Do clinicians prescribe exercise similarly in patients with different cardiovascular diseases? Findings from the EAPC EXPERT working group survey

Background: Although disease-specific exercise guidelines for cardiovascular disease (CVD) are widely available, it remains uncertain whether these different exercise guidelines are integrated properly for patients with different CVDs. The aim of this study was to assess the inter-clinician variance in exercise prescription for patients with various CVDs and to compare these prescriptions with recommendations from the EXercise Prescription in Everyday practice and Rehabilitative Training (EXPERT) tool, a digital decision support system for integrated state-of-the-art exercise prescription in CVD. Design: The study was a prospective observational survey. Methods: Fifty-three CV rehabilitation clinicians from nine European countries were asked to prescribe exercise intensity (based on percentage of peak heart rate (HRpeak)), frequency, session duration, programme duration and exercise type (endurance or strength training) for the same five patients. Exercise prescriptions were compared between clinicians, and relationships with clinician characteristics were studied. In addition, these exercise prescriptions were compared with recommendations from the EXPERT tool. Results: A large inter-clinician variance was found for prescribed exercise intensity (median (interquartile range (IQR)): 83 (13) % of HRpeak), frequency (median (IQR): 4 (2) days/week), session duration (median (IQR): 45 (18) min/session), programme duration (median (IQR): 12 (18) weeks), total exercise volume (median (IQR): 1215 (1961) peak-effort training hours) and prescription of strength training exercises (prescribed in 78% of all cases). Moreover, clinicians’ exercise prescriptions were significantly different from those of the EXPERT tool (p < 0.001). Conclusions: This study reveals significant inter-clinician variance in exercise prescription for patients with different CVDs and disagreement with an integrated state-of-the-art system for exercise prescription, justifying the need for standardization efforts regarding integrated exercise prescription in CV rehabilitation

Beyond outputs: pathways to symmetrical evaluations of university sustainable development partnerships

As the United Nations Decade of Education for Sustainable Development (2005–2014) draws to a close, it is timely to review ways in which the sustainable development initiatives of higher education institutions have been, and can be, evaluated. In their efforts to document and assess collaborative sustainable development program outcomes and impacts, universities in the North and South are challenged by similar conundrums that confront development agencies. This article explores pathways to symmetrical evaluations of transnationally partnered research, curricula, and public-outreach initiatives specifically devoted to sustainable development. Drawing on extensive literature and informed by international development experience, the authors present a novel framework for evaluating transnational higher education partnerships devoted to sustainable development that addresses design, management, capacity building, and institutional outreach. The framework is applied by assessing several full-term African higher education evaluation case studies with a view toward identifying key limitations and suggesting useful future symmetrical evaluation pathways. University participants in transnational sustainable development initiatives, and their supporting donors, would be well-served by utilizing an inclusive evaluation framework that is infused with principles of symmetry

Optimising exercise based cardiac rehabilitation programs in the Netherlands: One size does not FIT all

Als eerste beschrijft dit proefschrift 2 systematische reviews van de literatuur. Hierin wordt onderzocht wat de bijdrage van verschillende karakteristieken van fysieke trainingsprogramma’s voor revalidatie van hartpatiënten is in de positieve effecten hiervan op de inspanningscapaciteit. Hieruit bleek dat met name de totale trainingsomvang (product van duur en intensiteit) bepalend is voor het effect van de training. Daarna worden een tweetal studies beschreven waarin de inhoud van fysieke hartrevalidatieprogramma’s in Nederland beter in kaart wordt gebracht. Hieruit bleek dat momenteel meestal geen rekening wordt gehouden met individuele patientkarakteristieken in het voorschrijven van training. Bovendien worden lang niet altijd de laatste richtlijnen gevolgd. In het laatste deel van dit proefschrift beschrijven we ten eerste de ontwikkeling van een computergestuurd beslisondersteuningssysteem op basis van de laatste richtlijnen. Hierna wordt een studie beschreven waarin het effect van het gebruik van dit beslisondersteuningssysteem wordt getest op het gepersonaliseerd voorschrijven van trainingsprogramma’s in de hartrevalidatie. Hieruit bleek dat dit het gebruik van dit systeem niet leidde tot grote veranderingen in het voorschrijven van trainingsprogramma’s. Concluderend kunnen de bevindingen van dit proefschrift belangrijke gevolgen hebben voor de dagelijks praktijk van de fysieke hartrevalidatie. De bevindingen uit dit proefschrift kunnen met name gebruikt worden om nieuwe verbeterinitiatieven te ontwikkelen om meer gepersonaliseerd trainingsprogramma’s voor te schrijven in de hartrevalidatie teneinde de positieve effecten van hartrevalidatie nog beter te benutten

