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OBJECTIVE: This study examined predictors of physical performance, a key aspect of quality of life, in children with excess weight. METHODS: Participants were 269 children aged 6-12 years with a body mass index above the 85th percentile. Children completed a standardized physical performance task capturing lower extremity strength, balance, and gait speed. Height, weight, and waist circumference were objectively measured, and daily moderate-vigorous physical activity (min/day) and sedentary time (% of day) were assessed with a 7-day accelerometer protocol. RESULTS: Physical performance task completion averaged 15.0 (SD = 2.5) seconds. Children with higher body mass index z-scores and waist circumferences had significantly longer task completion times. The task took 1.8 additional seconds per 1.0 body mass index z-score (p < .001), and 1.2 additional seconds for every 20 cm higher waist circumference (p < .001). Daily moderate-vigorous physical activity and sedentary time were unrelated to physical performance, and did not moderate its associations with the adiposity measures. CONCLUSION: Among children with excess weight, physical performance declines with increasing levels of total and central adiposity. Daily activity levels do not moderate this association. Interventions that directly target weight reduction would likely yield the greatest improvement in physical performance in children with overweight or obesity.
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Adiposidade , Qualidade de Vida , Índice de Massa Corporal , Criança , Estudos Transversais , Exercício Físico , Humanos , Obesidade , Desempenho Físico Funcional , Circunferência da Cintura , Aumento de PesoRESUMO
Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the 2005 scientific statement from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation regarding medical director responsibilities for outpatient CR/SP programs, significant changes have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal legislation and regulations and changes in health care delivery and clinical practice that impact the roles and responsibilities of CR/SP medical directors.
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Assistência Ambulatorial/normas , American Heart Association , Doenças Cardiovasculares/prevenção & controle , Pessoal de Saúde/normas , Diretores Médicos/normas , Prevenção Secundária/normas , Assistência Ambulatorial/métodos , Reabilitação Cardíaca , Doenças Cardiovasculares/epidemiologia , Humanos , Guias de Prática Clínica como Assunto/normas , Prevenção Secundária/métodos , Sociedades Médicas/normas , Estados Unidos/epidemiologiaRESUMO
This study provides an initial understanding of print awareness, a foundational literacy skill, in a group of 12 unhoused children at two shelters in a large urban setting. Children ranged in age from 4;1 to 8;0, representing grades associated with learning to read (i.e., pre-kindergarten to second grade). Findings indicate that the majority of children in this sample were significantly delayed in their acquisition of print awareness skills. Caregivers were surveyed regarding their beliefs about supporting literacy development and what would be beneficial for helping them in this area. Responses indicated that almost all caregivers believed that some literacy development should occur outside of the school setting and that it would be helpful if they (the caregivers) were taught both what skills to teach and how to teach them.
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PURPOSE: This review encompasses several practical components of supervised exercise therapy (SET) for patients with claudication including referral, exercise training, and billing issues. Real-life SET session examples are also provided. SET was approved for reimbursement by the Centers for Medicare & Medicaid Services (CMS) in 2017, and there is continual growth of programs offering SET and in participation. The purpose of this review is to provide useful information for the clinical exercise professionals working with these patients. REVIEW METHODS: The 2016 ACC/AHA Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease (PAD) provided a class I (highest level) recommendation for the use of SET in those with symptomatic PAD. Since there has been much growth in the literature about the utility of SET, the literature was reviewed (PubMed) to provide information for this article. Topics reviewed include the benefits of exercise training, exercise prescription, billing, referral and participation, and best practices. SUMMARY: SET should be offered to all patients with symptomatic PAD who are not at risk of acute limb ischemia. For optimal results, SET should be implemented several times per week and in a progressive process to increase exercise intensity as tolerated. For best results, programs should recommend patients supplement SET with home exercise. Considerations for utilizing reimbursed sessions should also be discussed because patients have a maximum of 72 sessions/lifetime. Referral practices need refinement, and participation rates remain extremely low and may be influenced by demographics. Research on best practices and home or hybrid training must continue to address issues related to common enrollment and participation barriers. CONDENSED ABSTRACT: Supervised exercise training (SET) for symptomatic peripheral artery disease is a class IA recommendation and reimbursable by most insurances. Improvements in walking performance can be dramatic. However, referral and participation in SET remain very low and thus SET is vastly underutilized.
