Journal of Cardiopulmonary Rehabilitation and Prevention最新文献

Purpose: National guidelines have focused on increasing early referrals to cardiac rehabilitation (CR) before hospital discharge. However, patients often have not seen their cardiologists for a CR discussion, which may affect their willingness to enroll. This study compared the odds of enrollment between inpatient, outpatient, and dual (inpatient and outpatient) referrals.

Methods: A retrospective study was conducted on 1614 patients referred to CR within a university hospital system in Rhode Island from October 1, 2021 to September 30, 2022. Rates of CR enrollment were compared across inpatient (n = 807), outpatient (n = 670), and dual (n = 137) referral settings. Multivariable regression models, including demographics and comorbidities, were used to identify predictors of enrollment.

Results: A total of 874 (54%) patients enrolled with 40% of patients with inpatient referrals enrolling compared to 70% and 60% of those with outpatient and dual referrals, respectively ( P < .005). The average time between referral to initial visit was 24.2 ± 20.0 days. Regression modeling showed that patients with outpatient (OR = 3.74: 95% CI, 2.97-4.72) and those with dual referrals (OR = 2.09: 95% CI, 1.44-3.05) had higher odds of enrolling than those with inpatient referrals. Additionally, patients >80 years had lower odds of enrolling (OR = 0.50: 95% CI, 0.36-0.71) compared to younger patients.

Conclusions: Patients with outpatient referrals and dual referrals had greater odds of CR enrollment compared to those with inpatient referrals. Older patients (age >80 years) had lower odds of enrollment compared to those aged 50 to 65 years. Studies should focus on how to strengthen the inpatient CR referral process and tailor the CR discussion to meet older patient needs.

Purpose: Heat-related cardiovascular deaths are increasingly common for people with cardiovascular disease (CVD) in the face of a warming climate. Cardiac rehabilitation clinicians are well placed to educate people with CVD about the risks of heatwaves, but little is understood about their knowledge of this issue. We conducted an Australia-wide survey to understand cardiac rehabilitation clinician knowledge and attitudes regarding the health impacts of heatwaves for people with CVD.

Methods: This online REDCap survey was distributed through the National Heart Foundation, Australian Cardiovascular Health and Rehabilitation Association, and SOLVE-CHD networks to cardiac rehabilitation clinicians across Australia. Questions were open-ended and multiple choice about the health impacts of heatwaves and available support for people with CVD. Open-ended questions were thematically coded, and all other responses were presented as percentages.

Results: Ninety-nine clinicians in 7 states/territories (70% registered nurses) completed the survey. Only 17% believed sufficient information existed on the heat-health impacts for people with CVD, and 16% thought those with CVD were aware of these negative effects. Half (51%) of the respondents were aware that medication could influence physiological responses to heat but raised concerns regarding a lack of clear hydration guidance for people taking diuretics during a heatwave. Forty-five percent of clinicians said adequate information was available regarding exercise in the heat. Electric fan use (65%) and visiting a cooling center (64%) were the most recommended cooling strategies.

Conclusions: Generating educational material and incorporating evidence-based heat management strategies into rehabilitation programs will be vital to reduce cardiovascular events during heatwaves.

Purpose: As cardiac rehabilitation (CR) is highly effective, cost-effective, and professionally recommended, policymakers seek to increase utilization. Here we applied results from a randomized trial of case management (CM) and financial incentives (FI), paid as retail gift cards, separately and combined. We modeled their impact and cost-effectiveness compared to usual care (UC) in increasing quality-adjusted life years (QALYs).

Methods: Staff time logs, FI payouts, and CR attendance records generated short-term data. We derived the lifetime QALYs and cost-effectiveness (in 2022 US dollars) from a 2024 cost-effectiveness study of CR calibrated from an observational cohort of 601 099 CR-eligible Medicare beneficiaries. That cohort study controlled for confounding using instrumental variables (IV) and propensity-based (PB) matching.

Results: The FI alone and CM + FI combined interventions increased CR sessions significantly. Additional CR sessions per participant averaged 7.04 (95% CI, 0.93-13.15) with FI and 13.63 (95% CI, 7.86-19.41) with CM + FI. The CM alone intervention did not increase sessions significantly (mean = 1.53: 95% CI, -4.23 to 7.56). The CM + FI intervention generated the most lifetime QALYs, 0.733 (IV) and 1.100 (PB), and displayed a powerful synergy between CM and FI. Under CM + FI, the cost of financial payouts averaged $1088 (range $0-$1966), and total intervention costs averaged $2388. The lifetime cost-effectiveness of CM + FI was 29.966 (95% CI, 29.636-30.296, IV) or 29.257 (95% CI, 28.935-29.579 PB) QALYs/$million. Both values substantially surpassed the average threshold of the United States health care system (10.421 QALYs/$million).

Conclusions: The CM + FI intervention proved highly effective and more than twice as cost-effective as the average of all health interventions in the United States. Thus, CM + FI, combined with other effective interventions such as automatic referral and home-based CR, merit widespread implementation and funding.

Purpose: Home-based pulmonary rehabilitation (HBPR) with health coaching (HC) in people with chronic obstructive pulmonary disease (COPD) has been reported to produce behavior change by improving accelerometry-measured physical activity level and quality of life (QoL). However, a theoretical framework supporting the observed behavior change has not been tested in people with COPD. Therefore, the purpose of this secondary analysis was to examine the mechanism by which HBPR with HC improved physical and emotional QoL, by testing a theoretical framework that may support the positive effect of the intervention. The hypothesis was that the Self-Determination Theory (SDT) supports the behavior change observed after the 12-week HBPR with HC in patients with moderate to very severe COPD. This theory posits that by supporting the individual's experience of autonomy, competence, and relatedness can foster the most volitional and high-quality forms of motivation and engagement for a behavior change.

Methods: Structural Equation Models (Path Analysis) tested the underlying assumption that competence, autonomy, and relatedness were the factors associated with improvement in the physical and emotional QoL post-intervention.

Results: The path models supported the effect HBPR with HC on physical and emotional QoL through a direct effect on competence and relatedness ( P <.01) and an indirect effect through autonomy via competence and relatedness.

Conclusions: The effect of HBPR with HC in patients with COPD is mechanistically supported by SDT. Addressing competence, relatedness, and autonomy during the pulmonary rehabilitation process may impact physical and emotional QoL, which is of utmost importance to these patients.

Purpose: Cardiac rehabilitation (CR) improves health outcomes in patients with cardiovascular disease (CVD), but referral, participation, and completion rates are low. Home-based CR (HBCR) is a proposed solution, but studies on its efficacy are limited. We report our experience from a Veterans Affairs HBCR program on physical function, costs, and outcomes overlapping with the coronavirus disease-2019 (COVID-19) pandemic.

Methods: A 12-week HBCR program included case-managed individualized exercise and risk management. Six functional tests were conducted remotely, safety was monitored, and quality of life and costs were quantified. A composite outcome (death, myocardial infarction, stroke, and cardiac-related hospitalization) was compared between 70 HBCR participants, 131 patients referred to Community Care, and 71 patients undergoing usual care (no CR) over a mean follow-up of 2.5 ± 0.90 years.

Results: Among HBCR participants, there were significant improvements in right and left leg balance (145 and 56%, respectively, P < .001), 30-second chair stand (47%, P < .001), 2-minute step performance (41%, P < .001), right and left 30-second arm curl (31 and 30%, respectively, P < .001), 50-foot walk test (20%, P = .002), 8-foot up and go test (28%, P < .001), and steps/day (82%, P < .001). Composite events were lower among patients in the HBCR group versus those referred to Community Care ( P = .002). Health care costs were significantly lower among patients in the HBCR group compared to those in Community Care ($2101 vs $3289/subject, P < .001).

Conclusions: A HBCR program that included a broad spectrum of patients with CVD and multiple co-morbidities, performed largely during the COVID-19 pandemic, resulted in significant functional and outcome benefits and reduced costs.

Purpose: The aim of this study was to analyze the effect of exercise on endothelial function and other cardiovascular risk factors in patients with chronic obstructive pulmonary disease (COPD).

Methods: Forty patients were randomized to an 8-week pulmonary rehabilitation (PR) program or usual care. Symptoms, exercise capacity, and quality of life were measured at baseline and after intervention or observation. Flow-mediated brachial artery dilation (FMD), ankle-brachial index, intermittent claudication questionnaire, cardiovascular risk score, blood pressure, daily steps count, glucose, lipids, and C-reactive protein were evaluated before and after intervention.

Results: Participants had a mean age of 64.2 ± 6.7 years in the PR group and 62.2 ± 8.0 years in the usual care group. The forced expiratory volume in the first second was 45.5 ± 15.4% predicted in the PR group and 48.1 ± 24.3% predicted in the usual care group. Attending PR was associated with reduced symptoms, improved exercise capacity and quality of life in patients with COPD ( P < .005 for all). Endothelial function did not improve after PR (FMD% at baseline 9.38 ± 4.40 vs 9.67 ± 6.56 post PR; P = .87), and there was no difference between the 2 groups ( P = .61). However, exercise reduced C-reactive protein, triglycerides, and glucose and improved cardiovascular risk score, systemic blood pressure, and ankle-brachial index ( P < .005 for all).

Conclusions: Pulmonary rehabilitation elicited improvement in symptoms, exercise capacity, quality of life, and parameters related to cardiorespiratory fitness. The endothelial function measured by FMD did not change with exercise. However, other cardiovascular risk factors such as blood markers, systemic blood pressure, and lower limb blood flow improved after PR.