Psychometric validation of the short version of the Information Needs in Cardiac Rehabilitation scale through a first global assessment.

AIMS: Tailored education is recommended for cardiac patients, yet little is known about information needs in areas of the world where it is most needed. This study aims to assess (i) the measurement properties of the Information Needs in Cardiac Rehabilitation short version (INCR-S) scale and (ii) patient's information needs globally. METHODS AND RESULTS: In this cross-sectional study, English, simplified Chinese, Portuguese, or Korean versions of the INCR-S were administered to in- or out-patients via Qualtrics (January 2022-November 2023). Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated recruitment. Importance and knowledge sufficiency of 36 items were rated. Links to evidence-based lay education were provided where warranted. A total of 1601 patients from 19 middle- and high-income countries across the world participated. Structural validity was supported upon factor analysis, with five subscales extracted: symptom response/medication, heart diseases/diagnostic tests/treatments, exercise and return-to-life roles/programmes to support, risk factors, and healthy eating/psychosocial management. Cronbach's alpha was 0.97. Construct validity was supported through significantly higher knowledge sufficiency ratings for all items and information importance ratings for all subscales in cardiac rehabilitation (CR) enrolees vs. non-enrolees (all P < 0.001). All items were rated as very important-particularly regarding cardiac events, nutrition, exercise benefits, medications, symptom response, risk factor control, and CR-but more so in high-income countries in the Americas and Western Pacific. Knowledge sufficiency ranged from 30.0 to 67.4%, varying by region and income class. Ratings were highest for medications and lowest for support groups, resistance training, and alternative medicine. CONCLUSION: Identification of information needs using the valid and reliable INCR-S can inform educational approaches to optimize patients' health outcomes across the globe.

Patients need information to manage their heart diseases, such as what to do if they have chest pain, what a heart attack is, and how to take their medicine to lower the chances they will have another one, so a study of the information needs of over 1600 heart patients from around the globe was undertaken for the first time. Using the Information Needs in Cardiac Rehabilitation short version (INCR-S) scale­which was shown to be a good measurement tool through the study and hence may improve patient education­patients reported they most wanted information about heart events, heart-healthy eating, exercise benefits, their pills, symptom response, risk factor control, and cardiac rehabilitation­but more so in high-income countries in the Americas and Western Pacific. Knowledge sufficiency ratings for each item ranged from 30.0 to 67.4%, also varying by region and income class; perceived knowledge sufficiency ratings were highest for medications and lowest for support groups, resistance training, and alternative medicine.

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.

Translation, cultural adaptation, and psychometric validation of the Provider Attitudes toward Cardiac Rehabilitation and Referral (PACRR-C) Scale in Simplified Chinese.

BACKGROUND: The Provider Attitudes toward CR and Referral (PACRR) scale was translated into Simplified Chinese and psychometric validation ensued. METHODS: Brislin's Translation Model was applied, with two independent forward translations followed by back-translation. Experts assessed the face, content and cross-cultural validity of items, and item analysis followed. For validation, 227 physicians from hospitals in 14 Chinese provinces completed the PACRR-C. Structural validity was assessed through exploratory and confirmatory factor analysis. Internal and split-half reliability were assessed. RESULTS: Some items were rephrased and one item was deleted. The content validity index for the total scale was 0.965. The correlation coefficients between the 18 items and the total scale ranged between 0.28 and 0.76. Consistent with the English version, four factors were extracted (Cronbach's alpha ranged from 0.671-0.959) through the factor analysis, accounting for 71.21% of the total variance. Split-half reliability was 0.945. The greatest factors impacting physician's CR attitudes were inconvenience of the referral process (3.93 ± 0.65/5); lack of standard referral forms (3.92 ± 0.66), perceiving referral as the responsibility of another clinician (3.89 ± 0.67), and need for support in completing the referral form (3.89 ± 0.64). CONCLUSIONS/SIGNIFICANCE: The reliability, as well as content, face, cross-cultural, and structural validity of the 18-item, 4-subscale PACRR-C, were supported.

