The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial.

BACKGROUND: Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs. METHODS: The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation. DISCUSSION: Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23.

Comprehensive Cardiac Care: How Much Does It Cost?

The benefits of coordinating care between healthcare professionals and institutions are the main drivers behind reforms to the payment and delivery system for healthcare services. The purpose of this study was to analyse the costs incurred by the National Health Fund in Poland related to the comprehensive care model for patients after myocardial infarction (CCMI, in Polish: KOS-Zawal). METHODS: The analysis involved data from 1 October 2017 to 31 March 2020 for 263,619 patients who received treatment after a diagnosis of first or recurrent myocardial infarction as well as data for 26,457 patients treated during that period under the CCMI programme. RESULTS: The average costs of treating patients covered by the full scope of comprehensive care and cardiac rehabilitation under the programme (EUR 3113.74/person) were higher than the costs of treating patients outside of that programme (EUR 2238.08/person). At the same time, a survival analysis revealed a statistically significantly lower probability of death (p < 0.0001) in the group of patients covered by CCMI compared to the group not covered by the programme. CONCLUSIONS: The coordinated care programme introduced for patients after myocardial infarction is more expensive than the care for patients who do not participate in the programme. Patients covered by the programme were more often hospitalised, which might have been due to the good coordination between specialists and responses to sudden changes in patients' conditions.

Financial InceNtives for cArdiac rehabilitatioN ComplEtion (FINANCE) (single blind pragmatic RCT).

INTRODUCTION: Cardiac rehabilitation (CR) is strongly indicated in patients with acute myocardial infarction (MI), and has been proven to reduce mortality and recurrence and improve patients quality of life. Although clinical guidelines for CR have already been developed domestically and internationally, hospital-based CR remains underutilized. Currently, studies exploring strategies to improve CR participation in South Korea and Asia are limited. OBJECTIVES: This study aims to compare the effect of providing CR financial incentives to post-MI patients referred for outpatient CR and to confirm the effect of increasing CR participation and completion rates. METHODS: This single-blind, pragmatic, randomized controlled trial will be conducted at 2 tertiary hospitals for CR after acute MI. The control and experimental groups will be randomized, with each group consisting of 24 participants (total of 48 participants) assigned in a 1:1 ratio. The experimental group will receive 4, 7, and 11 USD per completed session of CR during the 1st to 12th, 13 to 24th, and 25th to 36th sessions of CR, respectively, for 3 months after enrollment. Participants who completed the 36 sessions will receive 260 USD incentives. The primary outcomes at 3 months will be used to assess the CR participation rate, as the number of CR sessions completed, and CR completion, as attendance of sessions greater than 50%, thus completion of ≥18 sessions. The outcomes will be used to compare changes in cardiorespiratory function (VO2 max, VO2 at anabolic threshold), the Korean activity scale index, EuroQol 5 dimensions, and the patient health questionnaire at 3 months after discharge and 6 and 12 months after baseline. DISCUSSION: Providing financial incentives may confirm the effect of increasing CR on participation and completion rates.

Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE.

PURPOSE: This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence. METHODS: We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type. RESULTS: In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States. CONCLUSIONS: The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.

Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery.

BACKGROUND: Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone. METHODS: A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty. RESULTS: The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone. CONCLUSIONS: Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.

Study on the clinical assessment of integrated rehabilitation of Traditional Chinese Medicine and western medication for acute myocardial infarction.

OBJECTIVE: This trial aims to evaluate the efficacy and safety of the Baduanjin exercise in patients with acute myocardial infarction (AMI). METHODS: A single-center, open, randomized controlled clinical trial will be conducted to evaluate the effectiveness of the Baduanjin exercise on the rehabilitation of AMI patients. It plans to enroll 64 patients. Patients will be divided evenly into 2 groups using a random number table method. There will be 32 cases in each group. Patients in the experimental group will be treated with standardized drug therapy combined with Baduanjin exercise, while patients in the control group will be treated with standardized drug therapy combined with routine exercise. The primary outcome is the peak oxygen consumption (Peak VO2) during cardiopulmonary exercise test (CPET). The secondary outcomes include CPET, echocardiography, Seattle angina pectoris scale, hospital depression and anxiety scale, Pittsburgh Sleep Quality Index scale, scores of 4 examinations, and diagnostic methods of traditional Chinese medicine and composite endpoint events, etc. DISCUSSION:: This study will be the first to evaluate the effect of the Baduanjin exercise on the Peak VO2 in patients with AMI. STUDY REGISTRATION: This study has been registered on the Chinese Clinical Trial Registry (No: ChiCTR1800016209, protocol version 1.2).

