[Systematic Reviews on the Effectiveness of Multidisciplinary Rehabilitation]. / Systematische Reviews zur Wirksamkeit der multidisziplinären Rehabilitation.

Systematic reviews and meta-analyses of clinical trials are considered to represent the highest level of scientific evidence in clinical medicine provided internationally accepted guidelines and checklists are followed.In systematic reviews and meta-analyses all clinical studies focussing a specific predefined clinical question are collected and evaluated. The results of systematic reviews strongly depend on the study protocol, including the exact definition of the population of interest, the therapeutic intervention under consideration and, last not least, the time period of observation. Moreover, evaluating multidisciplinary rehabilitation, its specifications with regard to therapeutic content, intensity and duration, supervision and general framework must be considered for correctly estimating determinants that control therapeutic success or failure.The range of potential risks of bias arising during planning, realization and publication of clinical studies is considerable and needs to be carefully estimated with regard to each single study included in meta-analysis.Taking together, the incremental scientific value of systematic reviews and meta-analyses cannot be taken for granted, but strongly depends on the methodological quality of the clinical studies being included as well as on the systematic process of the meta-analysis and the critical interpretation of the results.

[Work Participation after Multimodal Rehabilitation due to Cardiovascular Diseases - Representative Analyses using Routine Data of the German Pension Insurance]. / Berufliche Teilhabe nach einer medizinischen Rehabilitation aufgrund von kardiovaskulären Erkrankungen ­ Repräsentative Analysen auf Basis der Routinedaten der Deutschen Rentenversicherung.

PURPOSE: Cardiovascular diseases represent a large proportion of the disease burden of the adult population in Germany. Their importance in rehabilitation has increased continuously in recent years. Several studies have investigated return to work of cardiac patients after rehabilitation, which is relevant from the perspective of pension insurance. However, there is a lack of representative findings for the German region on employment trajectories and their influencing factors. METHODS: The rehabilitation statistics database of the German Pension Insurance (GPI) was used for this study. Subjects were patients with cardiovascular diseases undergoing rehabilitation in 2017. Analyses were performed for the total group and differentiated by relevant diagnosis groups. Occupational participation was operationalized via a monthly state variable up to 24 months after rehabilitation and the rate of all persons who were employed at the 12- and 24- month follow-up and in the 3 months before, respectively. Multiple logistic regression models were calculated to analyze the influencing factors. RESULTS: The total sample comprised 59,667 patients. The average age in all groups was between 53 and 56 years. Men were disproportionately represented; 70% of the services were provided as follow-up rehabilitations and 88% in the inpatient setting. Stable employment rates were 66% after one year and 63% after two years in the overall group (disease groups: 49% to 71%). The strongest influencing factors were the amount of pay and the number of sickness absence days before rehabilitation, active employment before rehabilitation, and age. CONCLUSION: For the first time, representative data on occupational participation following rehabilitation on behalf of the GPI are available for the disease groups considered. The analyses underline the need to focus on occupational perspectives already in medical rehabilitation or directly thereafter.

Geriatric or cardiac rehabilitation? Predictors of treatment pathways in advanced age patients after transcatheter aortic valve implantation.

BACKGROUND: Aim of the study was to find predictors of allocating patients after transcatheter aortic valve implantation (TAVI) to geriatric (GR) or cardiac rehabilitation (CR) and describe this new patient group based on a differentiated characterization. METHODS: From 10/2013 to 07/2015, 344 patients with an elective TAVI were consecutively enrolled in this prospective multicentric cohort study. Before intervention, sociodemographic parameters, echocardiographic data, comorbidities, 6-min walk distance (6MWD), quality of life and frailty (score indexing activities of daily living [ADL], cognition, nutrition and mobility) were documented. Out of these, predictors for assignment to CR or GR after TAVI were identified using a multivariable regression model. RESULTS: After TAVI, 249 patients (80.7 ± 5.1 years, 59.0% female) underwent CR (n = 198) or GR (n = 51). GR patients were older, less physically active and more often had a level of care, peripheral artery disease as well as a lower left ventricular ejection fraction. The groups also varied in 6MWD. Furthermore, individual components of frailty revealed prognostic impact: higher values in instrumental ADL reduced the probability for referral to GR (OR:0.49, p <  0.001), while an impaired mobility was positively associated with referral to GR (OR:3.97, p = 0.046). Clinical parameters like stroke (OR:0.19 of GR, p = 0.038) and the EuroSCORE (OR:1.04 of GR, p = 0.026) were also predictive. CONCLUSION: Advanced age patients after TAVI referred to CR or GR differ in several parameters and seem to be different patient groups with specific needs, e.g. regarding activities of daily living and mobility. Thus, our data prove the eligibility of both CR and GR settings.

