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Item Open Access A comparison of barriers to use of home versus site-based cardiac rehabilitation(Journal of Cardiopulmonary Rehabilitation and Prevention, 2013-09) Shanmugasegaram, Shamila; Oh, Paul; Reid, Robert D; McCumber, Treva; Grace, Sherry L.Purpose: Despite the established benefits of cardiac rehabilitation (CR), it remains significantly underutilized. It is unknown whether patient barriers to enrollment and adherence are addressed by offering choice of program type. The purpose of this study was to examine barriers to participation in CR by program type (site vs. home-based), and the relation of these barriers to degree of program participation and exercise behavior. Method: 1809 cardiac patients from 11 hospitals across Ontario completed a sociodemographic survey in-hospital, and clinical data were extracted from charts. They were mailed a follow-up survey one year later, which included the Cardiac Rehabilitation Barriers Scale and the Physical Activity Scale for the Elderly. Participants were also asked whether they attended CR, the type of program model attended, and the percentage of prescribed sessions completed. Results: Overall, 939 (51.9%) patients participated in CR, with 96 (10.3%) participating in a home-based program. Home-based participants reported significantly greater CR barriers compared to site-based participants (p<0.001), including distance. Mean barrier scores were significantly and negatively related to session completion and physical activity among site-based (ps<0.05), but not home-based CR participants (p>0.05). Conclusion: The barriers to CR are significantly different among patients attending site vs. home-based program, suggesting appropriate use of alternative models of care. Patient preferences should be considered when allocating patients to program models. Once in CR, programs should work towards identifying and tackling barriers among site-based participants. Abstract word count=231Item Open Access A Narrative Review on Women and Cardiac Rehabilitation: Program adherence and preferences for alternative models of care.(2010-11) Grace, Sherry L.; Racco, Cassandra; Chessex, Caroline; Rivera, Tiziana; Oh, PaulDespite the preponderance of evidence on the numerous benefits of CR, it remains largely under-utilized in women. The objective of this narrative review was to summarize and synthesize the literature on women and CR with regard to outcomes, adherence, and preferences for alternative models of CR. Studies of the effectiveness of CR have generally revealed no major differences between men and women. However, female-specific data are lacking on the effect of CR on mortality and morbidity. Research suggests that women and men may be equally likely to prefer home-based to hospital-based CR services. Women’s preferences for and outcomes in, women-only CR are beginning to be uncovered. Discussing program model options with female cardiac patients and referring to preferred types may be the appropriate approach until further evidence is available.Item Open Access A Prospective Examination of Patterns and Correlates of Exercise Maintenance in Coronary Artery Disease Patients(Springer Verlag, 2007) Ceccato, Natalie; Stewart, Donna Eileen; Grace, Sherry L.; Leung, YvonneItem Open Access A review of aboriginal women’s physical and mental health status in Ontario(Canadian Public Health Association, 2003-05) Grace, Sherry L.Item Open Access A Review of Cardiac Rehabilitation Delivery Around the World(Elsevier, 2017-10-13) Pesah, Ella; Supervia, Marta; Turk-Adawi, Karam; Grace, SherryHerein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases. Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.Item Open Access A simultaneous test of the relationship between identified psychosocial risk factors and recurrent events in coronary artery disease patients(2011-07) Grewal, Keerat; Gravely-Witte, Shannon; Stewart, Donna Eileen; Grace, Sherry L.Psychosocial factors are increasingly recognized as risk indicators for coronary artery disease (CAD) prognosis, and they are likely interrelated. The objective of this study is to simultaneously test the relationship between key psychosocial constructs as independent factor scores, and recurrent events in CAD patients. One thousand two hundred and sixty eight CAD outpatients of 97 cardiologists were surveyed at two points. Recurrent events or hospitalization in the intervening 9 months were reported. Factor analysis of items from the Hospital Anxiety and Depression Scale, Perceived Stress Scale, the ENRICHD Social Support Inventory, and Hostile Attitudes Scale was performed, to generate orthogonal factor scores. With adjustment for prognostic variables, logistic regression analysis was performed to examine the relationship between these factor scores and recurrent events. Factor analysis resulted in a six-factor solution: hostility, stress, anxiety, depressive