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Item Open Access Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients(Biomed Central, 2019-09-02) Sérvio, Thaianne Cavalcante; Britto, Raquel; Lima de Melo Ghisi, Gabriela; da Silva, Lilian Pinto; Duarte Novais Silva, Luciana; Lima, Márcia Maria Oliveira; Pereira, Danielle Aparecida Gomes; Grace, Sherry L.Background: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a lowresource setting. Methods: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed. Keywords: Health care services, Cardiac rehabilitation, Cardiac care facilities, Attitude of health personnelItem Open Access Barriers to cardiac rehabilitation use in Canada versus Brazil.(journals.lww.com/jcrjournal/pages/default.aspx, 2013-05) Lima de Melo Ghisi, Gabriela; Oh, Paul; Benetti, Magnus; Grace, Sherry L.PURPOSE: Despite its well-established benefits, cardiac rehabilitation (CR) is greatly underutilized globally. Barriers to its utilization have been identified in high-income countries. Given the growing epidemic of noncommunicable disease in low-to-middle income countries, the identification of barriers to use of these low-cost interventions is warranted. The aim of this study was to describe and compare barriers to cardiac rehabilitation (CR) use in Brazilian and Canadian cardiac outpatients. METHODS: Two cardiac samples consisting of 237 Brazilian (recruited from 2 CR centers in Southern Brazil) and 1434 Canadian (recruited from 11 community and academic hospitals in Ontario) outpatients were compared cross-sectionally. Barriers were assessed using the Cardiac Rehabilitation Barriers Scale (CRBS), psychometrically-validated in English and Portuguese. Mann-Whitney U tests were used to compare barriers between samples. RESULTS: Overall, 139 (58.6%) Brazilian and 779 (54.3%) Canadian respondents were enrolled in CR. The mean total barriers score for Brazilian respondents was 1.71±.63 and 2.37±1.0 (P<.001) for the Canadians. For 17/21 barriers, Canadians reported significantly greater barriers than Brazilians (P<.02). As their greatest barriers, Canadians rated already exercising at home/community and persona travel, while Brazilians identified distance to and cost of the CR program. CONCLUSION: Despite the significantly lower availability of CR in Brazil and the universal healthcare system in Canada, cardiac outpatients in Canada perceived significantly greater CR barriers. Arguably however, these barriers were more modifiable.Item Open Access Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the health action process approach(Elsevier, 2015-05) Lima de Melo Ghisi, Gabriela; Grace, Sherry; Thomas, Scott; Oh, PaulObjectives: To (1) test the effect of a Health Action Process Approach (HAPA) theory-based education program in cardiac rehabilitation (CR) compared to traditional education on patient knowledge and HAPA constructs; and, (2) investigate the theoretical correlates of exercise behavior among CR patients receiving theory-based education. Methods: CR patients were exposed to an existing or HAPA-based 6 month education curriculum in this quasi-experimental study. Participants completed a survey assessing exercise behavior, HAPA constructs, and knowledge pre and post-program. Results: 306 patients consented to participate, of which 146 (47.7%) were exposed to the theory-based educational curriculum. There was a significant improvement in patients’ overall knowledge pre- to post-CR, as well as in some HAPA constructs and exercise behavior, regardless of curriculum (p<0.05). Path analysis revealed that knowledge was significantly related to intention formation, and intentions to engage in exercise were not directly related to behavior, which required action planning. Conclusions: The theoretically-informed education curriculum was not associated with greater knowledge or exercise behavior as expected. Education in CR improves knowledge, and theoretical constructs related to exercise behavior. Practice implications: Educational curricula should be designed to not only increase patients’ knowledge, but also enhance intentions, self-efficacy, and action planning.Item 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, SherryPurpose: 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.Item Open Access Comprehensive Cardiac Rehabilitation Effectiveness in a Middle-Income Setting : A Randomized Controlled Trial(Wolters Kluwer, 