Determinants of Return to Work After Multicomponent Cardiac Rehabilitation.

OBJECTIVES: To explore predictors of return to work in patients after acute coronary syndrome and coronary artery bypass grafting, taking into account cognitive performance, depression, physical capacity, and self-assessment of the occupational prognosis. DESIGN: Observational, prospective, bicentric. SETTING: Postacute 3-week inpatient cardiac rehabilitation (CR). PARTICIPANTS: Patients (N=401) <65 years of age (mean 54.5±6.3y), 80% men. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Status of return to work (RTW) 6 months after discharge from CR. RESULTS: The regression model for RTW showed negative associations for depression (odds ratio 0.52 per SD, 95% confidence interval 0.36-0.76, P=.001), age (odds ratio 0.72, 95% confidence interval 0.52-1.00, P=.047), and in particular for a negative subjective occupational prognosis (expected incapacity for work odds ratio 0.19, 95% confidence interval 0.06-0.59, P=.004; unemployment odds ratio 0.08, 95% confidence interval 0.01-0.72, P=.024; retirement odds ratio 0.07, 95% confidence interval 0.01-0.067, P=.021). Positive predictors were employment before the cardiac event (odds ratio 9.66, 95% confidence interval 3.10-30.12, P<.001), capacity to work (fit vs unfit) at discharge from CR (odds ratio 3.15, 95% confidence interval 1.35-7.35, P=.008), and maximum exercise capacity (odds ratio 1.49, 95% confidence interval 1.06-2.11, P=.022). Cognitive performance had no effect. CONCLUSIONS: The patient's perception and expectation regarding the occupational prognosis play a crucial role in predicting return to work 6 months after an acute cardiac event and CR. These findings highlight the importance of the multimodal approach, in particular psychosocial components, of CR.

No impact of an extensive social intervention program on return to work and quality of life after acute cardiac event: a cluster-randomized trial in patients with negative occupational prognosis.

OBJECTIVES: To examine the effectiveness of extensive social therapy intervention during inpatient multi-component cardiac rehabilitation (CR) on return to work and quality of life in patients with low probability of work resumption after an acute cardiac event. METHODS: Patients after acute cardiac event with negative subjective expectations about return to work or unemployment (n = 354) were included and randomized in clusters of 3-6 study participants. Clusters were randomized for social counseling and therapy led by a social worker, six sessions of 60 min each in 3 weeks, or control group (usual care: individual counseling meeting by request). The return to work (RTW) status and change in quality of life (QoL, short form 12: Physical and Mental Component Summary PCS and MCS) 12 months after discharge from inpatient CR were outcome measures. RESULTS: The regression model for RTW showed no impact of the intervention (OR 1.1, 95% CI 0.6-2.1, P = 0.79; n = 263). Predictors were unemployment prior to CR as well as higher anxiety values at discharge from CR. Likewise, QoL was not improved by social therapy (linear mixed model: ΔPCS 0.3, 95% CI - 1.9 to 2.5; P = 0.77; n = 177; ΔMCS 0.7, 95% CI - 1.9 to 3.3; P = 0.58; n = 215). CONCLUSIONS: In comparison to usual care, an intensive program of social support for patients during inpatient cardiac rehabilitation after an acute cardiac event had no additional impact on either the rate of resuming work or quality of life.

[Quality Performance Measures in Cardiac Rehabilitation - Results of a Delphi Survey of Members of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR)]. / Indikatoren der Ergebnisqualität kardiologischer Rehabilitation.

