School of Kinesiology and Health Science

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Open Access
Desenvolvimento e validação da versão em português da Escala de Barreiras para Reabilitação Cardíaca
(Sociedade Brasileira de Cardiologia (SBC) , Brazil, 2012-04) Lima de Melo Ghisi, Gabriela; zulianello dos santos, rafaella; Schveitzer, Vanessa; Barros, Aline Lange; Recchia, Thais Lunardi; Oh, Paul; Benetti, Magnus; Grace, Sherry
Fundamento: As doenças cardiovasculares possuem alta incidência e prevalência no Brasil, porém a participação na Reabilitação Cardíaca (RC) é limitada e pouco investigada no país. A Escala de Barreiras para Reabilitação Cardíaca (CRBS) foi desenvolvida para avaliar as barreiras à participação e aderência à RC. Objetivo: Traduzir, adaptar culturalmente e validar psicometricamente a CRBS para a língua portuguesa do Brasil. Métodos: Duas traduções iniciais independentes foram realizadas. Após a tradução reversa, ambas versões foram revisadas por um comitê. A versão gerada foi testada em 173 pacientes com doença arterial coronariana (48 mulheres, idade média = 63 anos). Desses, 139 (80,3%) participantes de RC. A consistência interna foi avaliada pelo alfa de Cronbach, a confiabilidade teste-reteste pelo coeficiente de correlação intraclasse (ICC) e a validade de construto por análise fatorial. Testes-t foram utilizados para avaliar a validade de critério entre participantes e não participantes de RC. Os resultados da aplicação em função das características dos pacientes (gênero, idade, estado de saúde e grau de escolaridade) foram avaliados. Resultados: A versão em português da CRBS apresentou alfa de Cronbach de 0,88, ICC de 0,68 e revelou cinco fatores, cuja maioria apresentou-se internamente consistente e todos definidos pelos itens. O escore médio para pacientes em RC foi 1,29 (desvio padrão = 0,27) e para pacientes do ambulatório 2,36 (desvio padrão = 0,50) (p < 0,001). A validade de critério foi apoiada também por diferenças significativas nos escores totais por sexo, idade e nível educacional. Conclusão: A versão em português da CRBS apresenta validade e confiabilidade adequadas, apoiando sua utilização em estudos futuros. (Arq Bras Cardiol 2012;98(4):344-352)
Open Access
Psychometric validation of the Cardiac Rehabilitation Barriers Scale
(SAGE Journals, 2011) Shanmugasegaram, Shamila; Gagliese, Lucia; Oh, P.; Stewart, Donna Eileen; Brister, Stephanie J.; Chan, Victoria; Grace, Sherry
Objective: The purpose of this study was to investigate the factor structure and psychometric properties of the Cardiac Rehabilitation Barriers Scale (CRBS). Design, setting, and participants: In total, 2636 cardiac inpatients from 11 hospitals completed a survey. One year later, participants completed a follow-up survey, which included the CRBS. A subsample of patients also completed a third survey which included the CRBS, the Cardiac Rehabilitation Enrolment Obstacles scale, and the Beliefs About Cardiac Rehabilitation scale three weeks later. The CRBS asked participants to rate 21 cardiac rehabilitation barriers on a five-point Likert scale regardless of cardiac rehabilitation referral or enrolment. Results: Maximum likelihood factor analysis with oblique rotation resulted in a four-factor solution: perceived need/healthcare factors (eigenvalue = 6.13, Cronbach’s α = .89), logistical factors (eigenvalue = 5.83, Cronbach’s α = .88), work/time conflicts (eigenvalue = 3.78, Cronbach’s α = .71), and comorbidities/functional status (eigenvalue = 4.85, Cronbach’s α = .83). Mean total perceived barriers were significantly greater among non-enrollees than cardiac rehabilitation enrollees (P < .001). Convergent validity with the Beliefs About Cardiac Rehabilitation and Cardiac Rehabilitation Enrolment Obstacles scales was also demonstrated. Test-retest reliability of the CRBS was acceptable (intraclass correlation coefficient = .64). Conclusion: The CRBS consists of four subscales and has sound psychometric properties. The extent to which identified barriers can be addressed to facilitate greater cardiac rehabilitation utilization warrants future study.
