Cardiac Rehabilitation Referral Research Articles

Improving Cardiac Rehabilitation Referral Rates in Patients with Coronary Heart Disease from Diverse Communities Using an Electronic Order System

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 < 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.

Increasing Access to Cardiac Rehabilitation Services Among Disadvantaged Populations.

The Prince George's County Health Department encountered several challenges to increasing access to cardiac rehabilitation (CR) services among disadvantaged populations. They include excessive patient out-of-pocket costs; requirements that CR orders must be signed by a physician; provider reluctance to refer patients to CR, with most primary care providers preferring to refer clients to cardiologists for the latter to determine whether the patient needs CR referral; limited availability of CR programs; and difficulty identifying patients eligible for CR services. Discussions with other local health departments and public health practitioners indicate that these challenges are not unique to Maryland but are indicative of policy and system barriers that prevent the optimal delivery of cardiovascular health services. This practice report documents the challenges and the Prince George's County Health Department's efforts to resolve them and provides recommendations for decision-makers seeking to make CR programs more accessible to disadvantaged populations.

Improved Cardiac Rehabilitation Referral Rate Utilizing a Multidisciplinary Quality Improvement Team.

Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.

Nurse-Led Cardiac Rehabilitation Care Coordination Program: Improving Functional Outcomes for Patients Through Automatic Referral and Effective Care Coordination.

The aim of this investigation was to evaluate the impact of automated cardiac rehabilitation (CR) referral and nurse care coordination on patient and program outcomes. Specifically, the aim was to identify whether differences exist in physical and psychological function at CR Phase 2 enrollment and completion and CR Phase 2 participation and completion for hospitalized patients who receive in-person CR nurse visits versus phone consultation. Using a retrospective pre-/post-intervention descriptive design, a purposive sampling technique was used to select groups with matching clinical attributes. Dates were selected to mitigate the impact of COVID-19 on CR program enrollment and completion. Data were abstracted from the patient electronic medical record, telemetry documentation, and CR referral tracking tool. Patient descriptors included age, sex, cardiac diagnosis/procedure (post-coronary artery bypass graft surgery, myocardial infarction, percutaneous coronary intervention, heart failure, and aortic valve repair and replacement) and cardiac risk stratification category. Patient functional outcomes included the 6-min walk test and metabolic equivalents of task levels for functional capacity; psychological function was measured by the Patient Health Questionnaire assessment. Program outcomes included discharge to CR Phase 2 enrollment, CR sessions, and completion. Each group had 52 patients. Age was 64 ± 12yr, 68% were male. Perhaps indications for CR included coronary artery bypass graft surgery (44%), myocardial infarction (19%), percutaneous coronary intervention (20%), heart failure (10%), aortic valve repair and replacement (8%). Cardiac risk was low in 30%, intermediate in 65%, and high in 5%. The post-intervention group compared with the pre-intervention group had a shorter discharge to CR Phase 2 enrollment (35 ± 18 d vs 41 ± 28 d, P = .078) and significantly fewer sessions required for CR completion. Automated CR referral and nurse care coordination visits for hospitalized patients decreased the transition period between CR Phase 1 and 2. Patients were physically and psychologically prepared for earlier CR Phase 2 enrollment and successfully completed the program in fewer days than the pre-intervention group.

Abstract P165: Home- and Center-Based Cardiac Rehabilitation Utilization Among Adults With Heart Failure in Kaiser Permanente Southern California