OBJECTIVE: The present investigation aimed an explorative acquisition of potential performance measures for quantifying the quality of cardiac rehabilitation (CR) for patients under 65 years of age. METHODS: A 4-level web based Delphi survey of physicians, psychologists, and sports or physiotherapists in CR was conducted from April to July in 2016. The experts assessed several parameters of physical performance, social medicine, subjective health and cardiovascular risk factors regarding their suitability as performance measures of CR. RESULTS: Of the 44 predetermined as well as by the participants proposed parameters, 21 parameters (48%) were selected as potential performance measures. Half of these were psychosocial factors. Merely, smoking habits, blood pressure, LDL-cholesterol and maximum capacity on exercise-ECG achieved a consensus (agreement>75% of the respondents). CONCLUSIONS: The experts' choice of performance measures was little consistent. Therefore, a clinical investigation and scientific evaluation of the predefined parameters is essential.

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals.

BACKGROUND: In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation. METHODS: From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge. RESULTS: Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated. CONCLUSIONS: This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

[User Interest in Digital Health Technologies to Enhance Physical Activity in Students and Staff of a University]. / Nutzerinteresse an mobilen digitalen Assistenzsystemen zur Förderung körperlicher Aktivität bei Studierenden und Mitarbeitern einer Universität.

INTRODUCTION: Though health-enhancing effects of physical activity are well documented, the majority of the population is unable to implement present recommendations into daily routine. Mobile health (mHealth) technologies might be able to increase the physical activity level. However, the interest of potential users is a mandatory basis for this. METHOD: We conducted an online-survey from 06-07/2015 by asking students and employees from the University of Potsdam for their activity level, interest in mHealth training support and other relevant parameters. RESULTS: 1 217 students and 485 employees (67.3% and 67.5% female, 26.0±4.9 and 42.7±11.7 years, respectively) participated in the survey. 70.1% of employees and 52.7% of students did not follow the recommendation for physical activity (3 times per week). 53.2% (students) and 44.2% (employees), independent of age, sex, BMI and level of education or professional qualification, indicated their interest in mHealth technology offering training support. CONCLUSION: Even in a younger population with higher education, most respondents reported an insufficient level of physical activity. About half of them indicated their interest in training support. Therefore, the use of personalized mHealth technology may be of increasing significance for a positive change of lifestyle.

Impact of clinical and sociodemographic patient characteristics on the outcome of cardiac rehabilitation in older patients.

BACKGROUND: Cardiac rehabilitation (CR) seeks to simultaneously improve several outcome parameters related to patient risk factors, exercise capacity and subjective health. A single score, the multiple outcome criterion (MOC), comprised of alterations in 13 outcome variables was used to measure the overall success of CR in an older population. As this success depends on the older patient's characteristics at the time of admission to CR, we attempted to determine the most important influences. METHODS: The impact of baseline characteristics on the success of CR, measured by MOC, was analysed using a mixed model for 1,220 older patients (70.9 ± 7.0 years, 78.3 % men) who enrolled in 12 CR clinics. A multitude of potentially influential baseline patient characteristics was considered including sociodemographic variables, comorbidity, duration of hospital stay, exercise capacity, cardiovascular risk factors, emotional status, and laboratory and echocardiographic data. RESULTS: Overall, CR was successful, as indicated by the mean value of the MOC (0.6 ± 0.45; min -1.0, max 2.0; positive values denoting improvement, negative ones deterioration). Examples of association with negative MOC values included smoking (MOC -0.15, p < 0.001), female gender (MOC -0.07, p = 0.049), and a longer hospital stay (MOC -0.03, p = 0.03). An example of association with positive MOC value was depression score (MOC 0.06, p = 0.003). Further associations included maximal exercise capacity, blood pressure, heart rate and the rehabilitation centre attended. CONCLUSION: Our results emphasize the necessity to take into consideration baseline characteristics when evaluating the success of CR and setting treatment targets for older patients.

Effect of multicomponent rehabilitation on independence and functioning in elderly patients with common age-associated diseases: protocol for a scoping review (REHOLD).

