School of Kinesiology and Health Science

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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.
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Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline
(Canadian Journal of Cardiology, 2022-12) Lima de Melo Ghisi, Gabriela; Marzolini, Susan; Price, Jennifer; Beckie, Theresa; Mamataz, Taslima; Naheed, Aliya; Grace, Sherry
Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and may result in better quality-of-life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary healthcare providers, a policy-maker, and patient partners. The guideline was developed in accordance with AGREE II and RIGHT. Initial recommendations were based on a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR’s audit; N=76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A webcall was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (GRADE). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing) and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but one recommendation, ≥75% voted to include; implementability ratings were <5/7 for 4 recommendations, but only one for impact. Ultimately one recommendation was excluded, one separated into two and all revised (two substantively); one recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.
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Outcomes and Cost of Women-Focused Cardiac Rehabilitation: A Systematic Review and Meta-analysis
(Maturitas, 2022-06) Mamataz, Taslima; Lima de Melo Ghisi, Gabriela; Pakosh, Maureen; Grace, Sherry
Background: The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost. Methods: Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception-May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. “Women-focused” CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women’s preferences. No studies were excluded based on outcome. Two independent reviewers rated citations for potential inclusion, and 1 extracted data, including quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; Certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied. Results: 3498 unique citations were identified, of which 28 (52 papers) studies were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with usual care comparisons. When compared to active comparison, women-focused CR had no meaningful effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence), and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as 7/8 SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported favorable economic impact and another reduced sick days. Conclusions: Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed.
Open Access
Building Capacity through ICCPR’s Cardiovascular Rehabilitation Foundations Certification (CRFC): Evaluation of Reach, Barriers and Impact
(Journal of Cardiopulmonary Rehabilitation and Prevention, 2022-05) Babu, Abraham Samuel; Heald, Fiorella A.; Contractor, Aashish; Lima de Melo Ghisi, Gabriela; Buckley, John; Mola, Anna; Atrey, Alison; Lopez-Jimenez, Francisco; Grace, Sherry
Purpose: The International Council of Cardiac Rehabilitation and Prevention (ICCPR) developed an online Cardiac Rehabilitation Foundations Certification (CRFC; https://globalcardiacrehab.com/Certification) in October 2017, to build CR delivery capacity in low-resource settings based on their guidelines. Herein we evaluate its’ reach globally, barriers to its completion, as well as satisfaction and impact of the course among those completing it. Methods: The country of origin of all applicants was tallied. An online survey was developed for learners who completed the CRFC (completers), and for those who applied but did not yet complete the program (non-completers), administered using Google Forms. Results: With regard to reach, 236 applications were received from 23/203 (11.3%) countries; 51 (25%) were from low or middle-income countries. 130 (55.1%) have completed the CRFC; mean scores on the final exam were 88.3 ± 7.1%, with no difference by country income classification (P=.052). Sixteen (21.9%) non-completers and 37 (34.3%) completers responded to the survey. Barriers reported by non-completers were time constraints, cost, and technical issues. Overall satisfaction with the CRFC was high (4.49 ± 0.51/5); most completers would highly recommend the CRFC to others (4.30 ± 0.66), and perceived that the information provided will contribute to their work and/or the care of their patients (4.38 ± 0.89); 29 (78.4%) had used the information from the CRFC in their practice. Conclusions: The reach of the CRFC still needs to be broadened, in particular in low-resource settings. Learners are highly satisfied with the certification, and its impacts on CR practice are encouraging. Input has been implemented to improve the CRFC.
