Exercise rehabilitation in COPD and heart failure: comparison of two national audits.

Background: Pulmonary (PR) and cardiac rehabilitation (CR) are recommended in the management of chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF); the impact of coexisting COPD and CHF on completion and outcomes of rehabilitation programmes is unknown. We examined enrolment, completion and clinical outcomes of CR and PR in adults with COPD, CHF and coexisting COPD and CHF. Methods: The National Audit of CR and National COPD Audit Programme: clinical audits of PR were analysed (211 PR and 237 CR programmes); adults with a diagnosis of CHF, COPD or coexisting COPD and CHF were identified (COPD+CHF or CHF+COPD according to database). Propensity matching was conducted (age, sex, body mass index and functional status) between COPD+CHF and COPD, and CHF+COPD and CHF. Group by time interaction was examined using mixed 2×2 analysis of variance. Results: Those with CHF+COPD had lower enrolment and completion of CR compared to those with CHF; there were no differences in PR enrolment or completion between the two groups. Adults with COPD made a significantly larger gain in the incremental shuttle walk test compared to adults with COPD+CHF following PR (59.3 m versus 37.4 m); the improvements following CR were similar (CHF 77.3 m versus CHF+COPD 58.3 m). Similar improvements were made in the 6-min walk test following CR (CHF 45.1 m versus CHF+COPD 38.8 m) and PR (COPD 48.2 m versus COPD+CHF 44.0 m). Comparable improvements in quality of life and mood state were made following CR and PR, regardless of diagnosis. Conclusion: We have demonstrated that multi-morbid adults benefit from exercise-based rehabilitation, yet efforts are needed to promote completion. These findings support group-based, tailored, multi-morbid exercise rehabilitation.

Obese patients' characteristics and weight loss outcomes in cardiac rehabilitation: An observational study of registry data.

AIM: Cardiac rehabilitation (CR) guidelines advocate weight loss for obese patients but mean weight loss is small. We sought to determine the extent to which obese patients' characteristics prior to CR predict weight loss. METHODS: An observational, pre- and post CR study of routine practice using the UK National Audit of Cardiac Rehabilitation dataset was undertaken. Backward, stepwise, multiple linear regression analysis was used to identify characteristics prior to CR that predicted weight change in obese patients. RESULTS: In 29,601 obese patients undertaking CR, mean weight loss was 0.9 kg (SD 4.3; p < 0.001) in men (74% of sample) and 0.5 kg (SD 3.9; p < 0.001) in women. Smoking cessation since the cardiac event independently predicted less weight loss by 1.2 kg (95% CI; 0.9, 1.5 kg; p < 0.001). Diabetes, cardiac surgery, living in a deprived area, being female, low fitness levels and pain independently predicted less weight loss during CR. Higher initial weight, greater age and being employed predicted increased weight loss. CONCLUSION: This is the first study to identify how the characteristics of obese patients independently predict different amounts of weight loss during CR in free-living individuals. It is also the largest, registry-based study to investigate predictors of weight loss in obese patients in CR. Knowledge of the extent to which obese patients' characteristics predict more or less weight loss can aid: the generation of guidelines; agreement of realistic goals with patients; and tailoring of weight management support.

What factors are associated with patients walking fitness when starting cardiac rehabilitation?

INTRODUCTION: Patients with heart failure (HF) are now a priority group for cardiac rehabilitation (CR). A fundamental component of CR is increasing physical fitness through exercise training. Even though studies show fitness benefits, there is little evidence in routine populations of individual factors that may influence fitness. This study aims to evaluate the extent to which demographics and clinical measures predict physical fitness in patients with HF and develop reference values to guide practice. METHODS: Data from the National Audit Cardiac Rehabilitation (NACR) was analysed. 2047 patients (73% male) with HF completed an incremental shuttle walk test (ISWT). Backward regression accounting for patient characteristics and new comorbidity groups were used to identify predictors of distance using ISWT. Reference values were produced from the percentiles of the ISWT distance. RESULTS: Population age was 64.43 years (12.39 SD) with an average ISWT distance of 278.57 m (SD 158.57). Demographics, risk factors and comorbidities explained 26% of the variance in distance (adjusted R2 = 0.256, p value < 0.001). Diuretics (-33.01 m ±8.07 SD) and socioeconomic status (9.12 m ±2.91 SD) were significant predictors of baseline walking fitness. Furthermore, respiratory obstructions, musculoskeletal issues and metabolic diseases were associated with reduced walking distance of 29.8 m, 26.6 m and 18.4 m respectively. CONCLUSION: Use of diuretics, socioeconomic status and presence of comorbidities were significant predictors of walking performance in patients with HF who attended CR and were fit enough to carry out an ISWT. Reference values, to aid clinical practice, were developed that included age, gender and comorbidities status.

