Psychosocial well-being over the two years following cardiac rehabilitation initiation & association with heart-health behaviors

The objective of this research was to track psychosocial well-being over 2 years following cardiac rehabilitation (CR) initiation, and its' association with heart-health behaviors. Patients from 3 CR programs were approached at their first visit,and consenters completed a survey. Participants were emailed surveys again 6 months, 1 and 2 years later. Depressive symptoms (PHQ-8) and quality of life were assessed at each point, as were exercise, nutrition, smoking and medication adherence, among other well-being indicators. Of 411 participants, 46.7% were retained at 2 years. Post-CR, there was 70% concordance between participants' desired and actual work status. Depressive symptoms were consistently minimal over time (mean = 3.17 ± 0.37); Quality of life was high, and increased over time (p = .01). At 2 years, 56.9% participants met exercise recommendations, and 5.4% smoked. With adjustment, greater self-regulation was associated with significantly greater exercise at intake; greater exercise self-efficacy was significantly associated with greater exercise at 1 year; greater disease management self-efficacy was significantly associated with greater exercise at 2 years; greater environmental mastery (actual) was significantly associated with greater exercise at 2 years. Lower depressive symptoms were significantly associated with better nutrition at 2 years. CR initiators are thriving, and this relates to better exercise and diet.Social Sciences and Humanities Research Council (SSHRC

Interventions to promote patient utilisation of cardiac rehabilitation

Background: International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation. Objectives: First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations. Search methods: Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index ‐ Science (CPCI‐S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions. Selection criteria: We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity. Data collection and analysis: Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random‐effects meta‐regression for each outcome and explored prespecified study characteristics. Main results: Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation. Low‐quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta‐regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face‐to‐face; P = 0.01) were influential in increasing enrolment. Low‐quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home‐based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate‐quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi‐centre studies were less effective than those given in single‐centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small‐study bias for enrolment (insufficient studies to test for this in the other outcomes). With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women‐tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. Authors' conclusions: Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face‐to‐face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion

Cochrane corner:increasing patient utilisation of cardiac rehabilitation

No abstract available

Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement

Background: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its’ benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations. Methods: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment. Results: The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95±0.69 (mean ± standard deviation), 5.33±1.12 and 5.64±1.08, respectively. Conclusions: Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs

Promoting Patient Utilization of Cardiac Rehabilitation - Systematic Review and Knowledge Translation

Cardiac Rehabilitation (CR) is a proven, cost-effective outpatient model of care for secondary prevention of cardiovascular disease (CVD), a highly prevalent health condition worldwide. Unfortunately, despite the existence of some guidelines with recommendations to refer CVD patients to CR, rates of CR utilization are low. Lack of strong and supportive endorsement by a healthcare provider may serve as a barrier to utilization. The overall aim of the doctoral dissertation is to advance scholarly understanding and knowledge translation to promote CR utilization. For this purpose, three interlinked research studies were undertaken. Using rigorous Cochranes methodological standards, I first updated the Cochrane systematic review on interventions to promote patient utilization of CR. Next, the first-ever position statement on implementable recommendations to increase patient utilization of CR was developed in accordance with AGREE II, among other guideline checklists, to build on the findings of the updated systematic review. Finally, following Kirkpatricks framework in a multi-method study, an online course for healthcare providers was developed and tested to promote the implementation of the recommendations gained from the earlier work. The present dissertation is fundamental in the identification and knowledge transfer of effective interventions to promote patient utilization of CR programs. The recommendations and tools developed herein will potentially guide policy-makers, healthcare providers and cardiac patients towards greater utilization of CR and therefore, reduction of CVD risk

