School of Kinesiology and Health Science
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Browsing School of Kinesiology and Health Science by Author "Alter, David"
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Item Open Access Ambulatory Surveillance of Patients Referred for Cardiac Rehabilitation Following Cardiac Hospitalization: A Feasibility Study(2012-07) Alter, David; Habot, Juda; Grace, Sherry L.; Fair, Terry; Kiernan, David; Clark, Wendy; Fell, DavidPurpose: To examine the feasibility of implementing an ambulatory surveillance system for the monitoring of patients referred to cardiac rehabilitation following cardiac hospitalizations. Methods: This study consists of 1208 consecutive referrals to cardiac rehabilitation between October 2007 and April 2008. Patient attendance to cardiac rehabilitation, waiting-times for cardiac rehabilitation, and adverse events while waiting for cardiac rehabilitation were tracked by telephone surveillance by a nurse. Results: Among the 1208 consecutive patients referred, only 44.7% of referred patients attended cardiac rehabilitation; 36.4% of referred patients were known not to have attended any cardiac rehabilitation, while an additional 25.8% of referred patients were lost to follow-up. Among the 456 referred patients who attended the cardiac rehabilitation program, 19 (4.2%) experienced an adverse event while in the queue (13 of which were for cardiovascular hospitalizations with no deaths) with mean waiting times of 20 days and 24 days among those without and with adverse events, respectively. Among the 440 referred patients who were known not to have attended any cardiac rehabilitation program 114 (25.9%) had adverse clinical events while in the queue; 46 (10.4%) of these events required cardiac hospitalization and 8 (2%) patients died. Conclusions: Ambulatory surveillance for cardiac rehabilitation referrals is feasible. The high adverse event rates in the queue, particularly among patients who are referred but who do not attend cardiac rehabilitation programs underscores the importance of ambulatory referral surveillance systems for cardiac rehabilitation following cardiac hospitalizations.Item Open Access Cardiologists' charting varied by risk factor, and was often discordant with patient report(Elsevier Science B.V., Amsterdam, 2008-10) Grace, Sherry L.; Alter, David; Higginson, Lyall; Suskin, Neville; Stewart, Donna Eileen; Gravely-Witte, ShannonObjective: To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report. Study Design and Setting: A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance. Results: With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's K, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history. Conclusion: Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.Item Open Access Contribution of Patient and Physician Factors to Cardiac Rehabilitation Referral: A Prospective Multi-Level Study(2008-10) Grace, Sherry L.; Gravely-Witte, Shannon; Brual, Janette; Suskin, Neville; Higginson, Lyall; Alter, David; Stewart, Donna EileenIntroduction: Cardiac rehabilitation (CR) is a proven means of reducing mortality, yet is grossly under-utilized. This is due to both health system and patient-level factors, issues which have yet to be investigated concurrently. This study utilized a hierarchical design to examine physician and patient-level factors affecting verified CR referral. Methods: This was a prospective study using a multi-level design of 1490 CAD outpatients nested within 97 cardiology practices. Cardiologists completed a survey regarding CR attitudes. Outpatients were surveyed prospectively to assess sociodemographic, clinical, behavioral, psychosocial and health system factors affecting CR referral. CR referral was verified 9 months later with 40 sites. Results: 550 (43.4%) outpatients were referred to CR. Factors affecting verified referral in mixed logistic regression analyses were positive physician perceptions of CR (p=.03), shorter patient distance to the closest CR site (p=.003), fewer perceived CR barriers (p<.001) and personal control (p=.001). Conclusions: Both physician and patient factors play a role in CR referral. Not only is referral to CR affected by physician perceptions of such programs, including quality and perceived benefit, but is affected by patient’s perceived CR barriers which they may convey during CR discussions. Distance to CR was related to physician referral practice, despite the availability of home-based services.Item Open Access Posttraumatic Growth in Coronary Artery Disease Outpatients: Relationship to Degree of Trauma and Health Service Use(2012-04) Leung, Yvonne; Alter, David; Prior, Peter; Stewart, Donna Eileen; Irvine, Jane; Grace, Sherry L.Objectives Posttraumatic growth (PTG) is frequently reported after the strike of a serious medical illness. The current study sought to: 1) assess the relationship between degree of cardiac “threat” and PTG one year post-hospitalization; and 2) to explore the association between PTG and healthcare utilization. Methods In a cohort study, 2636 cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey,; clinical data were extracted from charts. One year later, 1717 of these outpatients completed a postal survey, which assessed PTG and healthcare utilization. Morbidity data were obtained retrospectively through probabilistic