Heart failure (HF) is a complex, debilitating disease that affects approximately 6.5 million Americans (Ades et al., 2013). HF is a large reason for hospital readmissions, and subsequently, a major contributor to rising health care costs. Unfortunately, there is no cure for HF, but various interventions such as cardiac rehabilitation (CR) have been employed to help patients manage the symptoms. However, the lack of patients ever being referred to cardiac rehabilitation is disturbing. Healthcare providers play an essential role in providing education about heart failure and CR, and thus should be knowledgeable about these principles themselves. Therefore, the aim of this project is to evaluate data from a survey sent to nurse practitioners (NPs) regarding whether HF patients are being referred to CR appropriately, and if barriers are limiting use of CR programs. This was a descriptive, nonexperimental study with a survey design seeking to understand if NP providers are following evidence-based guidelines when treating HF patients and if providers consider CR programs to be an appropriate treatment tool. A survey questionnaire was distributed to NPs who are members of Coalition of Arizona Nurses in Advanced Practice (CAZNAP). Data from 27 surveys were used for analysis. Results showed that nurse practitioner respondents felt they had a good understanding of heart failure education and diagnosis. A majority also considered CR to be a useful tool for HF patients, and all agreed that health care providers affect CR enrollment and participation rates. A mere nine respondents (33%) reported being introduced to the outcomes and benefits of CR in their graduate education. Findings also confirmed previous work suggesting that providers are not adequately referring HF patients to CR, as 33% of NPs reported they have never referred a patient to CR. With respect to these findings, it is important to identify methods to assist providers with proper education about CR and its referral methods. As supported by the literature review, improved referral rates to CR can lead to better management and health outcomes for HF patients. Therefore, further research is needed to identify interventions that promote increased CR referral rates.

Recent research indicates the need for a functional balance assessment in cardiac rehabilitation (CR) programs. One assessment technique that may be appropriate is the Community Balance and Mobility Scale (CBMS). The purpose of this study was to investigate psychometric properties of the CBMS when testing patients with cardiovascular disease (CVD). Thirty-one participants from community CR programs were recruited to perform the CBMS and measures of computerized dynamic posturography. Convergent validities between the measures were investigated using correlation coefficients, and floor and ceiling effects of the CBMS were analysed. The results indicated that the CBMS was moderately correlated with all computerized posturography variables, with no floor or ceiling effects present. Analysis of posturography results indicated that CR patients have decreased movement characteristics in the anterior and posterior directions. These findings indicate that the CBMS is a suitable tool to assess and monitor balance in a CR population.

The purpose of this thesis was to better understand physical activity (PA) maintenance among patients who have completed cardiac rehabilitation (CR). Study 1: This study was a systematic review and meta-analysis of 19 randomized controlled trials (RCTs) testing PA and exercise maintenance interventions for adults who have completed CR. Descriptive synthesis of the studies combined with meta-analysis results provided evidence of increased PA among intervention groups compared with control groups at follow-up. Results of the meta-analysis found a significant difference in PA in the intervention groups compared to the control groups, via multiple exercise outcomes including exercise sessions/week (SMD = 0.20; 95% CI, 0.04 - 0.35), kcal/week (SMD = 0.59; 95% CI, 0.19 - 0.98), and daily steps (SMD = 2.14; 95% CI, 0.90 - 3.38). There is evidence to support the effectiveness of interventions aimed at maintaining PA and exercise among adults who have completed CR. Study 2: This study was a synthesis of qualitative studies examining factors affecting PA maintenance among individuals who have completed CR. Eight studies met the criteria for inclusion. Multiple factors were identified among participants, including self-efficacy and motivation, social support, support with the transition from supervised hospital or centre-based exercise to exercise in the community or home, perceived safety of the exercise program, and availability and accessibility of PA resources and opportunities. Examining qualitative literature suggests factors at the intrapersonal-, interpersonal-, organizational- and neighbourhood-level are important in supporting exercise maintenance after completion of CR. Results from this synthesis identified key areas for tailored program design, grounded in a social ecological approach. Study 3: This study was a secondary analysis of trial data examining predictors of participants’ moderate to vigorous physical activity (MVPA) 26 weeks after enrollment in a RCT of a PA maintenance intervention. Participants completed baseline questionnaires assessing social ecological, demographic, clinical, fitness, and behavioural variables. MVPA was assessed by accelerometer at baseline and 26 weeks later. Univariate analyses revealed nine significant baseline predictors of MVPA at 26 weeks including beliefs about exercise benefits, beliefs about exercise barriers, baseline MVPA, peak oxygen consumption, diabetes, age, sex, marital status, and work status. Multivariate analysis indicated that baseline MVPA was the only independent predictor of MVPA at 26 weeks. Given the pre-eminence of baseline MVPA, the regression analyses were re-run without baseline MVPA in the model. In that case, peak oxygen consumption became the only independent predictor of MVPA at 26 weeks. Results have implications for targeting intervention for PA maintenance in the unsupervised phase. Conclusion: The findings of this thesis provided insights into the influences on long-term PA among cardiac patients post-CR and the strategies which can support long-term PA. While there have been positive developments in understanding PA maintenance, there are important knowledge gaps that remain unaddressed. These knowledge gaps include the measurement, monitoring, and surveillance of PA behaviour and ways in which intervention research could be improved. Further research will be required to address these knowledge gaps and to build on the growing knowledge of effective PA interventions to support people with heart disease.