An analysis of barriers to entry of cardiac rehabilitation in patients with diabetes: Using data from the National Audit of Cardiac Rehabilitation.

BACKGROUND: UK cardiac rehabilitation has reached for the first time 50% uptake in 2016; however, this still leaves 50% of the eligible group not starting cardiac rehabilitation. The characteristics of patients missing cardiac rehabilitation are relatively unknown with some studies in America suggesting that patients with diabetes have a reduced likelihood of joining cardiac rehabilitation. METHODS: This study used routinely collected data from the National Audit of Cardiac Rehabilitation to investigate proportional differences in patients with cardiovascular disease with, and without, diabetes taking up the offer of cardiac rehabilitation. RESULTS: The proportion of patients with diabetes entering cardiac rehabilitation dropped by between 7% and 15% depending on the age group (<40 years, 7% reduction; 61-80 years, 15%). The study's results showed that in all demographic and diagnostic groups, the proportion of patients with diabetes was significantly less than that of the eligible group ( p < 0.001). There was no difference in the proportion of loss, from eligible to starting cardiac rehabilitation, between males and females, which was 13% for both groups. CONCLUSION: This study confirms, in a new UK population with over 121,002 eligible patients, that there is a statistically significant drop in patients with diabetes taking up cardiac rehabilitation. This study is unique in looking at all four key diagnosis and treatment groups and comparing them to those taking up cardiac rehabilitation. To achieve the target of 65% uptake set by NHS England, improvements in identifying and targeting complex patients, such as those with diabetes, need to be adopted.

Are physical fitness outcomes in patients attending cardiac rehabilitation determined by the mode of delivery?

Background: Cardiac rehabilitation (CR) is a well-evidenced and effective secondary intervention proven to reduce mortality and readmission in patients with cardiovascular disease. Improving physical fitness outcomes is a key target for CR programmes, with supervised group-based exercise dominating the mode of the delivery. However, the method of traditional supervised CR fails to attract many patients and may not be the only way of improving physical fitness. Methods: Using real-world routine clinical data from the National Audit of Cardiac Rehabilitation across a 5-year period, this study evaluates the extent of association between physical fitness outcomes, incremental shuttle walk and 6 min walk test, and mode of delivery, delivered as traditional supervised versus facilitated self-delivered. Results: The proportion of patients receiving each mode were 80.6% supervised with 19.4% to self-delivered. The study analysis comprised of 10 142 patients who were included in the two models. The self-delivered group contained a greater proportion of females and older patients. The regression model showed no clinical or statistical significance between mode of delivery and post-CR physical fitness outcomes. Conclusions: This study is unique as it has identified through a routine clinical population that regardless of the mode of delivery of rehabilitation, patients improve their physical fitness outcomes at meaningful levels. This study provides a strong evidence base for patients to be offered greater choice in the mode of CR delivery as improvements in physical fitness are comparable.

Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.

OBJECTIVE: Cardiac rehabilitation (CR) is an evidence-based intervention delivered by a wide range of high-volume and low-volume centres; however, the extent of volume-outcome relationship is yet to be studied. There is a lack of consensus about the effect of volume on outcomes, with evidence of mixed effects in acute and chronic care. The aim of this study is, to investigate the extent of association of outcomes in CR with patient volume. METHODS: Data was validated and extracted from the national audit from 2012 to 2013 for each CR centre. Volume was calculated as the total number of patients entering outpatient CR. Hierarchical multiple regression models were used to test for relationships between volume and outcomes. The outcomes included body mass index, blood pressure, psychosocial well-being, cholesterol, smoking cessation and physical activity. The analyses were adjusted for centre and patient characteristics and confounders. RESULTS: The number of patients included in the volume analysis was 48 476, derived from 178 CR centres. The average age per centre was 66 years with a 70% male distribution of patients enrolled. Regression analysis revealed no volume-outcome relationship, additionally no statistical significance existed. CONCLUSIONS: Unlike cardiac surgery this study, after accounting for staffing, age, gender and comorbidity, shows no effect of volume on outcome following CR delivered by high-volume and low-volume programmes. Based on our data there is no support for centralisation of services. Our findings and methodology can be used as a benchmark for future volume-outcome relationship studies in CR.