Improving cardiac rehabilitation uptake: Potential health gains by socioeconomic status.

BACKGROUND: Globally, cardiac rehabilitation (CR) is recommended as soon as possible after admission from an acute myocardial infarction (MI) or revascularisation. However, uptake is consistently poor internationally, ranging from 10% to 60%. The low level of uptake is compounded by variation across different socioeconomic groups. Policy recommendations continue to focus on increasing uptake and addressing inequalities in participation; however, to date, there is a paucity of economic evidence evaluating higher CR participation rates and their relevance to socioeconomic inequality. METHODS: This study constructed a de-novo cost-effectiveness model of CR, utilising the results from the latest Cochrane review and national CR audit data. We explore the role of socioeconomic status by incorporating key deprivation parameters and determine the population health gains associated with achieving an uptake target of 65%. RESULTS: We find that the low cost of CR and the potential for reductions in subsequent MI and revascularisation rates combine to make it a highly cost-effective intervention. While CR is less cost-effective for more deprived groups, the lower level of uptake in these groups makes the potential health gains, from achieving the target, greater. Using England as a model, we estimate the expenditure that could be justified while maintaining the cost-effectiveness of CR at £68.4 m per year. CONCLUSIONS: Increasing CR uptake is cost-effective and can also be implemented to reduce known socioeconomic inequalities. Using an estimation of potential population health gains and justifiable expenditure, we have produced tools with which policymakers and commissioners can encourage greater utilisation of CR services.

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial.

OBJECTIVES: This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR). BACKGROUND: Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events. METHODS: A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO2) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year. RESULTS: Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079). CONCLUSIONS: Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).

Medication adherence, biological and lifestyle risk factors in patients with myocardial infarction: a ten-year follow-up on socially differentiated cardiac rehabilitation.

Objective: There is strong evidence that medication adherence and lifestyle changes are essential in patients undergoing secondary cardiovascular disease prevention. Cardiac rehabilitation (CR) increases medication adherence and improves lifestyle changes. Patients with cardiac diseases and a low educational level and patients with little social support are less responsive to improve medication adherence and to adapt lifestyle changes. The aim of the present study was to investigate the long-term effects of a socially differentiated CR intervention on medication adherence as well as changes in biological and lifestyle risk factors at two- five- and ten-year follow-up. Design: A prospective cohort study. Setting: The cardiac ward at Aarhus University Hospital, Denmark. Intervention: A socially differentiated CR intervention in addition to the standard CR program. Subjects: Patients admitted with first-episode myocardial infarction between 2000 and 2004, N = 379. Patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and extent of social network. Main outcome measures: Primary outcome was medication adherence to antithrombotics, beta-blockers, statins and angiotensin-converting enzyme inhibitors. Secondary outcomes were biological and lifestyle risk factors defined as; total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glycated hemoglobin, blood pressure and smoking status. Results: No significant long-term effect of the intervention was found. Conclusions: The results indicate a non-significant effect of the intervention. However, it was found that equality in health was improved in the study population except concerning smoking. General practitioners manage to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status. Key points The socially differentiated intervention did not significantly improve medication adherence or biological and lifestyle risk factors. Despite the non-significant effect of the intervention, equality in health was improved except concerning smoking. General practitioners managed to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.

[Performance indicators of cardiac rehabilitation in Hungary]. / A kardiológiai rehabilitáció teljesítménymutatói Magyarországon.