Open Access
Factors affecting healthcare provider referral to heart function clinics: A mixed-methods study
(Wolters Kluwer Health, Inc., 2023) Mamataz, Taslima; Lee, Douglas; Turk-Adawi, Karam; Hajaj, Ahmad; Code, Jillianne
Background: Heart failure (HF) care providers are gatekeepers for patients to appropriately access life-saving HF clinics. Objective: To investigate referring providers’ perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic. Methods: An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semi-structured interviews were performed with a purposive sample of HF providers eligible to refer (e.g., nurse-practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Teams. Transcripts were analyzed concurrently by two researchers independently using NVivo, using a deductive-thematic approach. Then a cross-sectional survey of similar providers across Canada was undertaken via Research Electronic Data Capture (REDCap), using an adapted version of the Provider Attitudes Toward Cardiac Rehabilitation and Referral (PACRR) scale. Results: Saturation was achieved upon interviewing seven providers. Four themes arose: knowledge about clinics and their characteristics, providers’ clinical expertise, communication and relationship with their patients, as well as clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were: skepticism regarding clinic benefit (4.1±0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral vs. other professionals (ps<.02), among other differences. One-third (n=13) reported the pandemic impacted their referral practices (e.g., limits to in-person care, patient concerns). Conclusion: While there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.
Open Access
Psychometric validation of the short version of the Information Needs in Cardiac Rehabilitation scale through a first global assessment
(Oxford University Press, 2024-05-09) Lima de Melo Ghisi, Gabriela; Cruz, Mayara; Vanderlei, Luiz Carlos; Liu, Xia; Xu, Zhimin; Jiandani, Mariya; Cuenza, Lucky; Kouidi, Evangelia; Giallauria, Francesco; Mohammed, Jibril; Maskhulia, Lela; Fernandes Trevizan, Patricia; Batalik, Ladislav; Pereira, Danielle; Tourkmani, Nidal; Burazor, Ivana; Venturini, Elio; Grudka, Gerlene; Rehfeld, Manuella Bennaton Cardoso Vieira; Neves, Victor Ribeiro; de Jesus Borges, Geovana; Kim, Won-Seok; Cha, Seungwoo; Zhang, Ling; Grace, Sherry
Aims Tailored education is recommended for cardiac patients, yet little is known about information needs in areas of the world where it is most needed. This study aims to assess (i) the measurement properties of the Information Needs in Cardiac Rehabilitation short version (INCR-S) scale and (ii) patient’s information needs globally. Methods and results In this cross-sectional study, English, simplified Chinese, Portuguese, or Korean versions of the INCR-S were administered to in- or out-patients via Qualtrics (January 2022–November 2023). Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated recruitment. Importance and knowledge sufficiency of 36 items were rated. Links to evidence-based lay education were provided where warranted. A total of 1601 patients from 19 middle- and high-income countries across the world participated. Structural validity was supported upon factor analysis, with five subscales extracted: symptom response/medication, heart diseases/diagnostic tests/treatments, exercise and return-to-life roles/programmes to support, risk factors, and healthy eating/psychosocial management. Cronbach’s alpha was 0.97. Construct validity was supported through significantly higher knowledge sufficiency ratings for all items and information importance ratings for all subscales in cardiac rehabilitation (CR) enrolees vs. non-enrolees (all P < 0.001). All items were rated as very important—particularly regarding cardiac events, nutrition, exercise benefits, medications, symptom response, risk factor control, and CR—but more so in high-income countries in the Americas and Western Pacific. Knowledge sufficiency ranged from 30.0 to 67.4%, varying by region and income class. Ratings were highest for medications and lowest for support groups, resistance training, and alternative medicine. Conclusion Identification of information needs using the valid and reliable INCR-S can inform educational approaches to optimize patients’ health outcomes across the globe. Lay summary Patients need information to manage their heart diseases, such as what to do if they have chest pain, what a heart attack is, and how to take their medicine to lower the chances they will have another one, so a study of the information needs of over 1600 heart patients from around the globe was undertaken for the first time. Using the Information Needs in Cardiac Rehabilitation short version (INCR-S) scale—which was shown to be a good measurement tool through the study and hence may improve patient education—patients reported they most wanted information about heart events, heart-healthy eating, exercise benefits, their pills, symptom response, risk factor control, and cardiac rehabilitation—but more so in highincome countries in the Americas and Western Pacific. Knowledge sufficiency ratings for each item ranged from 30.0 to 67.4%, also varying by region and income class; perceived knowledge sufficiency ratings were highest for medications and lowest for support groups, resistance training, and alternative medicine.