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Medicare , Doença Arterial Periférica , Idoso , Humanos , Estados Unidos , Doença Arterial Periférica/terapia , Claudicação Intermitente/terapia , Terapia por Exercício/métodos , CaminhadaRESUMO
OBJECTIVE: This study examined whether the efficacy of a standard-of-care pediatric obesity treatment was affected by the COVID-19 pandemic. METHODS: Analyses leveraged data from an ongoing pediatric obesity treatment trial involving 230 lower-income, urban children aged 6 to 12 years. Mixed-effects regression models compared children who participated in a 12-month weight-management intervention before versus during the COVID-19 pandemic on change from baseline in BMI z score (ΔzBMI) at 3, 6, 9, and 12 months. RESULTS: The observed pattern of ΔzBMI was significantly different before versus during the pandemic (χ2 = 22.73, p < 0.0001). Children treated before the pandemic maintained an average weight loss of -0.06 ΔzBMI at 12 months, whereas children treated during the pandemic steadily gained weight over time, averaging a net gain of 0.11 ΔzBMI at 12 months (χ2 = 34.99, p < 0.0001). Treatment session completion did not differ before versus during the pandemic (60.4% vs. 55.7%, respectively; p = 0.30) or account for differences in ΔzBMI. CONCLUSIONS: Similar reductions in intervention efficacy may be anticipated in other pediatric obesity treatment trials conducted during the COVID-19 pandemic. Many families that have struggled with managing their child's weight during this period may need encouragement to continue engaging in structured weight management as society renormalizes.
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COVID-19 , Obesidade Infantil , Índice de Massa Corporal , Criança , Humanos , Pandemias/prevenção & controle , Obesidade Infantil/epidemiologia , Obesidade Infantil/terapia , SARS-CoV-2RESUMO
PURPOSE: This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR. REVIEW METHODS: To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations. SUMMARY: A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.
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Reabilitação Cardíaca , Telerreabilitação , Terapia por Exercício , Humanos , Motivação , Qualidade de VidaRESUMO
OBJECTIVE: To evaluate the effectiveness of a traditional didactic session (TDS) as compared to a self-paced, interactive, multimedia module (SPM) on the application of evidence-based medicine (EBM) skills among medical students during their inpatient pediatric rotation. METHODS: We conducted a randomized controlled trial from June, 2017 to June, 2018 at a quaternary care children's hospital. Students were randomized to TDS or SPM during each 2-week block. All students completed a critical appraisal tool (CAT) of evidence related to a clinical question in a standardized appraisal form and self-reflected about the EBM process. The primary outcome was the numeric score of the CAT derived by using the validated Fresno tool. Secondary outcomes of knowledge, attitudes, confidence, and self-reported behaviors related to EBM were measured using validated surveys. Statistical analysis was performed using Student's t test for CAT scores and mixed-model procedure (PROC MIXED), with subject as random effect and time as repeated measure for the secondary outcomes. RESULTS: One hundred twenty-seven clerkship students were included. Overall, there was no significant difference in mean CAT scores for TDS (n = 59) versus SPM (n = 66) groups (90.3 vs 92.0, P = .65). There were no significant differences between SPM and TDS groups for knowledge (P = .66), attitudes (P = .97), confidence (P = .55), and accessing evidence (P = .27). Both groups showed significant gains in knowledge, attitudes, confidence, and accessing evidence from baseline to postcourse. Improvements in knowledge and confidence were sustained at 3-months. CONCLUSION: A SPM learning module is as effective as a TDS module for application of EBM concepts and knowledge to patient care.
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Estágio Clínico , Educação de Graduação em Medicina , Estudantes de Medicina , Criança , Medicina Baseada em Evidências/educação , Humanos , Aprendizagem , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management. METHODS: We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI. RESULTS: A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals. CONCLUSIONS: No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.