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Evaluation of an Online Course in Five Languages for Inpatient Cardiac Care Providers on Promoting Cardiac Rehabilitation: Reach, Effects and Satisfaction
(Journal of Cardiopulmonary Rehabilitation and Prevention, 2022-03) Heald, Fiorella A.; Santiago de Araújo Pio, Carolina; Liu, Xia; Rivera Theurel, Fernando; Pavy, Bruno; Grace, Sherry
Purpose: Evidence proves health care providers should promote cardiac rehabilitation (CR) to patients face-to-face to increase CR enrollment. An online course was designed to promote this at the bedside; it is evaluated herein in terms of reach, effect on knowledge, attitudes, discussion self-efficacy and practices, and satisfaction. Methods: Design was observational, one-group pretest-posttest. Some demographics were requested from learners taking all language versions of the 20-minute course: English, Portuguese, French, Spanish, and simplified Chinese, available at https://globalcardiacrehab.com/CR-Utilization. Investigator-generated items in the pre- and post-test and evaluation survey administered using Google Forms were based on Kirkpatrick’s training evaluation model. Results: The course was initiated by 522 learners from 33/203 (16.3%) countries; most commonly female (n=341, 65.3%) nurses (n=180, 34.5%) from high-income countries (n=259, 56.7%), completing the English (n=296, 56.7%) and Chinese (n=108, 20.7%) versions. 414 (79.3%) completed the post-test and 302 (57.9%) completed the evaluation. Median CR attitudes were 5/5 on the Likert scale at pre-test, suggesting some selection bias. Mean CR knowledge (7.22±2.14/10), discussion self-efficacy (3.86±0.85/5), and practice (4.13±1.11/5) significantly improved after completion of the course (all P<.001). Satisfaction was high regardless of language version (4.44±0.64/5; P=.593). Conclusions: This free, open-access course is effective in increasing CR knowledge, self-efficacy, and encouragement practices among participating inpatient cardiac providers, with high satisfaction. While testing impact on actual CR use is needed, it should be more broadly disseminated to increase reach, in an effort to increase patient enrollment in CR, to reduce morbidity and mortality.
Open Access
Cardiac Rehabilitation Effectiveness for Coronary Artery Disease by Clinical Era: Trial Sequential Analysis
(European Journal of Preventive Cardiology, 2020-12-01) Oliveros, María-José; Serón, Pamela; Buitrago-García, Diana; Grace, Sherry
Cardiac rehabilitation (CR) is an outpatient model of care for the secondary prevention of cardiovascular disease, which is widely and strongly recommended in international clinical guidelines. The latest update of the Cochrane systematic review on CR for patients with coronary artery disease1 found that CR is effective in preventing cardiovascular death and hospital admissions, but not all-cause mortality, reinfarctions and other complications, as reported in the previous update. This could be due to the inclusion of more recent trials. Thanks to advances in medicine, patients now have access to acute revascularization treatments such as thrombolysis and angioplasty, and therefore achieve better outcomes, such that some have hypothesized that CR may have less impact in the current clinical era2. Although the Cochrane review included a meta-regression which showed no impact of the publication year on the effectiveness,1 some others meta-analyses in the field that have included only recent trials,2,3 have contradicted this finding. In this context, we conducted a secondary analysis of these trials with the aim of examining whether there is sufficient data to determine effectiveness of CR on all-cause and cardiovascular mortality as well as hospitalization, and to test effectiveness over time, using trial sequential analysis (TSA) for the first time. With sequential analysis, it is possible to determine the need for more trials or whether the results are conclusive.4 Such analysis allows the effect to be observed as the participants in the primary studies accumulate even if the optimal sample size has not been reached, adjusting the threshold of statistical significance as the sample size is accumulated. 5
Open Access
Effects of Cardiac Rehabilitation in Low- and Middle-Income Countries: A systematic Review and Meta-Analysis of Randomised Controlled Trials
(Progress in Cardiovascular Diseases, 2022-01) Mamataz, Taslima; Uddin, Jamal; Alam, Sayed Ibn; Taylor, Rod S.; Pakosh, Maureen; Grace, Sherry
Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed,Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched frominception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g.,mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane’s tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I2 = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I2 = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I2 = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95% CI = -1.61 to −0.07; moderate-quality evidence; I2 = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I2 = 93%, low-quality evidence; mental: MD = 5.38, 95% CI=1.13 to 9.63; I2=84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Lowtomoderate-certainty evidence establishesCRas delivered in LMICs improves functional capacity, risk factor control and QoL.Whilemore high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).
