Recommendations to Enhance Physical Health for Individuals with Severe Mental Illness in Canadian Healthcare Organizations.

As Canadians with severe mental illness remain underserved and experience a high burden of physical health challenges and premature mortality, there is an unprecedented need to provide better physical healthcare to this population. Ways of addressing this gap include the delivery of physical healthcare in mental health settings ("reverse integration"). However, there is limited guidance on how to enact this integration. In this article, we outline the development of an integrated care strategy in Canada's largest mental health hospital and discuss system- and policy-level recommendations that healthcare organizations could consider in their initiatives.

Load Distribution Analysis for Weight and Ballistocardiogram Measurements of Heart Failure Patients using a Bed Scale.

Ballistocardiogram (BCG) is an emerging tool with the potential to monitor heart failure (HF) patients. A close association of the weight to the BCG as an intermediate signal source requires a careful design, where events such as saturation of the weight signal can result in the loss of the BCG. This work closely examined the factors around the weight while load cells placed under each support of a bed collected the BCG (e.g., body weight, distribution over the four supports of the bed). Following the calibration of weights based on the location of the polls, the study examined the ratios of loads in head-foot and lateral directions. The head-foot ratio was also correlated to the height. Twelve non-obese HF patients were recruited, and the weight and BCG were appropriately measured, where the average error of the weight measurements was 0.45 ± 0.30%. The mean ratio of the loads between head to foot sensors was 3.2 ± 0.7 with a maximum ratio of 4.5, showing that the head-ward sensors supported greater body weight. The ratio of the loads between the right to left sensors was 1.2 ± 0.1. The height and the head-to-foot ratio had an inverse correlation (r = 0.52). Based on the analysis, the head-ward sensors should have a higher capacity of up to three times that of the foot-ward sensors to prevent any signal saturation. Mobility issues were observed in some subjects, attributing to the lateral imbalance. These novel findings based on the end-users (i.e., HF population) may allow better allocation of conditioning resources to obtain the BCG (e.g., optimally adjusted sensitivity).

A Randomized Controlled Trial of an Exercise Maintenance Intervention in Men and Women After Cardiac Rehabilitation (ECO-PCR Trial).

BACKGROUND: Exercise maintenance interventions are needed for cardiac rehabilitation (CR) graduates to maintain moderate and vigorous-intensity physical activity (MVPA). We tested an exercise facilitator intervention (EFI) to promote exercise maintenance compared with usual care (UC) separately in men and women. METHODS: This was a 3-site, randomized (1:1), parallel-group, superiority trial (ECO-PCR). CR graduates were stratified by site and sex and randomly allocated (concealed). EFI participants received a face-to-face introductory session, 5 small-group counseling teleconferences, and 3 personal calls from a trained facilitator over 50 weeks. In-person assessments were undertaken at baseline and 26 and 52 weeks after randomization. The primary outcome was weekly minutes of MVPA, measured by accelerometer. Secondary outcomes were exercise capacity, risk factors, quality of life, and enrollment in community-based exercise programs. Effects were tested with the use of linear mixed models. RESULTS: A total of 449 CR graduates (135 women, 314 men) were randomised (n = 226 EFI, n = 223 UC). In the intention-to-treat analysis for men and for women, there were no significant effects for treatment or time on MVPA. In a planned secondary analysis that considered only those adherent to EFI (completed ≥ 66% of sessions; per-protocol), bouted MVPA (ie, in sustained bouts of ≥ 10 min) was higher in women in the EFI group (mean = 132.6 ± 135.2 min/wk at 52 weeks) compared with UC (111.8 ± 113.1; P = 0.013). Regarding secondary outcomes, in women, a treatment group main effect was observed for blood pressure (P = 0.011) and exercise capacity (P = 0.019; both per-protocol) favouring EFI; no other differences were observed. CONCLUSIONS: In this trial of CR completers, an EFI showed promise for women, but was ineffective in men.

Quantification of Resting-State Ballistocardiogram Difference Between Clinical and Non-Clinical Populations for Ambient Monitoring of Heart Failure.