Heart failure clinic inclusion and exclusion criteria: cross-sectional study of clinic's and referring provider's perspectives.

OBJECTIVES: There are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF clinic inclusion or exclusion criteria and how that related to referring providers' perspectives of ideal criteria. DESIGN, SETTING AND PARTICIPANTS: Two cross-sectional surveys were administered via research electronic data capture to clinic providers and referrers (eg, cardiologists, family physicians and nurse practitioners) across Canada. MEASURES: Twenty-seven criteria selected based on the literature and HF guidelines were tested. Respondents were asked to list any additional criteria. The degree of agreement was assessed (eg, Kappa). RESULTS: Responses were received from providers at 48 clinics (37.5% response rate). The most common actual inclusion criteria were newly diagnosed HF with reduced or preserved ejection fraction, New York Heart Association class IIIB/IV and recent hospitalisation (each endorsed by >74% of respondents). Exclusion criteria included congenital aetiology, intravenous inotropes, a lack of specialists, some non-cardiac comorbidities and logistical factors (eg, rurality and technology access). There was the greatest discordance between actual and ideal criteria for the following: inpatient at the same institution (κ=0.14), congenital heart disease, pulmonary hypertension or genetic cardiomyopathies (all κ=0.36). One-third (n=16) of clinics had changed criteria, often for non-clinical reasons. Seventy-three referring providers completed the survey. Criteria endorsed more by referrers than clinics included low blood pressure with a high heart rate, recurrent defibrillator shocks and intravenous inotropes-criteria also consistent with guidelines. CONCLUSIONS: There is considerable agreement on the main clinic entry criteria, but given some discordance, two levels of clinics may be warranted. Publicising evidence-based criteria and applying them systematically at referral sources could support improved HF patient care journeys and outcomes.

Impact of vaccination education in cardiac rehabilitation on attitudes and knowledge.

Clinical guidelines recommend influenza vaccination for cardiac patients, and COVID-19 vaccination is also beneficial given their increased risk. Patient education regarding vaccination was developed for cardiac rehabilitation (CR); impact on knowledge and attitudes were evaluated. A single-group pre-post design was applied at a Spanish CR program in early 2022. After baseline assessment, a nurse delivered the 40-minute group education. Knowledge and attitudes were re-assessed. Sixty-one (72%) of the 85 participants were vaccinated for influenza, and 40 (47%) for pneumococcus. Most participants perceived vaccines were important, and that the COVID-19 vaccine specifically was important, with three-quarters not influenced by vaccine myths/misinformation. The education intervention resulted in significant improvements in perceptions of the importance of vaccines (Hake's index 69%), understanding of myths (48%), knowledge of the different types of COVID vaccines (92%), and when they should be vaccinated. Vaccination rates are low despite their importance; while further research is needed, education in the CR setting could promote greater uptake.

Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation.

Background: Women are less likely than men to use cardiac rehabilitation (CR); thus, women-focused (W-F) CR was developed. Implementation of W-F CR globally was investigated, as well as barriers and enablers to its delivery. Methods: In this cross-sectional study, a survey was administered to CR programs via Research Electronic Data Capture (REDCap) from May to July, 2023. Potential respondents were identified via the International Council of Cardiovascular Prevention and Rehabilitation's network. Results: A total of 223 responses were received from 52 of 111 countries (46.8% country response rate) in the world that have any CR, across all 6 World Health Organization regions. Thirty-three programs (14.8%) from 30 countries reported offering any W-F programming. Programs commonly did offer elements preferred by women and recommended, namely, the following: patient choice of session time (n = 151; 70.6%); invitations for informal care providers and/or partners to attend sessions (n = 121; 57.1%); CR staff that have expertise in women and heart diseases (n = 112; 53.3%); separate changerooms for women (n = 38; 52.8%); and discussion of CR referral with patients (n = 112; 52.1%). Main barriers to delivery of W-F exercise were physical resources (n = 33; 14.8%), space (n = 30; 13.5%), and staff time (n = 26; 11.7%) and expertise (n = 33; 10.3%). Main barriers to delivery of W-F education were human resources (n = 114; 51.1%), educational resources (n = 26; 11.7%), and expertise in the content (n = 74; 33.2%). Enablers of W-F education delivery were availability of materials, in multiple modalities, as well as educated staff and financial resources. Conclusions: Despite the benefits, W-F CR is not commonly offered globally. Considering the barriers and enablers identified, the International Council of Cardiovascular Prevention and Rehabilitation is developing resources to expand delivery.

