Center-based Programs Research Articles

Investigation of the Effects of Home-Based Exercise and Cognitive Training on Cognitive and Physical Functions in Cardiac Patients: The COVEPICARDIO Study Protocol of a Randomized Clinical Trial.

Introduction: During the COVID-19 pandemic, confinement measures are likely to produce collateral damage to health (stress, confusion, anxiety), especially in frail individuals and those living with cardiovascular disease (CVD). In cardiac patients in particular, these measures dramatically increase the level of physical inactivity and sedentary lifestyle, which can decrease cardiorespiratory capacity and increase the risk of acute events, rehospitalization, and depressive syndromes. Maintaining a minimum level of physical activity and cognitive stimulation during the COVID-19 crisis is essential for cardiac patients. This study is designed to document the effects of 6 months of home-based physical exercise alone or combined with cognitive training on cognitive and physical functions in patients with CVD over 50 years old.Methods and Analysis: 122 patients (>50 years old) with stable CVD and no contraindication to perform physical exercise training will be recruited and randomly assigned to one of the 2 following arms: (1) Home-based physical exercise alone, (2) Home-based physical exercise combined with cognitive training. The intervention lasts 6 months, with remote assessments performed prior to, mid and post-training. A follow-up 6 months after the end of the intervention (12 month) is also proposed. The primary outcome is cognition, including general functioning (Montreal Cognitive Assessment (MoCA) score), as well as performances on measures of executive functions, processing speed, and episodic memory. The secondary outcome is physical performance, including balance, gait and mobility, leg muscle strength and estimated cardiorespiratory fitness. Tertiary outcomes include mood, anxiety, and health-related quality of life as assessed by self-reported online questionnaires.Discussion: With the COVID-19 crisis, there is a critical need for remote exercise and cognitive training, and to further investigate this topic, in particular for cardiac patients. The present context can be viewed as an opportunity to perform a major shift from center-based programs to home-based physical exercise. This is especially important to reach out to older adults living in remote areas, where access to such interventions is limited.ClinicalTrials.gov: [https://clinicaltrials.gov/ct2/show/NCT04661189], NCT04661189.

Implementation and first-year operating costs of an academic medical center-based syringe services program

BackgroundSyringe services programs (SSPs) remain highly effective, cost-saving interventions for the prevention of blood-borne infections among people who inject drugs. However, there have been restrictions regarding financial resources allocated to these programs, particularly in the US South. This study aimed to provide cost data regarding the implementation and first-year operations of an academic-based SSP utilizing fixed and mobile strategies, including the integration of onsite wound care.MethodsWe conducted a micro-costing study that retrospectively collected detailed resource utilization and unit cost data for both the fixed and mobile SSP strategies, including onsite wound care, from both healthcare and societal perspectives. A three-step approach was used to identify, measure, and value intervention costs, and cost components were categorized into implementation, variable program, and time-dependent costs. Sensitivity analysis was performed to examine the impact of SSP operational changes (i.e., needs-based distribution and opt-out HIV/HCV testing) on the cost-per-participant. Cost data we presented as overall cost and cost-per-participant adjusted to 2017 US dollars.ResultsA total of 452 and 129 participants enrolled in fixed and mobile SSP services, respectively. The total cost associated with implementation and first year operations for the fixed site was $407,217.22 or $729.72 per participant and $311,625.52 or $2415.70 per participant for the mobile unit. The largest cost component for both modalities was time-dependent costs (personnel and overhead), while intervention materials (syringes, injection equipment, naloxone) were less than 15% of the total program cost.Discussion/conclusionImplementation and operation of new SSP models continue to be low cost compared to treatment for the multitude of harms PWID face without access to evidence-based prevention. Future cost-effectiveness and cost–benefit analyses integrating a comprehensive SSP model within an academic institution, including onsite wound care and other medical services, will provide a more comprehensive understanding of this model, and state-level policy action must be taken to lift the prohibition of state and local funds for the implementation, sustainability, and maintenance of these programs in Florida.

Factors influencing participation in educational workshops as part of a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease: a retrospective study

ABSTRACT Background Pulmonary rehabilitation (PR) (primarily composed of an exercise training program (ET) and educational workshops) is an effective intervention for patients with chronic obstructive pulmonary disease. Although factors which influence participation in the full PR program have been reported, specific data on the educational component of PR have not been published. We aimed to identify factors which predict refusal to participate in the educational component of PR. Research design and methods 201 patient charts were retrospectively included in the analysis. Patients were classified according to their acceptance or refusal to participate in the educational workshops. Results The location of ET outside the center was independently related to refusal to participate in the educational workshops (OR = 0.01 [95%CI 0.00 to 0.17]). Patients who refused the workshops were less disabled according to the number of prescriptions of noninvasive ventilation, use of medical transport, oxygen consumption and workload achieved during cardiopulmonary exercise testing. Conclusions The location of exercise sessions during PR influences patients’ decisions to refuse or accept center-based educational workshops. When center-based PR programs are limited, and the ET is relocated to the patient’s home, the educational workshops should also be relocated. Trial registration The trial is registered at ClinicalTrials.gov (NCT04301245).