Open Access
Evidence-informed development of women-focused cardiac rehabilitation education
(Elsevier, 2023-11-18) Lima de Melo Ghisi, Gabriela; Hebert, Andree-Anne ; Oh, Paul; Colella, Tracey JF; Aultman, Crystal; Gonzaga Carvalho, Carolina; Nijhawan, Rajni; Ross, Marie-Kristelle; Grace, Sherry
Background: Despite their differential risk factor burden, context and often different forms of heart disease, cardiac rehabilitation (CR) programs generally do not provide women with needed secondary prevention information specific to them. Objective: to co-design evidence-informed, theory-based comprehensive women-focused education, building from Health e-University’s Cardiac College for CR. Methods: A multi-disciplinary, multi-stakeholder steering committee (N=18) oversaw the four-phase development of the women-focused curriculum. Phase 1 involved a literature review on women’s CR information needs and preferences, phase 2 a CR program needs assessment, phase 3 content development (including determining content and mode, assigning experts to create the content, plain language review and translation), and phase 4 will comprise evaluation and implementation. In phase 2, a focus group was conducted with Canadian CR providers; it was analyzed using Braun and Clarke’s iterative approach. Results: Nineteen providers participated in the focus group, with four themes emerging: current status of education, challenges to delivering women-focused education, delivery modes and topical resources. Results were consistent with those from our related global survey, supporting saturation of themes. Co-designed educational materials included 19 videos. These were organized across 5 webpages in English and French, specific to tests and treatments, exercise, diet, psychosocial well-being, and self-management. Twelve corresponding session slide decks with notes for clinicians were created, to support program delivery in CR flexibly. Conclusion: While further evaluation is underway, these open-access CR education resources will be disseminated for implementation, to support women in reducing their risk of cardiovascular sequelae.
Open Access
Cardiac rehabilitation registries around the globe: Current status and future needs
(Oxford University Press, 2024-05-22) Grace, Sherry; Hagström, Emil; Harrison, Alexander Stephen; Phillips, Samara; Bovin, Ann; Yokoyama, Miho N.; Niebauer, Josef; Makita, Shigeru; Raidah, Fabbiha; Bäck, Maria
Open Access
Promoting Cardiac Rehabilitation Program Quality in Low-Resource Settings: Needs Assessment and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation’s Registry Quality Improvement Supports
(Elsevier, 2024-03-12) Raidah, Fabbiha; Lima de Melo Ghisi, Gabriela; ANCHIQUE SANTOS, CLAUDIA VICTORIA; Soomro, Nabila; Candelaria, Dion; Grace, Sherry
Background: Cardiac rehabilitation (CR) registries have the potential to support quality improvement (QImp). This study investigated the QImp needs of International CR Registry-participating programs and their evaluation of its’ supports. Methods: ICRR offers comparative outcome dashboards and QImp sessions, among other features. In this qualitative study, ICRR data stewards from the 17 active on-boarded CR programs were invited to a focus group held in November 2023 via Teams; stewards not sufficiently-proficient in English were invited to provide written input. Deductive-thematic analysis using NVIVO was undertaken by 2 researchers; member-checking ensued. Results: Nine participated, and four provided input, from eight countries. Three themes emerged; saturation was achieved. First, QImp facilitators included training, institutional requirements, dedicated staff, resources in ac ademic centres and ICRR features. Second, QImp barriers included staffing issues, the global nature of the ICRR, and structural challenges in low-resource settings. Finally, ICRR supports for QImp included didactic webinars, hearing from other programs, 1–1 support offered and assessing minimum Certification standards. Conclusion: ICRR-participating programs are satisfied with QImp supports but encounter challenges, including related to language, staffing and other resources. CR registries should be leveraged and optimized to support CR programs to assess and improve their care quality.
