An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial.

BACKGROUND: Outpatient cardiac rehabilitation (CR) decreases mortality rates but is underutilized. Current median time from hospital discharge to enrollment is 35 days. We hypothesized that an appointment within 10 days would improve attendance at CR orientation. METHODS AND RESULTS: At hospital discharge, 148 patients with a nonsurgical qualifying diagnosis for CR were randomized to receive a CR orientation appointment either within 10 days (early) or at 35 days (standard). The primary end point was attendance at CR orientation. Secondary outcome measures were attendance at ≥1 exercise session, the total number of exercise sessions attended, completion of CR, and change in exercise training workload while in CR. Average age was 60±12 years; 56% of participants were male and 49% were black, with balanced baseline characteristics between groups. Median time (95% confidence interval) to orientation was 8.5 (7-13) versus 42 (35 to NA [not applicable]) days for the early and standard appointment groups, respectively (P<0.001). Attendance rates at the orientation session were 77% (57/74) versus 59% (44/74) in the early and standard appointment groups, respectively, which demonstrates a significant 18% absolute and 56% relative improvement (relative risk, 1.56; 95% confidence interval, 1.03-2.37; P=0.022). The number needed to treat was 5.7. There was no difference (P>0.05) in any of the secondary outcome measures, but statistical power for these end points was low. Safety analysis demonstrated no difference between groups in CR-related adverse events. CONCLUSIONS: Early appointments for CR significantly improve attendance at orientation. This simple technique could potentially increase initial CR participation nationwide. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01596036.

Intermittent drug techniques for schizophrenia.

BACKGROUND: Antipsychotic medication is considered the mainstay of treatment for schizophrenia and is generally regarded as highly effective, especially in controlling positive symptoms. However, long-term antipsychotic exposure has been associated with a range of adverse effects, including extra-pyramidal symptoms (EPS), neuroleptic malignant syndrome (NMS), tardive dyskinesia and death. Intermittent drug techniques refers to the 'use of medication only during periods of incipient relapse or symptom exacerbation rather than continuously'. The aim is to reduce the risk of typical adverse effects of antipsychotics by 'reducing long-term medication exposure for patients who are receiving maintenance treatment while limiting the risk of relapse', with a further goal of improving social functioning resulting from the reduction of antipsychotic-induced side effects OBJECTIVES: To review the effects of different intermittent drug techniques compared with maintenance treatment in people with schizophrenia or related disorders. SEARCH METHODS: We searched The Cochrane Schizophrenia Group Trials Register (April 2012) and supplemented this by contacting relevant study authors, handsearching relevant intermittent drug treatment articles and manually searching reference lists. SELECTION CRITERIA: All randomised controlled trials (RCTs) that compared intermittent drug techniques with standard maintenance therapy for people with schizophrenia. Primary outcomes of interest were relapse and hospitalisation. DATA COLLECTION AND ANALYSIS: At least two review authors selected trials, assessed quality and extracted data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data and estimated the 95% confidence interval (CI) around this. For non-skewed continuous endpoint data extracted from valid scales, we estimated mean difference (MD) between groups with a 95% CI. Where data displayed heterogeneity, these were analysed using a random-effects model. Skewed data are presented in tables. We assessed overall quality for clinically important outcomes using the GRADE approach. MAIN RESULTS: Of 241 records retrieved by the search, 17 trials conducted between 1961 and 2011, involving 2252 participants with follow-up from six weeks to two years, were included. Homogenous data demonstrated that instances of relapse were significantly higher in people receiving any intermittent drug treatment in the long term (n = 436, 7 RCTs, RR 2.46, 95% CI 1.70 to 3.54, moderate quality evidence). Intermittent treatment was shown to be more effective than placebo, however, and demonstrated that significantly less people receiving intermittent antipsychotics experienced full relapse by medium term (n = 290, 2 RCTs, RR 0.37, 95% CI 0.24 to 0.58, very low quality evidence). Hospitalisation rates were higher for people receiving any intermittent drug treatment by long term (n = 626, 5 RCTs, RR 1.65, 95% CI 1.33 to 2.06, moderate quality evidence). Results demonstrated little difference in instances of tardive dyskinesia in groups with any intermittent drug technique versus maintenance therapy, with equivocal results (displaying slight heterogeneity) at long term (n = 165, 4 RCTs, RR 1.15, 95% CI 0.58 to 2.30, low quality evidence). AUTHORS' CONCLUSIONS: Results of this review support the existing evidence that intermittent antipsychotic treatment is not as effective as continuous, maintained antipsychotic therapy in preventing relapse in people with schizophrenia. More research is needed to assess any potential benefits or harm of intermittent treatment regarding adverse effects typically associated with maintained antipsychotic treatment, as well as any cost-effectiveness of this experimental treatment.

