Cardiac Rehabilitation Utilization Research Articles

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.

Utility of Cardiac Rehabilitation for Long-Term Outcomes in Patients with Hospital-Acquired Functional Decline after Cardiac Surgery: A Retrospective Study.

Hospital-acquired functional decline is an important outcome that affects the long-term prognosis of patients after cardiac surgery. Phase II cardiac rehabilitation (CR) for outpatients is expected to improve prognosis; however, this is not clear in patients with hospital-acquired functional decline after cardiac surgery. Therefore, this study evaluated whether phase II CR improved the long-term prognosis of patients with hospital-acquired functional decline after cardiac surgery. This single-center, retrospective observational study included 2371 patients who required cardiac surgery. Hospital-acquired functional decline occurred in 377 patients (15.9%) after cardiac surgery. The mean follow-up period was 1219 ± 682 days in all patients, and there were 221 (9.3%) cases with major adverse cardiovascular events (MACE) after discharge during the follow-up period. The Kaplan-Meier survival curves indicated that hospital-acquired functional decline and non-phase II CR was associated with a higher incidence of MACE than other groups (log-rank, p < 0.001), additionally exhibiting prognosticating MACE in multivariate Cox regression analysis (HR, 1.59; 95% CI, 1.01-2.50; p = 0.047). Hospital-acquired functional decline after cardiac surgery and non-phase II CR were risk factors for MACE. The participation in phase II CR in patients with hospital-acquired functional decline after cardiac surgery could reduce the risk of MACE.

Cardiac rehabilitation utilization, barriers, and outcomes among patients with heart failure.

Exercise-based cardiac rehabilitation (CR) is effective for improving both primary (i.e., mortality and hospitalizations) and secondary (i.e., functional capacity and quality of life among) clinical outcomes among patients with heart failure (HF). The mechanisms that explain these benefits are complex and are linked to exercise adaptations such as central and peripheral hemodynamics combined with improved overall medical management. Despite the benefits of CR, utilization rates are low among CR eligible patients. Clinician-, patient-, and health system-related barriers have been identified as primary factors contributing to the lack of CR utilization among HF patients. These include patient referrals (clinician-related), psychosocial factors (patient-related), and patient access to CR services (health system-related). The aims of this review are to detail the components of each barrier as well as identify evidence-based strategies to improve CR utilization and adherence among HF. The improvements in primary and secondary outcomes along with the mechanisms that are linked to these changes will also be examined.

Virtual healthcare solutions for cardiac rehabilitation: a literature review.

Graphical AbstractAdherence to cardiac rehabilitation following a primary event has been demonstrated to improve quality of life, increase functional capacity, and decrease hospitalizations and mortality. Mobile technologies offer an opportunity to improve both the quality and utilization of cardiac rehabilitation, and recent clinical studies investigated this technology. This literature review summarizes the current use of mobile health, wearable activity monitors (WAMs), and other multi-component technologies deployed to support home-based virtual cardiac rehabilitation. The methodology was adapted from the Cochrane Handbook for Systematic Reviews of Interventions. We identified 2094 records, of which 113 were eligible for qualitative analysis. Different virtual cardiac rehabilitation solutions were implemented in the studies: (i) multi-component interventions in 48 studies (42.5%), (ii) WAMs in 27 studies (23.9%), (iii) web-based communications solutions, and (iv) mobile apps, both in 19 studies (16.4%). Functional capacity was the most frequently reported primary outcome (k = 37, 32.7%), followed by user adherence/compliance (k = 35, 31.0%), physical activity (k = 27, 23.9%), and quality of life (k = 14, 12.4%). Studies provided a mixed assessment of the efficacy of virtual cardiac rehabilitation in attaining either significant improvements over baseline or significant improvements in outcomes compared with conventional rehabilitation. Efficacy outcomes with virtual cardiac rehabilitation sometimes improve on the centre-based outcomes; however, superior clinical efficacy may not necessarily be the only outcome of interest. The promise of virtual cardiac rehabilitation includes the potential for increased user adherence and longer-term patient engagement. If these outcomes can be improved, that would be a significant justification for using this technology.