Open Access
Profile of women choosing mixed-sex women-only, and home-based cardiac rehabilitation models and impact on utilization
(The Journal of Women and Health, 2022-01-04) Heald, Fiorella A.; Marzolini, Susan; Colella, Tracey JF; Oh, Paul; Nijhawan, Rajni; Grace, Sherry
This study compared characteristics and program utilization in women electing to participate in mixed-sex, women-only, or home-based cardiac rehabilitation (CR). In this retrospective cohort study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017-February 2020 were analyzed. There were 727 women (74.7% mixed, 22.0% women-only, 3.3% home-based) who initiated CR. There were significantly more women who were not working in women-only than mixed-sex (80.4% vs 64.1%; P=.009). Session adherence was significantly greater with mixed-sex (58.8±28.9% sessions attended/25) than women-only (54.3±26.3% sessions attended/25; P=.046); program completion was significantly lower with home-based (33.3%) than either supervised model (59.7%; P=.035). Participation in women-only CR may be less accessible. Further research is needed to investigate offering remote women-focused sessions or peer support.
Open Access
How do healthcare workers judge pain in older palliative care patients with delirium near the end of life?
(2015) Gagliese, Lucia; Rodin, Rebecca; Chan, Vincent; Stevens, Bonnie; Zimmermann, Camilla
Context: Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging and there is currently no validated assessment tool for this task. Objectives: This retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain. Methods: We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (n = 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome. Results: We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behaviour. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting. Conclusion: These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.
Open Access
Healthcare workers’ judgments about pain in older palliative care patients with and without delirium
(American Journal of Hospice & Palliative Medicine, 2017) Mah, Kenneth; Rodin, Rebecca A.; Chan, Vincent W. S.; Stevens, Bonnie; Zimmermann, Camilla; Gagliese, Lucia
Delirium can interfere with the assessment and management of pain in older advanced cancer patients. This retrospective cohort study investigated whether healthcare workers’ (HCWs) pain judgments differ between older patients with advanced cancer who have been diagnosed with delirium and those who have not. We reviewed HCWs’ daily chart notations about pain in patients with advanced cancer, ≥ 65 years of age, who were admitted to a palliative care inpatient unit within a one-year period (N = 149). Proportions of days during hospitalization that HCWs judged patients to have pain and good pain control were calculated. Patients with and without a delirium diagnosis and across different delirium subtypes and trajectories were compared on both pain outcomes. The moderating effect of highest analgesic class administered was examined. Although most patients received opioid analgesics, mean proportions of days with judged pain were high (39%–60%), and mean proportions of days with judged good pain control were low (< 25%) across groups. HCWs judged that patients with delirium had significantly fewer days of good pain control than patients without delirium. The group difference in judged pain control was evident in patients who received either opioid or non-opioid medication. Cancer pain management is a mandate of palliative care, and our findings highlight the urgent need for better pain assessment in older patients with advanced cancer who have delirium, including a psychometrically sound protocol to assess pain accurately in this clinical group.
Open Access
Pain, aging and dementia: Towards a biopsychosocial model
(Progress in Neuropsychopharmacology & Biological Psychiatry, 2018) Gagliese, Lucia; Gauthier, Lynn; Narain, Nadine; Freedman, Tamlyn
Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.
Open Access
Healthcare professionals’ reports of the cues used to identify cancer pain in older people with delirium: a qualitative-quantitative content analysis
(Journal of Pain and Symptom Management, 2020) Graham, Carol A.; Chaves, Gabriela; Harrison, Rebecca; Gauthier, Lynn; Nissim, Rinat; Zimmermann, Camilla; Chan, Vincent; Rodin, Gary; Stevens, Bonnie; Gagliese, Lucia
Context: Healthcare professionals (HCP) currently judge pain presence and intensity in patients with delirium despite the lack of a valid, standardized assessment protocol. However, little is known about how they make these judgements. This information is essential to develop a valid and reliable assessment tool. Objectives: to identify pain cues that HCP report utilizing to judge pain in patients with delirium and to examine whether the pain cues differ based on patient cognitive status and delirium subtype. Methods: Mixed qualitative-quantitative design. Doctors and nurses were recruited. All participants provided written informed consent and prior to the recorded interview, demographic information was collected. Participants were asked to describe their practices and beliefs regarding pain assessment and management with older patients who are cognitively intact or who have delirium. Interviews were transcribed verbatim by Wordwrap and coded for pain cues. Coded data were imported into SPSS to conduct bivariate analyses. Results: The pain cue self-report and agitation were stated more often by the HCP s for intact and delirium patients, respectively. Considering the subtypes of delirium, the HCP s stated yelling χ2 (2, N = 159) = 11.14, p=0.004, when describing pain in hyperactive than in hypoactive and mixed delirium patients; and significantly more HCP s stated grimace χ2 (2, N = 159) = 6.88, p=0.03, when describing pain in hypoactive than hyperactive and mixed patients. Conclusion: This study outlines how HCP report conducting pain assessment in patients with delirium and, also, specify pain behaviour profiles for the subtypes of delirium.
