School of Kinesiology and Health Science

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Open Access
Using Aggregate Data on Health Goals, Not Disease Diagnoses, to Develop and Implement a Healthy Aging Group Education Series
(OMICS International, 2017-07-17) Oliver, D.; Cleghorn, L.; MacDonald-Werstuck, M.; Pauw, G.; Bauer, M.; Doyle, L.; McPhee, C.; C, O Neill; Guenter, D.; Winemaker, S.; White, J.; Price, D.; L, Dolovich
Background: The Healthy Aging Group Education Series was developed by interprofessional primary healthcare team members and researchers to address the health needs and goals of nutrition, fitness and function, and advance care planning identified using data from a randomized controlled trial. Methods: Older adults from one family practice were invited to attend the series and participate in the descriptive evaluation. The series was developed based on aggregated patient-reported data on health goals, risks, and needs gathered using a structured process. Surveys which included open-ended feedback and rated items of content and delivery evaluated the series. Program delivery expenses were itemized. Results: Of 69 people invited, a range of 26 to 37 people attended sessions. The overall series was rated positively with respect to meeting attendees’ expectations and being well-organized; 69.2% and 76.9% of attendees gave a positive rating respectively. Individual session feedback indicated a range of positive ratings (82.8-100%) for categories of effective and engaging presenters and providing new and relevant information. The majority of attendees (76.9%) indicated they would recommend the series to friends. The series continues to be offered regularly in the family practice. Conclusion: The health goal information (and not disease diagnosis) that was used to develop and deliver the program resulted in a program that was well received by participants and sustainable in the family practice.
Open Access
Peer support workers as a bridge: a qualitative study exploring the role of peer support workers in the care of people who use drugs during and after hospitalization
(Springer Nature, 2021-02-16) Lennox, Robin; Lamarche, Larkin; O’Shea, Tim
BACKGROUND: To describe the key qualities and unique roles of peer support workers in the care of people who inject drugs during and after hospitalization. METHODS: We conducted a qualitative study. Key stakeholders were recruited including: people who use drugs who had been hospitalized, healthcare team members, peer support workers, and employers of peer support workers. Data were collected from 2019 to 2020 using semi-structured interviews that were audio-recorded, transcribed, and analyzed thematically. RESULTS: Fourteen participants were interviewed: 6 people who use drugs who had been hospitalized, 5 healthcare team members, 2 peer support workers, and 1 employer of peer support workers. At the core of the data was the notion of peer workers acting as a bridge. We found four themes that related to functions of this bridge: overcoming system barriers, advocacy, navigating transitions within the healthcare system, and restoring trust between HCPs and PWUD. We found two themes for building a strong bridge and making the role of a peer support worker function effectively (training and mentorship, and establishing boundaries). We found three themes involving characteristics of an effective peer worker (intrinsic qualities, contributions of shared experiences, and personal stability). CONCLUSION: Peer support workers are highly valued by both people who use drugs and members of the healthcare team. Peer support workers act as a bridge between patients and healthcare providers and are critical in establishing trust, easing transitions in care, and providing unique supports to people who use drugs during and after hospitalization.
Open Access
The body mass index: What’s the use?
(Elsevier BV, 2025-06-13) Bailey, K Aly; Bessey, Meredith; Lamarche, Larkin; Griffin, Meridith
The body mass index (BMI) is a ubiquitous metric frequently used in body image research: as a correlate, covariate, descriptor, and more. However, the racist history of the measure is often unknown or unacknowledged. BMI was coined by Ancel Keys who used Adolphe Quetelet’s statistics of weight and height, later becoming a measurement of so-called “health.” Eugenics founder Francis Galton used Quetelet’s statistics to determine the abnormal, in a concerted effort to eliminate bodies seen as “unfit.” The BMI has been used to compare bodies to white masculinist ideals for decades (e.g., in insurance coverage, healthcare access), which is something body image scholars must reckon with if our collective goal is to subvert unrealistic, harmful, and damaging beauty ideals—not inadvertently validate them. In body image research to date, BMI use/usefulness helped unpack the complex relationship between negative and positive body image(s): BMI is consistently related to both. However, it has also been overused, and we argue—uncritically and inappropriately used—since it misses the root issue: fat discrimination and weight stigma. Thinking with critical race theorist Sara Ahmed’s (2019) work on “use,” we open a conversation on the potential implications of use/disuse of BMI. We outline the use, usefulness, and used-upness of BMI and offer reflections on what it means to be a critical user or outright refuser of this metric.