Factors Influencing Health-Related Quality of Life, Return to Work, and Optimal Utilization of Cardiac Rehabilitation in Adults with Cardiac Disorders-A Literature Review

Cardiovascular disease contributes to the largest burden of noncommunicable diseases leading to death and disability globally. Cardiac rehabilitation (CR) is recognized as a secondary prevention program for patients with cardiovascular disease. Its benefits include mortality reduction, symptom relief, reduction in smoking, improved exercise tolerance, risk factors modification, psychosocial well-being, and early return to work (RTW). Although these benefits are well known, intrinsic and extrinsic factors influencing CR utilization and optimization have not been studied. Thus, the present review aimed to explore factors that influence health-related quality of life (HRQoL), RTW, and optimal utilization of cardiac rehabilitation in adults with primary cardiac disorders. A review of the literature was performed using Cochrane Library, PubMed, CINAHL, and Google Scholar databases. Fifty-eight studies published in English during 2012-2022, conducted on adult patients were included in the review. Higher education, physician support, family support, and health insurance were facilitators of a better quality of life. A socially vulnerable group, depression-anxiety, cognitive impairments, and older age negatively influence HRQoL. RTW improves HRQoL. Comprehensive CR, social support, and health-care benefits lead to early occupational reintegration. Therefore, improving referral, enrollment, adherence, and completion are deemed necessary for optimal CR utilization.

National, regional, and urban-rural patterns in fixed-terrestrial broadband internet access and cardiac rehabilitation utilization in the United States

ObjectiveSparse patterns in fixed-terrestrial broadband internet access are predominantly observed among older adults and low income areas, which are interrelated factors also associated with low center-based cardiac rehabilitation (CR) utilization in the United States (US). Telehealth CR is proposed to increase CR utilization under an assumption that fixed-terrestrial broadband internet access is readily available nationwide and parallels CR utilization demand. We aimed to characterize national, geographical, and urban-rural patterns in fixed-terrestrial broadband internet access, CR eligibility rates, and center-based utilization throughout the US. MethodsCenters for Disease Control data were used to estimate CR eligibility rates and center-based utilization for 2017-2018 among Medicare fee-for-service beneficiaries aged ≥65 years. Census Bureau data for 2018 were used to estimate fixed-terrestrial broadband internet access among households of adults aged ≥65 years. ResultsSouthern states exhibited the highest percentage of households without broadband internet [median (IQR): 32% (24-39)] coupled with the highest CR eligibility rates [per 1,000 beneficiaries, median (IQR): 18 (15-21)] and lowest participation rates [percentage completing ≥1 session, median (IQR): 25% (17-33)]. Compared with urban areas, rural areas demonstrated significantly higher eligibility rates [15.5 (13.2-18.4) vs. 17.4 (14.5-21.0)], participation rates [30.6% (22.0-39.4) vs. 34.6% (22.6-48.3)], and percentage of households without broadband internet [23.8% (18.1-29.2) vs. 31.6% (26.5-37.6)], respectively. ConclusionOverlapping patterns in fixed-terrestrial broadband internet access and CR eligibility rates and center-based utilization suggest telehealth CR policies need to account for the possibility that lack of broadband-quality internet access could be a barrier to accessing telehealth CR delivery models.

Utilization Of Cardiac Rehabilitation During the SARS-CoV-2 Pandemic In Germany: A Difference-In-differences Analysis

Utilization Of Cardiac Rehabilitation During the SARS-CoV-2 Pandemic In Germany: A Difference-In-differences Analysis

Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE.

This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence. We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type. In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States. The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.

