Prioritization, Development, and Validation of American Association of Cardiovascular and Pulmonary Rehabilitation Performance Measures.

BACKGROUND: In 2014, the American Association of Cardiovascular and Pulmonary Rehabilitation Quality of Care Committee was asked to develop performance measures (PMs) to assess program quality and aid in program improvement and certification. METHODS: A 3-step process was used to prioritize, develop, and then validate new PMs for both cardiac and pulmonary rehabilitation programs. First, we surveyed national leadership, medical directors, and program directors to identify and rank various American Association of Cardiovascular and Pulmonary Rehabilitation potential PM topics. Then, the face validity of the drafted PMs was assessed in a second national survey. Finally, we assessed the inter- and intrarater reliability and feasibility of each PM by abstracting patient charts at programs throughout the United States. At each step, modifications were made to refine and improve the measures for clarity, reliability, and consistency. RESULTS: Through survey answers received from 302 people (19% response rate), we identified 5 categories for PM development: optimal blood pressure control, tobacco use cessation, and improvement in functional capacity, depression, and sensation of dyspnea. After drafting the PMs, a second survey with 82 respondents (57% response rate), found that the proposed PMs had good face validity. Finally, we found excellent inter- and intrarater reliability for the blood pressure, functional capacity, depression, and dyspnea measures (κ generally >0.80.) However, validity concerns were raised about the tobacco intervention PM as written, and it continues to undergo further refinement and testing. CONCLUSIONS: We developed and validated 5 new PMs for use in cardiac and pulmonary rehabilitation program quality assessment, improvement, and certification.

Comparative Analysis of High-Velocity Versus Low-Velocity Exercise on Outcomes After Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND AND PURPOSE: High-velocity (HV) exercise is defined as performing a concentric muscle contraction as fast as possible, or in 1 second or less. Low-velocity (LV) exercise is defined as using 2 seconds to complete the contraction. A comparison of HV to LV exercise performed by community dwelling older adults indicates that HV exercise produces greater gains in power and scores for the 8-ft up-and-go, 30-seond chair stand, and continuous scale physical function performance tests. The effectiveness of HV strengthening exercises has not been identified for individuals who undergo total knee arthroplasty (TKA). The purpose of this research study was to compare the effects of a 6-week exercise program, using either LV or HV contractions, on functional performance, gait, and pain of individuals who have undergone TKA. METHODS: Adults aged 60 to 89 years with a mean (standard deviation) age of 71.2 (6.8) years who underwent TKA an average of 15 days prior were randomly assigned to an HV exercise (n = 19) or LV exercise (n = 19) training group. The training program lasted for 12 sessions, over 6 to 7 weeks. The primary outcome was functional performance rated with the 6-Minute Walk Test. Secondary measures were the stair climb test, Timed Up and Go test, gait velocity, gait deviations measured with the Gait Abnormality Rating Scale, and pain via a visual analog scale. A 2×2 mixed model analysis of variance (group × time) was used for all outcomes. Comparison between LV and HV groups for posttest gait velocity and Gait Abnormality Rating Scale used independent t test and Mann-Whitney U test, respectively. RESULTS: At baseline no differences between groups were noted for sex, age, and height. The LV group weighed more and had more comorbid conditions. Spearman's ρ demonstrated that the greater comorbidities of the LV group correlated with a slower stair climb test at baseline. At posttest both groups exhibited significantly improved scores for all outcome measurements except the visual analog scale for pain. The HV group, but not the LV group, reported a significant decrease in pain at the end of the 6-week training program. CONCLUSIONS: Both HV and LV progressive exercises equally improve functional performance. Only the HV group reported significantly decreased pain at posttest.

Participation Rates, Process Monitoring, and Quality Improvement Among Cardiac Rehabilitation Programs in the United States: A NATIONAL SURVEY.

PURPOSE: Although strategies exist for improving cardiac rehabilitation (CR) participation rates, it is unclear how frequently these strategies are used and what efforts are being made by CR programs to improve participation rates. METHODS: We surveyed all CR program directors in the American Association of Cardiovascular and Pulmonary Rehabilitation's database. Data collection included program characteristics, the use of specific referral and recruitment strategies, and self-reported program participation rates. RESULTS: Between 2007 and 2012, 49% of programs measured referral of inpatients from the hospital, 21% measured outpatient referral from office/clinic, 71% measured program enrollment, and 74% measured program completion rates. Program-reported participation rates (interquartile range) were 68% (32-90) for hospital referral, 35% (15-60) for office/clinic referral, 70% (46-80) for enrollment, and 75% (62-82) for program completion. The majority of programs utilized a hospital-based systematic referral, liaison-facilitated referral, or inpatient CR program referral (64%, 68%, and 60% of the time, respectively). Early appointments (<2 weeks) were utilized by 35%, and consistent phone call appointment reminders were utilized by 50% of programs. Quality improvement (QI) projects were performed by about half of CR programs. Measurement of participation rates was highly correlated with performing QI projects (P < .0001.) CONCLUSIONS: : Although programs are aware of participation rate gaps, the monitoring of participation rates is suboptimal, QI initiatives are infrequent, and proven strategies for increasing patient participation are inconsistently utilized. These issues likely contribute to the national CR participation gap and may prove to be useful targets for national QI initiatives.