Open Access
Cardiac Rehabilitation Quality Improvement: A Narrative Review
(Lippincott, Williams & Wilkins, 2019-07) Moghei, Mahshid; Chessex, Caroline; Oh, Paul; Grace, Sherry
Purpose: Despite evidence of the effectiveness of cardiac rehabilitation (CR), there is wide variability in programs, which may impact their quality. The objectives of this review were to (1) evaluate the ways in which we measure CR quality internationally; (2) summarize what we know about CR quality and quality improvement; and (3) recommend potential ways to improve quality. Methods: For this narrative review, the literature was searched for CR quality indicators (QIs) available internationally and experts were also consulted. For the second objective, literature on CR quality was reviewed and data on available QIs were obtained from the Canadian Cardiac Rehabilitation Registry (CCRR). For the last objective, literature on health care quality improvement strategies that might apply in CR settings was reviewed. Results: CR QIs have been developed by American, Canadian, European, Australian, and Japanese CR associations. CR quality has only been audited across the United Kingdom, the Netherlands, and Canada. Twenty-seven QIs are assessed in the CCRR. CR quality was high for the following indicators: promoting physical activity post-program, assessing blood pressure, and communicating with primary care. Areas of low quality included provision of stress management, smoking cessation, incorporating the recommended elements in discharge summaries, and assessment of blood glucose. Recommended approaches to improve quality include patient and provider education, reminder systems, organizational change, and advocacy for improved CR reimbursement. An audit and feedback strategy alone is not successful. Conclusions: Although not a lot is known about CR quality, gaps were identified. The quality improvement initiatives recommended herein require testing to ascertain whether quality can be improved.
Open Access
Exercise rehabilitation in ventricular assist device recipients: a meta-analysis of effects on physiological and clinical outcomes
(Springer, 2018-04-06) Grosman-Rimon, Liza; Lalonde, Spencer; Sieh, Nina; Pakosh, Maureen; Rao, Vivek; Oh, P.; Grace, Sherry
Background: Exercise rehabilitation in heart failure patients has been shown to improve quality of life (QoL) and survival. It is also recommended in clinical practice guidelines for ventricular assist device (VAD) recipients. However, there have only been 2 meta-analyses on the effects of exercise rehabilitation in VAD patients, on only 2 outcomes. The objective of the review was to quantitatively evaluate the effect of exercise rehabilitation in VAD recipients on functional capacity, exercise physiology parameters, chronotropic responses, inflammatory biomarkers and neurohormones, heart structure and function, as well as clinical outcomes. Methods: The following databases were systematically searched: CCTR, CDSR, CINAHL, EMBASE, PsycInfo, and Medline through to November 2015, for studies reporting on VAD recipients receiving ≥2 sessions of aerobic training. Citations were considered for inclusion, and data were extracted in included studies as well as quality assessed, each by 2 investigators independently. Random-effects meta-analyses were performed where possible. Results: The meta-analysis showed that compared to usual care, exercise rehabilitation significantly improved peak VO2 (n=74, mean difference=1.94 mL·kg−1·min−1, 95% CI 0.633.26, p=0.004) and 6-minute walk test distance (n=52, mean difference=42.46 meters, 95% CI 8.45-76.46, p=0.01). No significant differences were found for the ventilatory equivalent slope (VE/VCO2) or ventilatory anaerobic threshold (VAT). In the 6 studies which reported QoL, exercise rehabilitation was beneficial in 4, with no difference observed in 2 studies. Conclusion: Exercise rehabilitation is associated with improved outcomes in VAD recipients, and therefore should be more systematically delivered in this population.