Contexte: Les femmes étant moins susceptibles que les hommes d'avoir recours à la réadaptation cardiaque (RC), il convient d'élaborer des programmes de RC qui sont mieux adaptés à leurs besoins. Le recours à de tels programmes dans le monde a fait l'objet d'une étude, laquelle portait également sur les obstacles à leur prestation et les facteurs qui les favorisent. Méthodologie: Dans cette étude transversale, un sondage a été mené auprès de programmes de RC via la REDCap (Research Electronic Data Capture) de mai à juillet 2023. Les participants potentiels au sondage ont été sélectionnés par le réseau de l'International Council of Cardiovascular Prevention and Rehabilitation. Résultats: Au total, 223 réponses ont été reçues de 52 pays sur 111 qui ont un programme de RC (taux de réponse des pays de 46,8 %), dans les 6 régions de l'Organisation mondiale de la Santé. Selon les résultats, trente-trois programmes (14,8 %) de 30 pays offrent des services axés sur les femmes. Les programmes offraient habituellement des éléments privilégiés par les femmes et recommandaient notamment des séances au moment choisi par les patientes (n = 151; 70,6 %); la possibilité de se faire accompagner par un aidant naturel et/ou un(e) partenaire (n = 121; 57,1 %); du personnel de RC possédant une expertise auprès des femmes et en matière de maladies cardiaques (n = 112; 53,3 %); des vestiaires réservés aux femmes (n = 38; 52,8 %); et une discussion avec les patientes sur leur orientation vers des spécialistes en RC (n = 112; 52,1 %). Les principaux obstacles à la prestation de services pour les femmes étaient les ressources physiques (n = 33; 14,8 %), l'espace (n = 30; 13,5 %) ainsi que la disponibilité du personnel (n = 26; 11,7 %) et son expertise (n = 33; 10,3 %). Les principaux obstacles à l'éducation destinée aux femmes étaient les ressources humaines (n = 114; 51,1 %), les ressources éducatives (n = 26; 11,7 %) et l'expertise liée au contenu (n = 74; 33,2 %). Les facteurs qui favorisent l'éducation destinée aux femmes étaient la disponibilité du matériel, sous plusieurs formes, de même que le personnel formé et les ressources financières. Conclusions: En dépit des bienfaits, la RC axée sur les femmes n'est pas couramment offerte dans le monde. En tenant compte des obstacles et des facteurs favorisant la prestation des services cités, l'International Council of Cardiovascular Prevention and Rehabilitation s'affaire à concevoir des ressources pour élargir la portée des programmes destinés aux femmes.

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.

Hybrid Cardiac Rehabilitation Program in a Low-Resource Setting: A Randomized Clinical Trial.