The current and potential capacity for cardiac rehabilitation utilization in the United States.

PURPOSE: Prior studies suggest that program capacity restraints may be an important reason for outpatient cardiac rehabilitation (CR) underutilization. We sought to measure current CR capacity and growth potential. METHODS: We surveyed all CR program directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November 2012. Respondents reported current enrollment levels, program capacity, expansion potential, and obstacles to growth. RESULTS: Of the 812 program directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs than nonrespondents but were otherwise representative of all registered AACVPR programs. Current enrollment, estimated capacity, and estimated expansion capacity were reported at a median (interquartile range) of 140 (75, 232), 192 (100, 300), and 240 (141, 380) patients annually, respectively. Using these data, we estimated that, in the year 2012, national CR utilization was 28% (min, max: 20, 38) of eligible patients. Even with modest expansion of all existing programs operating at capacity, a maximum of 47% (min, max: 32, 67) of qualifying patients in the United States could be serviced by existing CR programs. Obstacles to increasing patient participation were primarily controllable system-related problems such as facility restraints and staffing needs. CONCLUSIONS: Even with substantial expansion of all existing CR programs, there is currently insufficient capacity to meet national service needs. This limit probably contributes to CR underutilization and has important policy implications. Solutions to this problem will likely include the creation of new CR programs, improved CR reimbursement strategies, and new models of CR delivery.

Reliability of abstracting performance measures: results of the cardiac rehabilitation referral and reliability (CR3) project.

BACKGROUND: Assessment of the reliability of performance measure (PM) abstraction is an important step in PM validation. Reliability has not been previously assessed for abstracting PMs for the referral of patients to cardiac rehabilitation (CR) and secondary prevention (SP) programs. To help validate these PMs, we carried out a multicenter assessment of their reliability. METHODS: Hospitals and clinical practices from around the United States were invited to participate in the Cardiac Rehabilitation Referral Reliability (CR3) Project. Twenty-nine hospitals and 23 outpatient centers expressed interest in participating. Seven hospitals and 6 outpatient centers met participation criteria and submitted completed data. Site coordinators identified 35 patients whose charts were reviewed by 2 site abstractors twice, 1 week apart. Percent agreement and the Cohen κ statistic were used to describe intra- and interabstractor reliability for patient eligibility for CR/SP, patient exceptions for CR/SP referral, and documented referral to CR/SP. RESULTS: Results were obtained from within-site data, as well as from pooled data of all inpatient and all outpatient sites. We found that intra-abstractor reliability reflected excellent repeatability (≥ 90% agreement; κ ≥ 0.75) for ratings of CR/SP eligibility, exceptions, and referral, both from pooled and site-specific analyses of inpatient and outpatient data. Similarly, the interabstractor agreement from pooled analysis ranged from good to excellent for the 3 items, although with slightly lower measures of reliability. CONCLUSIONS: Abstraction of PMs for CR/SP referral has high reliability, supporting the use of these PMs in quality improvement initiatives aimed at increasing CR/SP delivery to patients with cardiovascular disease.

Successful outpatient cardiac rehabilitation in an adult patient post-surgical repair for tricuspid valve atresia and hypoplastic right ventricle: a case study.

CLINICAL CASE: This case report documents outpatient cardiac rehabilitation (CR) in a 28-year-old woman born with transposition of the great vessels, tricuspid atresia, hypoplastic right ventricle, and an atrial septal defect. Surgical procedures were performed during childhood to correct these defects. In 2006, she underwent the following procedures: Fontan revision with a graft to an extracardiac total cavopulmonary connection; ASD creation; right atrial reduction; bidirectional Glenn shunt; right atrial and modified left atrial Maze procedures; and placement of an epicardial dual-chamber anti-tachycardia pacemaker. The patient was referred to CR because of postoperative complaints of fatigue, dyspnea on exertion, and low exercise tolerance. At intake, she underwent a cardiopulmonary stress test, measurement of percentage body fat, and completed the Medical Outcomes Survey 36-Item Short-Form Health Survey, Diet Intake Survey, and Center for Epidemiologic Studies Depression Scale. After completing 36 sessions, all outcomes demonstrated improvement with the exception of percentage dietary fat intake. DISCUSSION: Despite increasing numbers of patients with congenital heart disease (CHD) surviving into adulthood, exercise prescription in this population remains poorly delineated. In this case, possible physiologic limitations to exercise included diminished cardiac output secondary to low pressures and flow rates in the pulmonary arteries and veins because of the absence of a functioning right ventricle, limited chronotropic response, and severe deconditioning. SUMMARY: This case presents an adult patient who underwent surgical procedures to avoid heart transplantation. Despite severe CHD with many surgical procedures, and what is effectively a 2-chambered heart, she was able to successfully complete CR, graduate to home exercise, return to independent home living, and pursue her master's degree.