INTRODUCTION: Elderly patients after hospitalisation for acute events on account of age-related diseases (eg, joint or heart valve replacement surgery) are often characterised by a remarkably reduced functional health. Multicomponent rehabilitation (MR) is considered an appropriate approach to restore the functioning of these patients. However, its efficacy in improving functioning-related outcomes such as care dependency, activities of daily living (ADL), physical function and health-related quality of life (HRQL) remains unclarified. We outline the research framework of a scoping review designed to map the available evidence of the effects of MR on the independence and functional capacity of elderly patients hospitalised for age-related diseases in four main medical specialties beyond geriatrics. METHODS AND ANALYSIS: The biomedical databases (PubMed, Cochrane Library, ICTRP Search Platform, ClinicalTrials) and additionally Google Scholar will be systematically searched for studies comparing centre-based MR with usual care in patients ≥75 years of age, hospitalised for common acute events due to age-related diseases (eg, joint replacement, stroke) in one of the specialties of orthopaedics, oncology, cardiology or neurology. MR is defined as exercise training and at least one additional component (eg, nutritional counselling), starting within 3 months after hospital discharge. Randomised controlled trials as well as prospective and retrospective controlled cohort studies will be included from inception and without language restriction. Studies investigating patients <75 years, other specialties (eg, geriatrics), rehabilitation definition or differently designed will be excluded. Care dependency after at least a 6-month follow-up is set as the primary outcome. Physical function, HRQL, ADL, rehospitalisation and mortality will be additionally considered. Data for each outcome will be summarised, stratified by specialty, study design and type of assessment. Furthermore, quality assessment of the included studies will be performed. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at national and/or international congresses. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/GFK5C.

Test-retest reliability of center of pressure measures for postural control assessment in older cardiac patients.

BACKGROUND: Elderly patients are a growing population in cardiac rehabilitation (CR). As postural control declines with age, assessment of impaired balance is important in older CR patients in order to predict fall risk and to initiate counteracting steps. Functional balance tests are subjective and lack adequate sensitivity to small differences, and are further subject to ceiling effects. A quantitative approach to measure postural control on a continuous scale is therefore desirable. Force plates are already used for this purpose in other clinical contexts, therefore could be a promising tool also for older CR patients. However, in this population the reliability of the assessment is not fully known. RESEARCH QUESTION: Analysis of test-retest reliability of center of pressure (CoP) measures for the assessment of postural control using a force plate in older CR patients. METHODS: 156 CR patients (≥75 years) were enrolled. CoP measures (path length (PL), mean velocity (MV), and 95% confidence ellipse area (95CEA)) were analyzed twice with an interval of two days in between (bipedal narrow stance, eyes open (EO) and closed (EC), three trials for each condition, 30 s per trial), using a force plate. For test-retest reliability estimation absolute differences (Δ: T0-T1), intraclass correlation coefficients (ICC) with 95% confidence intervals, standard error of measurement and minimal detectable change were calculated. RESULTS: Under EO condition ICC were excellent for PL and MV (0.95) and good for 95CEA (0.88) with Δ of 10.1 cm (PL), 0.3 cm/sec (MV) and 1.5 cm2 (95CEA) respectively. Under EC condition ICC were excellent (≥ 0.95) for all variables with larger Δ (PL: 21.7 cm; MV: 0.7 cm/sec; 95CEA: 2.4 cm2). SIGNIFICANCE: In older CR patients, the assessment of CoP measures using a force plate shows good to excellent test-retest reliability.

European Society of Cardiology Quality Indicators for Cardiovascular Disease Prevention: developed by the Working Group for Cardiovascular Disease Prevention Quality Indicators in collaboration with the European Association for Preventive Cardiology of the European Society of Cardiology.

AIMS: To develop a set of quality indicators (QIs) for the evaluation of the care and outcomes for atherosclerotic cardiovascular disease (ASCVD) prevention. METHODS AND RESULTS: The Quality Indicator Committee of the European Society of Cardiology (ESC) formed the Working Group for Cardiovascular Disease Prevention Quality Indicators in collaboration with Task Force members of the 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice and the European Association of Preventive Cardiology (EAPC). We followed the ESC methodology for QI development, which involved (i) the identification of the key domains of care for ASCVD prevention by constructing a conceptual framework of care, (ii) the development of candidate QIs by conducting a systematic review of the literature, (iii) the selection of the final set of QIs using a modified Delphi method, and (iv) the evaluation of the feasibility of the developed QIs. In total, 17 main and 14 secondary QIs were selected across six domains of care for ASCVD prevention: (i) structural framework, (ii) risk assessment, (iii) care for people at risk for ASCVD, (iv) care for patients with established ASCVD, (v) patient education and experience, and (vi) outcomes. CONCLUSION: We present the 2021 ESC QIs for Cardiovascular Disease Prevention, which have been co-constructed with EAPC using the ESC methodology for QI development. These indicators are supported by evidence from the literature, underpinned by expert consensus and aligned with the 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice to offer a mechanism for the evaluation of ASCVD prevention care and outcomes.