A Comparison of Physical Activity Between Home-Based and Centre-Based Pulmonary Rehabilitation: A Randomised Controlled Secondary Analysis.

Background: Pulmonary rehabilitation (PR) is a highly effective intervention for individuals with chronic obstructive pulmonary disease (COPD). Physical activity (PA) has been shown to increase after a centre-based programme, yet it is not clear if a home-based programme can offer the same benefit. This study aimed to evaluate the effect of home-based PR compared with the centre-based PR on the PA levels post 7 weeks of PR and 6 months follow-up.Method: In this study, 51 participants with COPD, of them, 36 (71%) men completed physical activity monitoring with a SenseWear Armband, at three time points (baseline, 7 weeks, and 6 months). The participants were randomly assigned to either centre-based supervised PR (n = 25; 69 ± 6 years; FEV1 55 ± 20% predicted) or home-based PR (n = 26; 68 ± 7 years; FEV1 42 ± 19% predicted) programmes lasting 7 weeks. The home-based programme includes one hospital visit, a self-management manual, and two telephone calls. The PA was measured as step count, time in moderate PA (3–6 metabolic equivalent of tasks [METs]) in bouts of more than 10 min and sedentary time (<2 METs).Results: Home-based PR increased step count significantly more than the centre-based PR after 7 weeks (mean difference 1,463 steps: 95% CI 280–2,645, p = 0.02). There was no difference in time spent in moderate PA was observed (mean difference 62 min: 95% CI −56 to 248, p = 0.24). Sedentary behaviour was also significantly different between the centre and home-based groups. The home group spent 52 min less time sedentary compared with the centre-based (CI −106 to 2, p = 0.039). However, after 6 months, the step count and time spent in moderate PA returned to baseline in both the groups.Conclusion: This study provides an important insight into the role of home-based PR which has the potential to be offered as an alternative to the centre-based PR. Understanding who may best respond from the centre or home-based PR warrants further exploration and how to maintain these initial benefits for the long-term.Trial Registry: ISRCTN: No.: ISRCTN81189044; URL: isrctn.com.

Suspension and expulsion in Colorado early care and education settings: Child, program, and community-level predictors.

Expulsion presents a significant risk in Early Care and Education (ECE) settings due to its association with early disadvantage and frequency of use. A statewide survey was conducted to characterize ECE suspension and expulsion (S/E) in Colorado. Child, program, and community-level factors were examined as predictors of S/E, alongside preventative intervention supports capable of reducing S/E. Six hundred and sixty three licensed child care programs participated in the survey, providing information on 19,848 enrolled children, 312 suspensions, and 74 expulsions. A series of multilevel hierarchical regressions were conducted, examining predictors for S/E. Children with IEPs/IFSPs were disproportionately suspended; 2-3-year-olds were disproportionately expelled; and boys, 5-6-year-olds, and children with disabilities were disproportionately suspended and expelled. Center-based programs, lower quality ratings, and "zero tolerance" policies predicted greater use of suspension. In contrast, school-district affiliation and knowledge of how to access infant and early childhood mental health consultation (IECMHC) decreased suspension. Lower levels of regional child poverty predicted higher use of expulsion. Affiliation with a school-district, IECMH consultant-led training, and use of quality coaches predicted decreased expulsion. This study identifies the need for ongoing protection for children with IEPs/ IFSPs and the preventative interventions that mitigate risk for S/E.

The role of cardiac rehabilitation in improving cardiovascular outcomes.

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.

Partially Pooled Propensity Score Models for Average Treatment Effect Estimation with Multilevel Data

Abstract Causal inference analyses often use existing observational data, which in many cases has some clustering of individuals. In this paper, we discuss propensity score weighting methods in a multilevel setting where within clusters individuals share unmeasured confounders that are related to treatment assignment and the potential outcomes. We focus in particular on settings where models with fixed cluster effects are either not feasible or not useful due to the presence of a large number of small clusters. We found, both through numerical experiments and theoretical derivations, that a strategy of grouping clusters with similar treatment prevalence and estimating propensity scores within such cluster groups is effective in reducing bias from unmeasured cluster-level covariates under mild conditions on the outcome model. We apply our proposed method in evaluating the effectiveness of centre-based pre-school programme participation on children’s achievement at kindergarten, using the Early Childhood Longitudinal Study Kindergarten data.

Effect of a personalised mHealth home-based training application on physical activity levels during and after centre-based cardiac rehabilitation: rationale and design of the Cardiac RehApp randomised control trial

Many patients lapse into a physically inactive lifestyle within months after cardiac rehabilitation (CR) programme completion. A mobile-health (mHealth) home-based training application can be used to intensify and/or prolong the...