The application of a continuous nourishment in a tidal inlet system: Case study Ameland Inlet

There is a demand by Rijkswaterstaat for CO2-neutral sustainable methods and technologies to maintain the Dutch coastline. The Zandwindmolen is a fixed CO2-neutral dredge, transport and nourishment concept that nourishes sediment continuously. The purpose of using a Zandwindmolen is to provide the entire surrounding area where the Zandwindmolen nourishes with sediment and allowing it to grow with the (accelerated) sea level rise. With the traditional nourishment method, it is often desired that the sand remains at the vulnerable site for as long as possible. Whereas, in a nourishment with the Zandwindmolen, it is often desirable for the sand to move to other nearby parts of the coast as quickly as possible.Between 2011 and 2020, 27.5 million m3 of sand has been nourished at the Ameland Inlet. Therefore, it might be considered as an erosion hotspot. Because of the fixed nourishment method of the Zandwindmolen and the continuous sand shortage at the Ameland Inlet, there is a match. However, the usefulness of a Zandwindmolen depends on the extent to which the nourished sand volume is dispersed by natural processes in the short and long term.In this study, both the short- and long-term effect of a continuous point nourishment in a tidal channel is investigated for four sediment fractions (100, 200, 300 and 400 μm). The goal is that the sediment is dispersed by nature in order to allow the entire Ameland Inlet (adjacent coastlines, coastal foundation, outer delta and Wadden Sea basin) to grow along with sea level rise.For optimal dispersion, the nourishment must be carried out by means of a spreader pontoon with a sediment mixture concentration of 1-2%. By doing so, a mixing plume is created in which sediment settles according to their individual settling velocity. This makes the mixing plume prone to the tidal ebb and flood current and can therefore be steered towards either the North- or Wadden Sea. In the short term (time scale: instantaneous to a few weeks), it appears that the dispersion of sediment is mainly determined by the initial sedimentation process of sediment and by re-suspension of settling sediment particles. The dispersion by natural sediment processes is minimal. In the longer term (timescale: half a year) the sediment spreads further after it has settled to the seabed. Based on half a year, the total dispersion is mainly determined by the short term dispersion.It is found that a continuous nourishment with the Zandwindmolen is expected to ensure that the intertidal areas in the eastern Wadden Sea can continue to grow naturally with (accelerated) sea level rise. Moreover, the natural distribution of the nourished sand will, through sediment connectivity, compensate for the erosion (autonomous and due to sea level rise) of the inlet (especially the outer delta) and is also expected to contribute to keeping the North Sea coast of Terschelling and Ameland safe. Therefore, the Zandwindmolen could be a useful new sustainable nourishment method in a tidal inlet.Zandwindmolen projectCivil Engineering | Hydraulic Engineerin

Practice Variations in Exercise Training Programs in Dutch Cardiac Rehabilitation Centers:Prospective, Observational Study

BACKGROUND: A recent survey among Dutch cardiac rehabilitation centers demonstrated considerable between-center variations in the contents of exercise training programs. For patients entering cardiac rehabilitation, current guidelines recommend tailored exercise training programs based on patient characteristics and rehabilitation goals. OBJECTIVE: This study was to analyze to what extent these patient characteristics are determinants of variations in training programs. DESIGN: This was a prospective, observational study with cross-sectional measurements among 10 cardiac rehabilitation centers. METHODS: The following data were obtained about patients entering cardiac rehabilitation: referral diagnosis, rehabilitation goals, and exercise training variables. Primary outcomes were variations in total aerobic training time, intensity, and volume before and after case-mix correction for population differences between centers. Secondary outcomes were variations in other training characteristics and the role of exercise testing in the determination of training intensity. Also, the roles of diagnosis and training goals in determining aerobic training time and intensity were studied. RESULTS: Data from 700 participants were analyzed. There were significant variations between centers in all aerobic and most resistance training characteristics. For aerobic training intensity, time, and volume, great variations remained after case-mix correction. An exercise test was performed for 656 participants (93.7%) but was used to determine training intensity in only 344 (52.4%) of these participants. In most centers, referral diagnosis and rehabilitation goals were unrelated to aerobic training time or intensity. LIMITATIONS: Some form of selection bias cannot be excluded because the competing centers represented a minority of Dutch exercise-based cardiac rehabilitation centers. CONCLUSIONS: This study showed that the contents of training programs varied considerably between cardiac rehabilitation centers, independent of population differences. Furthermore, aerobic training time and intensity were mostly unrelated to rehabilitation goals and referral diagnosis