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Ultrassonografia , Bexiga Urinária/diagnóstico por imagem , Infecções Urinárias , Criança Hospitalizada , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Bexiga Urinária/patologia , Infecções Urinárias/diagnóstico por imagemRESUMO
BACKGROUND: Studies have revealed an association between hospitalization of breastfed infants and weaning posthospitalization. It is unknown what steps inpatient providers at children's hospitals are currently taking to support breastfeeding mothers of hospitalized infants, their comfort providing breastfeeding counseling, and what training they receive. METHODS: We conducted a multicenter survey study of pediatric providers who care for infants hospitalized at 3 urban, tertiary-care children's hospitals over a 12-month period. A convenience sample of nurses, residents, and attending physicians agreed to participate. Participants completed a 24-question questionnaire addressing provider practices, comfort with breastfeeding counseling, and previous breastfeeding education. Data were summarized as medians (interquartile ranges) and frequencies (percentages). Kruskal-Wallis and χ2 tests were used to compare between provider types. RESULTS: A total of 361 out of 1097 (33%) eligible providers completed the survey: 133 (21%) nurses, 166 (45%) residents, and 62 (63%) attending physicians. Provider practices varied by provider type. We observed a general trend that providers do not routinely review breastfeeding techniques, directly observe feeds, or use standardized breastfeeding assessment tools. Residents and attending physicians were more likely than nurses to feel comfortable with breastfeeding counseling (P = .02). Residents were more likely than nurses and attending physicians to have received breastfeeding education in the last 3 years (P < .001). CONCLUSIONS: Practices, comfort, and previous education varied by provider type. There was a general pattern that providers do not routinely perform certain practices. Further studies are needed to determine if inpatient provider practices affect weaning posthospitalization and if inpatient quality improvement initiatives will help mothers continue breastfeeding posthospitalization.
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Aleitamento Materno , Hospitalização , Pacientes Internados , Assistência ao Paciente/normas , Feminino , Hospitais Pediátricos , Humanos , Lactente , Mães , Educação de Pacientes como Assunto , Inquéritos e Questionários , Estados UnidosRESUMO
PURPOSE: Most studies on pathogenesis of tumor metastasis focus on cell adhesion and migration. Little is understood of how cell cycle pathways critically affect cell fate of metastatic cells and their sensitivity to anticancer drugs. In this study, we investigated cell cycle checkpoint progression and regulation in the presence of cisplatin in metastatic hepatocellular carcinoma (HCC) cells. EXPERIMENTAL DESIGN: Cisplatin-mediated cell cycle progression and Polo-like kinase 1 (Plk1)-Cdc25A pathway were compared between metastatic and nonmetastatic HCC cells by flow cytometry, Western blots, and reverse transcription-PCR. Cdc25A expression in clinical HCC samples was detected using immunohistochemistry and its association with clinical HCC metastasis was analyzed. RESULTS: Cisplatin induced degradation of Cdc25A in nonmetastatic HCC cells but not in metastatic HCC cells. Hence, metastatic HCC cells showed defective S-M cell cycle phase arrest and continued to enter mitosis. Tumor expression of Cdc25A was strongly associated with metastatic diseases in HCC patients, and elevated Cdc25A expression significantly correlated with HCC tumor-node-metastasis staging and venous invasion. Metastatic HCC cells did not show down-regulation of Plk1 that was normally induced by DNA damage. Blockage of Plk1 expression in metastatic HCC cells initiated Cdc25A degradation in response to DNA damage, suggesting that Plk1 could be an upstream regulator of Cdc25A. Deregulated Plk1-Cdc25A pathway in metastatic HCC cells and primary tumors did not result in drug-induced mitotic catastrophe but rather in accumulation of damaged DNA due to checkpoint adaptation. CONCLUSIONS: Metastatic HCC cells showed a defective S-M checkpoint following cisplatin treatment and potential aberrant checkpoint adaptation, which might result from deregulation of Plk1-Cdc25A pathway.
