The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Promoting cardiac rehabilitation program quality in low-resource settings: Needs assessment and evaluation of the International Council of Cardiovascular Prevention and Rehabilitation's registry quality improvement supports.

BACKGROUND: Cardiac rehabilitation (CR) registries have the potential to support quality improvement (QImp). This study investigated the QImp needs of International CR Registry-participating programs and their evaluation of its' supports. METHODS: ICRR offers comparative outcome dashboards and QImp sessions, among other features. In this qualitative study, ICRR data stewards from the 17 active on-boarded CR programs were invited to a focus group held in November 2023 via Teams; stewards not sufficiently-proficient in English were invited to provide written input. Deductive-thematic analysis using NVIVO was undertaken by 2 researchers; member-checking ensued. RESULTS: Nine participated, and four provided input, from eight countries. Three themes emerged; saturation was achieved. First, QImp facilitators included training, institutional requirements, dedicated staff, resources in academic centres and ICRR features. Second, QImp barriers included staffing issues, the global nature of the ICRR, and structural challenges in low-resource settings. Finally, ICRR supports for QImp included didactic webinars, hearing from other programs, 1-1 support offered and assessing minimum Certification standards. CONCLUSION: ICRR-participating programs are satisfied with QImp supports but encounter challenges, including related to language, staffing and other resources. CR registries should be leveraged and optimized to support CR programs to assess and improve their care quality.

Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment.

BACKGROUND: Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women's greatest barriers according to enrollment status. METHODS: In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated. RESULTS: Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women's barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5). CONCLUSIONS: CR barriers-men's and women's-vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women's barriers in particular.

Sex differences in cardiac rehabilitation barriers among non-enrollees in the context of lower gender equality: a cross-sectional study.

BACKGROUND: Despite the benefits of cardiac rehabilitation (CR), it remains under-utilized, particularly by women. This study compared CR barriers between non-enrolling men and women in Iran, which has among the lowest gender equality globally. METHODS: In this cross-sectional study, CR barriers were assessed via phone interview in phase II non-attenders from March 2017 to February 2018 with the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P). T-tests were used to compare scores, with each of 18 barriers scored out of 5, between men and women. RESULTS: 357 (33.9%) of the sample of 1053 were women, and they were older, less educated and less often employed than men. Total mean CRBS scores were significantly greater in women (2.37 ± 0.37) than men (2.29 ± 0.35; effect size[ES] = 0.08, confidence interval[CI]: 0.03-0.13; p < 0.001). The top CR barriers among women were cost (3.35; ES = 0.40, CI:0.23-0.56; P < 0.001), transportation problems (3.24; ES = 0.41, CI:0.25-0.58; P < 0.001), distance (3.21; ES = 0.31, CI:0.15-0.48; P < 0.001), comorbidities (2.97; ES = 0.49, CI:0.34-0.64; P < 0.001), low energy (2.41; ES = 0.29, CI:0.18-0.41; P < 0.001), finding exercise as tiring or painful (2.22; ES = 0.11, CI:0.02-0.21; P = 0.018), and older age (2.27; ES = 0.18, CI:0.07-0.28; P = 0.001). Men rated "already exercise at home or in community" (2.69; ES = 0.23, CI:0.1-0.36; P = 0.001), time constraints (2.18; ES = 0.15, CI:0.07-0.23; P < 0.001) and work responsibilities (2.24; ES = 0.16, CI:0.07-0.25; P = 0.001) as greater CR barriers than women. CONCLUSION: Women had greater barriers to CR participation than men. CR programs should be modified to address women's needs. Home-based CR tailored to women's exercise needs and preferences should be considered.

Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost. METHODS: Medline, PubMed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception through to May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. "Women-focused" CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women's preferences. No studies were excluded on the basis of outcome. Two independent reviewers rated citations for potential inclusion, and one extracted data, including on quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied. RESULTS: 3498 unique citations were identified, of which 28 studies (52 papers) were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with "usual care" comparisons. Compared to "active comparison" group, women-focused CR had no meaningful additional effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence) and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as scores on seven of the eight SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported a favorable economic impact and another reported reduced sick days. CONCLUSIONS: Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed. PROSPERO REGISTRATION: CRD42020189760.

Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review.

BACKGROUND: Women do not participate in cardiac rehabilitation (CR) to the same degree as men; women-focused CR may address this. This systematic review investigated the: (1) nature, (2) availability, as well as (3a) utilization of, and (b) satisfaction with women-focused CR. METHODS: Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception to May 2020. Primary studies of any design were included. Adult females with any cardiac diseases, participating in women-focused CR (i.e., program or sessions included ≥ 50% females, or was 1-1 and tailored to women's needs) were considered. Two authors rated citations for inclusion. One extracted data, including study quality rated as per the Mixed-Methods Assessment Tool (MMAT), which was checked independently by a second author. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guideline. RESULTS: 3498 unique citations were identified, with 28 studies (53 papers) included (3697 women; ≥ 10 countries). Globally, women-focused CR is offered by 40.9% of countries that have CR, with 32.1% of programs in those countries offering it. Thirteen (46.4%) studies offered women-focused sessions (vs. full program), 17 (60.7%) were women-only, and 11 (39.3%) had gender-tailoring. Five (17.9%) programs offered alternate forms of exercise, and 17 (60.7%) focused on psychosocial aspects. With regard to utilization, women-focused CR cannot be offered as frequently, so could be less accessible. Adherence may be greater with gender-tailored CR, and completion effects are not known. Satisfaction was assessed in 1 trial, and results were equivocal. CONCLUSIONS: Women-focused CR involves tailoring of content, mode and/or sex composition. Availability is limited. Effects on utilization require further study.

Impacts of the COVID-19 Pandemic on Cardiac Rehabilitation Delivery around the World.

Background: We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients. Methods: In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification. Results: Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption. Conclusion: Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges. Highlights: - COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.- In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries.- The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training.- There is also significant psychosocial and economic impact on CR providers.- Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

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 availability and characteristics in Latin America and the Caribbean: A Global Comparison.

BACKGROUND: This study aimed to establish availability and characteristics of cardiac rehabilitation (CR) in Latin America and the Caribbean (LAC), where cardiovascular disease is highly prevalent. METHODS: In this cross-sectional sub-analysis focusing on the 35 LAC countries, local cardiovascular societies identified CR programs globally. An online survey was administered to identified programs, assessing capacity and characteristics. CR need was computed relative to ischemic heart disease (IHD) incidence from the Global Burden of Disease study. RESULTS: ≥1 CR program was identified in 24 LAC countries (68.5% availability; median = 3 programs/country). Data were collected in 20/24 countries (83.3%); 139/255 programs responded (54.5%), and compared to responses from 1082 programs in 111 countries. LAC density was 1 CR spot per 24 IHD patients/year (vs 18 globally). Greatest need was observed in Brazil, Dominican Republic and Mexico (all with >150,000 spots needed/year). In 62.8% (vs 37.2% globally P < .001) of CR programs, patients pay out-of-pocket for some or all of CR. CR teams were comprised of a mean of 5.0 ± 2.3 staff (vs 6.0 ± 2.8 globally; P < .001); Social workers, dietitians, kinesiologists, and nurses were significantly less common on CR teams than globally. Median number of core components offered was 8 (vs 9 globally; P < .001). Median dose of CR was 36 sessions (vs 24 globally; P < .001). Only 27 (20.9%) programs offered alternative CR models (vs 31.1% globally; P < .01). CONCLUSION: In LAC countries, there is very limited CR capacity in relation to need. CR dose is high, but comprehensiveness low, which could be rectified with a more multidisciplinary team.

Women-Only Cardiac Rehabilitation Delivery Around the World.