An Examination of Employee Immunization Policies Among Colorado Child Care Providers.

Child care employee vaccination policies can protect children and adults from vaccine-preventable diseases (VPDs) in child care programs. We aimed to understand the prevalence and characteristics of employee immunization policies at child care facilities and support among child care administrators for statewide employee vaccination regulations. A postal mail survey was distributed to a cross-sectional sample of 300 center-based and 300 home-based child care programs in Colorado. Programs were asked to report whether they had any type of policy requiring employee immunizations and if they would support statewide regulations mandating employee immunizations for influenza, pertussis, and measles. The response rate was 48% (288/600). About 55% of child care programs reported having an employee immunization policy. Child care centers (73%) were more likely than home-based child care programs (30%, P < .001) to report having a policy. Overall, 62% of respondents reported that they would support one or more statewide regulations requiring child care employees to be vaccinated. Home-based programs (71%) were more likely than center-based programs (53%, P = .001) to support one or more statewide child care employee immunization regulations. Our findings demonstrate the variability of employee immunization policies at child care programs across Colorado. These results may be used to inform strategies to increase employee immunization uptake and reduce the incidence of VPDs, including developing comprehensive employee immunization policies at the facility and state level. Future research is needed to understand vaccination knowledge, attitudes, and behaviors among child care employees including their perspectives on employee vaccination policies and regulations.

CENTER BASED VERSES TELE-REHABILITATION FOR DIABETES MELLITUS

Globally, new trends of practices are incorporating in health care sector, academics as well as in our daily lives to cope with the current population need. It is much needed to develop and implement new sophisticated practice models in rehabilitation to treat the different clinical conditions. Diabetes mellitus is one among the top 10 causes of death, with significant increase of 80% since year 20001. As estimated by International Diabetes Federation worldwide, 425 million people are suffering with diabetes mellitus.2 Diabetic neuropathy is one of highly prevalent condition which substantially affects patients by increasing frequency of falls, neuropathic pain and low quality of life (QOL).Diabetic patients suffer with following complaints i.e. Foot ulcers that develops due to peripheral vascular ischemia and poor pressure distribution on plantar surface of foot which increases the risk of fall due to loss of balance and disturbance in gait patterns.3 Total 20% of foot ulcers need an amputation wherein patients further suffer with secondary complications which in turn builds massive economic burden on health care system.4 The rehabilitation combined with diet and medications has proven as an effective method to treat diabetes and its neuropathy symptoms. Supervised conventional center based physical activity training programs are generally in practice to treat this metabolic condition. Though clinical effectiveness of these programs is established on clinical outcomes, with reduction in mortality rate, despite all the benefits of rehabilitation programs, very low patient attendance is observed in hospital based supervised rehabilitation programs. The regularity in exercise along with dietary intervention and fixed medication monitoring is the key component to manage diabetes. But high drop-out levels negatively affects the proven effectiveness of rehabilitation. There are different aspects for this low level of participation i.e. lack of time, approachability of a program, home bound work or obligations and psychological barriers etc. Therefore, new practice models are essential to improve the rate of participation on regular basis in these exercise program.5 Computer based technological incorporation in the field of health is evolving dramatically as a promising tool in improving quality of life cost effectively. It can also help us to achieve WHO goal “to improve access to health care services and professionals”. Tele-rehabilitation may prove effective as part of the rehabilitation program, especially for diabetic patients who fail to participate in conventional rehabilitation center-based programs due to domestic issues. The factors associated with suboptimal participation in rehabilitation at home are less prevalent. In tele-rehabilitation, patients are not bound to visit rehabilitation center or hospital; hence they have the freedom to perform exercise at home. But the limitations in utilization of this approach are: patient assessment and evaluation in a structured manner, monitoring the effect of program on regular basis, suitability of approach for all type of morbidities &amp; severity levels of diabetes and suitable equipment having required features for patients as well as practitioners.6 Tele-rehabilitation is a prospective opportunity to treat the diabetic patients through regular monitoring with less drop outs rather than center based approach. However, there is a need to identify the types and severity of diabetic patients for whom this approach is safe and effective. Secondly, it is required to define clinical assessment outcomes which can be monitored and assessed. Incorporation of advanced equipment and relevant operational training is indispensable. Development of Standardized documentation for patient evaluation, intervention and outcomes monitoring is imperative to long term sustainability and improvement of practice. It is equally important to ensure the security and confidentiality of Patient’s personal data and privacy.7

Effectiveness of Home-Based Cardiac Rehabilitation and Its Importance During COVID-19