2020-11) Grace, Sherry; Britto, Rachel R.; Oh, Paul; Ribeiro, Antonio L.; Chaves, Gabriela; Lima de Melo Ghisi, GabrielaPurpose: The impact of comprehensive cardiac rehabilitation (CCR) in Latin America is not well known. Herein, the pre-specified tertiary outcomes of a cardiac rehabilitation (CR) trial are reported: disease-related knowledge, depressive symptoms, and heart-health behaviors (exercise, diet, and smoking). Methods: This was a single-blinded, single-center (Brazil) randomized trial with three parallel arms: CCR (exercise + education) versus exercise-only CR versus wait-list control. Eligible patients were randomized in blocks of four with 1:1:1 concealed allocation. The CR program was 6 mo long. Participants randomized to exercise-only CR received 36 exercise classes; the CCR group also received 24 educational sessions, including a workbook. All outcomes were assessed at pre-test and 6-mo later (blinded). Analysis of covariance was performed by intention-to-treat (ITT) and per-protocol (PP). Results: A total of 115 (89%) patients were randomized; 93 (81%) were retained. There were significant improvements in knowledge with CCR (ITT [51.2 ± 11.9 pre and 60.8 ± 13.2 post] and PP; P < .01), with significantly greater knowledge with CCR versus control (ITT mean difference [MD] = 9.5, 95% CI, 2.3-16.8) and CCR vs exercise-only CR at post-test (ITT MD = 6.8, 95% CI, 0.3-14.0). There were also significant improvements in self-reported exercise with CCR (ITT [13.7 ± 15.8 pre and 32.1 ± 2 5.7 post] and PP; P < .001), with significantly greater exercise with CCR versus control at post-test (ITT MD = 7.6, 95% CI, 3.8-11.4). Also, there were significant improvements in diet with CCR (PP: 3.4 ± 7.5 pre and 8.0 ± 7.0 post; P < .05). Conclusions: In this first-ever randomized trial of CR for coronary artery disease in Latin America, the benefits of CCR have been supported.Item 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.Item Open Access Development and Psychometric Validation of a Scale to Assess Information Needs in Cardiac Rehabilitation: The INCR Tool(Patient Education and Counseling, 2013-06) Lima de Melo Ghisi, Gabriela; Grace, Sherry L.; Thomas, Scott; Evans, Michael F; Oh, PaulObjective: to develop and psychometrically-validate a tool to assess information needs in cardiac rehabilitation (CR) patients. Methods: After a literature search, 60 information items were identified. To establish content validity, they were reviewed by an expert panel (N=10). Refined items were pilot-tested in 34 patients on a 5-point Likert-scale from 1 “really not helpful” to 5 “very important”. A final version was generated and psychometrically-tested in 203 CR patients. The internal consistency was assessed using Cronbach's alpha, test-retest reliability via the intraclass correlation coefficient (ICC), the dimensional structure through AN EXPLORATORY factor analysis, and criterion validity was assessed with regard to patient’s education and duration in CR. Results: Cronbach's alpha was 0.96 and ICC was 0.85. Criterion validity was supported by significant differences in mean scores by educational level (p<0.05) and duration in CR (p<0.001). Factor analysis revealed six factors: exercise/stress/risk; heart/work/social; medication; safety; nutrition; and barriers/goals.. The mean total score was 4.08±0.53. Patients rated safety as their greatest information need. Conclusion: The INCR Tool was demonstrated to have good reliability and validity. Practice Implications: This is an appropriate tool for application in clinical and research settings, assessing patients’ needs during CR and as part of education programming.Item Open Access Development and Psychometric Validation of the Second Version of the Coronary Artery Disease Education Questionnaire (CADE-Q II)(Elsevier, 2015-03) Lima de Melo Ghisi, Gabriela; Grace, Sherry; Thomas, Scott; Evans, Michael F; Oh, PaulObjectives: To develop and psychometrically-validate a revised version of the Coronary Artery Disease Education Questionnaire (CADE-Q)- a tool to assess patients’ knowledge about CAD in cardiac rehabilitation (CR). Methods: After a needs assessment, a literature review and focus group with CR experts, the revised questionnaire was developed. It underwent pilot-testing in 30 patients, which lead to further refinement. The questionnaire was then psychometrically-tested in 307 CR patients. Internal consistency