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Oculomotor system can differentially process red and green colors during saccade programming in the presence of a competing distractor
(Experimental Brain Research, 2022-09-13) Ramezanpour, Hamidreza; Blizzard, Shawn; Kehoe, Devin; Fallah, Mazyar
Selective attention filters irrelevant information entering our brain to allow for fine-tuning of the relevant information processing. In the visual domain, shifts of attention are most often followed by a saccadic eye movement to objects and places of high relevance. Recent studies have shown that the stimulus color can affect saccade target selection and saccade trajectories. While those saccade modulations are based on perceptual color space, the level in the visual processing hierarchy at which color selection biases saccade programming remains unclear. As color has also been shown to influence manual response inhibition which is a key function of the prefrontal cortex, we hypothesized that the effects of color on executive functions would also inherently affect saccade programming. To test this hypothesis, we measured behavioral performance and saccade metrics during a modified saccadic Stroop task which reflects competition between color words (“RED” and “GREEN”) and their color at the level of the prefrontal cortex. Our results revealed that the oculomotor system can differentially process red and green colors when planning a saccade in the presence of a competing distractor.
Open Access
Traditional vs extended hybrid cardiac rehabilitation based on the continuous care model for patients who have undergone coronary artery bypass surgery in a middle-income country: A randomized controlled trial
(Archives of Physical Medicine and Rehabilitation, 2021-11) Pakrad, Fatemeh; ahmadi, fazlollah; Grace, Sherry; oshvandi, khodayar; Kazemnejad, Anoshirvan
Objective: To compare traditional (1-month supervised) vs hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (intervention) in patients who have undergone coronary artery bypass graft (CABG). Design: Randomized controlled trial, with blinded outcome assessment. Setting: A major heart center in a middle-income country. Participants: Of 107 eligible patients who were referred to CR during the period of study, 82.2% (N=88) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). There was 92.0% retention. Interventions: After CR, participants were given a mobile application and communicated biweekly with the nurse from months 1-4 to control risk factors. Main outcome measures: Quality of life (QOL, Short Form-36, primary outcome); functional capacity (treadmill test); and the Depression, Anxiety and Stress Scale were evaluated pre-CR, after 1 month, and 3 months after CR (end of intervention), as well as rehospitalization. Results: The analysis of variance interaction effects for the physical and mental component summary scores of QOL were <.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (P<.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (P<.001), with a clinically significant 1.5 metabolic equivalent of task increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) rehospitalizations in the control arm and none in intervention (P=.049). Intended theoretical mechanisms were also affected by the intervention. Conclusions: Extending CR in this accessible manner, rendering it more comprehensive, was effective in improving outcomes.
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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, Yaqing
Background: 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.
Open Access
Cardiac rehabilitation availability and characteristics in Latin America and the Caribbean: A global comparison
(American Heart Journal, 2021-10) Chacin-Suarez, Audry; Grace, Sherry; Anchique-Santos, Claudia; Supervia, Marta; Turk-Adawi, Karam; Britto, Raquel ; Scantlebury, Dawn; Araya-Ramirez, Felipe; GONZALEZ, GRACIELA; Benaim, Briseida; Fernandez, Rosalia; Hol, Jacqueline; Burdiat, Gerard; SALMON, RICHARD; Lomeli, Hermes; Mamataz, Taslima; Medina-Inojosa, Jose; Lopez Jimenez, Francisco
Background: This study aimed to establish availability and characteristics of cardiac rehabilitation (CR) in Latin America and the Caribbean (LAC), where cardiovascular disease is highly prevalent. Methods: In this cross-sectional sub-analysis focusing on the 35 LAC countries, local cardiovascular societies identified CR programs globally. An online survey was administered to identified programs, assessing capacity and characteristics. CR need was computed relative to ischemic heart disease (IHD) incidence from the Global Burden of Disease study. Results: ≥1 CR program was identified in 24 LAC countries (68.5% availability; median = 3 programs/country). Data were collected in 20/24 countries (83.3%); 139/255 programs responded (54.5%), and compared to responses from 1082 programs in 111 countries. LAC density was 1 CR spot per 24 IHD patients/year (vs 18 globally). Greatest need was observed in Brazil, Dominican Republic and Mexico (all with >150,000 spots needed/year). In 62.8% (vs 37.2% globally P < .001) of CR programs, patients pay out-of-pocket for some or all of CR. CR teams were comprised of a mean of 5.0 ± 2.3 staff (vs 6.0 ± 2.8 globally; P < .001); Social workers, dietitians, kinesiologists, and nurses were significantly less common on CR teams than globally. Median number of core components offered was 8 (vs 9 globally; P < .001). Median dose of CR was 36 sessions (vs 24 globally; P < .001). Only 27 (20.9%) programs offered alternative CR models (vs 31.1% globally; P < .01). Conclusion: In LAC countries, there is very limited CR capacity in relation to need. CR dose is high, but comprehensiveness low, which could be rectified with a more multidisciplinary team.