Cardiac rehabilitation is a secondary prevention and disease-management opportunity for individuals living with cardiovascular disease. The COVID-19 pandemic has caused postponements and cancellations for many health services, including 41% of cardiac rehabilitation programs in Canada. Cardiac rehabilitation effectively reduces the risk of mortality, morbidity, and hospitalizations in cardiac clients. Without access, individuals face challenges to improve their health, which places them at risk of adverse outcomes. This paper argues that transitioning to home-based cardiac rehabilitation programs during the pandemic is a reasonable strategy to meet the ongoing rehabilitation needs of cardiac patients. Home-based cardiac rehabilitation programs utilize limited hospital or clinic visits because the majority of exercise is performed at home through regular communication with a case manager. Programs utilize a variety of resources, including technology, to regularly monitor, educate, and counsel clients. The programs’ flexibility and convenience overcome many multi-level barriers which normally impede participants from accessing services. These programs have proven to be equally effective, if not more effective than centre-based programs, at improving mortality, cardiac events, exercise capacity and modifiable risk factors. Home-based programs are a valid alternative to support and protect a vulnerable population, especially those at high risk if diagnosed with COVID-19. Transitioning to a home-based platform may be a challenge, but the Canadian Cardiovascular Society has provided practical approaches to support programs. Adapting current plans and developing new ones, utilizing appropriate resources, having a conservative exercise program, monitoring clients, emphasizing education, being flexible, and enhancing safety are key steps for a successful transition.

COVID-19 era in long-term cardiac rehabilitation programs: how did physical activity and sedentary time change compared to previous years?

Funding AcknowledgementsType of funding sources: None.IntroductionCardiovascular rehabilitation (CR) was one of the many areas negatively affected by the COVID-19 pandemic. A high number of cardiovascular disease (CVD) patients had their centre-based program suspended. Physical activity (PA) recommendations for CVD patients are well established and its benefits largely documented. However, few studies have objectively measured the PA of these patients throughout the years and specifically during the COVID-19 pandemic. PurposeTo objectively measure PA and sedentary time (ST) during COVID-19 pandemic in comparison with the previous 2 years in CVD patients who were attending a phase III centre-based CR program. MethodsBefore COVID-19, eighty-seven CVD patients (mean age 62.9 ± 9.1, 82.8% male) were attending a face-to-face long-term CR program. Of the 87 patients, 78.2% have been on the program for at least 1 year. Every year, PA and ST were objectively assessed by accelerometery. After the CR centre-based program suspension due to COVID-19, efforts were done to create a CR home-based digital model to maintain the continuum of care and avoid losing the previous acquired benefits. After 7 months of suspension, the face-to-face CR centre was reopened and 57.5% (n = 50) patients returned. We completed the assessment of PA and ST of 37 patients (mean age 64.8 ± 8.1, 89.2% male) and compared it as follows: M1) two assessments before COVID-19; M2) last assessment before COVID-19; M3) 7 months after CR program suspension (last trimester of 2020). Patients wore an ActiGraph accelerometer for 7 consecutive days to assess daily and weekly minutes of light PA, moderate-to-vigorous PA and ST. We used repeated-measures ANOVA and Wilcoxon signed rank as a non-parametric alternative.ResultsIntention-to-treat analysis showed that in M3 patients decreased their average daily time spent in moderate-to-vigorous PA when compared with M2 (M3: 37.90 ± 3.30 min/day vs M2: 45.01 ± 3.14 min/day, p = 0.035), no changes were found between M1 and M2. Average daily time spent in light PA improved significantly from M1 to M2 (M1: 154.81 ± 7.20 min/day vs M2: 169.17 ± 6.44 min/day, p = 0.042) but did not change from M2 to M3. Despite this, in M3, 81.08% of the patients still met the recommendations for moderate-to-vigorous PA (M1: 89.19% and M2: 91.89%). No changes were found in ST.ConclusionDespite a significant decrease on the amount of moderate-to-vigorous PA during the COVID-19 era, most CVD patients, first in the centre-based CR program and after in the home-based CR program, were able to meet PA recommendations throughout the last years. These findings suggest that CVD patients who attend supervised long-term CR programs might be aware of the importance of reaching PA guidelines. Reducing ST by replacing it by PA of any intensity could be an important and reachable target for long-term CR programs.

Home-based Cardiac Rehabilitation in Covid Era: Is it a safe option?