Heart failure prevalence is projected to rise in the United States over the ensuing decades. Typical health education should be focused on primary prevention strategies; however, for those stricken with the disease, health educators should determine appropriate secondary prevention strategies for individuals to live a healthy life. One such strategy, recently approved for coverage by the Centers for Medicare and Medicaid, is cardiac rehabilitation. The impetus for the policy change was the heart failure ACTION trial. The trial unfortunately did not include patients that lived too far from cardiac rehabilitation centers, thus putting rural heart failure patients at a disadvantage. The purpose of the current study was to delineate how rural heart failure patients were referred to cardiac rehabilitation from an inpatient setting, to determine what factors were associated with initiation of cardiac rehabilitation, and to gain insight into rural heart failure patients’ motivation to partake in exercise. A purposive sample of rural heart failure patients were used for the study. Patients were selected from a rural hospital based upon their ejection fraction, per Medicare requirements. Participants completed a demographic survey as well as surveys regarding motivation to partake in exercise; six weeks later, the researcher determined if the rural heart failure participants initiated outpatient cardiac rehabilitation. Cardiac rehabilitation diagnosis, increased distance to cardiac rehabilitation, transportation and assistance, higher income, Caucasian race, and higher levels of educational attainment were independently associated with cardiac rehabilitation initiation. Further, higher levels of perceived autonomous motivation, autonomy support, and competence were associated with cardiac rehabilitation initiation. Conversely, low levels of perceived amotivation scores were associated with cardiac rehabilitation initiation. Not all heart failure patients in the current study were managed by a cardiologist while hospitalized. Lastly, the impetus of attaining the cardiac rehabilitation order for a primary diagnosis of heart failure came from the inpatient exercise physiologists.

Since its inception, cardiac rehabilitation has been effective at reducing risk factors for cardiovascular disease, improving quality of life, and decreasing morbidity and mortality rates. While women benefit as much as men from the therapeutic effects of cardiac rehabilitation, a disparity exists between referral, participation, and completion rates between men and women. The intent of this thesis was to examine recent literature to determine if those disparities still exist, to identify barriers that prevent women from participating, and to determine the role of the nurse in the promotion of cardiac rehabilitation among women. Current literature reveals that women are often older, single, financially unstable, less physically active, and diagnosed with more co-morbidities at the time of their first cardiac event. Women often lack strong physician referral and support, education about cardiac rehabilitation programs, and motivation to attend programs. Evidence gathered from current literature suggests that gender is not the primary reason for the disparity between cardiac rehabilitation participation rates among men and women, but rather the disparity exist~ because of the characteristics of these older women at the time of their first cardiac event. The nurse is the vital component to increasing cardiac rehabilitation participation rates among women. The nurse must serve as a patient advocate- providing information and structure to the referral process, as an educator- teaching women the benefits and safety of cardiac rehabilitation, and as social support- providing women with encouragement and follow-up during a frightening and life-changing experience.

