Evaluation of the American Association of Cardiovascular and Pulmonary Rehabilitation Exercise Risk Stratification Classification Tool Without Exercise Testing.

PURPOSE: The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommends that patients starting cardiac rehabilitation (CR) undergo stratification to identify risk for exercise-related adverse events (AE), but this tool has not been recently evaluated. METHODS: Among patients who enrolled in CR in 2016, we used the AACVPR risk stratification tool to evaluate the risk for AE and clinical events (CE). We defined AE as signs or symptoms that precluded or interrupted exercise during CR, and CE as events requiring an urgent evaluation outside of CR exercise sessions. RESULTS: During the study period, 657 patients with cardiovascular diagnoses were included and classified as high (58%), medium (31%), or low risk (11%). Over the course of CR (76 d, 17 sessions), there were 63 AE and 33 CE. Adverse events were mostly minor (no cardiac arrests or deaths) and managed by CR staff members. When compared with the low- or medium-risk groups, the high-risk group was more likely to have AE (HR 3.0 [95% CI, 1.7-5.9], P = .002) and CE (HR 3.7 [95% CI, 1.5-10.8], P = .002) with fair model discrimination (area under the curve: 0.637, P < .001). CONCLUSION: The AACVPR risk stratification tool was predictive of both AE and CE with fair discrimination, although event rates were low and mostly minor. Thus, the AACVPR model may require reevaluation to better identify truly at-risk patients for major AE.

Cardiac rehabilitation in Takotsubo cardiomyopathy: Predictors of utilization and effects of exercise training.

BACKGROUND: Takotsubo cardiomyopathy (TCM) patients may benefit from cardiac rehabilitation (CR). OBJECTIVES: The purpose to this study is to examine utilization of CR in TCM. METHODS: We conducted a review of hospitalized TCM patients at Baystate Medical Center between 2010 and 2017. We evaluated rates of referral, enrollment, adherence, and changes in exercise capacity. Predictors of CR utilization were analyzed using t-test, chi-square/odds ratio and multivariable hierarchical modeling when appropriate. RESULTS: Over 8 years, 35% of 590 patients with TCM were evaluated by phase I (inpatient) and 13.6% enrolled in phase II (outpatient) CR. Inpatient CR evaluation (OR 21, 95% CI 7-64) and cardiac catheterization (OR 5.7, 95% CI 1.9-17) were strong predictors of outpatient CR participation. Patients enrolling in CR attended 15±14 sessions and increased their exercise capacity by 1.2 METs (95% CI 0.9-1.5). CONCLUSION: CR is inconsistently used in TCM, despite the potential physiologic benefits of exercise in TCM.

Development of a Simple Clinical Tool for Predicting Early Dropout in Cardiac Rehabilitation: A SINGLE-CENTER RISK MODEL.

BACKGROUND: Nonadherence to cardiac rehabilitation (CR) is common despite the benefits of completing a full program. Adherence might be improved if patients at risk of early dropout were identified and received an intervention. METHODS: Using records from patients who completed ≥1 CR session in 2016 (derivation cohort), we employed multivariable logistic regression to identify independent patient-level characteristics associated with attending <12 sessions of CR in a predictive model. We then evaluated model discrimination and validity among patients who enrolled in 2017 (validation cohort). RESULTS: Of the 657 patients in our derivation cohort, 318 (48%) completed <12 sessions. Independent risk factors for not attending ≥12 sessions were age <55 yr (OR = 0.23, P < .001), age 55 to 64 yr (OR = 0.35, P < .001), age ≥75 yr (OR = 0.64, P = .06), smoker within 30 d of CR enrollment (OR = 0.40, P = .001), low risk for exercise adverse events (OR = 0.54, P = .03), and nonsurgical referral diagnosis (OR = 0.66, P = .02). Our model predicted nonadherence risk from 23-90%, had acceptable discrimination and calibration (C-statistics = 0.70, Harrell's E50 and E90 2.0 and 3.6, respectively) but had fair validity among 542 patients in the validation cohort (C-statistic = 0.62, Harrell's E50 and E90 2.1 and 11.3, respectively). CONCLUSION: We developed and evaluated a single-center simple risk model to predict nonadherence to CR. Although the model has limitations, this tool may help clinicians identify patients at risk of early dropout and guide intervention efforts to improve adherence so that the full benefits of CR can be realized for all patients.

Association Between Patient Cost Sharing and Cardiac Rehabilitation Adherence.

OBJECTIVE: To determine the association between cost sharing and adherence to cardiac rehabilitation (CR). PATIENTS AND METHODS: We collected detailed cost-sharing information for patients enrolled in CR at Baystate Medical Center in Springfield, Massachusetts, including the presence (or absence) and amounts of co-pays and deductibles. We evaluated the association between cost sharing and the total number of CR sessions attended as well as the influence of household income on CR attendance. RESULTS: In 2015, 603 patients enrolled in CR had complete cost-sharing information. In total, 235 (39%) had some form of cost sharing. Of these, 192 (82%) had co-pays (median co-pay, $20; interquartile range [IQR], $10-$32) and 79 (34%) had an unmet deductible (median, $500; IQR, $250-$1800). The presence of any amount or form of cost sharing was associated with 6 fewer sessions of CR (16; IQR, 4-36 vs 10; IQR, 4-27; P<.001). Patients hospitalized in November or December with deductibles that renewed in January attended 4.5 fewer sessions of CR (8.5; IQR, 3.25-12.50 vs 13; IQR, 5.25-36.00; P=.049). After adjustment for differences in baseline characteristics, every $10 increase in co-pay was associated with 1.5 (95% CI, -2.3 to -0.7) fewer sessions of CR (P<.001). Household income did not moderate these relationships. CONCLUSION: Cost sharing was associated with lower CR attendance and exhibited a dose-response relationship such that higher cost sharing was associated with lower CR attendance. Given that CR is cost-effective and underutilized, insurance companies and other payers should reevaluate their cost-sharing policies for CR.