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

Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course

Abstract Background A policy statement recommending that healthcare providers (HCPs) encourage cardiac patients to enroll in cardiac rehabilitation (CR) was recently endorsed by 23 medical societies. This study describes the development and evaluation of a guideline implementation tool. Methods A stepwise multiple-method study was conducted. Inpatient cardiac HCPs were recruited between September 2018–May 2019 from two academic hospitals in Toronto, Canada. First, HCPs were observed during discharge discussions with patients to determine needs. Results informed selection and development of the tool by the multidisciplinary planning committee, namely an online course. It was pilot-tested with target users through a think-aloud protocol with subsequent semi-structured interviews, until saturation was achieved. Results informed refinement before launching the course. Finally, to evaluate impact, HCPs were surveyed to test whether knowledge, attitudes, self-efficacy and practice changed from before watching the course, through to post-course and 1 month later. Results Seven nurses (71.4% female) were observed. Five (62.5%) initiated dialogue about CR, which lasted on average 12 s. Patients asked questions, which HCPs could not answer. The planning committee decided to develop an online course to reach inpatient cardiac HCPs, to educate them on how to encourage patients to participate in CR at the bedside. The course was pilot-tested with 5 HCPs (60.0% nurse-practitioners). Revisions included providing evidence of CR benefits and clarification regarding pre-CR stress test screening. HCPs did not remember the key points to convey, so a downloadable handout was embedded for the point-of-care. The course was launched, with the surveys. Twenty-four HCPs (83.3% nurses) completed the pre-course survey, 21 (87.5%) post, and 9 (37.5%) 1 month later. CR knowledge increased from pre (mean = 2.71 ± 0.95/5) to post-course (mean = 4.10 ± 0.62; p ≤ .001), as did self-efficacy in answering patient CR questions (mean = 2.29 ± 0.95/5 pre and 3.67 ± 0.58 post; p ≤ 0.001). CR attitudes were significantly more positive post-course (mean = 4.13 ± 0.95/5 pre and 4.62 ± 0.59 post; p ≤ 0.05). With regard to practice, 8 (33.3%) HCPs reported providing patients CR handouts pre-course at least sometimes or more, and 6 (66.7%) 1 month later. Conclusions Preliminary results support broader dissemination, and hence a genericized version has been created ( http://learnonthego.ca/Courses/promoting_patient_participation_in_CR_2020/promoting_patient_participation_in_CR_2020EN/story_html5.html ). Continuing education credits have been secured

Course for Promoting CR at Bedside - Evaluation

Purpose: Evidence proves health care providers should promote cardiac rehabilitation (CR) to patients face-to-face to increase CR enrollment. An online course was designed to promote this at the bedside; it is evaluated herein in terms of reach, effect on knowledge, attitudes, discussion self-efficacy and practices, and satisfaction. Methods: Design was observational, one-group pretest-posttest. Some demographics were requested from learners taking all language versions of the 20-minute course: English, Portuguese, French, Spanish, and simplified Chinese, available at https://globalcardiacrehab.com/CR-Utilization. Investigator-generated items in the pre- and post-test and evaluation survey administered using Google Forms were based on Kirkpatrick’s training evaluation model. Results: The course was initiated by 522 learners from 33/203 (16.3%) countries; most commonly female (n=341, 65.3%) nurses (n=180, 34.5%) from high-income countries (n=259, 56.7%), completing the English (n=296, 56.7%) and Chinese (n=108, 20.7%) versions. 414 (79.3%) completed the post-test and 302 (57.9%) completed the evaluation. Median CR attitudes were 5/5 on the Likert scale at pre-test, suggesting some selection bias. Mean CR knowledge (7.22±2.14/10), discussion self-efficacy (3.86±0.85/5), and practice (4.13±1.11/5) significantly improved after completion of the course (all P<.001). Satisfaction was high regardless of language version (4.44±0.64/5; P=.593). Conclusions: This free, open-access course is effective in increasing CR knowledge, self-efficacy, and encouragement practices among participating inpatient cardiac providers, with high satisfaction. While testing impact on actual CR use is needed, it should be more broadly disseminated to increase reach, in an effort to increase patient enrollment in CR, to reduce morbidity and mortality

Cardiac Rehabilitation Dose Around the World: Variation and Correlates.

Cardiac rehabilitation (CR) is recommended in clinical practice guidelines, but dose prescribed varies highly by country. This study characterized the dose offered in supervised CR programs and alternative models worldwide and their potential correlates. In this cross-sectional study, an online survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Countries were classified based on region and income categories. Dose was operationalized as program duration×sessions per week. Generalized linear mixed models were performed to assess correlates. Of 203 countries in the world, 111 (54.7%) offered CR; data were collected in 93 (83.8% country response rate; n=1082 surveys, 32.1% program response rate). Globally, supervised CR programs were a median of 24 sessions (n=619, 57.3% programs ≥12 sessions); home-based and community-based programs offered 6 and 20 sessions, respectively. There was significant variation in supervised CR dose by region (≤0.001), with the Americas (median, 36 sessions) offering a significantly greater dose than several other regions; there was also a trend for variation by country income classification. There was no difference in home-based dose by region (=0.43) but there was for community-based programs (<0.05; Americas offering greater dose). There was a significant dose variation in both home- and community-based programs by income classification (=0.002 and <0.001, respectively), with higher doses offered by upper-middle-income than high-income countries. Correlates of supervised CR dose included more involvement of physicians (=0.026), proximity to other programs (=0.002), and accepting patients with noncardiac indications (=0.037). CR programs in many countries may need to increase their dose, which could be supported through physician champions