Open Access
Health Care Use and Associated Time and Out of Pocket Expenditures for Patients With Cardiovascular Disease in a Publicly Funded Health Care System
(Elsevier, 2017-10-06) Ali, Saba; Moghei, Mahshid; Krahn, Murray; Chessex, Caroline; Grace, Sherry
Background The objectives of this study were to describe (1) health care use and associated patient time and out of pocket (OOP) costs over 2 years after a cardiac diagnosis, (2) the sociodemographic and clinical drivers of these costs, and (3) patient costs related to cardiac rehabilitation (CR) participation. Methods Secondary analysis was conducted in an observational prospective CR program evaluation cohort in Ontario, which has a publicly funded health care system. A convenience sample of patients from 1 of 3 CR programs was approached at the first visit, and consenting participants completed a survey. Participants were e-mailed surveys again 6 months and 1 and 2 years later; these later surveys assessed their cardiac care and medications and the time and OOP costs associated with care visits. Patient time was valued based on average wages in Ontario. Results Of 411 consenting patients, 240 (58.3%) completed CR, and 192 (46.7%) were retained at 2 years. Patients most often visited a general practitioner and had electrocardiography and treatment for angina. The total cost to patients over 2 years was CAD$73.70 ± $275.84 for time and $377.01 ± $321.72 for OOP costs ($525.93 ± $467.08 overall). With adjustment, there were significantly higher OOP costs for women (P < 0.001) and less educated (P < 0.001) patients. Participants spent considerable money that was relatively OOP on CR visits alone ($384.78 ± $269.67), with time costs at $379.07 ± $1035.49 ($939.43 ± $1333.29 overall; 1.6% share of 1 year's income). Conclusions In conclusion, time and OOP costs are modest for patients with cardiac conditions, except for CR. Alternative delivery models are needed, in particular for low-income patients.
Open Access
Cardiac Rehabilitation Availability and Delivery in Canada: How does it Compare to other High-Income Countries?
(Elsevier, 2018-09-28) Tran, Michelle; Pesah, Ella; Turk-Adawi, Karam; Supervia, Marta; Lopez-Jimenez, Francisco; Oh, P.; Baer, Carolyn; Grace, Sherry
Background Canada has insufficient cardiac rehabilitation (CR) capacity, yet unmet need is unknown. Moreover, Canada has CR guidelines, but whether delivery conforms has not been characterized by province/territory. This study aimed to establish (1) CR volumes, capacity, and density, as well as (2) the nature of programs, and (3) compare these (a) by province/territory and (b) with other high-income countries (HICs). Methods In this cross-sectional study, an online survey was administered to CR programs globally. National cardiac associations were engaged to facilitate program identification where available, or local champions. Density was computed using Canada’s Chronic Disease Surveillance System ischemic heart disease incidence estimates. Twenty-eight HICs with CR were selected for comparison (N = 619 programs), and multilevel analyses performed. Results CR was available in 10 of 13 (76.9%) provinces (no programs in Canada’s North), with 74 of 182 programs initiating a survey (40.7% response). Program volumes (median = 250) were greatest in Ontario, but ultimately there was only 1 CR spot per 4.55 patients with ischemic heart disease nationally (similar in other HICs), and 186,187 more spots are needed annually. Most programs were funded by government/hospital sources (n = 48, 66.7%), but in 23 (31.5%), patients paid some or all of program costs out-of-pocket. Guideline-indicated conditions were accepted in more than 90% of programs. Programs had a multidisciplinary team of 6.2 ± 2.1 staff, offering 7.7 ± 1.5/10 core components (varied by province, P = 0.001; return-to-work offered less frequently than other HICs; P = 0.03), over 42.0 ± 26.0 hours (provincial and other HIC differences, P < 0.001). Conclusions Canadian CR capacity must be augmented, but where available, services are consistent with other HICs.