Employment Status and Participation in Cardiac Rehabilitation: DOES ENCOURAGING EARLIER ENROLLMENT IMPROVE ATTENDANCE?

PURPOSE: For patients hospitalized for a cardiac event, an earlier appointment to outpatient cardiac rehabilitation (CR) increases participation. However, it is unknown what effect hastening CR enrollment might have among employed patients planning to return to work (RTW). METHODS: Using 2 complementary data sets from Henry Ford Hospital (HFH) and Mayo Clinic, we assessed when employed patients eligible for CR anticipated a RTW, the impact of an earlier appointment on CR enrollment, and the effect of employment status on the number of CR sessions attended. Patients at HFH attended CR at either 8 or 42 days (through randomization), whereas Mayo Clinic patients attended 10 days after hospital discharge per standard routines. RESULTS: Among 148 patients at HFH, 65 (44%) were employed and planned to RTW. Of these, 67% desired to RTW within 1 to 2 weeks, whereas 28% anticipated an RTW within 1 to 3 days. Home financial strain predicted nonparticipation in CR (P < .001) and was associated with an earlier planned RTW. Among 1030 patients at Mayo Clinic, 393 (38%) were employed. Employed (vs nonemployed) patients enrolled in CR 3.3 days sooner (P < .001), but attended 1.6 fewer CR sessions (P = .04). In employed patients from both health systems, an earlier (vs later) appointment to CR did not result in additional exercise sessions of CR. CONCLUSIONS: Employed patients plan to RTW quickly, in part because of home finances. They also enroll earlier into CR than nonemployed patients. Despite these findings, earlier appointments do not seem to favorably impact overall CR participation.

Intermittent drug techniques for schizophrenia.

Intermittent drug techniques refer to the "use of medication only during periods of incipient relapse or symptom exacerbation rather than continuously." The aim is to reduce the risk of adverse effects of antipsychotics by "reducing long-term medication exposure for patients who are receiving maintenance treatment while limiting risk of relapse," with a further goal of improving social functioning resulting from the reduction of antipsychotic-induced side effects. We reviewed the effects of different intermittent drug techniques compared with maintenance treatment in people with schizophrenia or related disorders. We searched The Cochrane Schizophrenia Group Trials Register (April 2012) and supplemented this by contacting relevant study authors and manually searching reference lists. All relevant randomized controlled trials (RCTs) were included.Of 241 records retrieved by the search, 17 trials were included. Homogenous data demonstrated that instances of relapse were significantly higher in people receiving any intermittent drug treatment in the long term (n=436, 7 RCTs, RR=2.46, 95% CI=1.70- to 3.54). Intermittent treatment was shown to be more effective than placebo, however, and demonstrated that significantly less people receiving intermittent antipsychotics experienced full relapse by medium term (n=290, 2 RCTs, RR=0.37, 95% CI=0.24-0.58). Intermittent antipsychotic treatment is not as effective as continuous, maintained antipsychotic therapy for preventing relapse in people with schizophrenia. It does seem, however, significantly better than no treatment.