Effectiveness and Utilization of Cardiac Rehabilitation Among People With CKD

IntroductionCardiac rehabilitation (CR) is a proven therapy for reducing cardiovascular death and hospitalization. Whether CR participation is associated with improved outcomes in patients with chronic kidney disease (CKD) is unknown.MethodsWe obtained data on all adult patients in Calgary, Alberta, Canada with angiographically proven coronary artery disease from 1996 to 2016 referred to CR from The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation. An estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 or kidney replacement therapy defined CKD. Predictors of CR use were estimated with multinomial logistic regression. The association between starting versus not starting and completion versus noncompletion of CR and clinical outcomes were estimated using multivariable Cox proportional hazards models.ResultsOf 23,215 patients referred to CR, 12,084 were eligible for inclusion. Participants with CKD (N = 1322) were older, had more comorbidity, lower exercise capacity on graded treadmill testing, and took longer to be referred and to start CR than those without CKD. CKD predicted not starting CR: odds ratio 0.73 (95% confidence interval [CI] 0.64–0.83). Over a median 1 year follow-up, there were 146 deaths, 40 (0.3%) from CKD and 106 (1.0%) not from CKD. Similar to those without CKD, the risk of death was lower in CR completers (hazard ratio [HR] 0.24 [95% CI 0.06–0.91) and starters (HR 0.56 [95% CI 0.29– 1.10]) with CKD.ConclusionCR participation was associated with comparable benefits in people with moderate CKD as those without who survived to CR. Lower rates of CR attendance in this high-risk population suggest that strategies to increase CR utilization are needed.

Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries: An Interrupted Time Series.

Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization. From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale. Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48-2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, -2.4 to -0.12) compared with the prior period. Results were somewhat sensitive to time window variations. The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.

Abstract 14590: Cardiac Rehabilitation Utilization After Percutaneous Coronary Intervention Remains Exceedingly Low and is Strongly Associated With the Treating Hospital and Operator: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

Introduction: Despite its proven benefits, cardiac rehabilitation (CR) use remains low. Identifying the sources of variation in CR referral and downstream use may help direct policies and quality improvement efforts. Objectives: We sought to quantify the magnitude of hospital and operator-level variation in CR referral and utilization after percutaneous coronary intervention (PCI). Methods: We used clinical registry data from patients (pts) discharged after PCI between 1/2012 and 10/2016 at 32 Michigan hospitals performing at least 100 PCIs linked to Blue Cross Blue Shield or Medicare claims. Registry and claims data were used to identify (i) CR referral prior to discharge and (ii) any CR use within 90 days after discharge. We calculated hospital-level risk and reliability adjusted rates of CR referral and utilization with Bayesian hierarchical regression models adjusted for patient characteristics and clustering by hospital and operator. Median odds ratios (MORs) with 95% credible intervals (CI) measured variation attributable to hospitals and operators. Results: Among 33,593 pts with a valid zip code and discharged home after PCI, 76.4% received an in-hospital referral for CR. Overall CR use was 26.7% and 31.3% among those who received an in-hospital referral. Adjusted rates of CR referral and use across hospitals ranged from 1.0%-100% and 14.9%-73.9%, respectively (Fig). After adjusting for pt factors, there was significant hospital and operator-level variation in CR referral with MORs of 5.91 (95% CI 4.02-9.34) and 1.71 (95% CI 1.60-1.85), respectively. There was also significant hospital and operator-level variation in CR use with MORs of 1.99 (95% CI 1.67 - 2.46) and 1.36 (95% CI 1.29 - 1.44), respectively. Conclusions: We found significant hospital and operator-level variation not only in post-PCI CR referral, but also CR utilization. Multi-faceted interventions targeting hospitals and PCI operators are needed to improve CR use after PCI.