Open Access
Women’s cardiac rehabilitation barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation’s first global assessment
(Canadian Journal of Cardiology, 2023-09-24) Lima de Melo Ghisi, Gabriela; Kim, Won-Seok; Cha, Seungwoo; Aljehani , Raghdah ; Cruz, Mayara Moura Alves; Vanderlei, Luiz Carlos; Pepera, Garyfallia; Liu, Xia; Xu, Zhimin; Maskhulia, Lela; Venturini, Elio; Chuang, Hung-Jui; Pereira, Danielle; Fernandes Trevizan, Patricia; Kouidi, Evangelia; Batalik, Ladislav; Ghanbari-Firoozabadi, Mahdieh; Burazor, Ivana; Jiandani, Mariya; Zhang, Ling; Tourkmani, Nidal; Grace, Sherry
Background: Cardiac rehabilitation (CR) programs are under-utilized globally, especially by women. This study investigated sex differences in CR barriers across all world regions for the first time, which characteristics were associated with greater barriers in women, and women’s greatest barriers by enrollment status. Methods: In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale (CRBS) was administered to CRindicated patients globally via Qualtrics from October/2021 to March/2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) community facilitated participant recruitment. Mitigation strategies were provided and rated. Results: 2163 patients from 16 countries across all six World Health Organization regions participated; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in two regions (Americas, Western Pacific) and men in one (Eastern Mediterranean; ps<.001). Women’s barriers were greatest in the Western-Pacific (2.6±0.4/5) and South-East Asian (2.5±0.9) regions (p<.001), with lack of CR awareness as the highest barrier in both. Women who were unemployed reported significantly higher barriers than those not (p<.001). Among non-enrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2±0.7/5). Conclusions: CR barriers – men’s and women’s – vary significantly by region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women’s barriers in particular.
Open Access
Technology‐based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle‐income setting: A randomized controlled trial protocol
(Research in Nursing & Health, 2022-11-12) Menezes, Henita Joshna; DSouza, Sonia; Padmakumar, Ramachandran; Babu, Abraham Samuel; Rao, Rohini R.; Kamath, Veena; Kamath, Asha; Grace, Sherry
Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower‐resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology‐based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart‐health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle‐income country. Following a pilot study, a single‐center, single‐blinded, 2 parallel‐arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre‐intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6‐month intervention comprises an app, website, SMS texts with generic heart‐health management advice, and bi‐weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent‐to‐treat. If results of this novel trial of women‐focused eCR in a middle‐income country demonstrate clinically‐significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.
Open Access
Pilot testing of the International Council of Cardiovascular Prevention and Rehabilitation Registry
(International Journal for Quality in Health Care, 2023-07-03) Grace, Sherry; Elashie, Sana; Sadeghi Mahonak, Masoumeh; Papasavvas, Theodoros; Hashmi, Farzana; Lima de Melo Ghisi, Gabriela; LARA VARGAS, JORGE ANTONIO; Al-Hashemi, Mohammed; Turk-Adawi, Karam
Background: The International Council of Cardiovascular Prevention and Rehabilitation developed an International CR Registry (ICRR) to support CR programs in low-resource settings to optimize care provision and patient outcomes. This study assessed: implementation of the ICRR, site data steward experience with on-boarding and data entry, and patient acceptability. Methods: Multi-method observational pilot involving: (1) analysis of ICRR data from 3 centers (Iran, Pakistan, Qatar) from inception to May 2022, (2) focus group with on-boarded site data stewards (also from Mexico, India), and (3) semi-structured interviews with participating patients. Results: 567 patients were entered. Based on volumes at each program, 85.6% of patients were entered in ICRR. 99.3% patients approached consented to participate. The average time to enter data at pre and follow-up assessments by source was 6.8-12.6 minutes. Of 22 variables pre-program, completion was 89.5%. Among patients with any follow-up data, of 4 program-reported variables, completion was 99.0% in program completers and 51.5% in non; of 10 patient-reported, variable completion was 97.0% in program completers and 84.8% in non. Proportion of patients with any follow-up data was 84.8% in program completers, with 43.6% of non-completers having any data entered other than completion status. Twelve data stewards participated in the focus group. Main themes were: valuable on-boarding process, data entry, process of engaging patients, and benefits of participation. Thirteen patients were interviewed. Themes were: good understanding of the registry, positive experience providing data, value of lay summary and eagerness for annual assessment. Conclusions: Feasibility and data quality of ICRR were demonstrated.