BACKGROUND: Women utilise cardiac rehabilitation (CR) significantly less than men. Gender-tailored CR improves adherence and mental health outcomes when compared to traditional programs. This study ascertained the availability of women-only (W-O) CR classes globally. METHODS: In this cross-sectional study, an online survey was administered to CR programs globally, assessing delivery of W-O classes, among other program characteristics. Univariate tests were performed to compare provision of W-O CR by program characteristics. RESULTS: Data were collected in 93/111 countries with CR (83.8% country response rate); 1,082 surveys (32.1% program response rate) were initiated. Globally, 38 (40.9%; range 1.2-100% of programs/country) countries and 110 (11.8%) programs offered W-O CR. Women-Only CR was offered in 55 (7.4%) programs in high-income countries, versus 55 (16.4%) programs in low- and middle-income countries (p<0.001); it was offered most commonly in the Eastern Mediterranean region (n=5, 55.6%; p=0.22). Programs that offered W-O CR were more often located in an academic or tertiary facility, served more patients/year, offered more components, treated more patients/session, offered alternative forms of exercise, had more staff (including cardiologists, dietitians, and administrative assistants, but not mental health care professionals), and perceived space and human resources to be less of a barrier to delivery than programs not offering W-O CR (all p<0.05). CONCLUSION: Women-Only CR was not commonly offered. Only larger, well-resourced programs seem to have the capacity to offer it, so expanding delivery may require exploiting low-cost, less human resource-intensive approaches such as online peer support.

Patient-Centered Care for Women: Delphi Consensus on Evidence-Derived Recommendations.

OBJECTIVE: Patient-centered care (PCC) could reduce gender inequities in quality of care. Little is known about how to implement patient-centered care for women (PCCW). We aimed to generate consensus recommendations for achieving PCCW. METHODS: We used a 2-round Delphi technique. Panelists included 21 women of varied age, ethnicity, education, and urban/rural residence; and 21 health professionals with PCC or women's health expertise. Panelists rated recommendations, derived from prior research and organized by a 6-domain PCC framework, on a 7-point Likert scale in an online survey. We used summary statistics to report response frequencies and defined consensus as when ≥85% panelists chose 5 to 7. RESULTS: The response rate was 100%. In round 1, women and professionals retained 46 (97.9%) and 42 (89.4%) of 47 initial recommendations, respectively. The round 2 survey included 6 recommendations for women and 5 recommendations for professionals (did not achieve consensus in round 1 or were newly suggested). In round 2, women retained 2 of 6 recommendations and professionals retained 3 of 5 recommendations. Overall, 49 recommendations were generated. Both groups agreed on 44 (94.0%) recommendations (13 retained by 100% of both women and clinicians): fostering patient-physician relationship (n = 11), exchanging information (n = 10), responding to emotions (n = 4), managing uncertainty (n = 5), making decisions (n = 8), and enabling patient self-management (n = 6). CONCLUSION: The recommendations represent the range of PCC domains, are based on evidence from primary research, and reflect high concordance between women and professional panelists. They can inform the development of policies, guidelines, programs, and performance measures that foster PCCW.

Multi-level strategies to tailor patient-centred care for women: qualitative interviews with clinicians.

BACKGROUND: Patient-centered care (PCC) is one approach for ameliorating persistent gendered disparities in health care quality, yet no prior research has studied how to achieve patient-centred care for women (PCCW). The purpose of this study was to explore how clinicians deliver PCCW, challenges they face, and the strategies they suggest are needed to support PCCW. METHODS: We conducted semi-structured qualitative interviews (25-60 min) with clinicians. Thirty-seven clinicians representing 7 specialties (family physicians, cardiologists, cardiac surgeons, obstetricians/gynecologist, psychiatrists, nurses, social workers) who manage depression (n = 16), cardiovascular disease (n = 11) and contraceptive counseling (n = 10), conditions that affect women across the lifespan. We used constant comparative analysis to inductively analyze transcripts, mapped themes to a 6-domain PCC conceptual framework to interpret findings, and complied with qualitative research reporting standards. RESULTS: Clinicians said that women don't always communicate their health concerns and physicians sometimes disregard women's health concerns, warranting unique PCC approaches.. Clinicians described 39 approaches they used to tailor PCC for women across 6 PCC domains: foster a healing relationship, exchange information, address emotions/concerns, manage uncertainty, make decisions, and enable self-management. Additional conditions that facilitated PCCW were: privacy, access to female clinicians, accommodating children through onsite facilities, and flexible appointment formats and schedules. Clinicians suggested 7 strategies needed to address barriers of PCCW they identified at the: patient-level (online appointments, transport to health services, use of patient partners to plan and/or deliver services), clinician-level (medical training and continuing professional development in PCC and women's health), and system-level (funding models for longer appointment times, multidisciplinary teamwork to address all PCC domains). CONCLUSIONS: Our research revealed numerous strategies that clinicians can use to optimize PCCW, and health care managers and policy-makers can use to support PCCW through programs and policies. Identified strategies addressed all domains of an established PCC conceptual framework. Future research should evaluate the implementation and impact of these strategies on relevant outcomes such as perceived PCC among women and associated clinical outcomes to prepare for broad scale-up.