Importance: While effective, cardiovascular rehabilitation (CR) as traditionally delivered is not well implemented in lower-resource settings. Objective: To test the noninferiority of hybrid CR compared with traditional CR in terms of cardiovascular events. Design, Setting, and Participants: This pragmatic, multicenter, parallel arm, open-label randomized clinical trial (the Hybrid Cardiac Rehabilitation Trial [HYCARET]) with blinded outcome assessment was conducted at 6 referral centers in Chile. Adults aged 18 years or older who had a cardiovascular event or procedure, no contraindications to exercise, and access to a mobile telephone were eligible and recruited between April 1, 2019, and March 15, 2020, with follow-up until July 29, 2021. Interventions: Participants were randomized 1:1 in permuted blocks to the experimental arm, which received 10 center-based supervised exercise sessions plus counseling in 4 to 6 weeks and then were supported at home via telephone calls and text messages through weeks 8 to 12, or the control arm, which received the standard CR of 18 to 22 sessions with exercises and education in 8 to 12 weeks. Main Outcomes and Measures: The primary outcome was cardiovascular events or mortality. Secondary outcomes were quality of life, return to work, and lifestyle behaviors measured with validated questionnaires; muscle strength and functional capacity, measured through physical tests; and program adherence and exercise-related adverse events, assessed using checklists. Results: A total of 191 participants were included (mean [SD] age, 58.74 [9.80] years; 145 [75.92%] male); 93 were assigned to hybrid CR and 98 to standard CR. At 1 year, events had occurred in 5 unique participants in the hybrid CR group (5.38%) and 9 in the standard CR group (9.18%). In the intention-to-treat analysis, the hybrid CR group had 3.80% (95% CI, -11.13% to 3.52%) fewer cardiovascular events than the standard CR group, and relative risk was 0.59 (95% CI, 0.20-1.68) for the primary outcome. In the per-protocol analysis at different levels of adherence to the intervention, all 95% CIs crossed the noninferiority boundary (eg, 20% adherence: absolute risk difference, -0.35% [95% CI, -7.56% to 6.85%]; 80% adherence: absolute risk difference, 3.30% [95% CI, -3.70% to 10.31%]). No between-group differences were found for secondary outcomes except adherence to supervised CR sessions (79.14% [736 of 930 supervised sessions] in the hybrid CR group vs 61.46% [1201 of 1954 sessions] in the standard CR group). Conclusions and Relevance: The results suggest that a hybrid CR program is noninferior to standard center-based CR in a low-resource setting, primarily in terms of recurrent cardiovascular events and potentially in terms of intermediate outcomes. Hybrid CR may induce superior adherence to supervised exercise. Clinical factors and patient preferences should inform CR model allocation. Trial Registration: ClinicalTrials.gov Identifier: NCT03881150.

Effectiveness of alternative vs traditional exercises on cardiac rehabilitation program utilization in women with or at high risk of cardiovascular disease: a systematic review protocol.

OBJECTIVE: This review will evaluate the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization and other outcomes in women with or at high risk of cardiovascular disease. INTRODUCTION: Exercise-based cardiac rehabilitation programs improve health outcomes in women with or at high risk of cardiovascular disease. However, such programs are underutilized worldwide, particularly among women. Some women perceive traditional gym-based exercise in cardiac rehabilitation programs (eg, typically treadmills, cycle ergometers, traditional resistance training) to be excessively rigorous and unpleasant, resulting in diminished participation and completion. Alternative forms of exercise such as yoga, tai chi, qi gong, or Pilates may be more enjoyable and motivating exercise options for women, enhancing engagement in rehabilitation programs. However, the effectiveness of these alternative exercises in improving program utilization is still inconsistent and needs to be systematically evaluated and synthesized. INCLUSION CRITERIA: This review will focus on randomized controlled trials of studies measuring the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization as well as clinical, physiological, or patient-reported outcomes in women with or at high risk of cardiovascular disease. METHODS: The review will follow the JBI methodology for systematic reviews of effectiveness. Databases including MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane CENTRAL, Embase (Ovid), Emcare (Ovid), Scopus, Web of Science, LILACS, and PsycINFO (Ovid) will be searched. Two independent reviewers will screen articles and then extract and synthesize data. Methodological quality will be assessed using JBI's standardized instruments. GRADE will be used to determine the certainty of evidence. REVIEW REGISTRATION: PROSPERO CRD42022354996.

Evidence-informed development of women-focused cardiac rehabilitation education.

