Cardiac Rehabilitation Enrollment Research Articles

Women with Rheumatoid Arthritis: The Unspoken Risk Factor

Women with Rheumatoid Arthritis: The Unspoken Risk Factor

Factors associated with enrollment and adherence in outpatient cardiac rehabilitation in Japan.

Despite the effectiveness of cardiac rehabilitation (CR), the participation percentage is low in Japan. Therefore, we investigated factors associated with enrollment and adherence in outpatient cardiac rehabilitation (OCR) in Japan. This was a single-hospital, case-controlled study. During a 2-year study period, 544 patients were hospitalized for ischemic heart disease, heart failure, or open heart surgery, and recommended for in-hospital CR. Among them, 78 OCR participants and 179 randomly selected nonparticipants were included in the study. These 2 groups were compared to examine factors associated with OCR enrollment. In addition, OCR participants were divided into those who continued OCR for 3 months (adherence group) and those who did not (nonadherence group), and these 2 groups were compared to examine factors associated with OCR adherence. Univariate and multivariate logistic regression analyses were conducted for both objectives and included sociodemographic, clinical, and OCR-related variables. OCR enrollment was significantly associated with younger age (OR, 0.96; 95% CI, 0.93-0.98) and shorter distance to the hospital (OR, 0.97; 95% CI, 0.95-0.99). OCR adherence was significantly associated with a history of ischemic heart disease (OR, 6.03; 95% CI, 1.62-22.5) and prescription of antidepressants and/or sleeping pills (OR, 4.14; 95% CI, 1.07-16.0). The main factors associated with OCR enrollment and adherence were sociodemographic factors related to easier hospital access and clinical conditions that reflected high disease awareness, respectively.

Safety of Early Enrollment into Outpatient Cardiac Rehabilitation After Open Heart Surgery

The safety of early enrollment (<2 weeks after hospital discharge) into cardiac rehabilitation (CR) after recent coronary artery bypass graft (CABG) surgery or heart valve surgery (HVS) has not previously been assessed and has important policy implications. Consequently, we performed a detailed review of all clinical adverse events within 6 months of hospital discharge. We compared early and late attendees for patients undergoing CABG surgery or HVS and included patients with myocardial infarction (MI) as an additional control group. We analyzed 112 patients undergoing CABG surgery, 69 patients undergoing HVS, and 59 patients with MI. Median time (interquartile range) from hospital discharge to CR enrollment was 10.5 (8 to 15), 12 (8.5 to 21), and 9 days (7 to 14), respectively. There was no difference in major event rates between early and late enrollees (17% vs 17%, respectively, log-rank p = 0.98) or by diagnosis (15%, 16%, and 22% for CABG surgery, HVS, and MI, respectively; log-rank p = 0.50). Sternal instability and wound infection rates were similar. CR-related adverse events trended toward increased event rates in surgical and early enrollees, but of 44 events, only 3 were exercise related, none resulted in permanent harm, and 41 (93%) were managed in CR without need for emergency services. In conclusion, it appears that a policy of encouraging early enrollment into CR in patients with a recent open heart surgery seems unlikely to harm patients when careful individualized assessment and exercise prescription take place within the bounds of an established CR program.

Effect of Early Enrollment on Outcomes in Cardiac Rehabilitation

Outpatient cardiac rehabilitation (CR) is most beneficial when delivered 1 to 3weeks after the index cardiac event. The effects of delayed enrollment on subsequent outcomes are unclear. A total of 1,241 patients were enrolled in CR after recent (<1 year) treatment of cardiac events or postcardiac surgery. Risk factors and metabolic equivalent levels (METs) during aerobic exercise were calculated before and after CR. The mean CR delay time was 34days (maximum of 327). Delay time >30days was associated with older age, female gender, nonwhite race, being unemployed, and increased length of hospital stay before CR after index cardiac event (p <0.05 vs 0 to 15 and 16 to 30days for all comparisons). Patients with delay time >30days had significant improvements in all CR metrics, but peak METs and weight improvements were lesser in magnitude compared with patients with CR delay times 0 to 15 and 16 to 30days. After multivariate adjustment, delay time >30days remained an independent predictor of decreased MET improvement compared with delay time 0 to 15days (β=-0.59, p <0.001). In conclusion, time to enrollment in CR varies substantially and is independently linked to demographics and length of index hospital stay. Delayed enrollment in CR is directly related to patient outcomes. Although all patients showed improvements in key metrics regardless of delay time, CR was of greatest benefit, particularly for weight and exercise capacity, when initiated within 15days of the index event.