Background: Cardiac rehabilitation (CR) is guideline-recommended for patients with chronic, stable heart failure (HF). Despite benefits in reducing the risk of outcomes and improved quality of life, referrals to and participation in CR are low. This study describes sociodemographic variability in referrals and participation in center-based CR (CBCR) and home-based CR (HBCR) among adults with HF in Kaiser Permanente Southern California. Methods: Adults ≥ 18 years of age with a history of HF, who were eligible for CR referral between April 2018 and April 2019 were identified. HF was defined using diagnosis codes and required to occur ≤ 30 days prior to their first CR session. Participation was defined as completing ≥ 1 session. Sociodemographics and comorbidities were described across four mutually exclusive groups: (1) no referral, (2) referral and non-participation, (3) participation in CBCR and (4) participation in HBCR. Results: Among 7,801 adults with HF eligible for CR, the mean age was 74 years, with the majority male (58%), non-Hispanic white (50%), and English-speaking (90%), and having high burden of comorbidities including atrial fibrillation (50%), chronic kidney disease (49%), and hypertension (82%). (Table) Only 326 (4%) adults received a referral for CR, with 128 (39%) not participating, 97 (30%) participating in CBCR, and 101 (31%) participating in HBCR. Those not receiving a CR referral had the highest proportion of older individuals and comorbidities. Those referred to CR but who did not participate were most likely to be male (70%) and single (16%). Household income was highest among those participating in CBCR and HBCR ($83,000 and $80,000, respectively, compared with overall median $77,000) but this was not statistically significant. Conclusion: Less than 5% of eligible HF patients were referred to CR and variability by age, income, marital status, and comorbidities were noted for referrals and participation. Reducing disparities in CR utilization may improve outcomes in this high-risk group.

Regional and temporal variations of spontaneous coronary artery dissection care according to consensus recommendations: a systematic review and meta-analysis

AimThe first expert consensus documents on management of patients with spontaneous coronary artery dissection (SCAD) were published in 2018. Worldwide quality of care, as measured by adherence to these recommendations,...

Quality-of-care for patients with spontaneous coronary artery dissection- a systematic review and meta-analysis

Abstract Introduction In 2018 the first consensus documents to guide investigation and treatment of spontaneous coronary artery dissection (SCAD) were published. The global quality-of-care of patients with SCAD, as measured by adherence to these recommendations, has not been systematically reviewed. Purpose We aimed to evaluate the quality-of-care, measured by adherence to five recommendations from the 2018 consensus statement [antiplatelets, beta-blockers, angiotensin converting enzyme inhibitors or aldosterone receptor blockers (ACEI/ARBs) in patients with left ventricular systolic dysfunction, screening for fibromuscular dysplasia (FMD) and referral to cardiac rehabilitation] in patients with SCAD. Secondary aims were to explore the relationship of high versus low guideline-recommendation adherence with major adverse cardiovascular events (MACE). Methods Four databases (MEDLINE, EMBASE, SCOPUS, CINAHL) were systematically searched from inception to 16th June 2022. Studies reporting any cohort of 11 or more patients with SCAD that included results of at least one consensus-recommendations were included. The proportion of patients receiving each of the treatments were analysed by random effects meta-analysis. Associations were assessed using meta-regression analysis. Results 54 studies, n=8456 patients (mean age 50.1 years, 89.5% female) were included in the analysis. A random effects meta-analysis found, 94.5% [95% confidence interval (CI): 90.8,97.7)\] received at least one antiplatelet, 78% (CI: 74.2,82.7) received beta-blockers, 54.6% (CI:42.0,66.6) were screened for FMD and 70.5% (CI: 62.6,77.3) were referred to cardiac rehabilitation. 59.3% (CI: 53.1,65.3) received ACEI/ARBs with left ventricular ejection fraction not reported in most studies. A single North American cohort reported 30% of patients met all four recommendations. There was significant heterogeneity in quality-of-care parameters, except for cardiac rehabilitation, according to geographic region (test of heterogeneity, p<0.001). No significant difference was observed in adherence to recommendations in studies published before and after the consensus documents publication (2018), except for lower cardiac rehabilitation referrals after 2018 (test of heterogeneity, p=0.006). There was no association between antiplatelet or beta-blocker use or FMD screening and follow-up MACE. Higher adherence to ACEI/ARBs was associated with lower MACE (p=0.02). Conclusion Adherence to consensus recommendations for care of patients with SCAD is far from perfect and varies significantly between regions of the world. Raising awareness among clinicians about consensus recommendations for care, combined with better evidence on treatment that can reduce MACE in patients with SCAD, are urgently needed.

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.

Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation

BackgroundWomen are less likely than men to use cardiac rehabilitation (CR); thus, women-focused (W-F) CR was developed. Implementation of W-F CR globally was investigated, as well as barriers and enablers to its delivery. MethodsIn this cross-sectional study, a survey was administered to CR programs via Research Electronic Data Capture (REDCap) from May to July, 2023. Potential respondents were identified via the International Council of Cardiovascular Prevention and Rehabilitation’s network. ResultsA total of 223 responses were received from 52 of 111 countries (46.8% country response rate) in the world that have any CR, across all 6 World Health Organization regions. Thirty-three programs (14.8%) from 30 countries reported offering any W-F programming. Programs commonly did offer elements preferred by women and recommended, namely, the following: patient choice of session time (n = 151; 70.6%); invitations for informal care providers and/or partners to attend sessions (n = 121; 57.1%); CR staff that have expertise in women and heart diseases (n = 112; 53.3%); separate changerooms for women (n = 38; 52.8%); and discussion of CR referral with patients (n = 112; 52.1%). Main barriers to delivery of W-F exercise were physical resources (n = 33; 14.8%), space (n = 30; 13.5%), and staff time (n = 26; 11.7%) and expertise (n = 33; 10.3%). Main barriers to delivery of W-F education were human resources (n = 114; 51.1%), educational resources (n = 26; 11.7%), and expertise in the content (n = 74; 33.2%). Enablers of W-F education delivery were availability of materials, in multiple modalities, as well as educated staff and financial resources. ConclusionsDespite the benefits, W-F CR is not commonly offered globally. Considering the barriers and enablers identified, the International Council of Cardiovascular Prevention and Rehabilitation is developing resources to expand delivery.

Prevalence and impact of cognitive impairment assessed by Mini-Cog in hospitalized cardiac rehabilitation referrals

Introduction and objectivesEvaluate patients referred for cardiac rehabilitation to determine the prevalence of cognitive impairment (CI) and compare readmission rates and mortality for those with and without CI. MethodsPatients were retrospectively divided into cohort A (Mini-Cog completed) and cohort B (Mini-Cog not completed). Cohort A was then divided into A1 (Mini-Cog positive for CI) and A2 (Mini-Cog negative for CI). ResultsOf 1440 patients, 986 (68%) completed the Mini-Cog (cohort A) and 454 (32%) patients did not (cohort B). Within cohort A, 46 (4.7%) had a positive Mini-Cog (cohort A1) and 940 (95.3%) had a negative Mini-Cog (cohort A2). Cohort A1 had significantly higher rates of all-cause readmission compared with cohorts A2 and B (63% vs 44% and 47%; P=.02), and significantly higher mortality (28% vs 9% vs 15%; P<.001), but was also significantly older, with more co-morbidities. After accounting for demographic and co-morbidity differences between cohorts A1 and A2 using propensity score matching and Cox proportional hazards model, cohort A1 had significantly increased rates of the composite outcome of readmission and/or death at 3-months (P=.002). ConclusionsPoor performance on the Mini-Cog identified an older group of phase I cardiac rehabilitation patients that had significantly increased rates of the combined end-point of readmission plus death.

Patterns of Referral and Postdischarge Utilization of Cardiac Rehabilitation Among Patients Hospitalized With Heart Failure: An Analysis From the GWTG-HF Registry.

Coverage for cardiac rehabilitation (CR) for patients with heart failure with reduced ejection fraction was expanded in 2014, but contemporary referral and participation rates remain unknown. Patients hospitalized for heart failure with reduced ejection fraction (≤35%) in the American Heart Association Get With The Guidelines-Heart Failure registry from 2010 to 2020 were included, and CR referral status was described as yes, no, or not captured. Temporal trends in CR referral were assessed in the overall cohort. Patient and hospital-level predictors of CR referral were assessed using multivariable-adjusted logistic regression models. Additionally, CR referral and proportional utilization of CR within 1-year of referral were evaluated among patients aged >65 years with available Medicare administrative claims data who were clinically stable for 6-weeks postdischarge. Finally, the association of CR referral with the risk of 1-year death and readmission was evaluated using multivariable-adjusted Cox models. Of 69,441 patients with heart failure with reduced ejection fraction who were eligible for CR (median age 67 years; 33% women; 30% Black), 17,076 (24.6%) were referred to CR, and referral rates increased from 8.1% in 2010 to 24.1% in 2020 (Ptrend<0.001). Of 8310 patients with Medicare who remained clinically stable 6-weeks after discharge, the CR referral rate was 25.8%, and utilization of CR among referred patients was 4.1% (mean sessions attended: 6.7). Patients not referred were more likely to be older, of Black race, and with a higher burden of comorbidities. In adjusted analysis, eligible patients with heart failure with reduced ejection fraction who were referred to CR (versus not referred) had a lower risk of 1-year death (hazard ratio, 0.84 [95% CI, 0.70-1.00]; P=0.049) without significant differences in 1-year readmission. CR referral rates have increased from 2010 to 2020. However, only 1 in 4 patients are referred to CR. Among eligible patients who received CR referral, participation was low, with <1 of 20 participating in CR.