The Pandora's Box of Frailty Assessments: Which Is the Best for Clinical Purposes in TAVI Patients? A Critical Review.

Frailty assessment is recommended before elective transcatheter aortic valve implantation (TAVI) to determine post-interventional prognosis. Several studies have investigated frailty in TAVI-patients using numerous assessments; however, it remains unclear which is the most appropriate tool for clinical practice. Therefore, we evaluate which frailty assessment is mainly used and meaningful for ≤30-day and ≥1-year prognosis in TAVI patients. Randomized controlled or observational studies (prospective/retrospective) investigating all-cause mortality in older (≥70 years) TAVI patients were identified (PubMed; May 2020). In total, 79 studies investigating frailty with 49 different assessments were included. As single markers of frailty, mostly gait speed (23 studies) and serum albumin (16 studies) were used. Higher risk of 1-year mortality was predicted by slower gait speed (highest Hazard Ratios (HR): 14.71; 95% confidence interval (CI) 6.50-33.30) and lower serum albumin level (highest HR: 3.12; 95% CI 1.80-5.42). Composite indices (five items; seven studies) were associated with 30-day (highest Odds Ratio (OR): 15.30; 95% CI 2.71-86.10) and 1-year mortality (highest OR: 2.75; 95% CI 1.55-4.87). In conclusion, single markers of frailty, in particular gait speed, were widely used to predict 1-year mortality. Composite indices were appropriate, as well as a comprehensive assessment of frailty.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2.

BACKGROUND: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients' groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. METHODS: Generation of evidence and search of literature have been described in part 1. RESULTS: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for "distress management" and "lifestyle changes". PE is able to increase patients' knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients' groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. CONCLUSIONS: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1.

BACKGROUND: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. METHODS: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. RESULTS: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. CONCLUSIONS: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Performance Measures for Short-Term Cardiac Rehabilitation in Patients of Working Age: Results of the Prospective Observational Multicenter Registry OutCaRe.

OBJECTIVE: To determine immediate performance measures for short-term, multicomponent cardiac rehabilitation (CR) in clinical routine in patients of working age, taking into account cardiovascular risk factors, physical performance, social medicine, and subjective health parameters and to explore the underlying dimensionality. DESIGN: Prospective observational multicenter register study in 12 rehabilitation centers throughout Germany. SETTING: Comprehensive 3-week CR. PARTICIPANTS: Patients (N=1586) ≤65 years of age (mean 53.8±7.3y, 77.1% men) in CR (May 2017-May 2018). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Feasibility, defined by data availability for ≥85% of patients (CR admission and discharge), and modifiability based on pre-post comparison (statistical significance, with P value<.01; standardized effect size≥.35; change by ≥5% points in categorical variables). In addition, latent factors were identified using an exploratory factor analysis (EFA). RESULTS: Based on feasibility and modifiability criteria, smoking behavior, lifestyle change behavior, blood pressure, endurance training load, depression in Patient Health Questionnaire-9 (PHQ-9), the 5-item World Health Organization Well-Being Index (WHO-5), physical and mental health and pain scale of the indicators of rehabilitation status-24 (IRES-24), and self-assessed health prognosis proved to be suitable performance measures. As a result of the EFA, 2 solid factors were identified: (1) subjective mental health including PHQ-9, WHO-5, mental health (IRES-24), mental quality of life, and anxiety and (2) physical health including physical quality of life, physical health and pain scale of IRES-24, and self-assessed occupational prognosis. A third factor represents the blood pressure. CONCLUSIONS: We provide a small set of performance measures, that are essentially based on 3 latent factors (subjective mental health, physical health, blood pressure). These performance measures can represent immediate success of comprehensive CR and be applied easily in clinical practice.

Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II).