Rehabilitation practice patterns for patients with heart failure: the United States perspective.

Many anticipate that the recent decision of the US Center for Medicare Services to expand cardiac rehabilitation (CR) reimbursement to include patients with systolic heart failure (HF) will lead to expanded application of exercise therapy for eligible HF patients. Nonetheless, US patterns of referral to and enrollment in CR for coronary heart disease have been notoriously poor, and such persistent under-enrollment suggests that there are entrenched obstacles that will impede the use of exercise therapy despite the new CR HF indication. However, application of CR for HF may still grow due to dynamic shifts in contemporary US health care.

Abstract 152: Factors Associated With Enrollment In Cardiac Rehabilitation: A Single-center Experience

Introduction: Cardiac rehabilitation (CR) is a vital component of secondary prevention shown to reduce mortality and improve quality of life. Despite this, referral to CR is low compared to other secondary prevention measures and enrollment of those referred is variable. We examined factors that are associated with enrollment to better understand ways in which participation in CR can be improved. Methods: Using data from the CR Center at the University of Michigan Health System, we analyzed 2012 patients who were referred to CR from January 1, 2008 to June 1, 2013. We systematically performed forward, step-wise multiple logistic regression to determine the best model for predicting acceptance of referral to CR. The outcome variable of interest was enrollment in CR if referred to CR. Results: Of the 2012 patients referred to CR, 1334 patients (66.3%) attended at least one session of CR. While there were no differences in age, gender or race between the two cohorts, there were several differences in baseline characteristics between those who enrolled vs. those who did not enroll. Those who enrolled in CR were more likely to be married (74.5% vs. 61.4%, P&lt;0.0001), employed (54.2% vs. 29.8%, P&lt;0.0001), insured (99.6% vs. 96.3%, P&lt;0.0001), and have two or more co-morbidities (51.5% vs. 41.7%, P &lt;0.0001). In the multiple logistic regression model, factors associated with enrollment (in descending order) were private insurance vs. none (OR=10.8; 95% CI 2.17-53.28, P=0.004), coronary artery bypass grafting vs. MI/ACS (OR= 3.42; 95% CI 1.68-6.99, P=0.0007), referral from cardiac surgery vs. cardiology (OR 3.15; 95% CI 1,43-6.95, P=0.004), outpatient vs. inpatient referral (OR=2.1, 95% CI 1.5 -2.9 , P=0.0001), unemployed (OR=1.55; 95% CI 1.09-2.2, P=0.01), and married (OR=1.41, 95% CI 1.04-1.92, P=0.01). Conclusion: Several patient and system-level factors are associated with enrollment in CR for those who were referred to CR at a single institution. These patient and organizational level variables represent opportunities for targeted interventions to improve CR utilization.

Pan-Canadian Development of Cardiac Rehabilitation and Secondary Prevention Quality Indicators

The Canadian Cardiovascular Society (CCS) is implementing the Canadian Heart Health Strategy and Action Plan recommendation to build knowledge infrastructure, through its Data Definitions and Quality Indicator (QI) project. The CCS selected cardiac rehabilitation (CR) and secondary prevention as a content area for QI development. In accordance with the CCS QI Best Practice Methodology, rapid reviews of the literature were conducted. A long list of 37 QIs, in the areas of structure, process, and outcome were developed. Through an online survey, 26 (42%) of all contacted external experts rated each QI on importance, scientific acceptability, and feasibility, using a 7-point scale. The overall mean rating was 5.4 ± 1.4. Through a consensus process, the working group excluded 8 QIs based on this feedback, and several others were revised. A 30-day Web consultation was then undertaken, to solicit input from the broader CCS and CR community. A “top 5” list of QIs was requested by the CCS, which were: (1) inpatients referred to CR; (2) wait times from referral to CR enrollment; (3) patient self-management education; (4) increase in exercise capacity; and (5) emergency response strategy. Knowledge translation activities are now under way to promote utilization of the QIs and ultimately improve CR care.

Cardiac Rehabilitation Enrollment Among Referred Patients

Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.