Clinicians Call for Physical Activity Guidelines for Pre- and Post- LVAD Implantation

Specific guidelines for physical activity (PA) have not been developed for individuals receiving left ventricular assist devices (LVAD). Therefore, the purpose of this study was to examine clinician PA recommendations pre- and post-LVAD and the utilization of cardiac rehabilitation (CR) services post-implantation. This exploratory, descriptive study was conducted via REDCap survey from April 2019 through October 2019. Clinicians provided implied consent by completing the survey, which was distributed through LVAD clinician list servs, in person at a targeted international conference, and through targeted emails sent to primary, secondary, and senior authors of manuscripts studying exercise or PA in LVAD recipients. Clinicians were asked demographic information about themselves and their implanting centers. Survey questions focused on pre- and post-LVAD implantation PA recommendations. Clinicians were also asked to discuss their thoughts on guidelines for post-implantation PA. Fifty-nine complete survey responses were recorded. Clinicians represented LVAD implanting centers from 10 countries including Israel, the United Kingdom, Germany, Italy, Canada, Spain, Australia, and 24 states in the U.S. Clinicians were 23/59 (38%) cardiologists or cardio-thoracic surgeons, 16/59 (27%) LVAD coordinators, 7/59 (12%) advance practice providers, and 8 identified as other. Clinicians reported their centers averaged 31 (SD 20.6) LVAD implantations a year. Although 93% (55/59) of clinicians reported they encourage PA in patients prior to LVAD only 22% percent (13/59) reported providing guidance about monitoring and controlling exertion during PA. Ninety percent of clinicians reported that they provided recommendations for type, frequency, intensity and duration of exercise post-LVAD. Most respondents (58/59) reported that patients are referred to CR post-LVAD; however, less than half of these clinicians reported a CR program tailored to LVAD patients. Nearly all clinicians (54/59) indicated a desire for practice guidelines for post-LVAD PA. Although clinicians agreed that PA is important in the pre- and post-LVAD implantation periods, there is little guidance or evidence to support best practices. Further research is needed to develop evidence-based guidelines to direct PA for patients pre- and post- LVAD implantation.

Utilization of Cardiac Rehabilitation Among Cardiac Intensive Care Unit Survivors

Cardiac rehabilitation (CR) is associated with decreased mortality and rehospitalization rates for patients with a variety of cardiac conditions. Although CR referral rates for STEMI patients have improved, rates for heart failure have remained low. Many of these patients are admitted to the cardiac intensive care unit (CICU). However, it is unknown how often CICU survivors qualify for cardiac rehabilitation, how often they are referred, and why eligible patients are not referred. This is a retrospective single-center study of 417 consecutive patients admitted to CICU for >48 hours from March 30, 2016 to March 30, 2017. We excluded patients with in-hospital mortality or those discharged AMA, to hospice or transferred. Chart abstraction was used to determine CR indications based on known American College of Cardiology/American Heart Association guidelines. If CR was indicated, medical records through September 2017 were reviewed to determine both referral and participation rates. In the absence of a referral, medical records were reviewed for potential barriers. A total of 296 CICU survivors were identified upon discharge with 185 (63%) having guideline-directed indications for CR referral. The most common indications were heart failure with reduced ejection fraction (HFrEF, 38%), cardiothoracic surgery (26%), and STEMI (23%). Upon discharge, only 30% of patients were referred to CR. The referral rate increased by 33% to 63% by 18 months postdischarge. CR referrals were most frequently placed following STEMI (91%), NSTEMI (80%), and postpercutaneous coronary intervention (80%). Only 35% of HFrEF discharges were referred to CR. Of patients not referred to CR, no explanation for a lack of referral was documented 87% of the time. In conclusion, nearly 2 of 3 patients discharged from the CICU had CR indications, most commonly HFrEF. CR referrals are frequently not placed and reason for nonreferral is rarely documented. CICU admission may provide a defined event to prompt referral.

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis.

Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13–1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20–0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36–0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02–1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion.

Cardiac Rehabilitation Utilization During an Acute Cardiac Hospitalization: A NATIONAL SAMPLE.