Open Access
Looking Beyond Binary Sex Classifications: Gender-Related Variables in Patients Entering Cardiac Rehabilitation
(Journal of Cardiopulmonary Rehabilitation and Prevention, 2022-05) Comeau, Katelyn; Terada, Tasuku; Chirico, Daniele; Vidal Almela, Sol; Grace, Sherry; Reid, Robert D.; Reed, Jennifer
Coronary artery disease (CAD) is a leading cause of death worldwide. There are known differences in the clinical and sociodemographic characteristics of males and females with CAD, such as higher mortality and poorer health-related quality of life (HR-QoL) following a revascularization procedure in females.1 Sex (i.e., males, females, intersex) is a biological construct, while gender encompasses socially-constructed roles, behaviors and self-expressions. When gender-related variables are included in analyses, post-revascularization sex-differences are often attenuated.2 Differences in health status and HR-QoL of patients with CAD may be better explained by considering gender-related variables (e.g., gender-identity, education and marital status) rather than biological sex alone.2,3,4 At cardiac rehabilitation (CR) entry, patients with CAD who have undergone coronary revascularization procedures frequently demonstrate low functional capacity, levels of physical activity and HR-QoL.5 Existing CR research is limited in investigating the independent effects of gender-related variables on functional capacity and HR-QoL. The purpose of this study was to examine the associations between gender-related variables and health-status indicators (i.e., functional capacity and HR-QoL) at CR entry.
Restricted
Controlled Pilot Test of a Translated Cardiac Rehabilitation Education Curriculum in Percutaneous Coronary Intervention Patients in a Middle-Income Country Delivered Using WeChat: Acceptability, Engagement, Satisfaction, and Preliminary Outcomes
(Health Education Research, 2022-09-10) Liu, X.; Grace, Sherry; Lima de Melo Ghisi, Gabriela; Wendan, Shi; Shen, C.; Oh, P.; Zhang, Y.; Zhang, Y.
In China, despite the rapid increase in percutaneous coronary interventions (PCI), cardiac rehabilitation (CR) is just burgeoning, leaving a need for comprehensive evidence-based education curricula. This pilot study assessed the acceptability of Simplified-Chinese CR education delivered via booklets and videos on WeChat asynchronously, and impact in improving knowledge, risk factors, health behaviors and quality of life. In this pre-post, controlled, observational study, interested PCI patients received the 12-week intervention, or usual care and WeChat without education. Participants completed validated surveys, including the Coronary Artery Disease Education-Questionnaire and Self-Management Scale. Acceptability (14 Likert-type items), engagement (minutes per week) and satisfaction were assessed in intervention participants. Ninety-six patients consented to participate (n=49 intervntion), of which 66 (68.8%) completed the follow-up assessments. Twenty-seven (77.1%) retained intervention participants engaged with the materials, rating content as highly acceptable (all means ≥4/5) and satisfactory (2.19±0.48/3); those engaging more with the intervention were significantly more satisfied (p=.03). While participants in both groups achieved some improvements, only intervention participants had significant increases in disease-related knowledge, reductions in body mass index and triglycerides, as well as improvements in diet (all p<.05). In this first study validating the recently-translated CR patient education intervention, acceptability and benefits have been supported.
Embargo
Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline
(Canadian Journal of Cardiology, 2022-12) Lima de Melo Ghisi, Gabriela; Marzolini, Susan; Price, Jennifer; Beckie, Theresa; Mamataz, Taslima; Naheed, Aliya; Grace, Sherry
Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and may result in better quality-of-life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary healthcare providers, a policy-maker, and patient partners. The guideline was developed in accordance with AGREE II and RIGHT. Initial recommendations were based on a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR’s audit; N=76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A webcall was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (GRADE). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing) and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but one recommendation, ≥75% voted to include; implementability ratings were <5/7 for 4 recommendations, but only one for impact. Ultimately one recommendation was excluded, one separated into two and all revised (two substantively); one recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.