Open Access
Cardiac Rehabilitation: Under-utilized globally
(Current Cardiology Reports, 2021-07-16) Grace, Sherry; Kotseva, Kornelia; Whooley, Mary
Purpose of review: Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. Recent findings: ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.
Open Access
Cardiac Rehabilitation Component Attendance and Impact of Intervening Clinical Events, as Well as Disease Severity and Risk Factor Burden
(Journal of Cardiopulmonary Rehabilitation and Prevention, 2021-01) Grace, Sherry; Prior, Peter; Mamataz, Taslima; Hartley, Tim; Oh, Paul; suskin, neville
Purpose: To examine: (1) the rate of clinical events precluding cardiac rehabilitation (CR) continuation, (2) CR attendance by component in those without events, and (3) the association between disease severity (eg, tobacco use, diabetes, and depression) and component attendance (eg, exercise, diet, stress management, and tobacco cessation). Methods: Retrospective analysis of electronic records of the CR program in London, Ontario, from 1999 to 2017. Patients in the supervised program are offered exercise sessions 2 times/wk with a minimum of 48 prescribed sessions tailored to patient need. Patients attending ≥1 session without major factors that would limit their exercise ability were included. Intervening events were recorded, as was component attendance. Results: Of 5508 enrolled, supervised patients, 3696 did not have a condition that could preclude exercise. Of those enrolled, one-sixth (n = 912) had an intervening event; these patients were less likely to work, more likely to have medical risk factors, had more severe angina and depression, and lower functional capacity. The remaining cohort attended a mean of 26.5 ± 21.3 sessions overall (median = 27; 19% attending ≥48 sessions), including 20.5 ± 17.4 exercise sessions (median = 21). After exercise, the most common components attended were individual dietary and psychological counseling. Patients with more severe angina and depressive symptoms as well as tobacco users attended significantly fewer total sessions, but more of some specific components. Conclusions: In one-sixth of patients, CR attendance and completion are impacted by clinical factors beyond their control. Many patients are taking advantage of components specific to their risk factors, buttressing the value of individually tailored, menu-based programming.
Open Access
The effects of maintenance cardiac rehabilitation: A systematic review and Meta-analysis, with a focus on sex
(Heart & Lung, 2021-07) Chowdhury, Mohiul; Heald, Fiorella Andani; Sanchez-Delgado, Juan C.; Pakosh, Maureen; Jacome Hortua, Adriana Marcela; Grace, Sherry
Phase III/IV cardiac rehabilitation (CR) is recommended to promote maintenance of benefits achieved during Phase II; there has been no meta-analysis to test this to date. This study determined the effects of maintenance CR on any outcome, with consideration of sex. Seven databases were searched from inception-January 2020. Randomized controlled trials on the effects of maintenance CR in cardiovascular disease patients who had graduated from CR were included. Level of evidence was evaluated with GRADEPro. 819 citations were identified, with 10 trials (21 papers) included (5238 participants; 859 [16.4%] female). Maintenance CR resulted in lower low-density lipoprotein (mean difference [MD]=-0.58; 95% confidence interval [CI]=- 1.06–-0.10, n=392) and greater quality of life (MD=0.28, 95% CI=0.05–0.52, n=118) when compared to usual care only. Outcomes for women and sex differences were mixed. In conclusion, maintenance programs appear to sustain patient’s quality of life, but more focus on women’s outcomes is needed.