Efficacy and Adherence Rates of a Novel Community-Informed Virtual World-Based Cardiac Rehabilitation Program: Protocol for the Destination Cardiac Rehab Randomized Controlled Trial.

BACKGROUND: Innovative restructuring of cardiac rehabilitation (CR) delivery remains critical to reduce barriers and improve access to diverse populations. Destination Cardiac Rehab is a novel virtual world technology-based CR program delivered through the virtual world platform, Second Life, which previously demonstrated high acceptability as an extension of traditional center-based CR. This study aims to evaluate efficacy and adherence of the virtual world-based CR program compared with center-based CR within a community-informed, implementation science framework. METHODS: Using a noninferiority, hybrid type 1 effectiveness-implementation, randomized controlled trial, 150 patients with an eligible cardiovascular event will be recruited from 6 geographically diverse CR centers across the United States. Participants will be randomized 1:1 to either the 12-week Destination Cardiac Rehab or the center-based CR control groups. The primary efficacy outcome is a composite cardiovascular health score based on the American Heart Association Life's Essential 8 at 3 and 6 months. Adherence outcomes include CR session attendance and participation in exercise sessions. A diverse patient/caregiver/stakeholder advisory board was assembled to guide recruitment, implementation, and dissemination plans and to contextualize study findings. The institutional review board-approved randomized controlled trial will enroll and randomize patients to the intervention (or control group) in 3 consecutive waves/year over 3 years. The results will be published at data collection and analyses completion. CONCLUSIONS: The Destination Cardiac Rehab randomized controlled trial tests an innovative and potentially scalable model to enhance CR participation and advance health equity. Our findings will inform the use of effective virtual CR programs to expand equitable access to diverse patient populations. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05897710.

Surveillance of the Initiation of, Participation in, and Completion of Cardiac Rehabilitation in Minnesota, 2017-2018.

INTRODUCTION: Cardiac rehabilitation (CR) is an evidence-based secondary prevention program designed to improve cardiovascular health after a cardiac event. The objective of our study was to identify gaps in CR use among publicly and privately insured people in Minnesota to assist in developing shared goals among public health, cardiac rehabilitation professionals, and program delivery sites to improve CR delivery. METHODS: We applied a published claims-based surveillance methodology to the Minnesota All Payer Claims Database to assess eligibility for, initiation of, participation in, and completion of CR by patients with qualifying events in 2017. We stratified results by sociodemographic and geographic factors and qualifying condition and used adjusted prevalence ratios to make statistical comparisons. RESULTS: Less than half (47.6%) of qualifying patients initiated CR within 1 year of their qualifying event; the rate was higher among men (vs women), adults aged 45 to 64 years (vs ≥65 y), and patients with commercial or Medicaid insurance coverage (vs Medicare). Among those who initiated CR, only 14.0% completed the full series of 36 sessions. Participation in at least 12 sessions and completion of 36 sessions was less likely among adults aged 18 to 64 (vs 65-74 y) and among patients covered by Medicaid (vs Medicare). Patterns of CR initiation, participation, and completion also varied geographically. CONCLUSION: This analysis expands on previous Medicare fee-for-service population CR surveillance and provides a first detailed look at the CR landscape in Minnesota, renewing attention to CR as a key secondary prevention strategy. Collaboration and sharing with partners has established the Minnesota Department of Health as a valuable partner in driving health system change to improve equitable provision of CR in Minnesota.

A Community-Informed Virtual World-Based Cardiac Rehabilitation Program as an Extension of Center-Based Cardiac Rehabilitation: MIXED-METHODS ANALYSIS OF A MULTICENTER PILOT STUDY.

PURPOSE: Innovative methods for delivering cardiac rehabilitation (CR) that provide strategies to circumvent the mounting barriers to traditional CR have the potential to widen access to a well-established secondary prevention strategy. Our study assesses the feasibility and acceptability of a novel virtual world-based CR (VWCR) program, Destination Rehab , as an extension of a conventional center-based CR program. METHODS: Adult cardiac patients hospitalized at Mayo Clinic hospitals with a diagnosis for CR and ≥1 modifiable, lifestyle risk factor target-sedentary lifestyle (<3 hr physical activity/wk), unhealthy diet (<5 servings fruits and vegetables/d), or current smoking (>1 yr)-were recruited. Patients participated in an 8-wk health education program using a virtual world (VW) platform from a prior proof-of-concept study and a post-intervention focus group. Primary outcome measures included feasibility and acceptability. Secondary outcome measures included changes from baseline to post-intervention in cardiovascular (CV) health behaviors and biometrics, CV health knowledge, and psychosocial factors. RESULTS: Of the 30 enrolled patients (age 59.1 ± 9.7 yr; 50% women), 93% attended ≥1 session and 71% attended ≥75% of sessions. The overall VWCR experience received an 8 rating (scale 0-10) and had high acceptability. Clinically relevant trends were noted in CV health behaviors and biometrics, although not statistically significant. CONCLUSIONS: The VWCR program is a feasible, highly acceptable, and innovative platform to potentially influence health behaviors and CV risk and may increase accessibility to disadvantaged populations with higher CV disease burdens.

Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions.

Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.

Prevalence of musculoskeletal and balance disorders in patients enrolled in phase II cardiac rehabilitation.

PURPOSE: To determine the prevalence of musculoskeletal, neurological, and balance problems in patients enrolled in early outpatient (phase II) cardiac rehabilitation. METHODS: Data were assessed retrospectively for 284 consecutive patients who attended the phase II Mayo Clinic Cardiac Rehabilitation program from April 2005 to August 2006. All participants completed a questionnaire that identified the presence of musculoskeletal pain, history of falls, joint replacements, osteoporosis, neurological disorders, and difficulties in performing activities of daily living. Balance assessment was evaluated using the single leg stance and the tandem gait tests. RESULTS: Of the total study population (mean age, 62.1 +/- 12.3 years), 25% reported musculoskeletal pain. A significantly higher prevalence of pain was noted in women than men (37% vs 20%, P = .004) and in those > 65 years than those < or = 65 years (35% vs 17%, P = .001). Back (29%), knee (17%), and hip (8%) pain were the most common symptoms, in order of decreasing frequency. Pain was worse with any activity in 32% of participants while 16% of participants had worsening at night. An abnormality in balance was present in 58% of the study participants and was significantly more common in women (71%) and those > 65 years (83%). Falls or gait instability or both were reported by 11% of participants. CONCLUSION: Musculoskeletal and balance limitations are common in persons enrolled in early outpatient cardiac rehabilitation, particularly in women and patients > 65 years. Cardiac rehabilitation programs should screen patients for musculoskeletal limitations and incorporate adaptations for treatment strategies of such patients.