was assessed using Cronbach's alpha, the dimensional structure through exploratory factor analysis, and criterion validity with regard to educational level. Results: Cronbach's alpha was 0.91. Criterion validity was supported by significant differences in mean scores by educational level (p<.001). Factor analysis revealed four factors, which were internally-consistent (0.65-0.77), and well-defined by items. The mean total score was 64.2±18.1/93. Patients with a history of heart failure, cardiomyopathy and percutaneous coronary intervention (p<0.05) had significantly higher knowledge scores compared with patients without such a history. Knowledge about exercise and their medical condition was significantly higher than risk factors, nutrition and psychosocial risk. Conclusions: The CADE-QII has good reliability and validity. Practical Implications: This tool may be useful to assess CR participants’ knowledge gaps, and to evaluate the efficacy of educational delivery in CR.Item Open Access Disease-related knowledge in cardiac rehabilitation enrollees: Correlates and changes(Elsevier, 2015-04) Grace, Sherry; Motamedi, Nickan; Britto, Raquel; Lima de Melo Ghisi, GabrielaObjectives: to describe (1)patients’ disease-related knowledge at cardiac rehabilitation(CR)entry; (2)correlates of this knowledge; (3)whether CR completion is related to knowledge; and (4)behavioral correlates of knowledge. Methods: For this prospective, observational study, a convenience sample of new CR patients were approached at 3 programs to complete a survey. It consisted of sociodemographic items, heart-health behavior surveys, and the CADE-Q. Patients were provided a similar survey 6 months later.Results:214patients completed the CADE-Q at both points, with scores demonstrating “acceptable” to “good” knowledge. Higher knowledge at CR entry was significantly associated with greater education, being married, greater English-language proficiency, and history of percutaneous coronary intervention(p=<.05). The 118(55.1%) patients that completed CR demonstrated significantly higher knowledge than non-enrollees at post-test(p≤.05).There was a significant positive association between knowledge and physical activity(p≤.01) and nutrition(p≤.05) at post-test, but no association with smoking or medication adherence. Conclusions: CR adherence ensures patients sustain knowledge needed to optimize their disease management, and perhaps ultimately their health outcomes. Practice implications: CR completion should be promoted so patients remain educated about their disease management, and the health behaviours observed will be practiced in a greater proportion of patients.Item Open Access The Effects of Cardiac Rehabilitation on Mortality and Morbidity in Women: a Meta-Analysis Attempt(National Center for Biotechnology Information, 2019-01) Lima de Melo Ghisi, Gabriela; Chaves, Gabriela Suéllen da Silva; bennett, amanda; Lavie, Carl; Grace, SherryCardiac rehabilitation (CR) reduces mortality and morbidity. However, there have been few women in CR trials, and no meta-analyses. Thirty-one potential trials were identified in recent systematic reviews. All authors were contacted for data by sex as this was rarely reported. Data were only available for 2 trials.Item Open Access Effects of comprehensive cardiac rehabilitation on functional capacity in a middle-income country: a randomised controlled trial(BMJ Publishing Group, 2018-10-03) Chaves, Gabriela Suellen da Silva; Lima de Melo Ghisi, Gabriela; Grace, Sherry L.; Oh, Paul; Ribeiro, Antonio L; Britto, Raquel;Objective: Despite the growing epidemic of cardiovascular diseases in middle-income countries, there is insufficient evidence about cardiac rehabilitation (CR) in these countries. Thus, the effects of comprehensive CR on functional capacity and risk factors were investigated in Brazil, to test the hypothesis that it results in better outcomes than exercise-only or no CR. Methods: Single-blinded, randomised controlled trial with three parallel arms: comprehensive CR (exercise+education) versus exercise-only CR versus wait-list control. Eligible coronary patients were randomised in blocks of four with 1:1:1 concealed allocation. Participants randomised to exercise-only CR received 36 exercise classes; comprehensive CR group also received 24 educational sessions. The primary outcome was incremental shuttle walk test (ISWT) distance; secondary outcomes