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, Francisco
Background: 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.
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, Brian
Purpose: 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.
Open Access
Perceptions of cardiology administrators about cardiac rehabilitation in South America and the Caribbean
(Lippincott, Williams & Wilkins, 2017-07) Lima de Melo Ghisi, Gabriela; Britto, Raquel; Servio, Thaianne Cavalcante; ANCHIQUE SANTOS, CLAUDIA VICTORIA; Fernandez, Rosalia; Rivas Estany, Eduardo; Santibañez, Claudio; GONZALEZ, GRACIELA; Burdiat, Gerard; Lopez-Jimenez, Francisco; HADDAD HERDY, ARTUR; Grace, Sherry
Background: Cardiac rehabilitation (CR) programs can address the cardiovascular disease epidemic in South America. However, there are factors limiting CR access at the patient, provider, and system levels. The latter 2 have not been extensively studied. The objective of this study was to investigate cardiology administrator's awareness and knowledge of CR and perceptions regarding resources for CR. Methods: This study was cross-sectional and observational in design. Cardiology administrators from South American and Caribbean countries were invited to participate by members of a professional association. Participants completed a questionnaire online. Descriptive analysis was performed and differences in CR knowledge, awareness, perception, and attitudes regarding CR were described overall, by institution funding source (private vs public) and presence of within-institution CR (yes vs no). Results: Most of the 55 respondents from 8 countries perceived CR as important for outpatient care (mean ± SD = 4.83 ± 0.38 out of 5; higher scores indicating more positive perceptions), with benefits including reduced hospital readmissions (4.31 ± 0.48) and length of stay (4.64 ± 0.71 days), not only for cardiac patients but for those with other vascular conditions (4.34 ± 0.68 days). Those working in public institutions (50.9%) and in institutions without a CR program (25.0%) were not as aware of, and less likely to value, CR services (P < .05). Only 13.2% of programs had dedicated funding. Conclusions: Similar to findings from high-income settings, cardiology administrators and cardiologists in South America value CR as part of cardiac patient care, but funding and availability of programs restrict capacity to deliver these services.
Open Access
Interventions Supporting Long-term Adherence and Decreasingcardiovascularevents(ISLAND): Pragmatic randomized trial protocol
(Elsevier, 2017-06-03) Ivers, Noah; Witteman, Holly; Presseau, Justin; Taljaard, Monica; McCready, Tara; Bosiak, Beth; Cunningham, Jennifer; Smarz, Shelley; Desveaux, Laura; Tu, Jack V.; Atzema, Clare; Oakes, Garth; Isaranuwatchai, Wanrudee; Grace, Sherry; Bhatia, R Sacha; Natarajan, Madhu Kailash; Grimshaw, Jeremy
Background Guidelines recommend cardiac rehabilitation (CR) and long-term use of cardiac medications for most patients who have had a myocardial infarction (MI), but adherence to these secondary prevention treatments is sub-optimal. Methods/Design This is a multi-center, pragmatic, three-arm randomized trial. Eligible patients are randomized postMI to usual care or one of two intervention arms. Patients in the first intervention arm receive mailouts sent on behalf of their cardiologist at 4, 8, 20, 32, and 44 weeks post-MI; content is designed to address determinants of adherence, and facilitate discussion between the patient and their health care team. Patients in the second intervention arm receive mail-outs plus automated interactive voice response system (IVRS) phone calls 2 weeks after each letter, as well as a telephone call by trained lay health workers if the IVRS identifies challenges with adherence. Outcomes are assessed 12 months post-MI via patient self-report and administrative data sources. Co-primary outcomes are adherence to cardiac medications and completion of CR. Secondary outcomes include cardiovascular events and mortality. An embedded, theory-informed process evaluation will explore the mechanism of action; an economic evaluation is also planned. Discussion We describe a complete program evaluation of a highly pragmatic, health-system intervention to support adherence to recommended treatments. Research ethics boards approved waiver of consent for patients enrolled in the trial with provision of multiple opportunities to opt-out and a debrief at the time of outcome assessment. The methods used here may provide a model for similar interventions.