Funding AcknowledgementsType of funding sources: None.IntroductionHome-based Cardiac Rehabilitation (CR-HB) models have been shown to be effective, however, there is a large variation of protocols and minimal evidence of effectiveness in higher risk populations, in which exercise at distance might be concerning. In addition, lack of reimbursement models has discouraged the widespread adoption of CR-HB. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has emerged due to the decreased availability of on-site services.PurposeEvaluation of the safety of a CR-HB program during COVID-19 pandemic. MethodsProspective cohort study which included patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB after the centre-based CR program closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including: 1.pts regular clinical and exercise risk assessment; 2.psychological tele-appointments and group sessions; 3. online exercise training sessions, which consisted of recorded videos and real time online exercise training sessions (each session recommended 3 times per week, during 60 minutes); 4.structured online educational program for pts and family members/caregivers, including educational videos and webinars; 5. follow-up fortnightly questionnaire to evaluate risk factors control and need for appointments or directing to hospital; 6. nutrition tele-appointments; 7. physician tele-appointments, scheduled according to follow-up questionnaire or at patients request (e-mail or telephone) to avoid unnecessary exposure and overload in the hospital. Minor and major adverse events such as hospitalizations due to cardiac event or other non CV reason, cardiac or noncardiac death, during or immediately after the exercise sessions, were collected.Results116 cardiovascular disease (CVD) pts (62.6 ± 8.9 years, 95 males) who were attending a Centre-based CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease; 13.8% pts had heart failure. The mean LVEF was 52 ± 11%; 31,1% of the population had at least moderate risk. Regarding risk factors, obesity was the most common risk factor (74.7%) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 98 CVD pts (85.5%) successfully completed all the online assessments. Three male participants dropped out for hospitalization due to knee surgery, pacemaker implantation and in-stent restenosis without relation to exercise sessions. No major events were registered during the exercise training sessions and only one minor adverse event, sprained ankle, was reported during the training sessions.ConclusionsThis CR-HB program, originated by the need of social distancing during COVID-19 pandemic, revealed to be a valuable and safe strategy to reach at distance most patients previously in a Centre-based CR program.

Cardiovascular risk factor control: is it possible with a home-based cardiac rehabilitation program?

Funding AcknowledgementsType of funding sources: None.IntroductionCardiovascular risk factors (CVRF) control, needing different strategies, through patient education, lifestyle changes and therapeutic optimization is a central core of cardiac rehabilitation. However, further studies are needed to demonstrate effectiveness of home-based Cardiac Rehabilitation (CR-HB) programs in controlling CVRF. PurposeTo evaluate the effectiveness of a CR-HB program in controlling cardiovascular risk factors.MethodsProspective cohort study including patients who were previously participating in a centre-based CR program and accepted to participate in a CR-HB program due to forced closure of the centre-based CR program for COVID-19 pandemic. The CR-HB consisted of a multidisciplinary digital CR program, including patient regular assessment, exercise, educational, and psychological and relaxation sessions. A structured online educational program for patients and family members/caregivers was provided including educational videos, and powerpoints and webinars. A real time Webinar regarding "nutritional myths and facts" was organized with the duration of 90 minutes as a substitution of the regular face-to-face regular workshop provided at our centre-based CR program. Also, self-control of blood pressure and heart rate and of glycemia in diabetics were promoted, as well as smoking cessation.To assess the impact of the CR-HB on risk factors control, all the patients were submitted to a clinical and analytical evaluation before and after the end of this at distance program. Results116 cardiovascular disease patients (62.6 ± 8.9 years, 95 males) who were attending a face-to-face CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease. Regarding risk factors, obesity was the most prevalent risk factor (74.7 %) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). Regarding the blood pressure control, 80% of the patients stated that almost daily they measured blood pressure at home; baseline systolic pressure decreased from 117 ± 13 to 113 ±12mmHg, p = 0.007, while there was no significant change in diastolic pressure. The majority (76%) of diabetic patients said they controlled blood glucose; HbA1c decreased from 6.1 ± 1.1 to 5.9 ± 0.9mg/dL (p = 0.047).Considering the lipid profile, LDL decreased (from 75 ± 30 to 65 ± 26mg/dL, p = 0.012). The Nt-proBNP also decreased (818 ± 1332 vs 414pg/ml ± 591, p = 0.042). There were no other statistically significant differences concerning risk factors modification. ConclusionsOur study showed that a Home-based Cardiac Rehabilitation program can improve or maintain cardiovascular risk factors control, which has important prognostic implications and is frequently a difficult task to achieve.

Home-based Cardiac Rehabilitation: the patients claim for new strategies but do they adhere?