symptoms, support and resilience. Logistic regression revealed that functional status and anxiety, with a trend for depressive symptoms, were related to experiencing a recurrent event. In this simultaneous test of psychosocial constructs hypothesized to relate to cardiac prognosis, anxiety may be a particularly hazardous psychosocial factor. While replication is warranted, efforts to investigate the potential benefits of screening and investigate treatments is needed.Item Open Access Access to cardiac rehabilitation among South Asian patients by referral method: A qualitative study(2010-05) Grewal, Keerat; Leung, Yvonne; Safai, Parissa; Stewart, Donna Eileen; Anand, Sonia; Gupta, Milan; Parsons, Cynthia; Grace, Sherry L.OBJECTIVES: South Asians (SA) suffer an increased prevalence of coronary artery disease. Although cardiac rehabilitation (CR) is effective, SA are among the least likely to participate. ‘Automatic’ referral increases CR utilization and may reduce access inequalities. METHODS: This study qualitatively explored whether CR referral knowledge/access varied by referral method among SA patients. Participants were SA cardiac patients from Ontario hospitals. Each hospital refers to CR through one of four methods: automatically through paper or electronically; through discussion with allied health professionals (liaison referral); or through usual referral at physician discretion. Data was collected via interviews and analyzed using Interpretive-descriptive analysis. RESULTS: Four themes emerged: 1) importance of pre-discharge CR discussions with health care providers; 2) limited knowledge of CR; 3) ease of referral process as facilitator of CR attendance; 4) participants’ need for personal autonomy over decision to attend CR. CONCLUSION: Liaison referral was perceived to be the most suitable method of referral for participants. It facilitated communication between patients and providers, ensuring improved CR understanding. Automatic referral may be less suited for this population, due to reduced patient-provider communication.Item Open Access Adapted Motivational Interviewing to Promote Exercise in Adolescents With Congenital Heart Disease: A Pilot Trial(Lippincott, Williams & Wilkins, 2018-10) McKillop, Adam; Grace, Sherry; Lima de Melo Ghisi, Gabriela; Allison, Kenneth; Banks, Laura; Kovacs, Adrienne H.; Schneiderman, Jane; McCrindle, BrianPurpose: To assess a motivational interviewing (MI) intervention to improve moderateto-vigorous physical activity (MVPA) in adolescents with congenital heart disease. Design: Pilot randomized controlled trial. Methods: Intervention participants received one-on-one telephone-based adapted MI sessions over 3 months. Outcomes were acceptability, change mechanisms (stage of change and self-efficacy), and limitedefficacy (PA, fitness and quality of life). Findings: 36 (66.7%) patients (50.0% male; 15.1±1.5 years) were randomized. Intervention participants completed 4.2±1.2/6 MI sessions, with no improvements in the high self-efficacy or stage of change observed (p>0.05). Overall, participants accumulated 47.24±16.36 minutes of MVPA/day, and had comparable outcomes to healthy peers (except for functional capacity). There was no significant difference in change in any outcome by group. Conclusions: The intervention was acceptable, but effectiveness could not be determined due to the nature and size of sample. Clinical Relevance: Pediatric cardiac rehabilitation remains the sole effective intervention to increase MVPA in this population.Item Open Access Adult Congenital Heart Disease-Coping And REsilience (ACHD-CARE): Rationale and methodology of a pilot randomized controlled trial(Elsevier, 2015-11) Kovacsa, Adrienne H.; Irvine, Jane; Silversides, Candice K.; Nolan, Robert; Kentner, Amanda C.; Grace, Sherry; Bandyopadhyay, Mimi; Kovacs, Adrienne H.Background and Aim: As a result of significant advances in diagnosis and treatment, approximately 90% of infants born with congenital heart disease (CHD) are now expected to reach adulthood. However, an increased risk of cardiac sequelae necessitates lifelong cardiac surveillance and can significantly impact psychosocial development. One-third of North American adults with CHD have diagnosable mood or anxiety disorders and most do not receive appropriate mental health treatment. There are currently no published trials investigating psychological interventions for this unique patient population. It is thus important to establish the feasibility of conducting a psychological intervention trial in this population. In this methods paper, we describe (1) the development of a group psychosocial intervention aimed at improving the psychosocial functioning, quality of life, and resilience of adults with CHD, and (2) the design of a study to determine the feasibility of a future full-scale randomized controlled trial. Methods: Based upon quantitative and qualitative (focus