Open Access
Outcomes and Cost of Women-Focused Cardiac Rehabilitation: A Systematic Review and Meta-analysis
(Maturitas, 2022-06) Mamataz, Taslima; Lima de Melo Ghisi, Gabriela; Pakosh, Maureen; Grace, Sherry
Background: The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost. Methods: Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception-May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. “Women-focused” CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women’s preferences. No studies were excluded based on outcome. Two independent reviewers rated citations for potential inclusion, and 1 extracted data, including quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; Certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied. Results: 3498 unique citations were identified, of which 28 (52 papers) studies were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with usual care comparisons. When compared to active comparison, women-focused CR had no meaningful effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence), and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as 7/8 SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported favorable economic impact and another reduced sick days. Conclusions: Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed.
Open Access
Building Capacity through ICCPR’s Cardiovascular Rehabilitation Foundations Certification (CRFC): Evaluation of Reach, Barriers and Impact
(Journal of Cardiopulmonary Rehabilitation and Prevention, 2022-05) Babu, Abraham Samuel; Heald, Fiorella A.; Contractor, Aashish; Lima de Melo Ghisi, Gabriela; Buckley, John; Mola, Anna; Atrey, Alison; Lopez-Jimenez, Francisco; Grace, Sherry
Purpose: The International Council of Cardiac Rehabilitation and Prevention (ICCPR) developed an online Cardiac Rehabilitation Foundations Certification (CRFC; https://globalcardiacrehab.com/Certification) in October 2017, to build CR delivery capacity in low-resource settings based on their guidelines. Herein we evaluate its’ reach globally, barriers to its completion, as well as satisfaction and impact of the course among those completing it. Methods: The country of origin of all applicants was tallied. An online survey was developed for learners who completed the CRFC (completers), and for those who applied but did not yet complete the program (non-completers), administered using Google Forms. Results: With regard to reach, 236 applications were received from 23/203 (11.3%) countries; 51 (25%) were from low or middle-income countries. 130 (55.1%) have completed the CRFC; mean scores on the final exam were 88.3 ± 7.1%, with no difference by country income classification (P=.052). Sixteen (21.9%) non-completers and 37 (34.3%) completers responded to the survey. Barriers reported by non-completers were time constraints, cost, and technical issues. Overall satisfaction with the CRFC was high (4.49 ± 0.51/5); most completers would highly recommend the CRFC to others (4.30 ± 0.66), and perceived that the information provided will contribute to their work and/or the care of their patients (4.38 ± 0.89); 29 (78.4%) had used the information from the CRFC in their practice. Conclusions: The reach of the CRFC still needs to be broadened, in particular in low-resource settings. Learners are highly satisfied with the certification, and its impacts on CR practice are encouraging. Input has been implemented to improve the CRFC.
Open Access
Evaluation of an Online Course in Five Languages for Inpatient Cardiac Care Providers on Promoting Cardiac Rehabilitation: Reach, Effects and Satisfaction
(Journal of Cardiopulmonary Rehabilitation and Prevention, 2022-03) Heald, Fiorella A.; Santiago de Araújo Pio, Carolina; Liu, Xia; Rivera Theurel, Fernando; Pavy, Bruno; Grace, Sherry
Purpose: Evidence proves health care providers should promote cardiac rehabilitation (CR) to patients face-to-face to increase CR enrollment. An online course was designed to promote this at the bedside; it is evaluated herein in terms of reach, effect on knowledge, attitudes, discussion self-efficacy and practices, and satisfaction. Methods: Design was observational, one-group pretest-posttest. Some demographics were requested from learners taking all language versions of the 20-minute course: English, Portuguese, French, Spanish, and simplified Chinese, available at https://globalcardiacrehab.com/CR-Utilization. Investigator-generated items in the pre- and post-test and evaluation survey administered using Google Forms were based on Kirkpatrick’s training evaluation model. Results: The course was initiated by 522 learners from 33/203 (16.3%) countries; most commonly female (n=341, 65.3%) nurses (n=180, 34.5%) from high-income countries (n=259, 56.7%), completing the English (n=296, 56.7%) and Chinese (n=108, 20.7%) versions. 414 (79.3%) completed the post-test and 302 (57.9%) completed the evaluation. Median CR attitudes were 5/5 on the Likert scale at pre-test, suggesting some selection bias. Mean CR knowledge (7.22±2.14/10), discussion self-efficacy (3.86±0.85/5), and practice (4.13±1.11/5) significantly improved after completion of the course (all P<.001). Satisfaction was high regardless of language version (4.44±0.64/5; P=.593). Conclusions: This free, open-access course is effective in increasing CR knowledge, self-efficacy, and encouragement practices among participating inpatient cardiac providers, with high satisfaction. While testing impact on actual CR use is needed, it should be more broadly disseminated to increase reach, in an effort to increase patient enrollment in CR, to reduce morbidity and mortality.