Uptake of Cardiac Rehabilitation in Te Whatu Ora – Counties Manukau During the Pandemic

Cardiac rehabilitation (CR) is an evidence-based range of interventions to support people with several cardiac issues. The impact of the COVID-19 pandemic created many challenges for health services and communities. Using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZAC-QI) CR database this study tracked referral, mode, and level of engagement from 2013 to 2023. Over 10 years, 9,134 referrals were identified, with a steadily decreasing number every year (1,040 in 2023 vs 672 in 2022; 35% decrease). The majority (70%) was male; mean age for males was 66 years, for females 67 years; and ethnicity was Māori 12%, Pacific 25%, Indian 12%, others 51%. Attendance of any program was 71%, with a 600% increase in clinics vs group interventions. The average uptake of the exercise program was 24%; Māori compared with Pacific and Euro/others (61% vs 71% vs 73%, p>0.001); and younger people (<60 years, 66% vs older >61 years, 73%, p>0.001) were least likely to attend, with no gender differences (male 71% vs Female 69%, p=NS). There has been a significant decline in CR referrals over the last 10 years, with a shift from group-based education to individualised clinic contacts. Uptake of exercise programs remains low. Novel interventions to support Māori and younger patients have been implemented.

International Registry of Cardiovascular diseases in Women (IROCW): Assessing the feasibility of large data registry in absence of funding and electronic database; initial data from Iraq

Abstract Funding Acknowledgements Type of funding sources: None. Background There is unmet need of sex focused registries to be the first step towards sex focused trials and guidelines. In Iraq due to absent electronic database and research funding, it is challenging to initiate long term cardiovascular registries. Also, for women patients follow up, it is challenging to contact them by male doctors due to cultural causes. Purpose IROCW aims to portrait the demographics focusing on sex-specific risk factors, presentation, in-hospital and 1-month outcomes of women admitted to cardiac centers or cardiology wards in general hospitals. Patients with any of the following diagnoses were included in the registry: IHD (ACS admitted to CCU or chronic coronary syndromes admitted for elective catheterization), arrhythmia, heart failure and valvular heart disease. Methods Under the Umbrella of Iraqi Scientific Council of Cardiology, a female interventional cardiologist was among leaders of the study, so, she enhanced the recruitment of female trainees besides male doctors to participate in data collection and patients follow up to bridge the cultural barriers. IROCW is a prospective, multicentre, cross-sectional study. Data collection using paper forms was done by investigators then data entry started and stopped after seven weeks to assess feasibility and reliability of data entry into google form that was designed for the registry. If the registry is feasible using paper forms and google form, then the next phase will be international and assessing 12-month cardiovascular outcomes (target number=10,000 patients; total number in all four arms of registry). Results n=150, mean age=60 years, 89.3% of patients reside in urban areas. Women were mostly married (67.8%) or widowed (25.5%). They were illiterate (47.3%) or having primary education (34.7%). 60% of women's family total income&amp;lt;500 USD. Most common risk factor was hypertension while menopause and gestational hypertension were most common sex-specific risk factors. In-hospital echocardiography was done in 26%. In-hospital heart failure was reported in 20% of patients. Aspirin, P2Y12 inhibitors, heparin, and statin were used in: 85.8%, 60.4%, 35.4% and 87.9% respectively. B-blockers, ACEI/ARBs and MRA were used in 71.1%, 62.8%, and 7.2% respectively. Dietary instructions as indicated on discharge was done properly in 96.6%, while smoking cessation counseling and referral for cardiac rehabilitation were not done properly. At 1-month follow up, patients were reachable in 91.5%. Conclusion Illiteracy and poor socio-economic status in women raise the importance of dedicated approach required for health education and care. Despite absent electronic data base and lack of research funding in Iraq, this study is feasible. The next international phase (Iraq and Sudan) will be initiated, so, data from LMIC from both Asia and Africa will be available to bridge knowledge gaps in CVD in women from these countries.