Inpatient cardiac rehabilitation (ICR) programs provide important services to hospitalized patients by delivering risk factor education, daily ambulation, and facilitation of referral to outpatient cardiac rehabilitation. However, little is known about ICR utilization or practice patterns. We examined the use of ICR, between January 2007 and June 2011, in a geographically and structurally diverse sample of US hospitals (Premier, Inc). Among 458 hospitals, there were 1 343 537 admissions with a qualifying diagnosis for outpatient cardiac rehabilitation. Formal ICR was available at 223 (49%) of these hospitals. Overall, patient utilization of ICR was low (21.2%) and varied by indication. Utilization was highest in those undergoing cardiac surgery (43.3%) and lowest in patients with medically managed myocardial infarction (15.6%) or heart failure (10.6%). A larger bed count, the presence of cardiac interventional services, and Midwest location were associated with increased likelihood of a hospital having an ICR program. In multivariable hierarchical analysis adjusting for known hospital characteristics among hospitals that provided ICR, multiple patient factors were associated with a lower likelihood of ICR utilization, including older age, more comorbidities, female sex, and Medicare insurance, but unspecified hospital characteristics explained the vast majority of the variability. We found substantial variation in the delivery of ICR across US hospitals and by patient condition. Overall, only a minority of eligible patients ever received ICR and fewer than half of hospitals treating cardiac patients provided formal ICR services. This substantial gap in the secondary prevention of heart disease warrants further investigation and intervention.

Functional Capacity but Not Early Uptake of Cardiac Rehabilitation Predicts Readmission in Patients With Metabolic Syndrome.

Phase II cardiac rehabilitation reduces hospital readmissions and cardiovascular disease risk factors and improves functional capacity. Cardiovascular disease risk factors double with patients with metabolic syndrome, a population less likely to adhere to cardiac rehabilitation. The aim of this study was to determine relationships between cardiac rehabilitation uptake timing, demographic variables and functional capacity, and readmission in patients with metabolic syndrome. This retrospective, medical records study involved 353 patients with metabolic syndrome who subsequently received cardiac rehabilitation. Logistic regression was used to examine relationships between time from discharge to cardiac rehabilitation uptake and readmission. Unordered categorical factors were compared between readmission groups using Pearson χ tests. Multivariable logistic regression was used to identify predictors of readmission. Patients readmitted within 30 and 90 days of hospitalization were more often women (P ≤ .018) and nonwhite (P ≤ .002) and had lower functional capacity (P < .001). In multivariable analysis, white race (odds ratio [OR], 0.50 [95% confidence interval (CI), 0.25-0.99]; P = .045) and higher functional capacity (OR, 0.80 [95% CI, 0.68-0.93]; P = .005) were protective against hospital readmission within the first 90 days. Race, sex, and functional capacity remained significant predictors of readmission at 1 year. In multivariable analysis, only race (OR, 0.41 [95% CI, 0.22-0.79]; P = .007) and functional capacity (OR, 0.83 [95% CI, 0.73-0.95]; P = .007) were significant. Early cardiac rehabilitation was not associated with readmission at any time point (P > .05). Sex, race, and functional capacity were important predictors of readmission for metabolic syndrome, even when cardiac rehabilitation intake was delayed. Results raise questions about the unique traits of patients with metabolic syndrome and need for novel approaches to improve cardiac rehabilitation utilization and functional capacity in metabolic syndrome.

Abstract 163: Implementation of a Physician Order Set Improves Adherence to Cardiac Care Unit Policy: A Quality Improvement Initiative

Objective: To determine if using physician order sets within the electronic health record improves adherence with local policy in the Cardiac Care Unit (CCU) at University of Florida Health - Jacksonville (UFH-J) Background: In 2015, CCU at UFH-J implemented a policy to guide the utilization of wearable cardioverter-defibrillators (WCD) in patients with heart failure and ejection fraction less or equal to 35%. Adherence to this policy was sparse and needed improvement. Methods: We hypothesized that developing an electronic order set would improve adherence to existing CCU policy. The policy to be addressed was the CCU WCD policy. Pre-intervention data from January 1-June 30, 2016 was analyzed for compliance. We evaluated policy compliance in heart failure patients admitted to the CCU. On July 1, 2016, a CCU admission order set, including a section on the WCD policy, launched. The order set was developed with multi-disciplinary input from nursing, nutrition, pharmacy, and physicians. To ensure adequate time for adjustment to the order set, the post-intervention data set was collected from January 1 - June 30, 2017. Results: Implementation of the CCU admission order set resulted in a 23% absolute increase in compliance with the CCU WCD policy. Additional benefits of the implementation of the order set that were not directly evaluated in this study include standardization of initial evaluation and patient care, improvement in the selection of the appropriate diet for cardiac patients with other dietary considerations including diabetes and renal disease, and an increase in the utilization of cardiac rehabilitation upon discharge. Conclusion: Implementation of an order set is an effective way to improve adherence to patient care policy. Further studies to assess impact of physician order sets on morbidity and mortality, especially in patients with a WCD are warranted.