group) research, we developed an 8-session Adult CHD–Coping And REsilience (ACHD-CARE) Program. We subsequently designed a 2-parallel arm non-blinded pilot randomized trial with a 1:1 individual patient allocation ratio. Inclusion criteria are documented CHD, age >18 years, English-language proficiency, no planned surgery, and clinically-elevated score (i.e., >8) on the Hospital Anxiety and Depression Scale depression (HADS-D) or anxiety (HADS-A) subscale. Exclusion criteria are current psychotherapy, reported suicidal intent, or significant cognitive impairment, psychosis, or personality disorder. Patients from a single tertiary centre are randomized to the ACHD-CARE intervention or Usual Care. The intervention is delivered during 90-minute sessions held weekly in small groups. Feasibility is assessed in the following five domains:(i) process (e.g., participant recruitment and retention), (ii) resources, (iii) management, (iv)scientific outcomes, and (v) acceptability of the intervention. Results: Our initial experiences indicate that the study design is feasible and acceptable to stakeholders. We have been able to successfully recruit and retain participants, although travel distance and competing time demands are barriers for many potential study participants. There have been no insurmountable challenges in study management. At the conclusion of the study, we will be poised to make one of three determinations: (1) a full-scale RCT is feasible, (2) a full-scale RCT is feasible with modifications, or (3) a full-scale RCT is not feasible. Conclusions: This study underscores the importance of carefully developing and testing the feasibility of psychosocial interventions in medical populations before moving to full-scale clinical trials. Feasibility outcomes from this study will guide the future evaluation and provision of psychological treatment for adults with CHD.Item Open Access Age- and sex- specific all-cause mortality risk greatest in metabolic syndrome combinations with elevated blood pressure from 7 U.S. cohorts(PLoS One, 2019) Yu, Winnie; Randhawa, Arshdeep K.; Blair, Steven N.; Sui, Xuemei; Kuk, JenniferBackground The association between metabolic syndrome (MetS) and all-cause mortality is well established but it is unclear if there are differences in mortality risk among the 32 possible MetS combinations. Hence, the purpose of this study is to evaluate the associations between different MetS combinations and its individual components with all-cause mortality, and to examine differences in the association by age and sex. Methods A merged sample of 82,717 adults from 7 U.S. cohorts was used. Results In our sample, MetS was present in 32% of men, 34% of women, 28% of younger adults (18–65 years) and 62% of older adults (>65 years) with 14,989 deaths over 14.6 ± 7.4 years of follow-up. Risk of all-cause mortality was higher in younger individuals with a greater number of MetS factors present, but in older adults having all 5 MetS factors was the only combination significantly associated with mortality. Regardless of age or sex, elevated blood pressure was the MetS factor most consistently present in MetS combinations that were significantly and most strongly associated with mortality. In fact, elevated blood pressure in the absence of other risk factors was significantly associated with mortality in men (HR, 95% CI = 1.56, 1.33–1.84), women (HR = 1.62, 1.44–1.81) and younger adults (HR = 1.61, 1.45–1.79). Conversely, waist circumference, glucose and triglycerides in isolation were not associated with mortality (p>0.05). Conclusion In a large U.S. population, different combinations of MetS components vary substantially in their associations with all-cause mortality. Men, women and younger individuals with MetS combinations including elevated blood pressure had stronger associations with greater mortality risk, with minimal associations between MetS and mortality risk in older adults. Thus, we suggest that future algorithms may wish to consider differential weighting of these common metabolic risk factors, particularly in younger populations.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 Amino acid-induced impairment of insulin sensitivity in healthy and obese rats is reversible(Physiological Reports, 2014-07-04) Jeganathan, Senthure; Abdullahi, Abdikarim; Zargar, Sana; Maeda, Naomi; Riddell, Michael; ADEGOKE, OLASUNKANMIHigh-protein diets (HPDs) promote weight loss but other studies implicate these diets and their constituent amino acids (AAs) in insulin resistance. We hypothesized that AA-induced insulin resistance is a temporal and reversible metabolic event. L6 myotubes were serum deprived for 4 h and then incubated in AA and/or insulin (100 nmol/L). Another group of cells was incubated overnight in AA + insulin, starved again, and then reincubated with AA and insulin. Mammalian (mechanistic) target of rapamycin complex 1 (mTORC1) signaling and glucose