Smoking cessation after hospitalization for myocardial infarction or cardiac surgery: Assessing patient interest, confidence, and physician prescribing practices.

BACKGROUND: Prioritizing and managing multiple behavior changes following a cardiac hospitalization can be difficult, particularly among smokers who must also overcome a serious addiction. HYPOTHESIS: Hospitalized smokers will report a strong interest in smoking cessation (SC) but will receive little assistance from their physicians. METHODS: We asked current smokers hospitalized for an acute cardiac event to prioritize their health behavior priorities, and inquired about their attitude toward SC therapies. We also assessed SC cessation prescriptions provided by their physicians. RESULTS: Of the 105 patients approached, 81 (77%) completed the survey. Of these, 72.5% ranked SC as their greatest health change priority, surpassing all other behavior changes, including: taking medications, attending cardiac rehabilitation (CR), dieting, losing weight, and attending doctor appointments. Patients felt that SCM (44%), CR (41%), and starting exercise (35%) would increase their likelihood for SC. While most patients agreed that smoking was harmful, 16% strongly disagreed that smoking was related to their hospitalization. At discharge, medication was prescribed to ~32% of patients, with equal frequency among patients who reported interest and those who reported no interest in using medications. CONCLUSION: The majority of hospitalized smokers with cardiac disease want to quit smoking, desire help in doing so, and overwhelmingly rate cessation as their highest health behavior priority, although some believe smoking is unrelated to their disease. The period following an acute cardiac event appears to be a time of great receptivity to SC interventions; however, rates of providing tailored, evidence-based interventions are disappointingly low.

A Motivational Telephone Intervention to Reduce Early Dropouts in Cardiac Rehabilitation: A FEASIBILITY PILOT STUDY.

PURPOSE: Cardiac rehabilitation (CR) improves outcomes, yet early dropout is common. The purpose of the study was to determine whether a motivational telephone intervention among patients at risk for nonadherence would reduce early dropouts. METHODS: We performed a randomized double-blind pilot study with the intervention group receiving the telephone intervention 1 to 3 d after outpatient CR orientation. The control group received the standard of care, which did not routinely monitor attendance until 2 wk after orientation. The primary outcome was the percentage of patients who attended their second exercise session as scheduled. Secondary outcomes included attendance at the second CR session at any point and total number of sessions attended. Because not everyone randomized to the intervention was able to be contacted, we also conducted a per-protocol analysis. RESULTS: One hundred patients were randomized to 2 groups (age 62 ± 15 yr, 46% male, 40% with myocardial infarction) with 49 in the intervention group. Patients who received the intervention were more likely to attend their second session as scheduled compared with the standard of care (80% vs 49%; relative risk = 1.62; 95% CI, 1.18-2.22). Although there was no difference in total number of sessions between groups, there was a statistically significant improvement in overall return rate among the per-protocol group (87% vs 66%; relative risk = 1.31; 95% CI, 1.05-1.63). CONCLUSIONS: A nursing-based telephone intervention targeted to patients at risk for early dropout shortly after their CR orientation improved both on-time and eventual return rates. This straightforward strategy represents an attractive adjunct to improve adherence to outpatient CR.

Patient Perception of How Smoking Status Influences Cardiac Rehabilitation Attendance After an Acute Cardiac Hospitalization.

PURPOSE: Patients hospitalized with a cardiac condition are less likely to attend cardiac rehabilitation (CR) if they are smokers despite the benefits of doing so. The present study sought to investigate how, if at all, a patient's decision to attend CR was influenced by his or her tobacco use post-discharge. METHODS: We surveyed smokers during their hospitalization for a cardiac condition. Four to 8 wk after discharge, a follow-up survey assessed self-reported CR attendance, smoking cessation (SC), and patient opinion of how their smoking status influenced CR attendance. RESULTS: Of the 81 patients who completed the baseline survey (68% male, 57 ± 10 y), 62 (77%) completed the follow-up survey. Consistent with prior findings, there was a substantial correlation between SC and CR attendance (OR: 16.0, P < .001) with 36 (44%) patients attending CR overall and 38 (47%) abstaining from smoking. Patients reported a wide variety of reasons for not attending CR, but most patients (n = 39, 63%) reported that their smoking status did not influence their decision to attend CR. However, 5 patients (8%) reported attending CR because they successfully quit smoking, and 5 (8%) attended CR anticipating support with SC. CONCLUSION: A strong relationship exists between SC and CR attendance following a cardiac hospitalization; however, most patients did not feel that their smoking status was a factor in their decision to attend CR. Regardless of the reason, it appears that success with one behavior may be related to the other and that both SC and CR attendance should be encouraged.