BACKGROUND: Despite numerous studies and meta-analyses the prognostic effect of cardiac rehabilitation is still under debate. This update of the Cardiac Rehabilitation Outcome Study (CROS II) provides a contemporary and practice focused approach including only cardiac rehabilitation interventions based on published standards and core components to evaluate cardiac rehabilitation delivery and effectiveness in improving patient prognosis. DESIGN: A systematic review and meta-analysis. METHODS: Randomised controlled trials and retrospective and prospective controlled cohort studies evaluating patients after acute coronary syndrome, coronary artery bypass grafting or mixed populations with coronary artery disease published until September 2018 were included. RESULTS: Based on CROS inclusion criteria out of 7096 abstracts six additional studies including 8671 patients were identified (two randomised controlled trials, two retrospective controlled cohort studies, two prospective controlled cohort studies). In total, 31 studies including 228,337 patients were available for this meta-analysis (three randomised controlled trials, nine prospective controlled cohort studies, 19 retrospective controlled cohort studies; 50,653 patients after acute coronary syndrome 14,583, after coronary artery bypass grafting 163,101, mixed coronary artery disease populations; follow-up periods ranging from 9 months to 14 years). Heterogeneity in design, cardiac rehabilitation delivery, biometrical assessment and potential confounders was considerable. Controlled cohort studies showed a significantly reduced total mortality (primary endpoint) after cardiac rehabilitation participation in patients after acute coronary syndrome (prospective controlled cohort studies: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20-0.69; retrospective controlled cohort studies HR 0.64, 95% CI 0.53-0.76; prospective controlled cohort studies odds ratio 0.20, 95% CI 0.08-0.48), but the single randomised controlled trial fulfilling the CROS inclusion criteria showed neutral results. Cardiac rehabilitation participation was also associated with reduced total mortality in patients after coronary artery bypass grafting (retrospective controlled cohort studies HR 0.62, 95% CI 0.54-0.70, one single randomised controlled trial without fatal events), and in mixed coronary artery disease populations (retrospective controlled cohort studies HR 0.52, 95% CI 0.36-0.77; two out of 10 controlled cohort studies with neutral results). CONCLUSION: CROS II confirms the effectiveness of cardiac rehabilitation participation after acute coronary syndrome and after coronary artery bypass grafting in actual clinical practice by reducing total mortality under the conditions of current evidence-based coronary artery disease treatment. The data of CROS II, however, underscore the urgent need to define internationally accepted minimal standards for cardiac rehabilitation delivery as well as for scientific evaluation.

Patient-reported outcomes predict return to work and health-related quality of life six months after cardiac rehabilitation: Results from a German multi-centre registry (OutCaRe).

BACKGROUND: Multi-component cardiac rehabilitation (CR) is performed to achieve an improved prognosis, superior health-related quality of life (HRQL) and occupational resumption through the management of cardiovascular risk factors, as well as improvement of physical performance and patients' subjective health. Out of a multitude of variables gathered at CR admission and discharge, we aimed to identify predictors of returning to work (RTW) and HRQL 6 months after CR. DESIGN: Prospective observational multi-centre study, enrolment in CR between 05/2017 and 05/2018. METHOD: Besides general data (e.g. age, sex, diagnoses), parameters of risk factor management (e.g. smoking, hypertension), physical performance (e.g. maximum exercise capacity, endurance training load, 6-min walking distance) and patient-reported outcome measures (e.g. depression, anxiety, HRQL, subjective well-being, somatic and mental health, pain, lifestyle change motivation, general self-efficacy, pension desire and self-assessment of the occupational prognosis using several questionnaires) were documented at CR admission and discharge. These variables (at both measurement times and as changes during CR) were analysed using multiple linear regression models regarding their predictive value for RTW status and HRQL (SF-12) six months after CR. RESULTS: Out of 1262 patients (54±7 years, 77% men), 864 patients (69%) returned to work. Predictors of failed RTW were primarily the desire to receive pension (OR = 0.33, 95% CI: 0.22-0.50) and negative self-assessed occupational prognosis (OR = 0.34, 95% CI: 0.24-0.48) at CR discharge, acute coronary syndrome (OR = 0.64, 95% CI: 0.47-0.88) and comorbid heart failure (OR = 0.51, 95% CI: 0.30-0.87). High educational level, stress at work and physical and mental HRQL were associated with successful RTW. HRQL was determined predominantly by patient-reported outcome measures (e.g. pension desire, self-assessed health prognosis, anxiety, physical/mental HRQL/health, stress, well-being and self-efficacy) rather than by clinical parameters or physical performance. CONCLUSION: Patient-reported outcome measures predominantly influenced return to work and HRQL in patients with heart disease. Therefore, the multi-component CR approach focussing on psychosocial support is crucial for subjective health prognosis and occupational resumption. TRIAL REGISTRATION: The study was registered at the German Clinical Trial Registry and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (DRKS00011418; http://www.drks.de/DRKS00011418, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00011418).