The Association Between Mobile App Use and Change in Functional Capacity Among Cardiac Rehabilitation Participants: Cohort Study

Cardiac rehabilitation (CR) is underused in the United States and globally, with participation disparities across gender, socioeconomic status, race, and ethnicities. The pandemic led to greater adoption of telehealth CR and mobile app use. Our primary objective was to estimate the association between CR mobile app use and change in functional capacity from enrollment to completion in patients participating in a CR program that offered in-person, hybrid, and telehealth CR. Our secondary objectives were to study the association between mobile app use and changes in blood pressure (BP) or program completion. We conducted a retrospective cohort study of participants enrolled in CR at an urban CR program in the United States. Participants were English speaking, at least 18 years of age, participated in the program between May 22, 2020, and May 21, 2022, and downloaded the CR mobile app. Mobile app use was quantified by number of exercise logs, vitals logs, and education material views. The primary outcome was change in functional capacity, measured by change in 6-minute walk distance (6MWD) from enrollment to completion. The secondary outcome was change in BP from enrollment to completion. We estimated associations using multivariable linear or logistic regression models adjusted for age, sex, race, ethnicity, socioeconomic status by ZIP code, insurance, and primary diagnosis for CR referral. A total of 107 participants (mean age 62.9, SD 13.02 years; 90/107, 84.1% male; and 57/105, 53.3% self-declared as White Caucasian) used the mobile app and completed the CR program. Participants had a mean 64.0 (SD 54.1) meter increase in 6MWD between enrollment and completion (P<.001). From enrollment to completion, participants with an elevated BP at baseline (≥130/80 mmHg) experienced a significant decrease in BP (systolic BP -11.5 mmHg; P=.002 and diastolic BP -7.7 mmHg; P=.003). We found no significant association between total app interactions and change in 6MWD (coefficient -0.03, 95% CI -0.1 to 0.07; P=.59) or change in BP (systolic coefficient 0.002, 95% CI -0.03 to 0.03; P=.87 and diastolic coefficient -0.005, 95% CI -0.03 to 0.02; P=.65). There was no significant association between total exercise logs and change in 6MWD (coefficient 0.1, 95% CI -0.3 to 0.4; P=.57) or total BP logs and change in BP (systolic coefficient -0.02, 95% CI -0.1 to 0.06; P=.63 and diastolic coefficient -0.02, 95% CI -0.09 to 0.04; P=.50). There was no significant association between total app interactions and completion of CR (adjusted odds ratio 1.00, 95% CI 0.99-1.01; P=.44). CR mobile app use as part of an in-person, hybrid, or telehealth CR program was not associated with greater improvement in functional capacity or BP or with program completion.

Evidence-Based Clinical Decision Support to Improve Care for Patients Hospitalized With Acute Myocardial Infarction.

Clinical decision support in the EHR is an innovation that can support guideline adherence in acute myocardial infarction. Cardiac rehabilitation referral and left ventricular systolic function assessment are part of evidence-based clinical practice guidelines associated with reduced morbidity and mortality following acute myocardial infarction. Effective clinical decision support is sustained by evidence-based principles for design and implementation. This quality improvement project evaluated the impact of practice advisories designed using principles of effective clinical decision support design to improve performance of left ventricular systolic function assessment and ambulatory referral to cardiac rehabilitation for patients hospitalized with acute myocardial infarction. Performance in cardiac rehabilitation referral and left ventricular systolic function assessment was measured for a 3-month interval pre- and post-intervention. Pre-implementation, cardiac rehabilitation referral or valid documented reason for non-referral was 80.3%. Rehabilitation referral or documented valid reason for non-referral increased to 98.4% post-implementation (P < .001). Left ventricular systolic function assessment increased from 94.2% to 100% following clinical decision support implementation (P = .120). This quality improvement project supports the positive impact of effective clinical decision support design and implementation to improve outcomes for patients hospitalized with acute myocardial infarction.