uptake were then measured. Healthy or insulin-resistant rats were gavaged with leucine (0.48 g/kg) and insulin sensitivity was examined. In myotubes, incubation with AA and insulin significantly (P < 0.05) increased the phosphorylation of the mTORC1 substrate ribosomal protein S6 kinase 1 (S6K1, T389) and of insulin receptor substrate 1 (IRS-1, serine residues), but suppressed insulinstimulated glucose uptake by 40% (P < 0.01). These modifications were mTORC1-dependent and were reversible. In vivo, leucine gavage reversibly increased S6K1 phosphorylation and IRS-1 serine phosphorylation 5- to 12- fold in skeletal muscle and impaired insulin tolerance of glucose (P < 0.05) in lean rats. In insulin-resistant rats, the impairment of whole blood glucose and AA metabolism induced by leucine gavage (0.001 < P < 0.05) was more severe than that observed in lean rats; however, the impairment was reversible within 24 h of treatment. If these data are confirmed in long-term studies, it would imply that the use of leucine/HPD in treating metabolic diseases is unlikely to have lasting negative effects on insulin sensitivity.Item Open Access Amount and Socio-Ecological Correlates of Exercise in Men and Women at Cardiac Rehabilitation Completion(Wolters Kluwer, 2018-11) Taherzadeh, Golnoush; Reid, Robert D; Prince, Stephanie; Blanchard, Chris M; Chessex, Caroline; Harris, Jennifer; Pipe, Andrew L.; Grace, SherryObjective The aim of the study was to describe (1) the amount of physical activity (PA) in cardiac rehabilitation (CR) graduates by sex, and (2) the correlates of their PA. Design Secondary analysis of baseline data from a randomized trial was undertaken. Graduates were recruited from three CR programs. Participants completed a questionnaire, which assessed constructs from the socio-ecological model (i.e., individual-level, social- and physical-environmental levels). Physical activity was measured objectively using an ActiGraph GT3X accelerometer. Multilevel modeling was performed. Results Two hundred fifty-five patients consented, of which 200 (78.4%) completed the survey and provided valid accelerometer data. Participants self-reported engaging in a mean ± standard deviation of 184.51 ± 129.10 min of moderate-to-vigorous-intensity PA (MVPA) per week (with men engaging in more than women, P < 0.05). Accelerometer data revealed participants engaged in 169.65 ± 136.49 mins of MVPA per week, with 43 (25.1%) meeting recommendations. In the mixed models, the socio-ecological correlate significantly related to greater self-reported MVPA was self-regulation (P = 0.01); the correlate of accelerometer-derived MVPA was neighborhood aesthetics (P = 0.02). Conclusions Approximately one-quarter of CR program completers are achieving MVPA recommendations, although two-thirds perceive they are. The CR programs should exploit accelerometry and promote self-regulation skills, namely, self-monitoring, goal-setting, positive reinforcement, time management, and relapse prevention. Patients should be encouraged to exercise in pleasing locations.Item Open Access Antenatal risk factors for postpartum depression: a synthesis of recent literature(Elsevier Science B.V., Amsterdam, 2004-07) Grace, Sherry L.; Wallington, Tamara; Stewart, Donna Eileen; Robertson, EmmaPostpartum nonpsychotic depression is the most common complication of childbearing, affecting approximately 10-15% of women and, as such, represents a considerable health problem affecting women and their families. This systematic review provides a synthesis of the recent literature pertaining to antenatal risk factors associated with developing this condition. Databases relating to the medical, psychological, and social science literature were searched using specific inclusion criteria and search terms, in order to identifY studies examining antenatal risk factors for postpartum depression. Studies were identified and critically appraised in order to synthesize the current findings. The search resulted in the identification of two major meta-analyses conducted on over 14,000 subjects, as well as newer subsequent large-scale clinical studies. The results of these studies were then summarized in terms of effect sizes as defined by Cohen. The findings from the meta-analyses of over 14,000 subjects, and subsequent studies of nearly 10,000 additional subjects found that the following factors were the strongest predictors of postpartum depression: depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, and a previous history of depression. Critical appraisal of the literature revealed a number of methodological and knowledge gaps that need to be addressed in future research. These include examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers, and the use of appropriate instruments assessing postpartum depression for use within different cultural groups.Item Open Access Antidepressant Use by Class: Association with Major Adverse Cardiac