Open Access
Cardiac Rehabilitation Effectiveness for Coronary Artery Disease by Clinical Era: Trial Sequential Analysis
(European Journal of Preventive Cardiology, 2020-12-01) Oliveros, María-José; Serón, Pamela; Buitrago-García, Diana; Grace, Sherry
Cardiac rehabilitation (CR) is an outpatient model of care for the secondary prevention of cardiovascular disease, which is widely and strongly recommended in international clinical guidelines. The latest update of the Cochrane systematic review on CR for patients with coronary artery disease1 found that CR is effective in preventing cardiovascular death and hospital admissions, but not all-cause mortality, reinfarctions and other complications, as reported in the previous update. This could be due to the inclusion of more recent trials. Thanks to advances in medicine, patients now have access to acute revascularization treatments such as thrombolysis and angioplasty, and therefore achieve better outcomes, such that some have hypothesized that CR may have less impact in the current clinical era2. Although the Cochrane review included a meta-regression which showed no impact of the publication year on the effectiveness,1 some others meta-analyses in the field that have included only recent trials,2,3 have contradicted this finding. In this context, we conducted a secondary analysis of these trials with the aim of examining whether there is sufficient data to determine effectiveness of CR on all-cause and cardiovascular mortality as well as hospitalization, and to test effectiveness over time, using trial sequential analysis (TSA) for the first time. With sequential analysis, it is possible to determine the need for more trials or whether the results are conclusive.4 Such analysis allows the effect to be observed as the participants in the primary studies accumulate even if the optimal sample size has not been reached, adjusting the threshold of statistical significance as the sample size is accumulated. 5
Open Access
Effects of Cardiac Rehabilitation in Low- and Middle-Income Countries: A systematic Review and Meta-Analysis of Randomised Controlled Trials
(Progress in Cardiovascular Diseases, 2022-01) Mamataz, Taslima; Uddin, Jamal; Alam, Sayed Ibn; Taylor, Rod S.; Pakosh, Maureen; Grace, Sherry
Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed,Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched frominception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g.,mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane’s tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I2 = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I2 = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I2 = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95% CI = -1.61 to −0.07; moderate-quality evidence; I2 = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I2 = 93%, low-quality evidence; mental: MD = 5.38, 95% CI=1.13 to 9.63; I2=84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Lowtomoderate-certainty evidence establishesCRas delivered in LMICs improves functional capacity, risk factor control and QoL.Whilemore high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).
Open Access
Profile of women choosing mixed-sex women-only, and home-based cardiac rehabilitation models and impact on utilization
(The Journal of Women and Health, 2022-01-04) Heald, Fiorella A.; Marzolini, Susan; Colella, Tracey JF; Oh, Paul; Nijhawan, Rajni; Grace, Sherry
This study compared characteristics and program utilization in women electing to participate in mixed-sex, women-only, or home-based cardiac rehabilitation (CR). In this retrospective cohort study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017-February 2020 were analyzed. There were 727 women (74.7% mixed, 22.0% women-only, 3.3% home-based) who initiated CR. There were significantly more women who were not working in women-only than mixed-sex (80.4% vs 64.1%; P=.009). Session adherence was significantly greater with mixed-sex (58.8±28.9% sessions attended/25) than women-only (54.3±26.3% sessions attended/25; P=.046); program completion was significantly lower with home-based (33.3%) than either supervised model (59.7%; P=.035). Participation in women-only CR may be less accessible. Further research is needed to investigate offering remote women-focused sessions or peer support.
Open Access
How do healthcare workers judge pain in older palliative care patients with delirium near the end of life?
(2015) Gagliese, Lucia; Rodin, Rebecca; Chan, Vincent; Stevens, Bonnie; Zimmermann, Camilla
Context: Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging and there is currently no validated assessment tool for this task. Objectives: This retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain. Methods: We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (n = 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome. Results: We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behaviour. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting. Conclusion: These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.