INTRODUCTION: With the improvement of the survival of acute cardiac events and the increasing age, there is a higher demand for cardiac rehabilitation care. AIM: The aim of our study is to analyse the performance indicators of cardiac inpatient rehabilitation care in Hungary financed by the statutory public health insurance system. DATA AND METHODS: Data were derived from the financial database of the National Health Insurance Fund of Hungary. We analysed the period between 2014 and 2017. We investigated the distribution of cardiac rehabilitation hospital beds, the patient turnover and the rehabilitation rate following acute care. RESULTS: In 2017, there were 1765 publicly financed cardiac rehabilitation hospital beds in Hungary (1.8 beds/10 000 population). We observed the lowest number of hospital bed number in Szabolcs-Szatmár-Bereg (0.27 beds/10 000 population), Hajdú-Bihar (0.28) and Fejér (0.6) counties. We found the highest number of hospital beds in Veszprém (11.47 beds/10 000 population), Gyor-Moson-Sopron (4.94) counties and in Budapest (2.27). Between 2014 and 2017, the annual number of patients was between 24 834 and 26 146, while the number of nursing days varied between 510 thousand and 542 thousand. The average length of stay showed a moderate increase from 19.2 days/patient (2014) to 20.2 days/patient (2017). Only 6.6-7.6% of the patients who underwent acute myocardial infarction received cardiac rehabilitation care. CONCLUSION: We found significant regional inequalities in both the capacities and the access to and utilization of cardiac rehabilitation healthcare services, which should be mitigated by health policy activities. The low proportion (6.6-7.6%) of patients who underwent acute myocardial infarction and received cardiac rehabilitation care, should be increased. Orv Hetil. 2019; 160(Suppl 1): 6-12.

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.

Effects of cardiovascular and cerebrovascular health events on work and earnings: a population-based retrospective cohort study.

BACKGROUND: Survivors of acute health events can experience lasting reductions in functional status and quality of life, as well as reduced ability to work and earn income. We aimed to assess the effect of acute myocardial infarction (MI), cardiac arrest and stroke on work and earning among working-age people. METHODS: For this retrospective cohort study, we used the Canadian Hospitalization and Taxation Database, which contains linked hospital and income tax data, from 2005 to 2013 to perform difference-in-difference analyses. We matched patients admitted to hospital for acute MI, cardiac arrest or stroke with controls who were not admitted to hospital for these indications. Participants were aged 40-61 years, worked in the 2 years before the event and were alive 3 years after the event. Patients were matched to controls for 11 variables. The primary outcome was working status 3 years postevent. We also assessed earnings change attributable to the event. We matched 19 129 particpants who were admitted to hospital with acute MI, 1043 with cardiac arrest and 4395 with stroke to 1 820 644, 307 375 and 888 481 controls, respectively. RESULTS: Fewer of the patients who were admitted to hospital were working 3 years postevent than controls for acute MI (by 5.0 percentage points [pp], 95% confidence interval [CI] 4.5-5.5), cardiac arrest (by 12.9 pp, 95% CI 10.4-15.3) and stroke (by 19.8 pp, 95% CI 18.5-23.5). Mean (95% CI) earnings declines attributable to the events were $3834 (95% CI 3346-4323) for acute MI, $11 143 (95% CI 8962-13 324) for cardiac arrest, and $13 278 (95% CI 12 301-14 255) for stroke. The effects on income were greater for patients who had lower baseline earnings, comorbid disease, longer hospital length of stay or needed mechanical ventilation. Sex, marital status or self-employment status did not affect income declines. INTERPRETATION: Acute MI, cardiac arrest and stroke all resulted in substantial loss in employment and earnings that persisted for at least 3 years after the events. These outcomes have consequences for patients, families, employers and governments. Identification of subgroups at high risk for these losses may assist in targeting interventions, policies and legislation to promote return to work.

Effectiveness and cost-effectiveness of a Yoga-based Cardiac Rehabilitation (Yoga-CaRe) program following acute myocardial infarction: Study rationale and design of a multi-center randomized controlled trial.

BACKGROUND: Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. METHODS: This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18-80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. CONCLUSION: This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings.

Exploring patient-reported outcomes of home-based cardiac rehabilitation in relation to Scottish, UK and European guidelines: an audit using qualitative methods.