Events in Patients with Coronary Artery Disease(Karger, 2018-03-13) Grace, Sherry; Medina-Inojosa, Jose; Thomas, Randal; Krause, Heather; Vickers-Douglas, Kristin S.; Palmer, Brian; Lopez-Jimenez, FranciscoBackground: To assess use of antidepressants by class in relation to cardiology practice recommendations, and the association of antidepressant use with the occurrence of major adverse cardiovascular events (MACE) including death. Methods: This is a historical cohort study of all patients who completed cardiac rehabilitation (CR) between 2002 and 2012 in a major CR center. Participants completed the Patient Health Questionnaire (PHQ-9) at the start and end of the program. A linkage system enabled ascertainment of antidepressant use and MACE through 2014. Results: There were 1,694 CR participants, 1,266 (74.7%) of whom completed the PHQ-9 after the program. Depressive symptoms decreased significantly from pre- (4.98 ± 5.20) to postprogram (3.57 ± 4.43) (p < 0.001). Overall, 433 (34.2%) participants were on antidepressants, most often selective serotonin reuptake inhibitors (SSRI; n = 299; 23.6%). The proportion of days covered was approximately 70% for all 4 major antidepressant classes; discontinuation rates ranged from 37.3% for tricyclics to 53.2% for serotonin-norepinephrine reuptake inhibitors (SNRI). Antidepressant use was significantly associated with lower depressive symptoms after CR (before, 7.33 ± 5.94 vs. after, 4.69 ± 4.87; p < 0.001). After a median follow-up of 4.7 years, 264 (20.9%) participants had a MACE. After propensity matching based on pre-CR depressive symptoms among other variables, participants taking tricyclics had significantly more MACE than those not taking tricyclics (HR = 2.46; 95% CI 1.37–4.42), as well as those taking atypicals versus not (HR = 1.59; 95% CI 1.05–2.41) and those on SSRI (HR = 1.45; 95% CI 1.07–1.97). There was no increased risk with use of SNRI (HR = 0.89; 95% CI 0.43–1.82). Conclusion: The use of antidepressants was associated with lower depression, but the use of all antidepressants except SNRI was associated with more adverse events.Item Open Access Automatic Referral to Cardiac Rehabilitation(Lippincott, Williams & Wilkins, 2004-07) Grace, Sherry L.; Evindar, Alexandra; Kung, Tabitha N.; Scholey, Patricia E.; Stewart, Donna EileenObjectives: Cardiac rehabilitation (CR) remains underused and inconsistently accessed, particularly for women and minorities. This study examined the factors associated with CR enrollment within the context of an automatic referral system through a retrospective chart review plus survey. Through the Behavioral Model of Health Services Utilization, it was postulated that enabling and perceived need factors, but not predisposing factors, would significantly predict patient enrollment. Subjects: A random sample of all atherosclerotic heart disease (AHD) patients treated at a tertiary care center (Trillium Health Centre, Ontario, Canada) from April 2001 to May 2002 (n = 501) were mailed a survey using a modified Dillman method (71% response rate). Measures: Predisposing measures consisted of sociodemographics such as age, sex, ethnocultural background, work status, level of education, and income. Enabling factors consisted of barriers and facilitators to CR attendance, exercise benefits and barriers (EBBS), and social support (MOS). Perceived need factors consisted of illness perceptions (IPQ) and body mass index. Results: Of the 272 participants, 199 (73.2%) attended a CR assessment. Lower denial/minimization, fewer logistical barriers to CR (eg, distance, cost), and lower perceptions of AHD as cyclical or episodic reliably predicted CR enrollment among cardiac patients who were automatically referred. Conclusion: Because none of the predisposing factors were significant in the final model, this suggests that factors associated with CR enrollment within the context of an automatic referral model relate to enabling factors and perceived need. A prospective controlled evaluation of automatic referral is warranted.Item Open Access Availability and Delivery of Cardiac Rehabilitation in the Eastern Mediterranean Region: How Does it Compare Globally?(Elsevier, 2019-06) Grace, Sherry; Alhashemi, Mohammed; Sarrafzadegan, Nizal; Sadeghi, Masoumeh; El-Heneidy, Asmaa; Afaneh, Jasser; Lopez-Jimenez, Francisco; Pesah, Ella; Supervia, Marta; Turk-Adawi, KaramBackground: This study aimed to (1) confirm cardiac rehabilitation (CR)availability, establish (2) CR density and unmet need, as well as (2) the nature of programs, and (3) compare these by (a) EMR country and (b) to other countries. Methods: In this cross-sectional study, a survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. CR need was based on Global Burden of Disease study ischemic heart disease (IHD) estimates. Results: Of the 22 EMR countries, CR programs were identified in 12 (54.5%). Nine (75.0% country response rate) countries