared with the remaining participants. Multivariable logistic regression was used to determine predictors of weight loss. Overall, 129 of 485 subjects (27%) with overweight or obesity reduced their weight by at least 3% (average percent weight change: -5.0% ± 1.8% vs -0.02% ± 2.2%, average weight change: -10.9 ± 5.0 vs -0.1 ± 4.4 pounds, and average BMI change: -1.7 ± 0.7 vs -0.02 ± 0.7 kg/m²). Compared with the remaining 356 patients, those who achieved the defined weight loss were younger (p=0.016) and had higher baseline weight (p=0.002) and BMI (p &lt;0.001). The weight loss group tended to be enrolled more likely for an acute myocardial infarction or percutaneous coronary intervention (p &lt;0.001) and less likely for coronary artery bypass grafting (p=0.001) or a heart valve procedure (p=0.05). By the end of the CR program, the weight loss group demonstrated a greater increase in Rate Your Plate - Heart score (7 [3, 11] vs 4 [1, 8]; p &lt;0.001) and a greater decrease in triglycerides (-20 ± 45 vs -7 ± 55 mg/dL; p=0.026) and glycated hemoglobin (-0.1 [-0.5, 0.1] vs 0.1 [-0.3, 0.4] %; p=0.05, among patients with diabetes or prediabetes). In a multivariable logistic regression model, baseline predictors of clinically meaningful weight loss included higher BMI and not being enrolled for a surgical CR indication (p=0.001). In conclusion, throughout 12 weeks of CR participation, 129 of 485 subjects (27%) with BMI ≥25 had a 3% or more reduction in body weight. Patients with higher baseline BMI and participants without a surgical enrollment diagnosis were more likely to achieve the defined weight loss. Efforts to improve CR referral and enrollment for eligible patients with overweight and obesity should be encouraged, and suitable and efficient weight reduction interventions in CR settings need to be further studied.

Meta-Analysis of Antidepressant Pharmacotherapy in Patients Eligible for Cardiac Rehabilitation: ANTIDEPRESSANT AMBIVALENCE.

Many patients exhibit clinically significant depression upon enrollment in cardiac rehabilitation (CR). Antidepressants are a first-line treatment option for depression, but the effectiveness of antidepressants in patients with heart disease is mixed. The purpose of this meta-analysis was to evaluate the efficacy of antidepressants for depression in patients eligible for CR. A meta-analysis was conducted including randomized controlled trials of antidepressants from January 1990 to September 2021 that compared antidepressants with placebo. Random-effects models were used between group effect sizes (Hedges' g ). A total of 13 trials with predominately White (68% ± 12; n =7) male (70% ± 11) samples averaging 61 ± 5 yr compared antidepressants (1128 participants) with placebo (1079 participants). Antidepressants reduced depressive symptoms ( g = 0.17: 95% CI, 0.08-0.27), but the effect was small. Heterogeneity among study effects was low ( I2 = 6.42) and nonsignificant ( Q = 10.75, P = .46), although patients with heart failure ( gHF = 0.05: 95% CI, -0.09 to 0.18) demonstrated smaller effects compared with patients with other cardiovascular disease conditions (g non-HF = 0.22: 95% CI, 0.11-0.32) ( QB [1] = 3.97; P &lt; .05). No study reported safety concerns associated with antidepressants. The effect size of antidepressant pharmacotherapy in this population is small. No trials reported on the combined effects of exercise and pharmacotherapy. If the patient is not suicidal, CR staff may consider patient preference and refer patients for additional treatment as necessary.

Trends in cardiac rehabilitation enrollment post-coronary artery bypass grafting upon implementation of automatic referral in Southeast Asia: A retrospective cohort study.

Introduction: Cardiac rehabilitation (CR) is an effective but underutilized intervention. Strategies have been identified to increase its use, but there is paucity of data testing them in low-resource settings. We sought to determine the effect of automatic referral post-coronary artery bypass graft (CABG) surgery on CR enrollment. Methods: This is a retrospective cohort study assessing cardiac patients referred to CR at a tertiary center in Southeast Asia from 2013 to 2019. The paper-based pathway was introduced at the end of 2012. The checklist with automatic CR referral on the third day post-operation prompted a nurse to educate the patient about CR, initiate phase 1 and encourage enrollment in phase 2. Patients who were not eligible for the pathway for administrative or clinical reasons were referred at the discretion of the attending physician (i.e., usual care). Enrollment was defined as attendance at≥1 CR visit.Results: Of 4792 patients referred during the study period, 394 enrolled in CR. Significantly more patients referred automatically enrolled compared to usual care (225 [11.8%] vs. 169 [5.8%]; OR=2.2, 95% CI=1.8-2.7), with increases up to 23.4% enrollment in 2014 (vs. average enrollment rate of 5.9% under usual referral). Patients who enrolled following automatic referral were significantly younger and more often employed (both P<0.001); no other differences were observed.Conclusion: In a lower-resource, Southeast Asian setting, automatic CR referral is associated with over two times greater enrollment in phase 2 CR, although efforts to maintain this effect are required.

Quality of life following cardiac rehabilitation in cardiac surgery patients

BackgroundUndergoing cardiac surgery often result in perioperative loss of health-related quality of life (HRQOL). Although participation rates in Australia is low, cardiac rehabilitation (CR) has been demonstrated to improve patient HRQOL in cardiac patients. Literature is unclear regarding the role of CR and HRQOL in the cardiac surgery (CS) patient population.MethodsA prospective non-randomised study was conducted on eligible cardiac surgery patients between December 2009 and March 2015. HRQOL was assessed using the Short Form 12 at baseline and post-operatively at 30 days and 180 days. CR participation was recorded and barriers to CR uptake was assessed using the Cardiac Rehabilitation Enrolment Obstacles (CREO) scale.ResultsAt 180 days, 107 patients participated in CR and 111 did not participate in CR. A significant improvement from baseline mental and physical HRQOL was observed in both groups at 30 days and 180 days (p < 0.002). No significant difference between group characteristics or HRQOL was observed at any time. A trend of superior improvement in mental QOL was observed in the CR group. The study is limited by poor initial uptake (218/1772 of eligible) and may be underpowered to observe a clinical difference. A significant difference in CREO scores were observed between the two groups at 30 days (13 out of 16 questions, p < 0.001) and 180 days (11 out of 16 questions, p < 0.011).ConclusionLiterature has shown that CR may improve numerous health outcomes in cardiac and CS patients, however CR uptake in Australia is low. Mental and Physical QOL is demonstrated to improve following CS, however further research is required to delineate the role of CR and QOL in CS patients. The CREO tool utilised in this study identified numerous potentially modifiable barriers to CR uptake. Specific strategies related to the survey are suggested to improve awareness, uptake, and adherence to CR, including advocacy of home-based and telehealth services.