School of Kinesiology and Health Science

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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.
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.
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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.