linkage to administrative data. The predicted risk of recurrent events for each participant was calculated using a logistic regression model, based on participants’ sociodemographic and clinical characteristics. The relationship among PTG, trauma and health service use was examined with multiple regression models. Results Greater PTG was significantly related to greater predicted risk of recurrent events (p<.001), but not the actual rate of recurrent events (p=.117). Moreover, greater PTG was significantly related to more physician visits (p=.006), and cardiac rehabilitation program enrolment (p=.001) after accounting for predicted risk and sociodemographic variables. PTG was not related to urgent healthcare use. Conclusions Greater PTG was related to greater objective risk of morbidity but not actual morbidity, suggesting that contemplation about the risk of future health problems may spur PTG. Moreover, greater PTG was associated with seeking non-urgent healthcare. Whether this translates to improved health outcomes warrants future study.Item Open Access Prevalence of musculoskeletal comorbidities in cardiac patients: A prospective investigation of correlates and health services utilization.(2012-05) Marzolini, Susan; Oh, Paul; Alter, David; Stewart, Donna Eileen; Grace, Sherry L.Objectives: To describe the prevalence of musculoskeletal conditions (MSKC) in patients with coronary artery disease (CAD), examine the sociodemographic, clinical and psychosocial predictors of these comorbidities, and describe healthcare utilization by MSK comorbidity status. Design/Participants: 1803 patients in whom a cardiac condition was the reason for hospital admission, were administered a questionnaire in hospital and 1 year later. Setting: Eleven hospitals in Ontario, Canada. Outcome Measures: Sociodemographic, MSKC, clinical and psychosocial factors were ascertained via questionnaire and in-hospital chart extraction. A healthcare utilization questionnaire was mailed 1 year later. Results: Over half (56%) of patients with CAD had MSKCs, with arthritis/joint pain accounting for 64.4% of these MSKCs. Patients who were older (OR=1.03), female (OR=1.87), white (OR=1.80), with higher body mass index (OR=1.05), depressive symptoms (OR=1.92), and lower family income (OR=1.46) were more likely to present with MSKCs. One year post-hospitalization, a greater proportion of those with MSKCs reported ≥1 cardiac-related emergency department visit (33.2 vs. 28.3%,p=0.03), hospital admission (30.7 vs. 22%, p=0.006), more primary care physician visits (6.6 ± 5.6 vs. 5.7 ± 4.6, p<0.001) and fewer cardiac rehabilitation referrals (61.5 vs. 70%, p<0.001). After adjusting for depressive symptoms, body mass index, age, income, ethnicity, and sex, MSKCs predicted only hospital readmissions. Conclusions: Over half of patients hospitalized for CAD have MSKCs. Those with MSKCs have a physical and psychosocial profile that places them at greater cardiovascular risk than those with CAD only, explaining, in part, their greater healthcare utilization. Despite a greater need for comprehensive risk factor management in patients with MSKCs, fewer were referred to cardiac rehabilitation.Item Open Access Time-to-Referral, Use, and Efficacy of Cardiac Rehabilitation After Heart Transplantation(Wolters Kluwer, 2015-03) Oh, Paul; Alter, David; Skeffington, Valerie; Bertelink, Robert; Mathur, Sunita; Corbett, Dale; Brooks, Dina; Grace, Sherry; Marzolini, SusanBackground: Timely access, adherence, and efficacy of cardiac rehabilitation programs (CRP) are important given the potential to mitigate/reverse the side-effects of immunosuppressive medications, weight gain, and cardiovascular deconditioning that place heart transplant (HT) recipients at increased cardiovascular risk. However, there is a dearth of information on use and efficacy of CRPs. Therefore, we examined process indicators (time-to-referral and correlates, program adherence) and clinical outcome indicators (functional capacity (VO2peak), anthropometrics) of CR post-HT compared to post-coronary artery bypass graft (CABG). Methods: Baseline and 6 month exercise stress test results, and anthropometrics were examined retrospectively among consecutively enrolled post-HT and age-and sex-matched CABG patients. Time-to-referral/program entry, attendance and completion rates were also measured. Results: HT (n=43) and CABG patients were referred 24.9±48.9 and 2.1±3.6 months respectively, following surgery(p=0.003). Once referred, there was no difference in elapsed-time to program entry (p=0.2). There was a positive relationship between time-to-referral and baseline waist circumference(r=0.5,p=0.001), body mass index (r=0.5,p=0.002), hip circumference (r=0.4,p=0.008), and body fat percentage (r=0.4,p=0.03) in HT. HT and CABG patients had similar rates of CRP dropout (27.9% vs. 37.2%respectively,p=0.4).There was improvement in VO2peakfor HT (2.4±4.2 mLkg-1min-1,p=0.02) and CABG (5.5±5.4 mLkg-1min-1,p<0.001), but was greater for CABG(p=0.04). Anthropometric measures remained stable for both cohorts (p>0.05). Conclusions: There is a lengthy delay in time-from-HT to CRP referral, though once referred, gain significant benefit in functional capacity. The appropriateness of this wait needs to be elucidated, however it appears that longer wait times are associated with adverse effects on body composition.