Programming Considerations for Including Patients With Heart Failure Into Phase 2 Cardiac Rehabilitation

Programming Considerations for Including Patients With Heart Failure Into Phase 2 Cardiac Rehabilitation

Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study

Objective: To determine the feasibility of a cardiac prehabilitation (Prehab) program for patients waiting for elective coronary artery bypass graft (CABG). Design: A two-group parallel randomized controlled trial. Setting: Medical fitness facility. Subjects: Seventeen preoperative elective CABG surgery patients were randomized to standard care (n = 9) or Prehab (n = 8). Intervention: Standard care: three-hour preassessment appointment. Prehab: exercise and education classes for 60 minutes/day, twice weekly for at least four weeks. Main measures: Data were collected at baseline, one week preoperatively, and three months postoperatively. The primary outcome measure was walking distance using a 6-minute walk test. Secondary outcome variables included 5-meter gait speed, and cardiac rehabilitation attendance three months postoperatively. Results: Fifteen patients (standard care, n = 7; Prehab, n = 8) completed the study. No Prehab patients developed cardiac symptoms during study participation. Walking distance remained unchanged in the standard care group; whereas, the Prehab group increased their walking distance to mean ± SD 474 ±101 and 487 ±106 m at the preoperative and three month postoperative assessments (p < 0.05). Gait speed was unchanged in the standard care group, but improved in the Prehab group by 27% and 33% preoperatively and three months postoperatively, respectively (p < 0.05). Enrollment in cardiac rehabilitation three months postoperatively was higher for Prehab participants (100%) than standard care participants (43%; p < 0.05). Conclusion: These data provide evidence for the feasibility of a Prehab intervention to improve the health status of patients waiting for elective CABG surgery. A larger trial of 92 patients will be utilized to demonstrate the safety and efficacy of Prehab.

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

Examining the Effect of a Patient Navigation Intervention on Outpatient Cardiac Rehabilitation Awareness and Enrollment

Awareness of and enrollment in outpatient cardiac rehabilitation (OCR) following a cardiac event or procedure remain suboptimal. Thus, it is important to identify new approaches to improve these outcomes. The objectives of this study were to identify (1) the contributions of a patient navigation (PN) intervention and other patient characteristics on OCR awareness; and (2) the contributions of OCR awareness and other patient characteristics on OCR enrollment among eligible cardiac patients up to 12 weeks posthospitalization. In this randomized controlled study, 181 eligible and consenting patients were assigned to either PN (n = 90) or usual care (UC; n = 91) prior to hospital discharge. Awareness of OCR was assessed by telephone interview at 12 weeks posthospitalization, and OCR enrollment was confirmed by staff at collaborating OCR programs. Of the 181 study participants, 3 died within 1 month of hospital discharge and 147 completed the 12-week telephone interview. Participants in the PN intervention arm were nearly 6 times more likely to have at least some awareness of OCR than UC participants (OR = 5.99; P = .001). Moreover, participants who reported at least some OCR awareness were more than 9 times more likely to enroll in OCR (OR = 9.27, P = .034) and participants who were married were less likely to enroll (P = .031). Lay health advisors have potential to improve awareness of outpatient rehabilitation services among cardiac patients, which, in turn, can yield greater enrollment rates in a program.

Cardiac rehabilitation barriers by rurality and socioeconomic status: a cross-sectional study.

IntroductionDespite greater need, rural inhabitants and individuals of low socioeconomic status (SES) are less likely to undertake cardiac rehabilitation (CR). This study examined barriers to enrollment and participation in CR among these under-represented groups.MethodCardiac inpatients from 11 hospitals across Ontario were approached to participate in a larger study. Rurality was assessed by asking participants whether they lived within a 30-minute drive-time from the nearest hospital, with those >30 minutes considered “rural.” Participants completed a sociodemographic survey, which included the MacArthur Scale of Subjective Social Status. One year later, they were mailed a survey which assessed CR utilization and included the Cardiac Rehabilitation Barriers Scale. In this cross-sectional study, CR utilization and barriers were compared by rurality and SES.ResultsOf the 1809 (80.4%) retained, there were 215 (11.9%) rural participants, and the mean subjective SES was 6.37 ± 1.76. The mean CRBS score was 2.03 ± 0.73. Rural inhabitants reported attending significantly fewer CR sessions (p < .05), and greater CR barriers overall compared to urban inhabitants (p < .01). Patients of lower subjective SES were significantly less likely to be referred, enroll, and participate in CR, and reported significantly greater barriers to CR compared to their high SES counterparts (p < .01). Prominent barriers for both groups included distance, cost, and transportation problems. These relationships sustained adjustment, and a significant relationship between having undergone coronary artery bypass graft surgery and lower barriers was also identified.ConclusionsThe results confirm that rural inhabitants and patients of low SES experience greater barriers to CR utilization when compared to their urban, high SES counterparts. It is time to implement known strategies to overcome these barriers, to achieve equitable and greater use of CR.