Open Access
Cardiac Rehabilitation Following Acute Coronary Syndrome in Women
(Springer, 2017-06-17) Bennett, Amanda L.; Lavie, Carl; Grace, Sherry
Opinion statement Acute coronary syndrome (ACS) is among the leading burdens of disease among women. It is a significant driver of morbidity and chronically undermines their quality of life. Cardiac rehabilitation (CR) is indicated for ACS patients in clinical practice guidelines, including those specifically for women. CR is a multi-component model of care, proven to reduce mortality and morbidity, including in women. However, women are significantly less likely to be referred to CR by providers, and if they are referred, to enroll and adhere to programs. Reasons include lack of physician encouragement, preference not to feel fatigue and pain, transportation barriers, comorbidities and caregiving obligations. Strategies to mitigate this under-use include systematic early inpatient referral, tailoring programs to meet women’sneedsand preferences (e.g., offering dance, opportunities for social interaction), and offering nonsupervised delivery models. Unfortunately, these strategies are not widely available to women. Given the greater longevity seen in women, the critical role CR plays in augmenting quality of life in this population must be recognized and care providers must do more to facilitate referral to and encourage participating in CR programs.
Open Access
A Review of Cardiac Rehabilitation Delivery Around the World
(Elsevier, 2017-10-13) Pesah, Ella; Supervia, Marta; Turk-Adawi, Karam; Grace, Sherry
Herein, 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.
Open Access
Patient-Reported Outcomes in Cardiac Rehabilitation : What Do We Know About Program Satisfaction? A Review
(Lippincott, Williams & Wilkins, 2016) Taherzadeh, Golnoush; Filippo, Deandra E.; Kelly, Shannon; van Engen-Verheul, Mariette; Peek, Niels; Oh, P.; Grace, Sherry
PURPOSE: Patient satisfaction has become an important indicator of quality and may be related to greater adherence to cardiac rehabilitation (CR). The objectives of this narrative review were to investigate (1) patient satisfaction with CR and its relationship to adherence or health outcomes, and (2) assessment tools applicable to CR. METHODS: A literature search was conducted on key resource databases, including MEDLINE, Health and Psychosocial Instruments, and Patient-Reported Outcomes and Quality of Life Instruments. A focused Internet and gray literature search was also conducted. RESULTS OF DATA SYNTHESIS: Eight studies were included. Patient satisfaction was high overall, especially related to education received. In 4 studies, patient satisfaction with treatment was compared in patients who attended CR with those who did not. In 2 of these studies where items were investigator generated, significant differences favoring CR were found. In the 2 studies where the treatment satisfaction subscale of the Seattle Angina Questionnaire was administered, no differences were observed. Only 1 study was identified, which examined the relationship of patient satisfaction with any outcome, and revealed that greater satisfaction was related to greater program adherence. There was a dearth of valid assessment tools. CONCLUSIONS: Despite recommendations in CR association guidelines to consider patient satisfaction, there is an absence of research assessing it. The studies that have assessed it administered tools of questionable psychometric rigor. It remains to be determined whether patient satisfaction is related to any meaningful outcomes.
Open Access
Objectively-measured sedentary time and its association with markers of cardiometabolic health and fitness among cardiac rehabilitation graduates
(Oxford University Press, 2020-08-29) Prince, Stephanie; Blanchard, Chris M; Grace, Sherry; Reid, Robert D.