BACKGROUND: Despite their differential risk factor burden, context and often different forms of heart disease, cardiac rehabilitation (CR) programs generally do not provide women with needed secondary prevention information specific to them. OBJECTIVE: to co-design evidence-informed, theory-based comprehensive women-focused education, building from Health e-University's Cardiac College for CR. METHODS: A multi-disciplinary, multi-stakeholder steering committee (N = 18) oversaw the four-phase development of the women-focused curriculum. Phase 1 involved a literature review on women's CR information needs and preferences, phase 2 a CR program needs assessment, phase 3 content development (including determining content and mode, assigning experts to create the content, plain language review and translation), and phase 4 will comprise evaluation and implementation. In phase 2, a focus group was conducted with Canadian CR providers; it was analyzed using Braun and Clarke's iterative approach. RESULTS: Nineteen providers participated in the focus group, with four themes emerging: current status of education, challenges to delivering women-focused education, delivery modes and topical resources. Results were consistent with those from our related global survey, supporting saturation of themes. Co-designed educational materials included 19 videos. These were organized across 5 webpages in English and French, specific to tests and treatments, exercise, diet, psychosocial well-being, and self-management. Twelve corresponding session slide decks with notes for clinicians were created, to support program delivery in CR flexibly. CONCLUSION: While further evaluation is underway, these open-access CR education resources will be disseminated for implementation, to support women in reducing their risk of cardiovascular sequelae.

Development and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Program Certification for Low-Resource Settings.

Background: Cardiac rehabilitation (CR) is a proven model of secondary prevention, but new sites, providing quality care, are needed in low-resource settings. This study (1) described the development of International Council of Cardiovascular Prevention and Rehabilitation's (ICCPR) Program Certification and (2a) tested its implementation, considering (b) appropriateness of quality standards for these settings. Methods: The Steering Committee finalized 13 standards, requiring 70% be met. They are assessed initially through International CR Registry (ICRR) program survey and patient data; if Certification appears possible, a two-hour virtual site assessment is arranged to corroborate. Standard operating procedures for Assessor training were developed. A multi-method pilot study was then undertaken with a quantitative (description of quality indicators) and qualitative (focus groups on MS Teams) component. ICRR sites with post-program data by April 2022 were invited to participate. Two team members independently analyzed focus group transcripts, using a deductive-thematic approach with NVIVO. Results: Five CR programs from the Eastern Mediterranean, South-East Asian and American regions participated. Upon application, with some data cleaning, initially four programs were eligible to proceed to virtual site assessment. Ultimately, all five programs were certified, each meeting a minimum of 12/13 standards (peak MET increase and program completion rate were not met by some centres). Four themes resulted from the two focus groups of 13 site data stewards: motivation and benefits (eg, international recognition, additional program resources), logistics (eg, communication, cost, site visit process), the standards and their assessment (eg, balance of rigor and feasibility), and suggestions for improvement (eg, website). Conclusion: ICCPR's Program Certification has been demonstrated to be feasible, rigorous, and acceptable. Standards are attainable in low-resource settings. Certified programs reap benefits including additional resources. This first international Certification is suitable for low-resource settings, to complement that from the American and European CR Societies.

Translation, Cultural Adaptation, and Validation of a Korean Version of the Information Needs in Cardiac Rehabilitation Scale.