Funding AcknowledgementsType of funding sources: None.IntroductionCardiac rehabilitation (CR) programs are established interventions to improve cardiovascular health, despite asymmetries in referral. With covid 19 outbreak, cardiac rehabilitation home based (CR-HB) programs emerged as an alternative. However, its adherence and implementation may vary greatly with socio-demographic factors.PurposeTo assess adherence to the various components of a CR-HB program. MethodsProspective cohort study which included patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB after the centre-based CR program closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including: 1.patient clinical and exercise risk assessment; 2.psychological tele-appointments; 3. online exercise training sessions; 4.structured online educational program for patients and family members/caregivers; 5. follow-up questionnaires; 6. nutrition tele-appointments; 7. physician tele-appointmentsAdherence to the program was assessed bydrop-out rate; number of exercise sessions in which each patient participated; number of educational sessions attended and a validated questionnaire on therapeutic adherence (composed of 7 questions with minimum punctuation of 7 and maximum of 40 points).Results116 cardiovascular disease (CVD) pts (62.6 ± 8.9 years, 95 males) who were attending a Centre-based CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease; 13.8% pts had heart failure; the mean LVEF was 52 ± 11%. Regarding risk factors, obesity was the most common risk factor (74.7 %) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). Ninety-eight pts (85.5%) successfully completed the program. Almost half (46.9%) of the participants did at least one online exercise training session per week. Among the pts who did online exercise training sessions, 58% did 2-3 times per week, 27% once per week and 15% more than 4 times per week. The pts participated, on average, in 1.45 ± 2.6 education sessions (rate of participation of 13,2%) and therapeutic adherence was high (39,7 ± 19; min 35-40). Regarding educational status of the pts, 33 pts (45,2%) had a bachelor degree. These pts tended to participate more in exercise sessions (1,7 ± 1,7 vs 1,2 ± 1,4 sessions per week) and in education sessions (2.13 vs 1.6), although this difference was not statistically significant. The therapeutic adherence did not vary with patients’ level of education. ConclusionOur results showed that a high percentage of patients completed the program and almost half were weekly physically active. However, in regard to educational sessions, the degree of participation was much lower. Educational status seemed to correlate with a higher degree of participation and, in the future, patient selection might offer better results in these kinds of programs.

Digital home-based multidisciplinary cardiac rehabilitation: the way to counteract physical inactivity during the COVID-19 pandemic?

Funding AcknowledgementsType of funding sources: None.IntroductionCentre-based cardiac rehabilitation (CR) programs have been forced to close due to the need for physical and social distancing imposed by COVID-19 pandemic. A major problem emerges concerning the potential harmful effects resulting from the suspension of the centre-based CR programs, leading to physical inactivity and unhealthy lifestyle routines. Therefore, the development of alternative delivery models to maintain access to CR programs and to avoid physical inactivity should be organized and tested.PurposeTo assess the physical activity (PA) levels in a group of patients with known cardiovascular disease (CVD), after completing 3-months of a home-based multidisciplinary digital CR program, organized as an alternative method to the centre-based CR suspended program.MethodsOne hundred and sixteen patients with CVD (62.6 ± 8.9 years, 95 males) who were previously attending a face-to-face CR program were included and the following parameters were assessed at baseline and 3 months: self-reported PA and sedentary behaviour, adherence to the online CR program, cardiovascular and non-cardiovascular symptoms, feelings towards the pandemic, dietary habits, risk factor control, safety and adverse events. The intervention consisted in a multidisciplinary digital CR program, including online exercise training sessions, online educational sessions, psychological online group sessions, risk factor control, nutritional and psychological consults and patient regular assessment by cardiologist and nurse.ResultsNinety-eight CVD patients successfully completed all the online assessments (15.5% drop-out). It was observed a significant increase from moderate-to-vigorous PA (230 ± 198 mins/week to 393 ± 378 mins/week, p < 0.001) and a decrease of the sedentary time at 3-months (6.47 ± 3.26 hours/day to 5.17 ± 3.18 hours/day, p < 0.001). Seventy percent of the patients met the PA recommendations and 41% reached more than 300 minutes per week of moderate to vigorous PA at 3 months. Almost half of the participants (46.9%) did at least more than one online exercise training session per week and attended at least one of the online educational sessions. There were no major adverse events reported and only one minor non-cardiovascular event occurred.ConclusionPatients with CVD, who suspended centre-based CR due to COVID-19 pandemic and started a home-based multidisciplinary digital CR program, had a significant improvement in moderate to vigorous PA after 3 months. Therefore, home-based CR programs showed to be a good option for selected clinically stable patients, who are eligible for CR and cannot attend a centre-based CR program due to COVID-19 pandemic or eventually other reasons.

COVID-19 era in long-term cardiac rehabilitation programs: how was muscle strenght and lean mass affected in cardiovascular patients?