Socioeconomic Inequalities and Predictors of Cardiac Rehabilitation Referral: Real World Evidence.

To identify factors associated with CR referral following an acute coronary syndrome (ACS) at a university hospital. We analyzed 2,814 hospitalizations due to ACS between 2017 and 2019 in Centro Hospitalar São João. The hospital's morbidity database was used to retrieve patient information. CR referral and participation was identified from administrative databases and clinical records. Socioeconomic data was obtained from municipality of residence-level data rather than patient-specific data. Of 2,814 hospitalizations, 72% (2,028 cases) were eligible for CR. Mean age was 65.2 ± 13.4; 72% men, 33% diabetic, 57.1% hypertensive and 63.6% dyslipidemic. CR referral rate was low, at 18.8%, with 42 (11.0%) not attending CR and 39 (10.2%) dropping out. Females (odds ratio (OR): 0.72 (95% CI: 0.52-1.00), older patients (OR: 0.57 (0.42-0.77)); 55-64 years vs <55 years) and those coming from lower income municipalities (OR: 0.53 (0.41-0.69)), below median vs above median) with lower education level (OR: 0.70 (0.54-0,92); ≤ 4 years vs >4 years) were less likely to be referred to CR. There is a need for new strategies to promote CR in disadvantaged groups, as gender, age, and socioeconomic inequities in access to CR remain unresolved.

Advances, Challenges, and Progress in Cardiac Rehabilitation in Chronic CVD Management.

To review the benefits, challenges, and advances in cardiac rehabilitation (CR) in the management of cardiovascular disease (CVD). Novel strategies of delivering CR are being studied that use remote technologies to link patients with CR professionals. These strategies used alone or in tandem with center-based, face-to-face strategies appear to have shorter-term effectiveness, but additional work is needed to assess the longer-term impact. Cardiac rehabilitation improves patient outcomes, but only a minority of eligible individuals participate. Solutions exist to help bridge the barriers to CR participation, including systematic solutions, such as automatic CR referral of eligible patients. Efforts are underway to improve participation, improve the effectiveness of CR therapies, and enhance the reach of CR into new patient groups. Future work in the field is focused on opportunities to advance the science, practice, and policies that will shape and improve the delivery and impact of CR services.

Cardiovascular Rehabilitation Delivery and Outcomes in Switzerland in More Than a Hundred Thousand Patients Over the Last Decade.

Cardiovascular Rehabilitation Delivery and Outcomes in Switzerland in More Than a Hundred Thousand Patients Over the Last Decade.

Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey.

The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice. An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March-December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May-July 2021). Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR-exercise and education-were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support. Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations.

Evaluating the impact of the COVID-19 pandemic on the delivery and efficiency of cardiac rehabilitation.

The SARS-CoV-2 (COVID-19) pandemic brought disruption to cardiac rehabilitation (CR) services in the UK, requiring innovation and use of remote interventions. This retrospective longitudinal study compares single-centre CR service data across three time periods: 'pre' (June 2019 to December 2019), 'during' (January 2020 to May 2020) and 'post' (June 2020 to December 2020), evaluating adaptations in programme delivery and subsequent effect on efficiency. There were 614 patients (72.7% male) identified between June 2019 and December 2020. Eligible CR referrals reduced 30.3% and encountered >50% decrease in engagement 'during' the pandemic, compared with 'pre' pandemic. The 'post' pandemic hybrid redesign led to a significant reduction in hospital discharge to CR contact (mean 5.39 days, p=0.001), and time spent in CR (41.33 days, p=0.001) when compared with 'pre' and 'during' figures. CR engagement significantly increased 'post' pandemic for ST-elevation myocardial infarction (STEMI)/non-STEMI (NSTEMI)/acute coronary syndrome (ACS) (56%, p=0.02) and 'post' cardiac surgery (76%, p=0.015). Referrals to cardiac psychology increased >50% 'post' pandemic (7.8%, p=0.038). A 'post' pandemic hybrid CR programme is effective at reducing wait times, increasing engagement and reducing time to completion of CR, compared with 'pre' and 'during' pandemic figures. A significant increase in cardiac psychology referrals 'post' pandemic highlights the importance of psychology support within CR.