<p> Exercise programs designed for cardiac patients frequently report high dropout rates. Little is known about the reasons for this high rate of dropout; further, little is known about health behavior patterns including physical activity subsequent to graduation or dropout from exercise programs. Identification of reasons for dropout and the pattern of physical activity after participation in formal exercise rehabilitation would provide information regarding achievement and maintenance of treatment goals.</p> <p> Entry characteristics were determined for 84 male cardiac patients (45 compliers and 39 dropouts) from the McMaster Cardiac Rehabilitation Exercise Program. Follow-up information pertaining to areas of: a) health; b) employment, smoking, activity, and dietary status; c) reasons for joining the program; d) perceived benefits achieved; and e) factors contributing to compliance with or dropout from the exercise program was obtained from 63 subjects (41 compliers and 22 dropouts) who responded to a questionnaire by mail.</p> <p> The dropout rate at the end of the 6 month program was 46.4% (39 of 84 subjects) with one-half of all dropout occurring within the first 2 months of the 6 month program. Upon entry into the exercise program, a significantly greater proportion of dropouts (43.6%, n=17) than compliers (8.9%, n=4) were found to be regular smokers. Likewise, a significantly greater proportion of dropouts (82.1%, n=32) than compliers (55.6%, n=25) were found to be inactive in their leisure habits upon entry. Dropouts were also more likely to be blue collar workers (71.8%, n=28), and younger in age (x̅ age = 48.4 years) when compared to compliers (37.8%, n=17; x̅ age = 54.3 years) upon entry into the exercise program. Upon follow-up, compliers were significantly more likely to report active leisure habits (85.4%, n=35) than were responding dropouts (45.5%, n=10). Compliers were also significantly more likely to report moderate work activity levels upon follow-up (54.8%, n=17) compared to dropouts (22.2%, n=4). Reasons for compliance to and withdrawal from the exercise program provided by respondents centred around psychosocial and personal convenience categories.</p> <p> Although statistically significant, the greater follow-up activity levels noted among compliers in this study appear to be only temporary, short-term patterns which tend to diminish with time. It is suggested that compliance-improving strategies be developed through further study with the aim of encouraging the long-term maintenance of desired behavior change.</p> / Thesis / Master of Science (MSc)

No description available.

Economic justification for rehabilitative services has resulted in the need for outcome based research which could quantify success or failure in individual patients and formulate baseline variables which could predict outcomes. The purpose of this study is to investigate the utilization of baseline clinical, exercise test, and psychosocial variables to predict clinically relevant changes in exercise tolerance of cardiac patients who participated in early outpatient cardiac rehabilitation. Clinical records were analyzed retrospectively to obtain clinical, psychosocial and exercise test data for 94 patients referred to an early outpatient cardiac rehabilitation program at a large urban hospital in the Southeast US. All patients participated in supervised exercise training 3d/wk for 2-3 months. A standardized training outcome score STO) was devised to evaluate training effect by tabulating changes in patients predicted VO2, body weight and exercising heart rates after 8-12 weeks of exercise based cardiac rehabilitation. STO = Predicted VO2 change + BW change- HR change. The Multi-Factorial Analysis was applied to derive coefficients in the STO formula so that the STO scores reflected the independent effects of BW, HR and Predicted V02 changes on training outcome. Patients were classified into one of three possible outcome categories based on STO scores, i.e. improvement, no change, or decline. Thresholds for classifying patients were the following; STO scores greater than or equal to 3 SEM above the mean = improved, (N= 40: 41%), STO scores less than or equal to 3 SEM below the mean = decline, (N=34: 35%), STO scores within 3 SEM= no change, (N=23: 24%). Multiple logistic regression was used to identify patient attributes predictive of improvement, decline, or no change from measures routinely collected at the point of admission to rehabilitation. The model for prediction of improvement correctly classified 70% of patients as those who improved vs. those who did not (sensitivity 70%, specificity 71%). This model generated the following variables as having predictive capabilities; recent CABG, emotional status, social status, calcium channel blocker, recent angioplasty, maximum diastolic BP, maximum systolic BP and resting systolic BP. The model for predicting those who declined vs. those who did not decline demonstrated higher correct classification rate of 74% and specificity (84%). This model generated the following variables as having predictive capabilities; social status, calcium channel blocker, orthopedic limitation, role function, QOL score and Digitalis. However, these models may include certain bias because the same observations to fit the model were also used to estimate the classification errors. Therefore, cross validation was performed utilizing the single point deletion method; this method yielded somewhat lower fraction correct classification rates (66%,69%) and sensitivity rates (56%,44%) for improvement vs. no improvement and decline vs. no decline groups respectively. Conclusion A combined set of baseline clinical, psychosocial and exercise measures can demonstrate moderate success in predicting training outcome based on STO scores in hospital outpatient cardiac rehabilitation. In contrast psychosocial data seem to account for more of the variance in prediction of decline than other types of baseline variables examined in this study. Baseline blood pressure responses both at rest and during exercise were the greatest predictors of improvement. However, cross validation of these models indicates that these results could be biased eliciting overly optimistic predictive capabilities, due to the analysis of fitted data. These models need to be validated in independent sample with patients in similar settings. / Master of Science

No description available.