Patients' expectations of returning to work, co-morbid disorders and work capacity at discharge from cardiac rehabilitation.

OBJECTIVE: We aimed to characterize patients after an acute cardiac event regarding their negative expectations around returning to work and the impact on work capacity upon discharge from cardiac rehabilitation (CR). METHODS: We analyzed routine data of 884 patients (52±7 years, 76% men) who attended 3 weeks of inpatient CR after an acute coronary syndrome (ACS) or cardiac surgery between October 2013 and March 2015. The primary outcome was their status determining their capacity to work (fit vs unfit) at discharge from CR. Further, sociodemographic data (eg, age, sex, and education level), diagnoses, functional data (eg, exercise stress test and 6-min walking test [6MWT]), the Hospital Anxiety and Depression Scale (HADS) and self-assessment of the occupational prognosis (negative expectations and/or unemployment, Würzburger screening) at admission to CR were considered. RESULTS: A negative occupational prognosis was detected in 384 patients (43%). Out of these, 368 (96%) expected not to return to work after CR and/or were unemployed before CR at 29% (n=113). Affected patients showed a reduced exercise capacity (bicycle stress test: 100 W vs 118 W, P<0.01; 6MWT: 380 m vs 421 m, P<0.01) and were more likely to receive a depression diagnosis (12% vs 3%, P<0.01), as well as higher levels on the HADS. At discharge from CR, 21% of this group (n=81) were fit for work (vs 35% of patients with a normal occupational prognosis (n=175, P<0.01)). Sick leave before the cardiac event (OR 0.4, 95% CI 0.2-0.6, P<0.01), negative occupational expectations (OR 0.4, 95% CI 0.3-0.7, P<0.01) and depression (OR 0.3, 95% CI 0.1-0.8, P=0.01) reduced the likelihood of achieving work capacity upon discharge. In contrast, higher exercise capacity was positively associated. CONCLUSION: Patients with a negative occupational prognosis often revealed a reduced physical performance and suffered from a high psychosocial burden. In addition, patients' occupational expectations were a predictor of work capacity at discharge from CR. Affected patients should be identified at admission to allow for targeted psychosocial care.

Impact of cognitive performance on disease-related knowledge six months after multi-component rehabilitation in patients after an acute cardiac event.

BACKGROUND: Although associations between cardiovascular diseases and cognitive impairment are well known, the impact of cognitive performance on the success of patient education as a core component of cardiac rehabilitation remains insufficiently investigated so far. DESIGN: Prospective observational study in two inpatient cardiac rehabilitation centres between September 2014 and August 2015 with a follow-up six months after cardiac rehabilitation. METHOD: At admission to and discharge from cardiac rehabilitation, the cognitive performance of 401 patients (54.5 ± 6.3 years, 80% men) following an acute coronary syndrome and/or coronary artery bypass graft was tested using the Montreal Cognitive Assessment. Patients' disease-related knowledge was determined using a quiz (22 items for medical knowledge and 12 items for healthy lifestyle and behaviour) at both times and at follow-up. The change in knowledge after cardiac rehabilitation was analysed in multivariable regression models. Potentially influencing parameters (e.g. level of education, medication, cardiovascular risk factors, coronary artery bypass graft, comorbidities, exercise capacity) were considered. RESULTS: During cardiac rehabilitation, disease-related knowledge was significantly enhanced in both scales. At follow-up, the average level of medical knowledge was significantly reduced, while lifestyle knowledge remained at a stable level. The maintenance of knowledge after cardiac rehabilitation was predominantly predicted by prior knowledge, cognitive performance at discharge from cardiac rehabilitation and, in the case of medical knowledge, by coronary artery bypass graft. CONCLUSION: Patient education in cardiac rehabilitation led to enhanced disease-related knowledge, but the maintenance of this essentially depended on patients' cognitive performance, especially after coronary artery bypass graft. Therefore, patient education concepts in cardiac rehabilitation should be reconsidered and adjusted as needed.