were cardiovascular risk factors. All outcomes were assessed at baseline and 6 months later. Analysis of covariance was performed on the basis of intention-to-treat (ITT) and per-protocol. Results: 115 (88.5%) patients were randomised; 93 (80.9%) were retained. There were improvements in ISWT distance from pretest to post-test with comprehensive (from 358.4±132.6 to 464.8±121.6 m; mean change=106.4; p<0.001) and exercise-only (from 391.5±118.8 to 488.1±106.3 m; mean change=96.5, p<0.001) CR, with significantly greater functional capacity with comprehensive CR versus control (ITT: mean difference=75.6±30.7 m, 95% CI 1.4 to 150.2). There were also reductions in systolic blood pressure with comprehensive CR (ITT: reduction of 6.2±17.8 mm Hg, p=0.04). There were no significant differences for other outcomes. Conclusion: Results showed clinically significant improvements in functional capacity and blood pressure with CR, and significantly greater functional capacity with comprehensive CR compared with usual care.Item Embargo Establishing a process to translate and adapt health education materials for natives and immigrants: The case of Mandarin adaptations of cardiac rehabilitation education(Heart & Lung, 2021-11) Liu, Xia; Lima de Melo Ghisi, Gabriela; Meng, Shu; Grace, Sherry; Wendan, Shi; Zhang, Ling; Gallagher, Robyn; Oh, Paul; Aultman, Crystal; Sandison, Nicole; Ding, Biao; Zhang, YaqingBackground: Cardiac rehabilitation (CR) is a proven model of secondary prevention in which patient education is a core component. Objectives: to translate and culturally-adapt CR patient education for Mandarin-speaking patients living in China as well as immigrants, and offer recommendation for best practices in adaptation for both. Methods: these steps were undertaken in China and Canada: (1) preparation; (2) translation and adaptation; (3) review by healthcare providers based on PEMAT-P; (4) think-aloud review by patients; and (5) finalization. Results: Two independent Mandarin translations were undertaken using best practices: one domestic (China) and one international (immigrants). Input by 23 experts instigated revisions. Experts rated the language and content as culturally-appropriate, and perceived the materials would benefit their patients. A revised version was then administered to 36 patients, based on which a few edits were made to optimize understandability. Conclusions: some important differences emerged between translations adapted for native versus immigrant settings.Item Open Access Healthcare Providers’ Awareness of the Information Needs of their Cardiac Rehabilitation Patients throughout the Program Continuum(Elsevier, 2014-04) Lima de Melo Ghisi, Gabriela; Grace, Sherry; Thomas, Scott; Evans, Michael; Sawula, Heather; Oh, PaulObjectives: to: (1) describe cardiac rehabilitation (CR) participant information needs, (2) investigate whether CR providers are cognizant of patient’s information needs and preferred delivery formats, and (3) whether patient information needs change over the course of CR. Methods: In this cross-sectional study, 306 CR patients and 28 CR providers completed a survey. The survey consisted of the Information Needs in CR (INCR) questionnaire, and items about preferred education delivery formats. Results: Low-income CR participants had significantly greater information needs than high-income participants. CR providers were cognizant of patient information needs, except patients did desire more information on diagnosis and treatment than providers perceived (p<.01). Books, lectures and discussion were identified as the preferred delivery formats by both patients and providers. There were some significant differences in patient information needs over the course of the program, particularly in relation to concerns and risk factors. Conclusion: CR patients desire information in many areas, particularly regarding emergency/safety and diagnosis/treatment. CR providers were highly cognizant of patient information needs; however, these do change over time. Practice Implications: These findings could inform evaluation and improvement of CR education programming, to ensure programs are meeting patient information needs across all stages of recovery.Item Open Access Knowledge and exercise behavior maintenance in cardiac rehabilitation patients receiving educational interventions(American Association of Heart Failure Nurses, 2015-11) Lima de Melo