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Carcinoma Hepatocelular/metabolismo , Proteínas de Ciclo Celular/metabolismo , Ciclo Celular , Neoplasias Hepáticas/metabolismo , Metástase Neoplásica , Proteínas Serina-Treonina Quinases/metabolismo , Proteínas Proto-Oncogênicas/metabolismo , Fosfatases cdc25/metabolismo , Idoso , Carcinoma Hepatocelular/patologia , Linhagem Celular Tumoral , Cisplatino/farmacologia , Dano ao DNA , Regulação para Baixo , Feminino , Humanos , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Transdução de Sinais , Quinase 1 Polo-LikeRESUMO
One-third of children in the United States are overweight or obese. Comorbidities continue into adulthood if a healthy weight is not established. While expert guidelines for management of this condition are recognized, provider adherence to guidelines is lacking. The purpose of this quality improvement project was to evaluate the effectiveness of the chronic care model (CCM) on improving primary care provider identification, prevention, and management of childhood overweight and obesity. A pre- and postintervention chart audit was completed to evaluate documentation of 20 assessment measures included in expert guidelines. A chi-square analysis was conducted to assess differences. Statistically significant improvements were found in documentation of parental obesity, family medical history, sleep assessment, endocrine assessment, and weight classification as a diagnosis. Use of the CCM had a positive impact on provider adherence to expert guidelines. Furthermore, not all aspects of the CCM must be used to see statistically significant improvements.
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Obesidade Infantil/terapia , Criança , Doença Crônica , Técnicas de Apoio para a Decisão , Humanos , Obesidade Infantil/diagnóstico , Melhoria de Qualidade , Estados UnidosRESUMO
Intensive trawling activities in Hong Kong waters have seriously depleted fishery resources and damaged marine benthic habitats over the last four decades. To minimize further destruction and rehabilitate fishery resources, the Hong Kong Government implemented a permanent territory-wide trawling closure on 31 December 2012. Such a trawl ban creates a unique opportunity to investigate recoveries in ecosystem structure and function following a major shift in disturbance regime by removing impacts from a major gear. This study was designed to test the hypothesis that dominant predatory mantis shrimps, including Harpiosquilla harpax, Miyakella nepa, Oratosquillina interrupta, and Oratosquilla oratoria would show signs of recovery following the trawl ban. Their population dynamics were investigated before and after the trawl ban. The results showed that their mean weight, mean carapace length and proportion of large-sized individuals increased significantly 3.5 years after the trawl ban, whilst their abundance, biomass and maximum length remained unchanged. This study suggests that the stomatopod assemblage in the human-dominated Hong Kong waters shows some initial signs of possible recovery following the trawl ban but also highlights the complexity of implementing fishery management and detecting changes resulted from management measures in a heavily urbanized seascape where many biotic and abiotic factors can influence their population dynamics.
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Organismos Aquáticos/crescimento & desenvolvimento , Crustáceos/crescimento & desenvolvimento , Ecossistema , Atividades Humanas , Dinâmica Populacional , Animais , Biomassa , Biometria , Tamanho Corporal , Peso Corporal , Conservação dos Recursos Naturais , Crustáceos/anatomia & histologia , Hong Kong , Água do MarRESUMO
One of the ongoing challenges in tissue engineering is the synthesis of a hemocompatible vascular graft. Specifically, the material used in the construct should have antithrombogenic properties and support the growth of vascular cells. Our laboratory has designed a novel biodegradable, elastomeric copolymer, poly(1,8-octanediol citrate) (POC), with mechanical and degradation properties suitable for vascular tissue engineering. The hemocompatibility of POC in vitro and its ability to support the attachment and differentiation of human aortic endothelial cell (HAEC) was assessed. The thrombogenicity and inflammatory potential of POC were assessed relative to poly(l-lactide-co-glycolide) and expanded poly(tetrafluoroethylene), as they have been used in FDA-approved devices for blood contact. Specifically, platelet aggregation and activation, protein adsorption, plasma clotting, and hemolysis were investigated. To assess the inflammatory potential of POC, the release of IL-1beta and TNF-alpha from THP-1 cells was measured. The cell compatibility of POC was assessed by confirming HAEC differentiation and attachment under flow conditions. POC exhibited decreased platelet adhesion and clotting relative to control materials. Hemolysis was negligible and protein adsorption was comparable to reference materials. IL-1beta and TNF-alpha release from THP-1 cells was comparable among all materials tested, suggesting minimal inflammatory potential. POC supported HAEC differentiation and attachment without any premodification of the surface. The results described herein are encouraging and suggest that POC is hemocompatible and an adequate candidate biomaterial for in vivo vascular tissue engineering.