The influence of training characteristics on the effect of exercise training in patients with coronary artery disease: systematic review and meta-regression analysis

Background: Although exercise-based cardiac rehabilitation improves exercise capacity of coronary artery disease patients, it is unclear which training characteristic determines this improvement. Total energy expenditure and its constituent training characteristics (training intensity, session frequency, session duration and programme length) vary considerably among clinical trials, making it hard to compare studies directly. Therefore, we performed a systematic review and meta-regression analysis to assess the effect of total energy expenditure and its constituent training characteristics on exercise capacity. Methods: We identified randomised controlled trials comparing continuous aerobic exercise training with usual care for patients with coronary artery disease. Studies were included when training intensity, session frequency, session duration and programme length was described, and exercise capacity was reported in peakVO(2). Energy expenditure was calculated from the four training characteristics. The effect of training characteristics on exercise capacity was determined using mixed effects linear regression analyses. The analyses were performed with and without total energy expenditure as covariate. Results: Twenty studies were included in the analyses. The mean difference in peakVO(2) between the intervention group and control group was 3.97 ml.min(-1).kg(-1) (p <0.01, 95% CI 2.86 to 5.07). Total energy expenditure was significantly related to improvement of exercise capacity (effect size 0.91 ml.min(-1).kg(-1) per 100 J.kg(-1) p <0.01, 95% CI 0.77 to 1.06), no effect was found for its constituent training characteristics after adjustment for total energy expenditure. Conclusions: We conclude that the design of an exercise programme should primarily be aimed at optimising total energy expenditure rather than on one specific training characteristic. (C) 2017 The Authors. Published by Elsevier Ireland Lt

A computerized decision support system did not improve personalization of exercise-based cardiac rehabilitation according to latest recommendations

AIMS: Recent studies showed that exercise-based cardiac rehabilitation (ECR) programmes are often not personalized to individual patient characteristics according to latest recommendations. This study investigates whether a computerized decision support (CDS) system based on latest recommendations and guidelines can improve personalization of ECR prescriptions. Pseudo-randomized intervention study. METHODS AND RESULTS: Among participating Dutch cardiac rehabilitation centres, ECR programme characteristics of consecutive patients were recorded during 1 year. CDS was used during a randomly assigned 4-month period within this year. Primary outcome was concordance to latest recommendations in three phases (before, during, and after CDS) for 12 ECR programme characteristics. Secondary outcome was variation in training characteristics. We recruited ten Dutch CR centres and enrolled 2258 patients to the study. Overall concordance of ECR prescriptions was 59.9% in Phase 1, 62.1% in Phase 2 (P = 0.82), and 59.9% in Phase 3 (P = 0.56). Concordance varied from 0.0% to 99.9% for the 12 ECR characteristics. There was significant between-centre variation for most training characteristics in Phases 1 and 2. In Phase 3, there was only a significant variation for aerobic and resistance training intensity (P = 0.01), aerobic training volume (P < 0.01), and the number of strengthening exercises but no longer for the other characteristics. Aerobic training volume was often below recommended (28.2%) and declined during the study. CONCLUSION: CDS did not substantially improve concordance with ECR prescriptions. As aerobic training volume was often lower than recommended and reduced during the study, a lack of institutional resources might be an important barrier in personalizing ECR prescriptions

How to use concept mapping to identify barriers and facilitators of an electronic quality improvement intervention

Systematic quality improvement (QI) interventions are increasingly used to change complex health care systems. Results of randomized clinical trials can provide quantitative evidence whether QI interventions were effective but they do not teach us why and how QI was (not) achieved. Qualitative research methods can answer these questions but typically involve only a small group of respondents against high resources. Concept mapping methodology overcomes these drawbacks by integrating results from qualitative group sessions with multivariate statistical analysis to represent ideas of diverse stakeholders visually on maps in an efficient way. This paper aims to describe how to use concept mapping to qualitatively gain insight into barriers and facilitators of an electronic QI intervention and presents experiences with the method from an ongoing case study to evaluate a QI system in the field of cardiac rehabilitation in the Netherland