Is patient-centred care for women a priority for policy-makers? Content analysis of government policies.

BACKGROUND: Considerable research shows that women experience gendered disparities in healthcare access and quality. Patient-centred care (PCC) could reduce inequities by addressing the patient's clinical and personal needs. Healthcare policies can influence service delivery to optimise patient outcomes. This study assessed whether and how government policies recognise and promote PCC for women (PCCW). METHODS: We analysed the content of English-language policies published in Canada from 2010 to 2018 on depression and cardiac rehabilitation - conditions featuring known gendered inequities - that were identified on government websites. We extracted data and used summary statistics to enumerate mentions of PCC and women's health. RESULTS: We included 30 policies (20 depression, 10 cardiac rehabilitation). Of those, 20 (66.7%) included any content related to PCC (median 1.0, range 0.0 to 5.0), most often exchanging information (14, 46.7%) and making decisions (13, 43.3%). Less frequent domains were enabling self-management (8, 26.7%), addressing emotions (6, 20.0%) and fostering the relationship (4, 13.3%). No policies included content for the domain of managing uncertainty. A higher proportion of cardiac rehabilitation guidelines included PCC content. Among the 30 policies, 7 (23.3%) included content related to at least one women's health domain (median 0.0, range 0.0 to 3.0). Most frequently included were social determinants of health (4, 13.3%). Fewer policies mentioned any issues to consider for women (2, 28.6%), issues specific to subgroups of women (2, 28.6%) or distinguished care for women from men (2, 28.6%). No policies included mention of abuse or violence, or discrimination or stigma. The policies largely pertained to depression. Despite mention of PCC or women's health, policies offered brief, vague guidance on how to achieve PCCW; for example, "Patients value being involved in decision-making" and "Women want care that is collaborative, woman- and family-centered, and culturally sensitive." CONCLUSIONS: Despite considerable evidence of need and international recommendations, most policies failed to recognise gendered disparities or promote PCC as a mitigating strategy. These identified gaps represent opportunities by which government policies could be developed or strengthened to support PCCW. Future research should investigate complementary strategies such as equipping policy-makers with the evidence and tools required to develop PCCW-informed policies.

Identifying strategies to implement patient-centred care for women: Qualitative interviews with women.

OBJECTIVE: Patient-centred care (PCC) is one approach for mitigating gendered inequities in health care quality. Little is known about how to implement PCC for women (PCCW). This study explored women's views about PCCW implementation. METHODS: Descriptive analysis of semi-structured qualitative telephone interviews with diverse women about PCC using an established 6-domain PCC framework. RESULTS: Participants were 33 women who varied in health care experience, age, education and setting. Themes were consistent across these characteristics. Women said that clinicians often dismissed their healthcare concerns. We transformed desired PCC elements into strategies to implement PCCW, 27 at the point-of-care (i.e. assume a non-judgmental disposition, demonstrate active listening, elicit questions, acknowledge emotions, explore preferences for treatment, and offer self-care information) and 3 at the system level (education for women/girls and clinicians about PCCW, widespread access to women's-only services or women clinicians). CONCLUSION: Many women experienced suboptimal PCC. By sharing their PCC experiences, women identified PCC elements of importance to them, and insight on actionable point-of-care and system-level strategies to implement PCCW. PRACTICE IMPLICATIONS: This study revealed numerous ways that clinicians can foster PCCW, and insight on how healthcare managers and policy-makers can support PCCW implementation.

Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers?

BACKGROUND: People after stroke benefit from comprehensive secondary prevention programs including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use. OBJECTIVE: The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use. DESIGN: This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada. METHODS: Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators. RESULTS: Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, have poorer attendance at OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] vs 87.1% [SD = 16.6%], respectively) and completion (66.7% vs 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%). LIMITATIONS: Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes. CONCLUSIONS: An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.

How is patient-centred care conceptualized in women's health: a scoping review.

BACKGROUND: Gendered disparities in health care delivery and outcomes are an international problem. Patient-centred care (PCC) improves patient and health system outcomes, and is widely advocated to reduce inequities. The purpose of this study was to review published research for frameworks of patient-centred care for women (PCCW) that could serve as the basis for quality improvement. METHODS: A scoping review was conducted by searching MEDLINE, EMBASE, CINAHL, SCOPUS, Cochrane Library, and Joanna Briggs index for English-language quantitative or qualitative studies published from 2008 to 2018 that included at least 50% women aged 18 years or greater and employed or generated a PCCW framework. Findings were analyzed using a 6-domain PCC framework, and reported using summary statistics and narrative descriptions. RESULTS: A total of 9267 studies were identified, 6670 were unique, 6610 titles were excluded upon title/abstract screening, and 11 were deemed eligible from among 60 full-text articles reviewed. None were based on or generated a PCCW framework, included solely women, or analyzed or reported findings by gender. All studies explored or described PCC components through qualitative research or surveys. None of the studies addressed all 6 domains of an established PCC framework; however, additional PCC elements emerged in 9 of 11 studies including timely responses, flexible scheduling, and humanized management, meaning tailoring communication and treatment to individual needs and preferences. There were no differences in PCC domains between studies comprised primarily of women and other studies. CONCLUSIONS: Given the paucity of research on PCCW, primary research is needed to generate knowledge about PCCW processes, facilitators, challenges, interventions and impacts, which may give rise to a PCCW framework that could be used to plan, deliver, evaluate and improve PCCW.

How do and could clinical guidelines support patient-centred care for women: Content analysis of guidelines.

OBJECTIVES: Patient-centred care (PCC) improves multiple patient and health system outcomes. However, many patients do not experience PCC, particularly women, who are faced with disparities in care and outcomes globally. The purpose of this study was to identify if and how guidelines address PCC for women (PCCW). METHODS: We searched MEDLINE, EMBASE, National Guideline Clearing House, and guideline developer websites for publicly-available, English-language guidelines on depression and cardiac rehabilitation, conditions with known gendered inequities. We used summary statistics to report guideline characteristics, clinical topic, mention of PCC according to McCormack's framework, and mention of women's health considerations. We appraised guideline quality with the AGREE II instrument. RESULTS: A total of 27 guidelines (18 depression, 9 cardiac rehabilitation) were included. All 27 guidelines mentioned at least one PCC domain (median 3, range 1 to 6), most frequently exchanging information (20, 74.1%), making decisions (20, 74.1%), and enabling patient self-management (21, 77.8%). No guidelines fully addressed PCC: 9 (50.0%) of 18 depression guidelines and 3 (33.3%) of 9 cardiac rehabilitation guidelines addressed 4 or more PCC domains. Even when addressed, guidance was minimal and vague. Among 14 (51.9%) guidelines that mentioned women's health, most referred to social determinants of health; none offered guidance on how to support women impacted by these factors, engage women, or tailor care for women. These findings pertained even to women-specific guidelines. Reported use or type of guideline development process/system did not appear to be linked with PCCW content. Based on quality appraisal with AGREE II, guidelines were either not recommended or recommended with modifications. In particular, the stakeholder involvement AGREE II domain was least addressed, but guidelines that scored higher for stakeholder involvement also appeared to better address PCCW. IMPLICATIONS: This research identified opportunities to generate guidelines that achieve PCCW. Strategies include employing a PCC framework, considering gender issues, engaging women on guideline-writing panels, and including patient-oriented tools in guidelines. Primary research is needed to establish what constitutes PCCW.

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.