Funding AcknowledgementsType of funding sources: None.IntroductionExercise prescription is one of the main components of phase III Cardiac Rehabilitation (CR) programs due to its documented prognostic benefits. It has been well established that, when added to aerobic training, resistance training (RT) leads to greater improvements in peripheral muscle strength and muscle mass in patients with cardiovascular disease (CVD). With COVID-19, most centre-based CR programs had to be suspended and CR patients had to readjust their RT program to a home-based model where weight training was more difficult to perform. How COVID-19 Era impacted lean mass and muscle strength in trained CVD patients who were attending long-term CR programs has yet to be discussed.PurposeTo assess upper and lower limb muscle strength and lean mass in CVD patients who had their centre-based CR program suspended due to COVID-19 and compare it with previous assessments.Methods87 CVD patients (mean age 62.9 ± 9.1, 82.8% male), before COVID-19, were attending a phase III centre-based CR program 3x/week and were evaluated annually. After 7 months of suspension, 57.5% (n = 50) patients returned to the face-to-face CR program. Despite all constraints caused by COVID-19, body composition and muscle strength of 35 participants (mean age 64.7 ± 7.9, 88.6% male) were assessed. We compared this assessment with previous years and established three assessment time points: M1) one year before COVID-19 (2018); M2) last assessment before COVID-19 (2019); M3) the assessment 7 months after CR program suspension (last trimester of 2020). Upper limbs strength was measured using a JAMAR dynamometer, 30 second chair stand test (number of repetitions – reps) was used to measure lower limbs strength and dual energy x-ray absorptiometry was used to measure upper and lower limbs lean mass. Repeated measures ANOVA were used.ResultsIntention to treat analysis showed that upper and lower limbs lean mass did not change from M1 to M2 but decreased significantly from M2 to M3 (arms lean mass in M2: 5.68 ± 1.00kg vs M3: 5.52 ± 1.06kg, p = 0.004; legs lean mass in M2: 17.40 ± 2.46kg vs M3: 16.77 ± 2.61kg, p = 0.040). Lower limb strength also decreased significantly from M2 to M3 (M2: 23.31 ± 5.76 reps vs M3: 21.11 ± 5.31 reps, p = 0.014) after remaining stable in the year prior to COVID-19. Upper limb strength improved significantly from M1 to M2 (M1: 39.00 ± 8.64kg vs M2: 40.53 ± 8.77kg, p = 0.034) but did not change significantly from M2 to M3 (M2 vs M3: 41.29 ± 9.13kg, p = 0.517).ConclusionAfter CR centre-based suspension due to COVID-19, we observed a decrease in upper and lower limbs lean mass and lower limb strength in previously trained CVD patients. These results should emphasize the need to promote all efforts to maintain physical activity and RT through alternative effective home-based CR programs when face-to-face models are not available or possible to be implemented.

Home-based Cardiac Rehabilitation - the real barriers of programs at distance

Funding AcknowledgementsType of funding sources: None.IntroductionDespite the established benefits of cardiac rehabilitation (CR), it remains significantly underutilized. Home-based CR (CR-HB) programs should offer the same core CR components as Centre-based programs (CR-CB) but several aspects need to be adapted, communication and supervision must be improved. Although CR-HB has been successfully deployed and is a valuable alternative to CR-CB, there is less structured experience with these non-uniform programs and further studies are needed to understand which patients (pts) are indicated to this type of program.PurposeTo investigate pt-perceived facilitators and barriers to home-based rehabilitation exercise.MethodsProspective cohort study which included pts who were participating in a CR-CB program and accepted to participate in a CR-HB program after CR-CB closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including pt risk evaluation and regular assessment, exercise, educational and psychological sessions. The online exercise training sessions consisted of recorded videos and real time online supervised exercise training group sessions. It was recommended to do each session 3 times per week, during 60 min. A pictorial exercise training guidebook was available to all participants including instructions regarding safety, clothing and warm-up, and a detailed illustrated description of each exercise sessions. Also, for questions or difficulties regarding the exercises, an e-mail and telephone was provided. Once a month, real time CR exercise sessions was provided with a duration of 60min.Results116 cardiovascular disease pts (62.6 ± 8.9years, 95 males) who were attending a face-to-face CR program were included in a CR-HB program. The majority of the pts had coronary artery disease (89%) and 5% valvular disease. Regarding risk factors, obesity was the most common (75%) followed by hypertension (60%), family history (42%), dyslipidaemia (38%), diabetes (18%), and smoking (13%). Almost half (47%) of the participants did at least one online exercise training session per week: 58% did 2-3 times per week, 27% once per week and 15% more than 4 times per week. Participants who did less than one exercise session per week reported as cause: lack of motivation (38%), preference of a different mode of exercise training such as exercise in the exterior space (26%), technology barrier such as impossibility to stream online videos (11%), fear of performing exercise without supervision (4%), and limited space at home (4%).ConclusionsOur study based on real-life results of a CR-HB program shows a sub-optimal rate of participation in exercise sessions due to different causes, but mainly for the lack of motivation to exercise alone or preference for walking in exterior space. The knowledge of the CR-HB program barriers will facilitate to find out strategies to increase the participation rate and to select the best candidates for this type of programs.