OBJECTIVE: : To translate and culturally adapt the Information Needs in Cardiac Rehabilitation (INCR) questionnaire into Korean and perform psychometric validation. METHODS: : The original English version of the INCR, in which patients are asked to rate the importance of 55 topics, was translated into Korean (INCR-K) and culturally adapted. The INCR-K was tested on 101 cardiac rehabilitation (CR) participants at Kangwon National University Hospital and Seoul National University Bundang Hospital in Korea. Structural validity was assessed using principal component analysis, and Cronbach's alpha of the areas was computed. Criterion validity was assessed by comparing information needs according to CR duration and knowledge sufficiency according to receipt of education. Half of the participants were randomly selected for 1 month of re-testing to assess their responsiveness. RESULTS: : Following cognitive debriefing, the number of items was reduced to 41 and ratings were added to assess participants' sufficient knowledge of each item. The INCR-K structure comprised eight areas, each with sufficient internal consistency (Cronbach's alpha>0.7). Criterion validity was supported by significant differences in mean INCR-K scores based on CR duration and knowledge sufficiency ratings according to receipt of education (p<0.05). Information needs and knowledge sufficiency ratings increased after 1 month of CR, thus supporting responsiveness (p<0.05). CONCLUSION: : The INCR-K demonstrated adequate face, content, cross-cultural, structural, and criterion validities, internal consistency, and responsiveness. Information needs changed with CR, such that multiple assessments of information needs may be warranted as rehabilitation progresses to facilitate patient-centered education.

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.

Factors Affecting Referral and Patient Access to Heart Function Clinics in Ontario: A Qualitative Study of Stakeholders.

Background: Though heart failure patients benefit from multidisciplinary care in heart function clinics (HFCs), utilization is suboptimal and inequitable. This study investigated factors influencing referral and patient access to HFCs from multiple stakeholders' perspectives, namely policy-makers (PM), providers at HFCs and patients. Methods: In this qualitative study, semi-structured interviews with a purposive sample of Ontario stakeholders were conducted between February-June 2020 and July-December 2022 (paused due to pandemic) via Teams. Interview transcripts were concurrently analyzed using systematic text condensation with Nvivo. Two authors coded individually, with disagreements discussed with senior author. Results: Interviews with 7 HFCs (6 physicians, 1 nurse), 6 PM and 4 patients were completed before saturation; 5 themes emerged. First, with regard to health system organization, stakeholders reported gaps related to continuity of care, limited capacity and insufficient funding. Second, with regard to referral appropriateness and timeliness, sub-themes related to unclear referral criteria, varying clinic scope, and delays in triage, testing and time-to-visit. The third theme related to clinic characteristics, raised issues of varying clinic services and composition of healthcare professions/expertise. The fourth theme regarding patient factors related to comorbidity/frailty, socioeconomic status, barriers due to location (parking, traffic) and affinity to specific providers. The final theme related to the COVID-19 pandemic concerned increased referral volumes, loss to follow-up care, transition to online delivery modalities and patient refusal of in-person visits. Many facilitators to improve HFC referral and access were raised. Conclusions: Resources must be provided, and stakeholders brought together to standardize and integrate the HF care continuum.

Contexte: Bien que les patients souffrant d'insuffisance cardiaque bénéficient de soins multidisciplinaires dans des cliniques de fonction cardiaque, l'utilisation de ces dernières est sous-optimale et inéquitable. Cette étude visait à examiner les facteurs influençant l'orientation et l'accès des patients aux cliniques de fonction cardiaque du point de vue de plusieurs parties prenantes, à savoir les décideurs politiques, les professionnels de la santé travaillant dans ces cliniques et les patients. Méthodologie: Dans le cadre de cette étude qualitative, des entretiens semi-structurés ont été menés de février à juin 2020 et de juillet à décembre 2022 (interruption en raison de la pandémie) sur la plateforme Teams avec un échantillon d'intervenants choisis à dessein. Les transcriptions des entretiens ont été analysées simultanément en utilisant la condensation systématique de l'information à l'aide du logiciel Nvivo. Deux auteurs ont effectué individuellement l'encodage, et les divergences ont fait l'objet de discussions avec l'auteur principal. Résultats: Des entretiens avec des professionnels de sept cliniques de fonction cardiaque (6 médecins, 1 infirmière), six décideurs politiques et quatre patients ont été réalisés avant l'atteinte de la saturation des réponses, ce qui a permis de dégager cinq thèmes. Premièrement, en ce qui concerne l'organisation du système de santé, les intervenants ont signalé des lacunes liées à la continuité des soins, une capacité limitée et à financement insuffisant. Deuxièmement, sur le plan de l'adéquation et de la rapidité de l'orientation, les sous-thèmes étaient liés à des critères d'orientation mal définis, à des champs variables d'application clinique et à des retards dans le triage, les tests et les consultations. Le troisième thème portait sur les caractéristiques des cliniques et les questions relatives à la diversité des services cliniques et à la composition du personnel et des experts en santé. Le quatrième thème avait trait aux patients, notamment leurs troubles concomitants, leur fragilité, leur statut socio-économique, les difficultés d'accès (stationnement, circulation) et l'affinité avec certains professionnels. Le dernier thème découlait de la pandémie de COVID- 19 et concernait l'augmentation du nombre de patients, la perte de contact durant le suivi, la transition vers des modalités de prestation en ligne et le refus des patients de se présenter en personne. La question de la nécessité d'un grand nombre de facilitateurs pour améliorer l'orientation et l'accès aux cliniques de fonction cardiaque a également a été soulevée. Conclusions: Des ressources supplémentaires sont requises, et les intervenants doivent travailler de concert afin d'assurer un continuum de soins normalisé et intégré pour les patients atteints d'insuffisance cardiaque.