A ballistocardiogram (BCG) is a versatile bio-signal that enables ambient remote monitoring of heart failure (HF) patients in a home setting, achieved through embedded sensors in the surrounding environment. Numerous methods of analysis are available for extracting physiological information using the BCG; however, most have been developed based on non-clinical subjects. While the difference between clinical and non-clinical populations are expected, quantification of the difference may serve as a useful tool. In this work, the differences in resting-state BCGs of the two cohorts in a sitting posture were quantified. An instrumented chair was used to collect the BCG from 29 healthy adults and 26 NYHA HF class I and II patients while seated without any stress test for five minutes. Five 20-second epochs per subject were used to calculate the waveform fluctuation metric at rest (WFMR). The WFMR was obtained in two steps. The ensemble average of the segmented BCG heartbeats within an epoch were calculated first. Mean square errors (MSE) between different ensemble average pairs were then retrieved. The MSEs were averaged to produce the WFMR. The comparison showed that the clinical cohort had higher fluctuation than the non-clinical population and had at least 82.2% separation, suggesting that greater errors may result when existing algorithms were used. The WFMR acts as a bridge that may enable important features, including the addition of error margins in parameter estimation and ways to devise a calibration strategy when resting-state BCG is unstable.

A Longitudinal Examination of the Social-Ecological Correlates of Exercise in Men and Women Following Cardiac Rehabilitation.

Cardiac patients who engage in ≥150 min of moderate- to vigorous-intensity physical activity (MVPA)/week have lower mortality, yet MVPA declines even following cardiac rehabilitation (CR), and is lower in women. A randomized trial of nine socioecological theory-based exercise facilitation contacts over 50 weeks versus usual care (1:1 parallel arms) was undertaken (NCT01658683). The tertiary objective, as presented in this paper, was to test whether the intervention impacted socioecological elements, and in turn their association with MVPA. The 449 participants wore an accelerometer and completed questionnaires post-CR, and 26, 52 and 78 weeks later. At 52 weeks, exercise task self-efficacy was significantly greater in the intervention arm (p = 0.01), but no other differences were observed except more encouragement from other cardiac patients at 26 weeks (favoring controls). Among women adherent to the intervention, the group in whom the intervention was proven effective, physical activity (PA) intentions at 26 weeks were significantly greater in the intervention arm (p = 0.04), with no other differences. There were some differences in socioecological elements associated with MVPA by arm. There were also some differences by sex, with MVPA more often associated with exercise benefits/barriers in men, versus with working and the physical environment in women.

Cardiac Rehabilitation Quality Improvement: A NARRATIVE REVIEW.

PURPOSE: Despite evidence of the effectiveness of cardiac rehabilitation (CR), there is wide variability in programs, which may impact their quality. The objectives of this review were to (1) evaluate the ways in which we measure CR quality internationally; (2) summarize what we know about CR quality and quality improvement; and (3) recommend potential ways to improve quality. METHODS: For this narrative review, the literature was searched for CR quality indicators (QIs) available internationally and experts were also consulted. For the second objective, literature on CR quality was reviewed and data on available QIs were obtained from the Canadian Cardiac Rehabilitation Registry (CCRR). For the last objective, literature on health care quality improvement strategies that might apply in CR settings was reviewed. RESULTS: CR QIs have been developed by American, Canadian, European, Australian, and Japanese CR associations. CR quality has only been audited across the United Kingdom, the Netherlands, and Canada. Twenty-seven QIs are assessed in the CCRR. CR quality was high for the following indicators: promoting physical activity post-program, assessing blood pressure, and communicating with primary care. Areas of low quality included provision of stress management, smoking cessation, incorporating the recommended elements in discharge summaries, and assessment of blood glucose. Recommended approaches to improve quality include patient and provider education, reminder systems, organizational change, and advocacy for improved CR reimbursement. An audit and feedback strategy alone is not successful. CONCLUSIONS: Although not a lot is known about CR quality, gaps were identified. The quality improvement initiatives recommended herein require testing to ascertain whether quality can be improved.

Amount and Socio-Ecological Correlates of Exercise in Men and Women at Cardiac Rehabilitation Completion.

OBJECTIVE: The aim of the study was to describe (1) the amount of physical activity (PA) in cardiac rehabilitation (CR) graduates by sex, and (2) the correlates of their PA. DESIGN: Secondary analysis of baseline data from a randomized trial was undertaken. Graduates were recruited from three CR programs. Participants completed a questionnaire, which assessed constructs from the socio-ecological model (i.e., individual-level, social- and physical-environmental levels). Physical activity was measured objectively using an ActiGraph GT3X accelerometer. Multilevel modeling was performed. RESULTS: Two hundred fifty-five patients consented, of which 200 (78.4%) completed the survey and provided valid accelerometer data. Participants self-reported engaging in a mean ± standard deviation of 184.51 ± 129.10 min of moderate-to-vigorous-intensity PA (MVPA) per week (with men engaging in more than women, P < 0.05). Accelerometer data revealed participants engaged in 169.65 ± 136.49 mins of MVPA per week, with 43 (25.1%) meeting recommendations. In the mixed models, the socio-ecological correlate significantly related to greater self-reported MVPA was self-regulation (P = 0.01); the correlate of accelerometer-derived MVPA was neighborhood aesthetics (P = 0.02). CONCLUSIONS: Approximately one-quarter of CR program completers are achieving MVPA recommendations, although two-thirds perceive they are. The CR programs should exploit accelerometry and promote self-regulation skills, namely, self-monitoring, goal-setting, positive reinforcement, time management, and relapse prevention. Patients should be encouraged to exercise in pleasing locations.

Health Care Use and Associated Time and Out of Pocket Expenditures for Patients With Cardiovascular Disease in a Publicly Funded Health Care System.

BACKGROUND: The objectives of this study were to describe (1) health care use and associated patient time and out of pocket (OOP) costs over 2 years after a cardiac diagnosis, (2) the sociodemographic and clinical drivers of these costs, and (3) patient costs related to cardiac rehabilitation (CR) participation. METHODS: Secondary analysis was conducted in an observational prospective CR program evaluation cohort in Ontario, which has a publicly funded health care system. A convenience sample of patients from 1 of 3 CR programs was approached at the first visit, and consenting participants completed a survey. Participants were e-mailed surveys again 6 months and 1 and 2 years later; these later surveys assessed their cardiac care and medications and the time and OOP costs associated with care visits. Patient time was valued based on average wages in Ontario. RESULTS: Of 411 consenting patients, 240 (58.3%) completed CR, and 192 (46.7%) were retained at 2 years. Patients most often visited a general practitioner and had electrocardiography and treatment for angina. The total cost to patients over 2 years was CAD$73.70 ± $275.84 for time and $377.01 ± $321.72 for OOP costs ($525.93 ± $467.08 overall). With adjustment, there were significantly higher OOP costs for women (P < 0.001) and less educated (P < 0.001) patients. Participants spent considerable money that was relatively OOP on CR visits alone ($384.78 ± $269.67), with time costs at $379.07 ± $1035.49 ($939.43 ± $1333.29 overall; 1.6% share of 1 year's income). CONCLUSIONS: In conclusion, time and OOP costs are modest for patients with cardiac conditions, except for CR. Alternative delivery models are needed, in particular for low-income patients.

Quality and Variability of Cardiovascular Rehabilitation Delivery: APPLYING THE CANADIAN QUALITY INDICATORS.

PURPOSE: Cardiac care, including cardiovascular rehabilitation (CR), is most effective if it is high-quality. The aim of this study was to describe CR quality, using the recently developed Canadian Cardiovascular Society CR quality indicators (QIs). Difference in quality between CR sites was also assessed. METHODS: Secondary analysis was conducted on an observational, prospective, multisite CR program evaluation cohort. A convenience sample of patients from 1 of 3 CR programs was approached at their first CR visit, and consenting participants completed a survey. Clinical data were extracted from charts pre- and postprogram. Of the 30 CR QIs, 21 (70.0%) were assessable: 10 process, 9 outcome, and 2 structure QIs. RESULTS: Of 411 consenting patients, 209 (53.0%) completed CR. The greatest quality was observed for assessment of blood pressure (98.1%), communication with primary health care at CR discharge (94.2%), and patient enrollment (94.0%). The lowest quality was observed for wait time from hospital discharge (9.2%), assessments of blood glucose (42.1%), and lipid control (53.0%). Of the 7 QIs that had an established benchmark, quality for 2 (28.6%) was above the benchmark (particularly assessment of blood pressure). Significant between-site differences were observed in 11 (64.7%) QIs. The magnitude of quality differences between sites was largest for assessment of lipid control (72.6%), assessment of blood glucose control (69.0%), and wait time in median days from referral to enrollment (30.6 days). CONCLUSION: There is wide variability in CR program quality, both overall and between CR sites. Quality improvement in particular aspects of CR care is required.

Cardiac rehabilitation costs.

BACKGROUND: Despite the clinical benefits of cardiac rehabilitation (CR) and its cost-effectiveness, it is not widely received. Arguably, capacity could be greatly increased if lower-cost models were implemented. The aims of this review were to describe: the costs associated with CR delivery, approaches to reduce these costs, and associated implications. METHODS: Upon finalizing the PICO statement, information scientists were enlisted to develop the search strategy of MEDLINE, Embase, CDSR, Google Scholar and Scopus. Citations identified were considered for inclusion by the first author. Extracted cost data were summarized in tabular format and qualitatively synthesized. RESULTS: There is wide variability in the cost of CR delivery around the world, and patients pay out-of-pocket for some or all of services in 55% of countries. Supervised CR costs in high-income countries ranged from PPP$294 (Purchasing Power Parity; 2016 United States Dollars) in the United Kingdom to PPP$12,409 in Italy, and in middle-income countries ranged from PPP$146 in Venezuela to PPP$1095 in Brazil. Costs relate to facilities, personnel, and session dose. Delivering CR using information and communication technology (mean cost PPP$753/patient/program), lowering the dose and using lower-cost personnel and equipment are important strategies to consider in containing costs, however few explicitly low-cost models are available in the literature. CONCLUSION: More research is needed regarding the costs to deliver CR in community settings, the cost-effectiveness of CR in most countries, and the economic impact of return-to-work with CR participation. A low-cost model of CR should be standardized and tested for efficacy across multiple healthcare systems.

Perceptions of seniors with heart failure regarding autonomous zero-effort monitoring of physiological parameters in the smart-home environment.

BACKGROUND: Technological advances are leading to the ability to autonomously monitor patient's health status in their own homes, to enable aging-in-place. OBJECTIVES: To understand the perceptions of seniors with heart failure (HF) regarding smart-home systems to monitor their physiological parameters. METHODS: In this qualitative study, HF outpatients were invited to a smart-home lab, where they completed a sequence of activities, during which the capacity of 5 autonomous sensing modalities was compared to gold standard measures. Afterwards, a semi-structured interview was undertaken. These were transcribed and analyzed using an interpretive-descriptive approach. RESULTS: Five themes emerged from the 26 interviews: (1) perceptions of technology, (2) perceived benefits of autonomous health monitoring, (3) disadvantages of autonomous monitoring, (4) lack of perceived need for continuous health monitoring, and (5) preferences for autonomous monitoring. CONCLUSIONS: Patient perception towards autonomous monitoring devices was positive, lending credence to zero-effort technology as a viable and promising approach.

Patient satisfaction with cardiac rehabilitation: association with utilization, functional capacity, and heart-health behaviors.

BACKGROUND: Cardiac rehabilitation (CR) societies recommend assessment of patient satisfaction given its association with health care utilization and outcomes. Recently, the Patient Assessment of Chronic Illness Care (PACIC, Glasgow) was recommended as an appropriate tool for the CR setting. The objectives of this study were to 1) describe patient satisfaction with CR, 2) test the psychometric properties of the PACIC in the CR setting, and 3) assess the association of patient satisfaction with CR utilization and outcomes. METHODS: Secondary analysis was conducted on an observational, prospective CR program evaluation cohort. A convenience sample of patients from 1 of 3 CR programs was approached at their first CR visit, and consenting participants completed a survey. Clinical data were extracted from charts pre- and post-program. Participants were e-mailed surveys again 6 months (including the PACIC) and 1 and 2 years later. RESULTS: Of 411 consenting patients, 247 (60.2%) completed CR. The mean PACIC score was 2.8±1.1/5. Internal reliability was α=0.95. The total PACIC score varied significantly by site (F=3.12, P=0.046), indicating discriminant validity. Patient satisfaction was significantly related to greater CR adherence (r=0.22, P<0.01) and completion (t=2.63, P<0.01), greater functional status at CR discharge (r=0.17, P=0.03) and 2 years post-intake (r=0.19, P=0.03), greater physical activity at discharge (r=0.18, P=0.02), as well as lower depressive symptoms at discharge (r=-0.16, P=0.02) and 1-year follow-up (r=-0.19, P=0.03). These associations sustained adjustment for sex. CONCLUSION: Patients were relatively satisfied with their care. The PACIC is a psychometrically validated scale, which could serve as a useful tool to assess patient satisfaction with CR.

Burden, screening, and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: a prospective study.

BACKGROUND: Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality among women. Women with CVD experience a greater burden of psychosocial distress than men, and practice guidelines promote screening in cardiac patients, especially women. The objectives herein were to describe the burden of psychosocial distress, extent of screening, forms of treatment, and whether receipt of treatment was related to psychosocial distress symptom severity at follow-up, among women. METHODS: Within a multi-center trial of women randomized to cardiac rehabilitation models, consenting participants were asked to complete surveys upon consent and 6 months later. Clinical data were extracted from charts. This study presents a secondary analysis of the surveys, including investigator-generated items assessing screening and treatment, the Beck Depression Inventory-II, the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-2. RESULTS: Of the 128 (67.0%) participants with valid baseline and follow-up survey results, 48 (40.3%) self-reported that they recalled being screened, and of these, 10 (21.3%) recalled discussing the results with a health care professional. Fifty-six (43.8%) retained participants had elevated symptoms of psychosocial distress at baseline, of which 25 (44.6%) were receiving treatment. Regression analyses showed that treatment of psychosocial distress was not significantly associated with follow-up depressive symptoms, but was significantly associated with greater follow-up anxiety. CONCLUSIONS: Findings reiterate the great burden of psychosocial distress among women with CVD. Less than half of patients with elevated symptoms were treated, and the treatment approaches appeared to insufficiently achieve symptom relief.

Ecologically optimizing exercise maintenance in men and women post-cardiac rehabilitation: Protocol for a randomized controlled trial of efficacy with economics (ECO-PCR).

BACKGROUND: Exercise-based cardiac rehabilitation (CR) participation results in increased cardio-metabolic fitness, which is associated with reduced mortality. However, many graduates fail to maintain exercise post-program. ECO-PCR investigates the efficacy and cost-effectiveness of a social ecologically-based intervention to increase long-term exercise maintenance following the completion of CR. METHODS/DESIGN: A three-site, 2-group, parallel randomized controlled trial is underway. 412 male and 192 female (N=604) supervised CR participants are being recruited just before CR graduation. Participants are randomized (1:1 concealed allocation) to intervention or usual care. A 50-week exercise facilitator intervention has been designed to assist CR graduates in the transition from structured, supervised exercise to self-managed home- or community-based (e.g., Heart Wise Exercise programs) exercise. The intervention consists of 8 telephone contacts over the 50week period: 3 individual and 5 group. Assessments occur at CR graduation, and 26, 52 and 78weeks post-randomization. The primary outcome is change in minutes of accelerometer-measured moderate to vigorous-intensity physical activity (MVPA) from CR graduation to 52weeks post-randomization. Secondary measures include exercise capacity, quality of life, and cardiovascular risk factors. Analyses will be undertaken based on intention-to-treat. For the primary outcome, an analysis of variance will be computed to test the change in minutes of MVPA in each group between CR graduation and 52week follow-up (2 [arm]×2 [time]). Secondary objectives will be assessed using mixed-model repeated measures analyses to compare differences between groups over time. Mean costs and quality-adjusted life years for each arm will be estimated.

Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial.

OBJECTIVE: To compare program adherence and functional capacity between women referred to supervised mixed-sex, supervised women-only, or home-based cardiac rehabilitation (CR). PATIENTS AND METHODS: Cardiac Rehabilitation for Heart Event Recovery (CR4HER) was a single-blind, 3 parallel-arm, pragmatic randomized controlled trial. The study took place between November 1, 2009, and July 31, 2013. Low-risk patients with coronary artery disease were recruited from 6 hospitals in Ontario, Canada. Consenting participants completed a preprogram survey, and clinical data were extracted from charts. Participants were referred to CR at 1 of 3 sites. After intake assessment, including a graded exercise stress test, eligible patients were randomized to supervised mixed-sex, supervised women-only, or home-based CR. Six months later, CR adherence and exit assessment data were ascertained. RESULTS: Of the 264 consenting patients, 169 (64.0%) were eligible and randomized. Twenty-seven (16.0%) did not attend, and 43 (25.4%) attended a different model. Program adherence was moderate overall (54.46%±35.14%). Analysis of variance revealed no significant differences based on per-protocol analysis (P=.63), but as-treated, home-based participants attended significantly more than did women-only participants (P<.05). Overall, there was a significant increase in functional capacity preprogram to postprogram (P<.001). Although there were no significant differences in functional capacity by model at CR exit based on per-protocol analysis, there was a significant difference on an as-treated basis, which sustained adjustment. Women attending mixed-sex CR attained significantly higher post-CR functional capacity than did women attending home-based programs (P<.05). CONCLUSION: Offering women alternative program models may not promote greater CR adherence or functional capacity; however, replication is warranted. Other proven strategies such as action planning and self-monitoring should be applied. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01019135.

Elements of patient-health-care provider communication related to cardiovascular rehabilitation referral.

Cardiovascular rehabilitation has been designed to decrease the burden of cardiovascular disease. This study described (1) patient-health-care provider interactions regarding cardiovascular rehabilitation and (2) which discussion elements were related to patient referral. This was a prospective study of cardiovascular patients and their health-care providers. Discussion utterances were coded using the Roter Interaction Analysis System. Discussion between 26 health-care providers and 50 patients were recorded. Cardiovascular rehabilitation referral was related to greater health-care provider interactivity (odds ratio = 2.82, 95% confidence interval = 1.01-7.86) and less patient concern and worry (odds ratio = 0.64, 95% confidence interval = 0.45-0.89). Taking time for reciprocal discussion and allaying patient anxiety may promote greater referral.

Integrated cardiovascular rehabilitation: how do noncardiac and polyvascular disease patients fare?

INTRODUCTION: The burden of noncommunicable disease is increasing. Preliminary evidence suggests that benefits of cardiovascular rehabilitation (CR) participation are also observed in patients with stroke and diabetes (vascular diseases [VDs]). This study compared (1) CR utilization by clinical indication; (2) sociodemographic and clinical characteristics of VD patients who participate in CR versus those who do not; and (3) change in risk factors, functional capacity, psychosocial well-being, and health behaviors from pre- to postprogram in cardiac versus VD patients who participated in CR. METHODS: This multisite study invited new CR patients to complete a survey preprogram and again 6 months later. Clinical data including risk factors and exercise test results were extracted from patients' charts at both time points. The surveys included the Duke Activity Status Index, the Godin Leisure-Time Exercise Questionnaire, the Morisky Medication Adherence Survey, and the Patient Health Questionnaire. RESULTS: Overall, 237 (84.0%) completed the pre-CR survey, and 201 (71.3%) completed the final survey. Cardiac patients (n = 104, 68.9%) were significantly more likely to complete CR than VD patients (n = 37, 54.4%; P = .039). Vascular disease patients who enrolled in CR engaged in more physical activity pre-program (P < .05). Cardiac patients who attended CR achieved significant improvements in activity status, exercise behavior, and nutrition at the posttest (P < .01 for each). Among VD patients, there were trends toward lower depressive symptoms and greater exercise in those who participated in CR by posttest. CONCLUSIONS: This study of integrated chronic disease management provides preliminary support for the benefits of CR for patients with vascular disease.

Women's preferences for cardiac rehabilitation program model: a randomized controlled trial.

BACKGROUND: Although cardiac rehabilitation (CR) is effective, women often report programs do not meet their needs. Innovative models have been developed that may better suit women. The objectives of the study were to describe: (1) adherence to CR model allocation; (2) satisfaction by model attended; and (3) CR preferences. DESIGN AND METHODS: Tertiary objectives from a randomized controlled trial of female patients randomized to mixed-sex, women-only, or home-based CR were tested. Patients were recruited from six hospitals. Consenting participants were asked to complete a survey and undertook a CR intake assessment. Eligible patients were randomized. Participants were mailed a follow-up survey six months later. Adherence to model allocation was ascertained from CR charts. RESULTS: Overall 169 (18.6%) patients were randomized, of which 116 (68.6%) completed the post-test survey. Forty-five (26.6%) participants did not receive the allocated model, with those referred to home-based CR least likely to attend the allocated model (n = 25; 45.4%). Semi-structured interviews revealed participants also often switched from women-only to mixed-sex CR due to time conflicts. Satisfaction was high across all models (mean = 4.23 ± 1.16/5; p = 0.85) but participants in the women-only program felt significantly more comfortable in their workout attire (p = 0.003) and perceived the environment as less competitive (p = 0.02). Patients equally preferred mixed-sex (n = 44, 41.9%) and women-only (n = 44, 41.9%) CR, over home-based (n = 17, 16.2%), with patients preferring the model they attended. CONCLUSION: Females were highly satisfied regardless of CR model attended but preferred supervised programs most. Patient preference and session timing should be considered in program model allocation decisions.

Reducing risk with e-based support for adherence to lifestyle change in hypertension (REACH): protocol for a multicentred randomised controlled trial.

INTRODUCTION: Web-based lifestyle counselling designed to improve adherence to self-management behaviours for diet, exercise and medication has been shown to reduce blood pressure (BP). However, the long-term clinical outcome of these interventions is not established. Our aim was to establish whether an e-counselling program is independently associated with improved clinical outcomes over a 12-month period, as defined by the following criteria: (1) reduction of systolic BP, diastolic BP, pulse pressure and associated risk factors for cardiovascular events; and (2) adherence to self-management behaviour (diet, exercise, smoke-free living and prescribed medication). METHODS AND ANALYSIS: Reducing risk with e-based support for adherence to lifestyle change in hypertension is a two-parallel group, double-blind randomised controlled trial that will utilise a two (Groups: e-counselling vs control) by three (assessment intervals: baseline, 4-month and 12-month outcome) design. BP, lipoprotein cholesterol, physical activity and dietary behaviours and psychological distress will be measured at each assessment. We plan to recruit 528 participants (35-74 years of age) diagnosed with stage 1 or 2 hypertension (systolic BP, 140-180 mm Hg; diastolic BP 90-110 mm Hg) from three major cities (Toronto, London, Vancouver) and one rural area (Grey Bruce region) across Canada between February 2012 and July 2015. Controls will receive general educational e-messages on heart healthy living and the e-counselling group will receive tailored e-messages that are matched to their stage of readiness for change. For both groups, e-messages will be sent proactively on a weekly basis during months 1-4, then bi-weekly during months 5-8 and then monthly during months 9-12. ETHICS AND DISSEMINATION: Ethical approval has been obtained from all recruitment sites. This will be one of the first studies to evaluate the long-term efficacy of preventive e-counselling strategies for cardiovascular disease prevention in patients with hypertension. Findings from this study will be used to guide the ongoing development of e-counselling services. TRIAL REGISTRATION: Clinicaltrial.gov NCT01541540; http://clinicaltrials.gov/ct2/show/NCT01541540.

How do hospital administrators perceive cardiac rehabilitation in a publicly-funded health care system?

BACKGROUND: Patient and provider-related factors affecting access to cardiac rehabilitation (CR) have been extensively studied, but health-system administration factors have not. The objectives of this study were to investigate hospital administrators' (HA) awareness and knowledge of cardiac rehabilitation (CR), perceptions regarding resources for and benefit of CR, and attitudes toward and implementation of inpatient transition planning for outpatient CR. METHODS: A cross-sectional and observational design was used. A survey was administered to 679 HAs through Canadian and Ontario databases. A descriptive examination was performed, and differences in HAs' perceptions by role, institution type and presence of within-institution CR were compared using t-tests. RESULTS: 195 (28.7%) Canadian HAs completed the survey. Respondents reported good knowledge of what CR entails (mean=3.42±1.15/5). Awareness of the closest site was lower among HAs working in community versus academic institutions (3.88±1.24 vs. 4.34±0.90/5 respectively; p=.01). HAs in non-executive roles (4.77±0.46/5) perceived greater CR importance for patients' care than executives (4.52±0.57; p=.001). HAs perceived CR programs should be situated in both hospitals and community settings (n=134, 71.7%). CONCLUSIONS: HAs value CR as part of patients' care, and are supportive of greater CR provision. Those working in community settings and executives may not be as aware of, or less-likely to value, CR services. CR leaders from academic institutions might consider liaising with community hospitals to raise awareness of CR benefits, and advocate for it with the executives in their home institutions.