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Physician Factors Affecting Cardiac Rehabilitation Referral and Patient Enrollment: A Systematic Review

Physicians play an important role in CR referral and enrollment. Despite established benefits and recommendations, cardiac rehabilitation (CR) enrollment rates are pervasively low. The reasons cardiac patients are missing from CR programs are multifactorial and include provider factors. A number of studies have now investigated physician factors associated with referral to CR programs and patient enrollment. The objective of this study was to qualitatively and systematically review this literature. A literature search of MEDLINE, PsycINFO, CINAHL, Embase, and EBM was conducted for published articles from database inception to October 2011. Overall, 17 articles were included following a process of independent review of each article by 2 authors. Seven (41.2%) were graded as good quality according to Downs and Black criteria. There were no randomized controlled trials. Results showed that medical specialty (ie, cardiac specialists more likely to refer; n = 8 studies) and other physician‐reported reasons (eg, physician report of their reasons for CR referral and physician sex) were related to referral. Physician factors related to patient enrollment in CR were physician endorsement, medical specialty, being referred, and physician attitudes toward CR. Physician factors are consistently related to CR referral and enrollment. The role of physician endorsements in promoting patient enrollment should be optimized and exploited.

Abstract 180: What is the Potential Capacity for Increasing Cardiac Rehabilitation Utilization in the United States?

Introduction: Cardiac rehabilitation (CR) is an effective but highly underutilized therapy for heart disease. Efforts are underway to increase CR referral and enrollment, but little is known about the potential capacity for growth in CR utilization in the United States. To address this concern, we estimated the current national capacity of CR programs across the United States and assessed obstacles to potential growth. Methods: We surveyed all CR Program Directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November of 2012. Respondents reported current enrollment levels, current program capacity, program capacity given reasonable expansion, and obstacles to growth. Results: Of 812 Program Directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs compared to non-respondents (4.0 vs. 4.6 full time employees, p = 0.01), but were otherwise similar. Current enrollment levels demonstrated a median [IQ range] of 140 [75,232] patients per year and a current estimated capacity of 192 [100,300] patient per year. Respondents estimated that programs could expand services by 25% to 240 [141,380] patients annually, assuming a significant increase in patient demand and a feasible increase in resources. We estimate that if programs filled to their current capacity, national CR utilization rates would increase from 34.7% to 46.4% (95% CI, 43.9 to 48.9) of eligible US patients each year. Given feasible program expansion, utilization could increase to a maximum of 58.4% (95% CI, 55.2 to 61.6) of qualifying patients. Capacity projections based upon absolute patient numbers and national statistics revealed concordant results. The most commonly cited obstacles to increasing patient participation are shown in the figure. As seen, the majority (88%) are controllable system-related factors unrelated to patient behavior. Conclusions: Even with substantial expansion of all existing CR programs, there is currently insufficient capacity in current CR programs to meet national service needs. Solutions to this problem will likely include the creation of new CR programs, and new policies that improve reimbursement for CR and also embrace new models of CR delivery.

Effect of referral strategies on access to cardiac rehabilitation among women.

Despite its proven benefits and need, women's access to cardiac rehabilitation (CR) is suboptimal. Referral strategies, such as systematic referral, have been advocated to improve access to CR. This study examined sex differences in CR referral and enrollment by referral strategies; and the impact of referral strategies for referral and enrollment concordance among women. Prospective cohort study. This prospective study included 2635 coronary artery disease inpatients from 11 Ontario hospitals that utilized one of four referral strategies. Participants completed a sociodemographic survey, and clinical data were extracted from charts. One year later, 1809 participants (452 (25%) women) completed a mailed survey that assessed CR utilization. Referral strategies were compared among women using generalized estimating equations to control for the effect of hospital. Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p < 0.001), and enrolled in CR (58.6% and 49.3% respectively, p = 0.001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (OR 10.3, 95% CI 4.11-25.58) and enrollment (OR 6.6, 95% CI 4.34-9.92) among women when compared with usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (K = 0.85), and decreased with referral intensity. While a lower proportion of referred patients enroll, systematic and liaison-facilitated inpatient referral strategies result in the greatest CR enrollment rates among women. Such strategies have the potential to improve access among women, and reduce 'cherry picking' of patients for referral.