Pilot testing of the International Council of Cardiovascular Prevention and Rehabilitation Registry.

The International Council of Cardiovascular Prevention and Rehabilitation developed an International Cardiac Rehabilitation (CR) Registry (ICRR) to support CR programs in low-resource settings to optimize care provision and patient outcomes. This study assessed implementation of the ICRR, site data steward experience with on-boarding and data entry, and patient acceptability. Multimethod observational pilot involves (I) analysis of ICRR data from three centers (Iran, Pakistan, and Qatar) from inception to May 2022, (II) focus group with on-boarded site data stewards (also from Mexico and India), and (III) semistructured interviews with participating patients. Five hundred sixty-seven patients were entered. Based on volumes at each program, 85.6% of patients were entered in ICRR. 99.3% patients approached consented to participate. The average time to enter data at pre- and follow-up assessments by source was 6.8-12.6 min. Of 22 variables preprogram, completion was 89.5%. Among patients with any follow-up data, of four program-reported variables, completion was 99.0% in program completers and 51.5% in none; of 10 patient-reported variables, completion was 97.0% in program completers and 84.8% in none. The proportion of patients with any follow-up data was 84.8% in program completers, with 43.6% of noncompleters having any data entered other than completion status. Twelve data stewards participated in the focus group. Main themes were valuable on-boarding process, data entry, process of engaging patients, and benefits of participation. Thirteen patients were interviewed. Themes were good understanding of the registry, positive experience providing data, and value of lay summary and eagerness for annual assessment. Feasibility and data quality of ICRR were demonstrated.

Global perspectives on heart disease rehabilitation and secondary prevention: a scientific statement from the Association of Cardiovascular Nursing and Allied Professions, European Association of Preventive Cardiology, and International Council of Cardiovascular Prevention and Rehabilitation.

Cardiovascular disease is a leading cause of death, morbidity, disability, and reduced health-related quality of life, as well as economic burden worldwide, with some 80% of disease burden occurring in the low- and middle-income country (LMIC) settings. With increasing numbers of people living longer with symptomatic disease, the effectiveness and accessibility of secondary preventative and rehabilitative health services have never been more important. Whilst LMICs experience the highest prevalence and mortality rates, the global approach to secondary prevention and cardiac rehabilitation, which mitigates this burden, has traditionally been driven from clinical guidelines emanating from high-income settings. This state-of-the art review provides a contemporary global perspective on cardiac rehabilitation and secondary prevention, contrasting the challenges of and opportunities for high vs. lower income settings. Actionable solutions to overcome system, clinician, programme, and patient level barriers to cardiac rehabilitation access in LMICs are provided.

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.