Enhancing Participation in Cardiac Rehabilitation: A Question of Proximity and Integration of Outpatient Services

Numerous investigations have established the strong clinical utility of cardiac rehabilitation, while clinical guidelines continually call for a high level of referral and participation. Historically, medical facilities have faced challenges referring eligible patients to cardiac rehabilitation, enrolling only a small portion of those receiving referral. Consequently, less than ~10% of qualifying patients receive any amount of cardiac rehabilitation. This sobering figure has prompted many efforts to identify barriers to referral as well as enrollment and accordingly propose strategies to bolster participation rates. Although reports have highlighted improvements through focused approaches, enrollment rates still lag behind the goal of reaching 70% by 2022, proposed by the Million Hearts Cardiac Rehabilitation Collaborative. An area of inquiry that has received little to no attention in this effort has been the influence of proximity between physician-driven outpatient clinics and cardiac rehabilitation facilities. In this report we outline the development and design of a clinical faculty practice aimed to maintainclose geographical proximity between our physicianclinic and the cardiac rehabilitation area. We also propose that our impressive enrollment rates of 57% within our facility and 73% when including patients that started alternative exercise programs were likely due to establishing a close proximity between the respective practices.

Cardiac rehabilitation following an acute coronary syndrome: Trends in referral, predictors and mortality outcome in a multicenter national registry between years 2006-2013: Report from the Working Group on Cardiac Rehabilitation, the Israeli Heart Society.

Background Utilization of cardiac rehabilitation is suboptimal. The aim of the study was to assess referral trends over the past decade, to identify predictors for referral to a cardiac rehabilitation program, and to evaluate the association with one-year mortality in a large national registry of acute coronary syndrome patients. Design and methods Data were extracted from the Acute Coronary Syndrome Israeli Survey national surveys between 2006-2013. A total of 6551 patients discharged with a diagnosis of acute coronary syndrome were included. Results Referral to cardiac rehabilitation following an acute coronary syndrome increased from 38% in 2006 to 57% in 2013 ( p for trend < 0.001). Multivariate modeling identified the following independent predictors for non-referral: 2006 survey, older age, female sex, past stroke, heart or renal failure, prior myocardial infarction, minority group, and lack of in-hospital cardiac rehabilitation center (all p < 0.01). Kaplan-Meier survival analyses showed one-year survival rates of 97% vs 92% in patients referred for cardiac rehabilitation as compared to those not referred (log-rank p < 0.01). Multivariate analysis showed that referral for cardiac rehabilitation was associated with a 27% mortality risk reduction at one-year follow-up ( p = 0.03). Consistently, a 32% lower one-year mortality risk was evident in a propensity score matched group of 3340 patients (95% confidence interval 0.48-0.95, p = 0.02). Conclusions Over the past decade there was a significant increase in cardiac rehabilitation referral following an acute coronary syndrome. However, cardiac rehabilitation is still under-utilized in important high-risk subsets of this population. Patients referred to cardiac rehabilitation have a lower adjusted mortality risk.

Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit.

BackgroundCardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation.Methods and ResultsData from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees, using the Huber–White–sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98–0.99), having a partner (OR 1.31, 95% CI 1.17–1.48), not being employed (OR 0.86, 95% CI 0.77–0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77–0.92), greater anxiety (OR 1.02, 95% CI 1.003–1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42–0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09–2.47).Conclusions CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence‐based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized.