Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle-income setting: A randomized controlled trial protocol.

Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower-resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart-health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle-income country. Following a pilot study, a single-center, single-blinded, 2 parallel-arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre-intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6-month intervention comprises an app, website, SMS texts with generic heart-health management advice, and bi-weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent-to-treat. If results of this novel trial of women-focused eCR in a middle-income country demonstrate clinically-significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.

Trends in cardiac rehabilitation enrollment post-coronary artery bypass grafting upon implementation of automatic referral in Southeast Asia: A retrospective cohort study.

Introduction: Cardiac rehabilitation (CR) is an effective but underutilized intervention. Strategies have been identified to increase its use, but there is paucity of data testing them in low-resource settings. We sought to determine the effect of automatic referral post-coronary artery bypass graft (CABG) surgery on CR enrollment. Methods: This is a retrospective cohort study assessing cardiac patients referred to CR at a tertiary center in Southeast Asia from 2013 to 2019. The paper-based pathway was introduced at the end of 2012. The checklist with automatic CR referral on the third day post-operation prompted a nurse to educate the patient about CR, initiate phase 1 and encourage enrollment in phase 2. Patients who were not eligible for the pathway for administrative or clinical reasons were referred at the discretion of the attending physician (i.e., usual care). Enrollment was defined as attendance at≥1 CR visit. Results: Of 4792 patients referred during the study period, 394 enrolled in CR. Significantly more patients referred automatically enrolled compared to usual care (225 [11.8%] vs. 169 [5.8%]; OR=2.2, 95% CI=1.8-2.7), with increases up to 23.4% enrollment in 2014 (vs. average enrollment rate of 5.9% under usual referral). Patients who enrolled following automatic referral were significantly younger and more often employed (both P<0.001); no other differences were observed. Conclusion: In a lower-resource, Southeast Asian setting, automatic CR referral is associated with over two times greater enrollment in phase 2 CR, although efforts to maintain this effect are required.

Editor's Choice - Effect of Physical Activity and Tobacco Use on Mortality and Morbidity in Patients with Peripheral Arterial Disease After Revascularisation: A Korean Nationwide Population Based Cohort Study.

OBJECTIVE: To investigate the effects of physical activity (PA) and tobacco use on adverse clinical outcomes after revascularisation for peripheral arterial disease (PAD) in the Western Pacific region, where PAD cases and tobacco use are among the highest in the world. METHODS: This was a retrospective cohort study using the Korean National Health Insurance Service (NHIS) database and included patients who had received revascularisation for PAD between 2010 and 2015. They were categorised as active or inactive based on the number of days per week they engaged in PA and as current or non-tobacco users (self report). The primary outcome was all cause mortality. Secondary outcomes included major adverse outcome (a composite of all cause mortality, myocardial infarction, and stroke) and major adverse limb event (MALE, a composite of amputation and recurrent revascularisation). RESULTS: The relatively healthy cohort comprised 8 324 patients (mean age 64.7 years; 76.9% male) following revascularisation for PAD. Among them, 32.7% were inactive and 26.4% were tobacco users. Active patients had better outcomes than inactive patients (all cause mortality adjusted hazard ratio [adjHR] 0.766; 95% CI 0.685 - 0.855, major adverse outcome adjHR 0.795; 95% CI 0.719 - 0.878, MALE adjHR 0.858; 95% CI 0.773 - 0.953). Tobacco users had poorer outcomes than non-users (all cause mortality adjHR 1.279; 95% CI 1.124 - 1.456, major adverse outcome adjHR 1.263; 95% CI 1.124 - 1.418, MALE adjHR 1.291; 95% CI 1.143 - 1.458). CONCLUSION: Even after receiving revascularisation for PAD, a sizable proportion of patients were physically inactive and used tobacco, leading to adverse clinical outcomes such as death, cardiovascular morbidity, and amputation in Korea. These modifiable risk factors should be addressed systematically, and a comprehensive approach including supervised exercise programmes and tobacco cessation is needed in patients with PAD.

Validity and Reliability of the Cardiac Rehabilitation Barriers Scale in the Czech Republic (CRBS-CZE): Determination of Key Barriers in East-Central Europe.

Cardiovascular rehabilitation (CR) is an effective secondary preventive model of care. However, the use of CR is insufficient, and the reasons for this are not well-characterized in East-Central Europe. This prospective observational study psychometrically validated the recently translated Cardiac Rehabilitation Barriers Scale for the Czech language (CRBS-CZE) and identified the main CR barriers. Consecutive cardiac in/out-patients were approached from January 2020 for 18 months, of whom 186 (89.9%) consented. In addition to sociodemographic characteristics, participants completed the 21-item CRBS-CZE (response options 1-5, with higher scores representing greater barriers), and their CR utilization was tracked. Forty-five (24.2%) participants enrolled in CR, of whom 42 completed the CRBS a second time thereafter. Factor analysis revealed four factors, consistent with other CRBS translations. Internal reliability was acceptable for all but one factor (Cronbach's alpha range = 0.44-0.77). Mean total barrier scores were significantly higher in non-enrollers (p < 0.001), decreased from first and second administration in these enrollers (p < 0.001), and were lower in CR completers (p < 0.001), supporting criterion validity. There were also significant differences in barrier scores by education, geography, tobacco use, among other variables, further supporting validity. The biggest barriers to enrolment were distance, work responsibilities, lack of time, transportation problems, and comorbidities; and the greatest barriers to adherence were distance and travel. Several items were considered irrelevant at first and second administration. Other barriers included wearing a mask during the COVID-19 pandemic. The study demonstrated sufficient validity and reliability of CRBS-CZE, which supports its use in future research.

Traditional vs Extended Hybrid Cardiac Rehabilitation Based on the Continuous Care Model for Patients Who Have Undergone Coronary Artery Bypass Surgery in a Middle-Income Country: A Randomized Controlled Trial.

OBJECTIVE: To compare traditional (1-month supervised) vs hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (intervention) in patients who have undergone coronary artery bypass graft (CABG). DESIGN: Randomized controlled trial, with blinded outcome assessment. SETTING: A major heart center in a middle-income country. PARTICIPANTS: Of 107 eligible patients who were referred to CR during the period of study, 82.2% (N=88) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). There was 92.0% retention. INTERVENTIONS: After CR, participants were given a mobile application and communicated biweekly with the nurse from months 1-4 to control risk factors. MAIN OUTCOME MEASURES: Quality of life (QOL, Short Form-36, primary outcome); functional capacity (treadmill test); and the Depression, Anxiety and Stress Scale were evaluated pre-CR, after 1 month, and 3 months after CR (end of intervention), as well as rehospitalization. RESULTS: The analysis of variance interaction effects for the physical and mental component summary scores of QOL were <.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (P<.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (P<.001), with a clinically significant 1.5 metabolic equivalent of task increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) rehospitalizations in the control arm and none in intervention (P=.049). Intended theoretical mechanisms were also affected by the intervention. CONCLUSIONS: Extending CR in this accessible manner, rendering it more comprehensive, was effective in improving outcomes.

Cardiac Rehabilitation Component Attendance and Impact of Intervening Clinical Events, as Well as Disease Severity and Risk Factor Burden.

PURPOSE: To examine: (1) the rate of clinical events precluding cardiac rehabilitation (CR) continuation, (2) CR attendance by component in those without events, and (3) the association between disease severity (eg, tobacco use, diabetes, and depression) and component attendance (eg, exercise, diet, stress management, and tobacco cessation). METHODS: Retrospective analysis of electronic records of the CR program in London, Ontario, from 1999 to 2017. Patients in the supervised program are offered exercise sessions 2 times/wk with a minimum of 48 prescribed sessions tailored to patient need. Patients attending ≥1 session without major factors that would limit their exercise ability were included. Intervening events were recorded, as was component attendance. RESULTS: Of 5508 enrolled, supervised patients, 3696 did not have a condition that could preclude exercise. Of those enrolled, one-sixth (n = 912) had an intervening event; these patients were less likely to work, more likely to have medical risk factors, had more severe angina and depression, and lower functional capacity. The remaining cohort attended a mean of 26.5 ± 21.3 sessions overall (median = 27; 19% attending ≥48 sessions), including 20.5 ± 17.4 exercise sessions (median = 21). After exercise, the most common components attended were individual dietary and psychological counseling. Patients with more severe angina and depressive symptoms as well as tobacco users attended significantly fewer total sessions, but more of some specific components. CONCLUSIONS: In one-sixth of patients, CR attendance and completion are impacted by clinical factors beyond their control. Many patients are taking advantage of components specific to their risk factors, buttressing the value of individually tailored, menu-based programming.

Comprehensive Cardiac Rehabilitation Effectiveness in a Middle-Income Setting: A RANDOMIZED CONTROLLED TRIAL.

PURPOSE: The impact of comprehensive cardiac rehabilitation (CCR) in Latin America is not well known. Herein, the pre-specified tertiary outcomes of a cardiac rehabilitation (CR) trial are reported: disease-related knowledge, depressive symptoms, and heart-health behaviors (exercise, diet, and smoking). METHODS: This was a single-blinded, single-center (Brazil) randomized trial with three parallel arms: CCR (exercise + education) versus exercise-only CR versus wait-list control. Eligible patients were randomized in blocks of four with 1:1:1 concealed allocation. The CR program was 6 mo long. Participants randomized to exercise-only CR received 36 exercise classes; the CCR group also received 24 educational sessions, including a workbook. All outcomes were assessed at pre-test and 6-mo later (blinded). Analysis of covariance was performed by intention-to-treat (ITT) and per-protocol (PP). RESULTS: A total of 115 (89%) patients were randomized; 93 (81%) were retained. There were significant improvements in knowledge with CCR (ITT [51.2 ± 11.9 pre and 60.8 ± 13.2 post] and PP; P < .01), with significantly greater knowledge with CCR versus control (ITT mean difference [MD] = 9.5, 95% CI, 2.3-16.8) and CCR vs exercise-only CR at post-test (ITT MD = 6.8, 95% CI, 0.3-14.0). There were also significant improvements in self-reported exercise with CCR (ITT [13.7 ± 15.8 pre and 32.1 ± 2 5.7 post] and PP; P < .001), with significantly greater exercise with CCR versus control at post-test (ITT MD = 7.6, 95% CI, 3.8-11.4). Also, there were significant improvements in diet with CCR (PP: 3.4 ± 7.5 pre and 8.0 ± 7.0 post; P < .05). CONCLUSIONS: In this first-ever randomized trial of CR for coronary artery disease in Latin America, the benefits of CCR have been supported.

Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation.

Background: Cardiac rehabilitation (CR) is recommended in clinical practice guidelines for comprehensive secondary prevention. While India has a high burden of cardiovascular diseases (CVD), availability and nature of services delivered there is unknown. In this study, we undertook secondary analysis of the Indian data from the global CR audit and survey, conducted by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR). Methods: In this cross-sectional study, an online survey was administered to CR programs, identified in India by CR champions and through snowball sampling. CR density was computed using Global Burden of Disease study ischemic heart disease (IHD) incidence estimates. Results: Twenty-three centres were identified, of which 18 (78.3%) responded, from 3 southern states. There was only one spot for every 360 IHD patients/year, with 3,304,474 more CR spaces needed each year. Most programs accepted guideline-indicated patients, and most of these patients paid out-of-pocket for services. Programs were delivered by a multidisciplinary team, including physicians, physiotherapists, among others. Programs were very comprehensive. Apart from exercise training, which was offered across all centers, some centers also offered yoga therapy. Top barriers to delivery were lack of patient referral and financial resources. Conclusions: Of all countries in ICCPR's global audit, the greatest need for CR exists in India, particularly in the North. Programs must be financially supported by government, and healthcare providers trained to deliver it to increase capacity. Where CR did exist, it was generally delivered in accordance with guideline recommendations. Tobacco cessation interventions should be universally offered.

Cardiac rehabilitation availability and delivery in Brazil: a comparison to other upper middle-income countries.

BACKGROUND: Brazil has insufficient cardiac rehabilitation capacity, yet density and regional variation in unmet need is unknown. Moreover, South America has CR guidelines, but whether delivery conforms has not been described. OBJECTIVE: This study aimed to establish: (1) cardiac rehabilitation volumes and density, and (2) the nature of programmes, and (3) compare these by: (a) Brazilian region and (b) to other upper middle-income countries (upper-MICs). METHODS: In this cross-sectional study, a survey was administered to cardiac rehabilitation programmes globally. Cardiac associations were engaged to facilitate programme identification. Density was computed using Global Burden of Disease study ischaemic heart disease incidence estimates. Results were compared to data from the 29 upper-MICs with cardiac rehabilitation (N=249 programmes). RESULTS: Cardiac rehabilitation was available in all Brazilian regions, with 30/75 programmes initiating a survey (40.0% programme response rate). There was only one cardiac rehabilitation spot for every 99 ischaemic heart disease patient. Most programmes were funded by government/hospital sources (n=16, 53.3%), but in 11 programmes (36.7%) patients depended on private health insurance. Guideline-indicated conditions were accepted in ≥70% of programmes. Programmes had a team of 3.8±1.9 staff (versus 5.9±2.8 in other upper-MICs, p<0.05), offering 4.0±1.6/10 core components (versus 6.0±1.5 in other upper-MICs, p<0.01; more tobacco cessation and return-to-work counselling needed in particular) over 44.5 sessions/patient (Q25-75=29-65) vs. 32 sessions/patient (Q25-75=15-40) in other upper-MICs (p<0.01). CONCLUSION: Brazilian cardiac rehabilitation capacity must be augmented, but where available, services are consistent across regions, but differ from other upper-MICs in terms of staff size and core components delivered.

Exercise-based rehabilitation for major non-communicable diseases in low-resource settings: a scoping review.

INTRODUCTION: While there is substantial evidence for the benefits of exercise-based rehabilitation in the prevention and management of non-communicable disease (NCD) in high-resource settings, it is not evident that these programmes can be effectively implemented in a low-resource setting (LRS). Correspondingly, it is unclear if similar benefits can be obtained. The objective of this scoping review was to summarise existing studies evaluating exercise-based rehabilitation, rehabilitation intervention characteristics and outcomes conducted in an LRS for patients with one (or more) of the major NCDs. METHODS: The following databases were searched from inception until October 2018: PubMed/Medline, Embase, CINAHL, Cochrane Library, PsycINFO and trial registries. Studies on exercise-based rehabilitation for patients with cardiovascular disease, diabetes, cancer or chronic respiratory disease conducted in an LRS were included. Data were extracted with respect to study design (eg, type, patient sample, context), rehabilitation characteristics (eg, delivery model, programme adaptations) and included outcome measures. RESULTS: The search yielded 5930 unique citations of which 60 unique studies were included. Study populations included patients with cardiovascular disease (48.3%), diabetes (28.3%), respiratory disease (21.7%) and cancer (1.7%). Adaptations included transition to predominant patient-driven home-based rehabilitation, training of non-conventional health workers, integration of rehabilitation in community health centres, or triage based on contextual or patient factors. Uptake of adapted rehabilitation models was 54%, retention 78% and adherence 89%. The majority of the outcome measures included were related to body function (65.7%). CONCLUSIONS: The scope of evidence suggests that adapted exercise-based rehabilitation programmes can be implemented in LRS. However, this scope of evidence originated largely from lower middle-income, urban settings and has mostly been conducted in an academic context which may hamper extrapolation of evidence to other LRS. Cost-benefits, impact on activity limitations and participation restrictions, and subsequent mortality and morbidity are grossly understudied.

What constitutes patient-centred care for women: a theoretical rapid review.

BACKGROUND: Women experience disparities in health care delivery and outcomes. Patient-centred care for women (PCCW) is needed. This study examined how PCC has been conceptualized and operationalized in women's health research. METHODS: We conducted a theoretical rapid review of PCCW in MEDLINE, EMBASE, CINAHL and SCOPUS from 2008 to 2018 for studies involving women aged 18 years or greater with any condition, and analyzed data using an established 6-domain framework of patient-centred communication. RESULTS: We included 39 studies, which covered the following clinical areas: maternal care, cancer, diabetes, HIV, endometriosis, dementia, distal radius fracture, overactive bladder, and lupus erythematosus. The 34 (87.2%) studies that defined or described PCC varied in the PCC elements they addressed, and none addressed all 6 PCC domains. Common domains were exchanging information (25, 73.5%) and fostering the patient-clinician relationship (22, 64.7%). Fewer studies addressed making decisions (16, 47.1%), enabling patient self-management (15, 44.1%), responding to emotions (12, 35.3%), or managing uncertainty (1, 2.9%). Compared with mixed-gender studies, those comprised largely of women more frequently prioritized exchanging information above other domains. Few studies tested strategies to support PCCW or evaluated the impact of PCCW; those that did demonstrated beneficial impact on patient knowledge, satisfaction, well-being, self-care and clinical outcomes. CONCLUSIONS: Studies varied in how they conceptualized PCCW, and in many it was defined narrowly. Few studies examined how to implement or measure PCCW; thus, we lack insight on how to operationlize PCCW. Thus, further research is needed to confirm this, and whether PCCW differs across conditions, knowledge needed to inform policies, guidelines and measures aimed at improving health care and associated outcomes for women.

Cardiac rehabilitation delivery in low/middle-income countries.

OBJECTIVE: Cardiac rehabilitation (CR) availability, programme characteristics and barriers are not well-known in low/middle-income countries (LMICs). In this study, they were compared with high-income countries (HICs) and by CR funding source. METHODS: A cross-sectional online survey was administered to CR programmes globally. Need for CR was computed using incident ischaemic heart disease (IHD) estimates from the Global Burden of Disease study. General linear mixed models were performed. RESULTS: CR was identified in 55/138 (39.9%) LMICs; 47/55 (85.5% country response rate) countries participated and 335 (53.5% programme response) surveys were initiated. There was one CR spot for every 66 IHD patients in LMICs (vs 3.4 in HICs). CR was most often paid by patients in LMICs (n=212, 65.0%) versus government in HICs (n=444, 60.2%; p<0.001). Over 85% of programmes accepted guideline-indicated patients. Cardiologists (n=266, 89.3%), nurses (n=234, 79.6%; vs 544, 91.7% in HICs, p=0.001) and physiotherapists (n=233, 78.7%) were the most common providers on CR teams (mean=5.8±2.8/programme). Programmes offered 7.3±1.8/10 core components (vs 7.9±1.7 in HICs, p<0.01) over 33.7±30.7 sessions (significantly greater in publicly funded programmes; p<0.001). Publicly funded programmes were more likely to have social workers and psychologists on staff, and to offer tobacco cessation and psychosocial counselling. CONCLUSION: CR is only available in 40% of LMICs, but where offered is fairly consistent with guidelines. Governments should enact policies to reimburse CR so patients do not pay out-of-pocket.

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.

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.

The Effects of Cardiac Rehabilitation on Mortality and Morbidity in Women: A META-ANALYSIS ATTEMPT.

PURPOSE: Cardiac rehabilitation (CR) is associated with significant reductions in mortality and morbidity, but few women are included in trials. Therefore, a meta-analysis of the effects of CR in women is warranted. METHODS: Randomized controlled trials from recent systematic reviews that included women attending comprehensive CR and reporting the outcomes of mortality and morbidity (hospitalization, myocardial infarction, bypass surgery, percutaneous coronary intervention) were considered for inclusion. An updated search of the literature was performed from the end date of the last search, based on the Cochrane strategy. Authors were contacted to provide results on women where none were reported. RESULTS: On the basis of 2 recent systematic reviews, 80 trials were identified. Fifty (62.5%) were excluded, most commonly due to lack of inclusion of women (n = 18; 22.5%). One trial was identified through the search update. Of 31 potential trials meeting inclusion criteria, 1 reported results on women and many were old, and hence data by sex were no longer available. Ultimately, data for women were available in 2 trials. Therefore, it was deemed inappropriate to undertake this meta-analysis. CONCLUSIONS: This review corroborates the dearth of data on CR in women despite the fact that cardiovascular disease is the leading cause of death in women. Given the totality of evidence, including reductions in mortality and morbidity in nonrandomized studies, and evidence of benefit for other important outcomes such as functional capacity and quality of life, women should continue to be referred to CR.

Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis.

A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane's tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54⁻0.85) and ET (HR = 0.75, 95% CrI = 0.60⁻0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57⁻0.99), ET (HR = 0.75, 95% CrI = 0.56⁻0.99) and PE (HR = 0.68, 95% CrI = 0.47⁻0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58⁻0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.

Availability and characteristics of cardiac rehabilitation programs in one Brazilian state: a cross-sectional study.

BACKGROUND: Cardiac rehabilitation (CR) is a recommended model of care for cardiovascular diseases; however, is not widely available and is underutilized, especially in low- and middle-income countries. OBJECTIVES: To identify the CR programs available in one Brazilian state (Minas Gerais; MG) and describe their characteristics by funding type. METHODS: In this multi-center descriptive study, CR programs were identified in four MG regions and 41 CR coordinators were sent a survey to report the characteristics of their programs, including CR components described in guidelines and barriers to patients' participation. Descriptive and comparative analysis between public and private programs were carried out. RESULTS: Forty-one CR programs were identified, only 21.9% public. Nineteen completed the survey. The majority of CR programs offered initial assessment and physical training. Components of comprehensive CR programs that were rarely offered included treatment of tobacco dependence, psychological support and lipid control. Physical therapists were present in all CR programs. The six-minute walk test was used in most programs to assess functional capacity. Programs were located intra-hospital only in public hospitals. Phase 2 (initial outpatient) and phase 4 (maintenance) were offered significantly more in private programs when compared to public ones. The main barrier for CR participation was the lack of referral. CONCLUSIONS: The availability of CR programs in MG state is low, especially public programs. Most programs do not offer all core components of CR.