Effect of Patient Navigation on Enrollment in Cardiac Rehabilitation

Effect of Patient Navigation on Enrollment in Cardiac Rehabilitation

Perceptions of barriers to cardiac rehabilitation use in Brazil

Cardiovascular diseases (CVD) are the leading cause of mortality in middle-income countries, such as Brazil. However, given the diversity in health care systems in Brazil, access to proven services, such as cardiac rehabilitation (CR), varies widely.PurposeTo describe and compare multilevel barriers to CR enrollment and participation in three Brazilian cohorts: (1) cardiac outpatients not attending CR (public or private system); (2) cardiac outpatients paying for CR; and (3) residents at high-risk of CVD with access to a free comprehensive exercise program but not making use of the program.MethodsBrazilian residents from two cities were invited to participate – Florianopolis, an urban center; and Luzerna, a rural center. Respondents completed a survey including the Cardiac Rehabilitation Barriers Scale. Mann–Whitney U tests were used to compare barriers between cohorts cross-sectionally.ResultsSix hundred twenty-eight Brazilians consented to participate: 237 (37.7%) from Florianopolis, of which 139 (22.1%) participated in CR; and 391 (62.3%) from Luzerna. The mean total CR barriers for the sample were 1.66 ± 0.6 and differed significantly by cohort (P < 0.001). CR nonattendees from Florianopolis (eg, distance and not knowing about CR) and participants from Luzerna (eg, work and family responsibilities) reported significantly higher barriers than CR attendees from Florianopolis.ConclusionCR nonattendees reported significantly greater barriers than CR attendees. It is hoped that the provision of CR will increase, and that the development of the programs will be in a manner which mitigates the chief barriers identified herein.

Cardiac rehabilitation may not provide a quality of life benefit in coronary artery disease patients

BackgroundImprovements in patient-reported health-related quality of life (HRQoL) are important goals of cardiac rehabilitation (CR). In patients undergoing coronary angiography for angina and with documented coronary artery disease (CAD), the present study compared HRQoL over 6 months in CR participants and non-participants. Clinical predictors of CR participants were also assessed.MethodsA total of 221 consecutive patients undergoing angiography for angina with documented CAD and who were eligible for a CR program were recruited. CR participants were enrolled in a six-week Phase II outpatient CR course (31%, n = 68) within 2 months following angiography and the non-participants were included as a control. At baseline (angiography), one and six months post angiography, clinical and HRQoL data were obtained including the Short Form-36 (SF-36) and the Seattle Angina Questionnaire (SAQ). The response rate for the HRQoL assessment was 68% (n = 150). Cross sectional comparisons were age-adjusted and performed using logistic or linear regression as appropriate. Longitudinal changes in HRQoL were assessed using least squares regression. Finally, a multiple logistic regression was fitted with CR participant as the final outcome.ResultsAt angiography, the CR non-participants were older, and age-adjusted analyses revealed poorer physical (angina limitation: 54 ± 25 versus 64 ± 22, p <0.05) and mental HRQoL (significant psycho-social distress: 62%, n = 95 versus 47%, n = 32, p <0.05) compared to the CR participants. In addition, the CR participants were more likely to have undergone angiography for myocardial infarction (OR = 2.8, 95% CI 1.5-5.3, p = 0.001). By six months, all patients showed an improvement in HRQoL indices, however the rate of improvement did not differ between the controls and CR participants.ConclusionFollowing angiography, CAD patients reported improvements in both generic and disease-specific HRQoL, however CR participation did not influence this outcome. This may be explained by biases in CR enrollment, whereby acute patients, who may be less limited in HRQoL compared to stable, chronic patients, are targeted for CR participation. Further investigation is required so CR programs maximize the quality of life benefits to all potential CR patients.