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Materiais Biocompatíveis , Prótese Vascular , Citratos , Polímeros , Engenharia Tecidual , Adsorção , Bioprótese , Proteínas Sanguíneas/metabolismo , Diferenciação Celular , Células Cultivadas , Células Endoteliais/citologia , Hemólise , Hemorreologia , Humanos , Inflamação/etiologia , Teste de Materiais , Microscopia Eletrônica de Varredura , Ativação Plaquetária , Adesividade PlaquetáriaRESUMO
The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.
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Reabilitação Cardíaca/normas , Infarto do Miocárdio/reabilitação , Revascularização Miocárdica/reabilitação , Cooperação do Paciente/estatística & dados numéricos , Prevenção Secundária/normas , American Heart Association , Reabilitação Cardíaca/estatística & dados numéricos , Centers for Disease Control and Prevention, U.S. , Centers for Medicare and Medicaid Services, U.S. , Humanos , Guias de Prática Clínica como Assunto , Prevenção Secundária/métodos , Estados UnidosRESUMO
Poly(glycerol-sebacate) (PGS) is an elastomeric biodegradable polyester that could potentially be used to engineer blood vessels in vivo. However, its blood-material interactions are unknown. The objectives of this study were to: (a) fabricate PGS-based biphasic tubular scaffolds and (b) assess the blood compatibility of PGS in vitro in order to get some insight into its potential use in vivo. PGS was incorporated into biphasic scaffolds by dip-coating glass rods with PGS pre-polymer. The thrombogenicity (platelet adhesion and aggregation) and inflammatory potential (IL-1beta and TNFalpha expression) of PGS were evaluated using fresh human blood and a human monocyte cell line (THP-1). The activation of the clotting system was assessed via measurement of tissue factor expression on THP-1 cells, plasma recalcification times, and whole blood clotting times. Glass, tissue culture plastic (TCP), poly(l-lactide-co-glycolide) (PLGA), and expanded polytetrafluorethylene (ePTFE) were used as reference materials. Biphasic scaffolds with PGS as the blood-contacting surface were successfully fabricated. Relative to glass (100%), platelet attachment on ePTFE, PLGA and PGS was 61%, 100%, and 28%, respectively. PGS elicited a significantly lower release of IL-1beta and TNFalpha from THP-1 cells than ePTFE and PLGA. Similarly, relative to all reference materials, tissue factor expression by THP-1 cells was decreased when exposed to PGS. Plasma recalcification and whole blood clotting profiles of PGS were comparable to or better than those of the reference polymers tested.
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Materiais Biocompatíveis , Prótese Vascular , Decanoatos , Glicerol/análogos & derivados , Polímeros , Engenharia Tecidual , Linhagem Celular , HumanosRESUMO
Background In the United States, overweight/obesity among youth has reached epidemic proportions. The purpose of this project was to (1) examine primary care provider adherence to American Academy of Pediatrics guidelines; (2) compare adherence based on patients' weight classification, age, race, and gender; and (3) identify areas for improvement in health care delivery. Methods A retrospective chart audit and feedback quality improvement project was conducted with a stratified random sample of 175 charts of 6- to 19-year-olds seen for well-child visits. Frequencies of provider adherence were reported. χ(2) Analyses of weight classification, age, race, or gender influence on adherence was calculated. Results After discussion with the primary care providers, 5 areas were identified as priorities for change (diagnosis based on BMI, parental history of obesity, sleep assessment, endocrine assessment, and attendance of patients at the follow-up visit). Conclusion Cost-efficient, feasible strategies to improve provider adherence to recommendations for identification, prevention and management of childhood overweight and obesity were identified.
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Sobrepeso/diagnóstico , Sobrepeso/terapia , Pediatria/métodos , Atenção Primária à Saúde , Adolescente , Adulto , Criança , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Sobrepeso/prevenção & controle , Obesidade Infantil/diagnóstico , Obesidade Infantil/prevenção & controle , Obesidade Infantil/terapia , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
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.