Ghisi, Gabriela; Grace, Sherry; Thomas, Scott; Marques Vieira, Ariany; Ziesemer Costa, Isabel; Oh, PaulObjectives: To test whether a theoretically-based education curriculum results in more sustained knowledge, higher scores on Health Action Process Approach (HAPA)constructs, and greater exercise behavior 6 months post-cardiac rehabilitation ( CR) when compared to traditional CR education. Background: Patient education is a core component of CR. No research has examined whether this education results in sustained improvements post-program. Methods: In this quasi-experimental study, participants exposed to the traditional vs HAPA-based education completed surveys pre, post-CR, and 6 months post-discharge assessing knowledge, HAPA constructs, and exercise. Results: Ninety-three participants completed the final survey. Knowledge increases post-CR were sustained 6 months post-program, with no differences by curriculum. Many improvements in HAPA constructs observed post-CR were sustained, except for some decay in self-efficacy. Minutes of exercise per week were significantly greater in participants exposed to the HAPA-based curriculum 6 months post-program. Conclusions: HAPA-based education in CR has sustained effects on exercise.Item Open Access A Longitudinal Examination of the Social-Ecological Correlates of Exercise in Men and Women Following Cardiac Rehabilitation(MDPI, 2019-02) Grace, Sherry L.; Oh, Paul; Blanchard, Chris M; Prince, Stephanie; Chessex, Caroline; Pipe, Andrew; Lima de Melo Ghisi, Gabriela; Wooding, Evyanne; Reid, Robert D.; Moghei, MahshidItem Open Access A Longitudinal Examination of the Social-Ecological Correlates of Exercise in Men and Women Following Cardiac Rehabilitation(MDPI, 2019-02-16) Moghei, Mahshid; Reid, Robert D.; Wooding, Evyanne; Lima de Melo Ghisi, Gabriela; Pipe, Andrew; Chessex, Caroline; Prince, Stephanie; Blanchard, Chris M; Oh, Paul; Grace, Sherry L.Cardiac patients who engage in ≥150 min of moderate- to vigorous-intensity physical activity (MVPA)/week have lower mortality, yet MVPA declines even following cardiac rehabilitation (CR), and is lower in women. A randomized trial of nine socioecological theory-based exercise facilitation contacts over 50 weeks versus usual care (1:1 parallel arms) was undertaken (NCT01658683). The tertiary objective, as presented in this paper, was to test whether the intervention impacted socioecological elements, and in turn their association with MVPA. The 449 participants wore an accelerometer and completed questionnaires post-CR, and 26, 52 and 78 weeks later. At 52 weeks, exercise task self-efficacy was significantly greater in the intervention arm (p = 0.01), but no other differences were observed except more encouragement from other cardiac patients at 26 weeks (favoring controls). Among women adherent to the intervention, the group in whom the intervention was proven effective, physical activity (PA) intentions at 26 weeks were significantly greater in the intervention arm (p = 0.04), with no other differences. There were some differences in socioecological elements associated with MVPA by arm. There were also some differences by sex, with MVPA more often associated with exercise benefits/barriers in men, versus with working and the physical environment in women.Item Open Access Maintenance of Gains, Morbidity, and Mortality at 1 Year Following Cardiac Rehabilitation in a Middle‐Income Country: A Wait‐List Control Crossover Trial(American Heart Association, 2019-02-15) Chaves, Gabriela; Lima de Melo Ghisi, Gabriela; Britto, Raquel; Grace, Sherry L.Background-—Despite the epidemic of cardiovascular diseases in middle-income countries, few trials are testing the benefits of cardiac rehabilitation (CR). This trial assessed (1) maintenance of functional capacity, risk factor control, knowledge, and hearthealth behaviors and (2) mortality and morbidity at 6 months following CR in a middle-income country. Methods and Results-—Eligible Brazilian coronary patients were initially randomized (1:1:1 concealed) to 1 of 3 parallel arms (comprehensive CR [exercise plus education], exercise-only CR, or wait-list control). The CR programs were 6 months in duration, at which point follow-up assessments were performed. Mortality and morbidity were ascertained from chart and patient or family report (blinded). Controls were then offered CR (crossover). Outcomes were again assessed 6 months later (blinded). ANCOVA was performed for each outcome at 12 months. Overall, 115 (88.5%) patients were randomized, and 62 (53.9%) were retained at 1 year. At 6 months, 23 (58.9%) of those 39 initially randomized to the wait-list control elected to attend CR. Functional capacity, risk factors, knowledge, and heart-health behaviors were maintained from 6 to 12 months in participants from both CR arms (all P>0.05). At 1 year, knowledge was significantly greater with comprehensive CR at either time point (P<0.001). There were 2 deaths. Hospitalizations (P=0.03), nonfatal myocardial infarctions (P=0.04), and percutaneous coronary interventions (P=0.03) were significantly fewer with CR than control at 6 months. Conclusions-—CR participation is associated with lower morbidity, long-term maintenance of functional capacity, risk factors, and heart-health behaviors, as well as with greater cardiovascular knowledge compared with no CR. Clinical Trial Registration-—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02575976. (J Am Heart Assoc. 2019;8: e011228. DOI: 10.1161/JAHA.118.011228.) Key Words: cardiac rehabilitation • coronary disease • morbidity/mortality • rehabilitation • risk factorItem Restricted 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, SherryBackground: 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.Item Open Access A systematic review of patient education in cardiac patients: Do they increase knowledge and promote health behavior change?(Elsevier, 2014-05) Lima de Melo Ghisi, Gabriela; Abdallah, Flavia; Grace, Sherry; Thomas, Scott; Oh, PaulObjective: (1) to investigate the impact of education on patients’ knowledge; (2) to determine if educational interventions are related to health behavior change in cardiac patients; and (3) to describe the nature of educational interventions. Methods: A literature search of several electronic databases was conducted for published articles from database inception to August 2012. Eligible articles included cardiac patients, and described delivery of educational interventions by a healthcare provider. Outcomes were knowledge, smoking, physical activity, dietary habits, response to symptoms, medication adherence, and psychosocial well-being. Articles were reviewed by 2 authors independently. Results: Overall, 42 articles were included, of which 23(55%) were randomized controlled trials, and 16(38%) were considered “good” quality. Eleven studies (26%) assessed knowledge, and 10 showed a significant increase with education. With regard to outcomes, educational interventions were significantly and positively related to physical activity, dietary habits, and smoking cessation. The nature of interventions were poorly described and most frequently delivered post-discharge, by a nurse, and in groups. Conclusions: Findings support the benefits of educational interventions in CHD, though increase in patients’ knowledge and behavior change. Practice Implications: Future reporting of education interventions should be more explicitly characterized, in order to be reproducible and assessed.Item Open Access Validation of a Portuguese version of the Information Needs in Cardiac Rehabilitation (INCR) scale in Brazil(2014-06-11) Lima de Melo Ghisi, Gabriela; zulianello dos santos, rafaella; Bonin, Christiani Batista Decker; Grace, Sherry L.; Oh, Paul; Benetti, MagnusObjectives: to translate, culturally adapt and psychometrically validate the Information Needs in Cardiac Rehabilitation (INCR) tool to Portuguese. Background: The identification of information needs is considered the first step to improve knowledge that ultimately could improve health outcomes. Methods: The Portuguese version generated was tested in 300 cardiac rehabilitation patients (CR) (34% women; mean age=61.3±2.1 years old). Test-retest reliability was assessed using intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and the criterion validity was assessed with regard to patients’ education and duration in CR. Results: All 9 subscales were considered internally consistent (á > 0.7). Significant differences between mean total needs and educational level (p<0.05) and duration in CR (p=0.03) supported criterion validity. The overall mean (4.6±0.4), as well as the means of the 9 subscales were high (emergency/safety was the greatest need). Conclusion: The Portuguese INCR was demonstrated to have sufficient reliability, consistency and validity.