participated, and 24/49 (49.0% program response rate) surveys were initiated. There was 1 CR spot for every 104 incident IHD patients/year(versus 12globally). One-third of programs were privately funded (n=8; versus globally p<.001), and in 18 (75.0%) programs patients paid some or all of the cost out-of-pocket (versus n=378, 36.3% globally; p<.001). Over 80% of programs accepted guideline-indicated patients. Nurses (n=20, 95.2%), cardiologists (n=18, 85.7%) and dietitians (n=18, 85.7%) were the most common healthcare providers on the CR team (mean=6.4±2.2/program; 5.9±2.8 globally, p=.18). On average, programs offered 8.9±1.7/11 core components (versus 8.7±1.9 globally, p=.90). These were most commonly initial assessment, management of risk factors, and patient education (n=21, 100.0% for each), and least commonly return-to-work counselling (n=1571.4%). Mean dose was 27.0±13.5 sessions (versus 28.7±27.6 globally, p=.38).Seven (33.3%) programs offered some alternative models. Conclusion: CR is insufficiently implemented, with 2,079,283 more spots needed/year across the EMR. But where offered, CR is consistent with guidelines.Item Open Access Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients(Biomed Central, 2019-09-02) Sérvio, Thaianne Cavalcante; Britto, Raquel; Lima de Melo Ghisi, Gabriela; da Silva, Lilian Pinto; Duarte Novais Silva, Luciana; Lima, Márcia Maria Oliveira; Pereira, Danielle Aparecida Gomes; Grace, Sherry L.Background: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a lowresource setting. Methods: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed. Keywords: Health care services, Cardiac rehabilitation, Cardiac care facilities, Attitude of health personnelItem Open Access Barriers to cardiac rehabilitation use in Canada versus Brazil.(journals.lww.com/jcrjournal/pages/default.aspx, 2013-05) Lima de Melo Ghisi, Gabriela; Oh, Paul; Benetti, Magnus; Grace, Sherry L.PURPOSE: Despite its well-established benefits, cardiac rehabilitation (CR) is greatly underutilized globally. Barriers to its utilization have been identified in high-income countries. Given the growing epidemic of noncommunicable disease in low-to-middle income countries, the identification of barriers to use of these low-cost interventions is warranted. The aim of this study was to describe and compare barriers to cardiac rehabilitation (CR) use in Brazilian and Canadian cardiac outpatients. METHODS: Two cardiac samples consisting of 237 Brazilian (recruited from 2 CR centers in Southern Brazil) and 1434 Canadian (recruited from 11 community and academic hospitals in Ontario) outpatients were compared cross-sectionally. Barriers were assessed using the Cardiac Rehabilitation Barriers Scale (CRBS), psychometrically-validated in English and Portuguese. Mann-Whitney U tests were used to compare barriers between samples. RESULTS: Overall, 139 (58.6%) Brazilian and 779 (54.3%) Canadian respondents were enrolled in CR. The mean total barriers score for Brazilian respondents was 1.71±.63 and 2.37±1.0 (P<.001) for the Canadians. For 17/21 barriers, Canadians reported significantly greater barriers than Brazilians (P<.02). As their greatest barriers, Canadians rated already exercising at home/community and persona travel, while Brazilians identified distance to and cost of the CR program. CONCLUSION: Despite the significantly lower availability of CR in Brazil and the universal healthcare system in Canada, cardiac outpatients in Canada perceived significantly greater CR barriers. Arguably however, these barriers were more modifiable.Item Open Access Barriers to Cardiac Rehabilitation: Does Age Make a Difference?(2009-11-26T19:52:08Z) Grace, Sherry L.; Shanmugasegaram, Shamila; Gravely-Witte, Shannon; Brual, Janette; Suskin, Neville; Stewart, Donna EileenPURPOSE: To quantitatively investigate age differences in barriers to cardiac rehabilitation (CR) enrollment and participation. METHODS: Cardiac outpatients (N = 1,273, mean age = 65.9 ± 11.2) completed a mailed survey to discern barriers to CR enrollment and participation. Both enrollees and nonenrollees were asked to rate 18 CR barriers on a 5-point Likert scale. RESULTS: Of the respondents, 535 (43%) reported participating in CR at 1 of 40 sites, with younger patients being more likely to participate (P=.002). Older age was positively related to total CR barriers (P<.001). Older patients more strongly endorsed the following CR barriers: already exercising at home (P=.001), confidence in ability to selfmanage their condition (P=.003), perception of exercise as tiring or painful (P=.001), not knowing about CR (P=.001), lack of physician encouragement (P<.001), comorbidities (P<.001), and perception that CR would not improve their health (P<.001). CONCLUSION: Given that the benefits of CR are achieved in older patients as well as the young, interventions to overcome these modifiable barriers to enrollment and participation are needed.