Background Sedentary time is an independent risk factor for cardiometabolic disease and mortality. It is unknown how much time individuals with coronary artery disease spend being sedentary or how their sedentary time relates to markers of health. The objectives of this study were to: (a) quantify sedentary time in a post-cardiac rehabilitation (CR) population, and (b) assess association with cardiometabolic risk, independent of moderate-to-vigorous physical activity. Design Cross-sectional. Methods As part of a larger trial, 263 recent CR graduates (∼10 days post-CR, mean age 63.6 ± 9.3 years, 75% male) wore an ActiGraph GT3X accelerometer during waking hours (≥4 days, ≥10 hours/day) to quantify sedentary time (≤150 counts per minute). Spearman correlations were computed to assess relationships between sedentary time (adjusted for wear time) with markers of cardiometabolic health and fitness. Significant markers were examined using multiple linear regressions. Results Participants spent an average of 8 hours/day sedentary (∼14 bouts/day). Sedentary time was negatively correlated with high-density lipoprotein and O2peak and positively correlated with triglycerides, body mass index and waist circumference. After adjusting for age, sex, medications and moderate-to-vigorous physical activity, hours/day of sedentary time remained significantly associated with logO2peak (β = −0.02, p = 0.001) and body mass index (β = 0.49, p = 0.02). Conclusions Findings suggest that even among a group of post-CR individuals who are already probably more active than patients who have not undergone CR, sedentary time remains high and is associated with poorer cardiorespiratory fitness, suggesting a possible new area of focus among CR programs.
Open Access
Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial
(Elsevier, 2016-02-01) Grace, Sherry; Midence, Liz; Oh, Paul; Brister, Stephanie; Chessex, Caroline; Stewart, Donna Eileen; Arthur, Heather M.
Objective To compare program adherence and functional capacity between women referred to supervised mixed-sex, supervised women-only, or home-based cardiac rehabilitation (CR). Patients and Methods Cardiac Rehabilitation for Heart Event Recovery (CR4HER) was a single-blind, 3 parallel-arm, pragmatic randomized controlled trial. The study took place between November 1, 2009, and July 31, 2013. Low-risk patients with coronary artery disease were recruited from 6 hospitals in Ontario, Canada. Consenting participants completed a preprogram survey, and clinical data were extracted from charts. Participants were referred to CR at 1 of 3 sites. After intake assessment, including a graded exercise stress test, eligible patients were randomized to supervised mixed-sex, supervised women-only, or home-based CR. Six months later, CR adherence and exit assessment data were ascertained. Results Of the 264 consenting patients, 169 (64.0%) were eligible and randomized. Twenty-seven (16.0%) did not attend, and 43 (25.4%) attended a different model. Program adherence was moderate overall (54.46%±35.14%). Analysis of variance revealed no significant differences based on per-protocol analysis (P=.63), but as-treated, home-based participants attended significantly more than did women-only participants (P<.05). Overall, there was a significant increase in functional capacity preprogram to postprogram (P<.001). Although there were no significant differences in functional capacity by model at CR exit based on per-protocol analysis, there was a significant difference on an as-treated basis, which sustained adjustment. Women attending mixed-sex CR attained significantly higher post-CR functional capacity than did women attending home-based programs (P<.05). Conclusion Offering women alternative program models may not promote greater CR adherence or functional capacity; however, replication is warranted. Other proven strategies such as action planning and self-monitoring should be applied. Trial Registration clinicaltrials.gov Identifier: NCT01019135.
Open Access
Cardiac rehabilitation delivery model for low-resource settings
(BMJ Publishing Group Ltd, 2016-05-15) Grace, Sherry; Turk-Adawi, Karam; Contractor, Aashish; Atrey, Alison; Campbell, Norm; Derman, Wayne; Lima de Melo Ghisi, Gabriela; Oldridge, Neil; Sarkhar, Bidyut K.; Yeo, Tee Joo; Lopez Jimenez, Francisco; mendis, shanthi; Oh, Paul; hu, dayi; Sarrafzadegan, Nizal
Objective: Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries. Methods: A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (i.e., physical activity, diet, tobacco, and mental health), (2) medical risk factor management (e.g., lipid control, blood pressure control), (3) education for self-management; and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not. Results: Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in lowresource settings were summarized in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by nonphysician healthcare workers, in non-clinical settings. Conclusions: Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.
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.