OBJECTIVES: The Heart Manual (HM) is the UK's leading facilitated home-based cardiac rehabilitation (CR) programme for individuals recovering from myocardial infarction and revascularisation. This audit explored patient-reported outcomes of home-based CR in relation to current Scottish, UK and European guidelines. SETTING: Patients across the UK returned their questionnaire after completing the HM programme to the HM Department (NHS Lothian). PARTICIPANTS: Qualitative data from 457 questionnaires returned between 2011 and 2018 were included for thematic analysis. Seven themes were identified from the guidelines. This guided initial deductive coding and provided the basis for inductive subthemes to emerge. RESULTS: Themes included: (1) health behaviour change and modifiable risk reduction, (2) psychosocial support, (3) education, (4) social support, (5) medical risk management, (6) vocational rehabilitation and (7) long-term strategies and maintenance. Both (1) and (2) were reported as having the greatest impact on patients' daily lives. Subthemes for (1) included: guidance, engagement, awareness, consequences, attitude, no change and motivation. Psychosocial support comprised: stress management, pacing, relaxation, increased self-efficacy, validation, mental health and self-perception. This was followed by (3) and (4). Patients less frequently referred to (5), (6) and (7). Additional themes highlighted the impact of the HM programme and that patients attributed the greatest impact to a combination of all the above themes. CONCLUSIONS: This audit highlighted the HM as comprehensive and inclusive of key elements proposed by Scottish, UK and EU guidelines. Patients reported this had a profound impact on their daily lives and proved advantageous for CR.

Older Adult Attendance in Cardiac Rehabilitation: IMPACT OF FUNCTIONAL STATUS AND POSTACUTE CARE AFTER ACUTE MYOCARDIAL INFARCTION IN 63 092 MEDICARE BENEFICIARIES.

PURPOSE: Older adults who use postacute care (PAC) after hospitalization for myocardial infarction (MI) are often overlooked as cardiac rehabilitation (CR) candidates because of physical limitations. This research describes the impact of functional status and PAC, including inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), or home health care (HHC), on CR initiation in Medicare beneficiaries discharged from the hospital following an index MI. METHODS: The Chronic Condition Warehouse database of Medicare beneficiaries discharged to PAC following index MI in 2008 (n = 63 092) was used for this retrospective study. Functional status at PAC discharge was described as dependent, needed assistance, needed supervision, or independent. Logistic regression examined factors associated with CR initiation. RESULTS: CR was initiated by 3% and 21% of beneficiaries discharged from PAC as dependent or independent, respectively. Beneficiaries who were dependent, needed assistance, or needed supervision were 78% (95% CI, 0.18-0.28), 60% (0.32-0.49), and 51% (0.41-0.57) less likely to initiate CR compared with independent beneficiaries. Those who had used IRF were 40% more likely to initiate CR compared with those who had used HHC, with no difference observed between those who had used SNF compared with HHC. CONCLUSIONS: Functional status at PAC discharge was strongly associated with CR initiation. Beneficiary initiation of CR was at proportions corresponding to the level of independence. Beneficiaries discharged from PAC as independent initiated CR at rates slightly higher than non-PAC users, and those discharged from IRF were more likely to initiate CR. These findings are promising and more targeted recruitment from PAC may increase CR initiation and completion, resulting in continued improvement in functional status.

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). Final rule.

This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

Influence of Depression on Utilization of Cardiac Rehabilitation Postmyocardial Infarction: A STUDY OF 158 991 MEDICARE BENEFICIARIES.

PURPOSE: On the basis of several small studies, depression is often considered a barrier to cardiac rehabilitation (CR) enrollment and program completion. The purpose of this research was to examine the association between depression diagnosis and participation in CR in a large sample of Medicare beneficiaries with recent myocardial infarction (MI). METHODS: This was a retrospective study of Medicare beneficiaries with an MI during 2008 (N = 158 991). CR enrollment was determined by the Carrier and Outpatient files using the Healthcare Common Procedure Coding System #93797 or #93798. Depression diagnosis was obtained from the International Classification of Diseases, Ninth Revision (ICD-9) codes in the Medicare Provider Analysis and Review (MEDPAR), Outpatient and Carrier Files. The association between depression diagnosis and CR attendance was evaluated using multivariable logistic regression. RESULTS: Overall, 14% (n = 22 735) of the study population attended CR within 1 year of MI diagnosis. Twenty-eight percent (n = 43 827) had a diagnosis of depression, with 96% of cases documented before enrollment in CR. Twenty-eight percent with a diagnosis of depression compared with 9% without depression attended CR. In adjusted analysis, patients with depression were 3.9 (99% CI, 3.7-4.2) times more likely to attend CR compared with those without depression. Program completion (≥25 sessions) was more common in those with depression (56%) than in those without (35%) (P < .001). CONCLUSIONS: Diagnosis of depression in Medicare beneficiaries was strongly associated with attending CR and attending more sessions of CR compared with those without depression. Depression is not a barrier to CR participation after MI in Medicare beneficiaries.