Body composition, lipid profile and mediterranean diet adherence in cardiovascular disease patients attending a long-term exercise-based cardiac rehabilitation program during COVID-19 pandemic

Funding AcknowledgementsType of funding sources: None.Introduction Cardiovascular disease (CVD) is recognized as a major public health issue and remains the leading cause of mortality worldwide. There is a clear association between adiposity, blood lipid profile, and adherence to the Mediterranean diet (MD) with the risk of CVD. However, the assessment of body composition parameters, dietary patterns and nutritional intervention in CVD patients undergoing a cardiovascular rehabilitation (CR) program remains insufficient. Purpose to characterize body composition, lipid profile and MD adherence in patients with CVD who were attending an exercise-based CR program during COVID-19 era. Methods The study was developed between October 2020 and January 2021 in a phase III centre-based CR program. Body composition was assessed by dual energy x-ray absorptiometry Hologic Explorer-W. Adherence to the MD was assessed by the 14-item MD questionnaire. Fasting blood sample was taken for measurement of lipid profile. Results A sample of 41 patients (mean age 64.4 ± 7.9 years, 87.8% male) was evaluated. The most prevalent CVD were coronary artery disease (89.5%) and heart failure (21.1%). The main CVD risk factors at admission in the CR program were dyslipidaemia (71.1%), hypertension (68.4%), physical inactivity (26.3%) and diabetes mellitus (21.0%). In our sample the mean body mass index was 28 ± 3.8 kg/m2, being most patients overweight (75.6%), and having a substantially increased risk of metabolic complications (85.3%) accordingly to waist-hip ratio. Body composition assessment showed that 14.6% of the patients had a body fat mass index above 90th percentile. Although only 9.8% of the patients had reduced fat free mass, 17.1% showed appendicular lean mass below the reference value. In addition, less than one third of the patients (31.7%) revealed a high adherence to the MD pattern. A sub-analysis on blood lipids (n = 26) showed that most patients had levels of LDL cholesterol (76.9%) and non-HDL cholesterol (65.4%) above the therapeutic target and 15.4% had triglycerides higher than 150 mg/dl. Conclusion Body composition, lipid profile and dietary patterns, play a major role in CVD secondary prevention. Our findings showed that a substantial number of CVD patients, in COVID-19 era, did not have optimal body composition, were above lipid profile targets, and had a low/medium adherence to the MD. Thus, this study highlights the relevance of nutrition on cardiometabolic status and demonstrates the crucial role of nutritional intervention as an integrated part of a long-term phase III CR program. Moreover, further research about nutritional intervention in patients undergoing CR is warranted.

Home-based cardiac rehabilitation during COVID-19 pandemic: effectiveness of an educational intervention

Funding AcknowledgementsType of funding sources: None.IntroductionPatient education is considered a core component of cardiac rehabilitation (CR) and nowadays, particularly during the COVID-19 pandemic, online education programs are critical. However, the best strategy for implementing these digital programs to increase patients’ adherence and learning is not fully established.PurposeTo assess the uptake and effectiveness of an educational intervention transmitted through video sessions integrated into a home-based CR program (CR-HB).MethodsProspective cohort study including patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB program during COVID-19 pandemic. The CR-HB program consisted of a multidisciplinary online program with educational videos for pts and family members / caregivers, that aimed to educate on necessary behavioural and lifestyle changes. Weekly, a 15-minute video was uploaded and lectured by the correspondent health professional from the CR team. The educational sessions covered the following topics: COVID-19 and cardiovascular (CV) disease, coronary artery disease, hypertension, dyslipidemia, smoking cessation, diabetes, medical therapy and adherence, healthy diet, exercise and physical activity, sedentary behaviour and sexual dysfunction and CV disease.At the end of the program we applied a 10 questions questionnaire to evaluate the knowledge of pts about the topics of educational sessions. All the pts answered the questionnaire and results were compared between the pts who attended the educational sessions and the ones who didn’t.Results 116 pts with CV disease were included in the CR-HB program (62.6 ± 8.9 years, 95 males). Almost 90% (n = 103) of the participants had coronary artery disease and the mean LVEF was 52 ± 11%. Obesity was the most common risk factor (75%) followed by hypertension (60%), family history of CV disease (42%), dyslipidemia (38%), diabetes (18%), and smoking (13%).The pts participated, on average, in 1.45 ± 2.6 education sessions (rate participation of 13.2%). About half of the pts (49%) attended, at least, one session and these pts attended, on average, 3 sessions (2.96 ± 3.0). The questionnaire results were better in pts who attended at least 1 educational session than in those who did not attend any (7.4 ± 1.9 vs 7,1 ± 1.7), however this difference was not statistically significant.Regarding education status, 33 pts (45.2%) had a bachelor degree and this group of pts had a significant higher result in questionnaire (7.8 ± 1.9 vs 6.7 ± 1.8; p = 0.015) and tended to participate more often in education sessions (2.13 vs 1.6, p = 0.06).ConclusionsOur study showed a low rate of participation in sessions, highlighting the importance of developing strategies to increase motivation and adherence to online educational programs. Also, more literate patients had significantly greater health knowledge and adherence to educational sessions, suggesting that this population could benefit more from this type of programs.