Rationale Within Australia, cardiac rehabilitation attendance is poor, with typically thirty percent of eligible patients attending programs. The majority of cardiac patients are not receiving the support or detailed information required to increase physical activity participation after hospitalisation. Further, many cardiac patients are not exercising independently, regardless of their attendance at cardiac rehabilitation. As physical activity is important in the prevention and treatment of heart disease, there could be substantial benefits to the individual and cost savings for the health system if cardiac patients were more active. Physical activity interventions based on social cognitive theory have demonstrated success in improving physical activity among people with chronic diseases. However, there is little research conducted with cardiac patients, in particular, with those who do not attend cardiac rehabilitation. This research addresses this gap in public health practice by providing an intervention to cardiac patients, irrespective of their attendance at cardiac rehabilitation, thereby addressing a population that is often overlooked and hard to reach. Research aims ?? To determine the uptake rate of cardiac rehabilitation in the north Illawarra and Shoalhaven areas of New South Wales and identify the characteristics of cardiac rehabilitation attendees and non attendees. ?? To evaluate the efficacy of a pedometer based physical activity intervention in cardiac patients referred to cardiac rehabilitation. Methodology This thesis consisted of three related studies: a cross sectional analysis of the characteristics of cardiac rehabilitation referrals (n = 944) over a 10 month period; and two randomised controlled trials conducted simultaneously. The Cardiac Rehabilitation Trial participants (n = 110) were patients who had attended cardiac rehabilitation; Community Trial participants (n = 215) were those who did not attend cardiac rehabilitation. The six week intervention evaluated in the trials included self monitoring of daily physical activity using a pedometer and step calendar, and two behavioural counselling and goal setting sessions delivered via telephone. Additional support for intervention group participants was provided through two brief telephone calls made after the six week intervention period. Self reported physical activity levels were collected at baseline, six weeks and six months. The questionnaire also collected information about psychosocial factors affecting physical activity participation. The exercise capacity of the participants in the Cardiac Rehabilitation Trial was objectively measured at baseline, six weeks and six months using a gas exchange analysis system. Results The cardiac rehabilitation uptake rate was 28.8 per cent of referred patients. Cardiac rehabilitation attendees were significantly younger and more likely to have had a coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI) procedure than non attendees. Study groups in both trials were not significantly different at baseline. In the Cardiac Rehabilitation Trial, improvements in total weekly physical activity sessions (p=0.002), walking time (p=0.013) and walking sessions (p<0.001) in the intervention group were significantly greater than the change in the control group at the end of the six week intervention. At six months, improvements in the intervention group remained significantly greater than the control group in total physical activity time (p=0.044), total physical activity sessions (p=0.016) and walking sessions (p=0.035) after adjusting for baseline differences. These self reported behavioural changes were corroborated by improvements in cardiorespiratory fitness at six months in the intervention group (p=0.010). Improvements in the intervention group in behavioural (p=0.039) and cognitive (p=0.024) self management strategy use were significantly greater than the controls at six weeks after adjusting for baseline differences. The improvement in cognitive strategy use (p=0.001) remained significantly greater in the intervention group compared to controls at six months after adjusting for baseline differences. Self efficacy, outcome expectancies and psychological distress were not significantly different between groups at six weeks or six months after adjusting for baseline differences. In the Community Trial, improvements in total weekly physical activity time (p=0.027), total physical activity sessions (p=0.003), walking time (p=0.013) and walking sessions (p=0.002) in the intervention group were significantly greater than the control group at six weeks after adjusting for baseline differences. At six months, improvements in total physical activity time (p=0.015), total physical activity sessions (p=0.019), walking time (p=0.002) and walking sessions (p=0.026) in the intervention group remained significantly greater than the control group after adjusting for baseline differences. Improvements in outcome expectancies (p=0.038) and cognitive self management strategy use (p=0.028) in the intervention group were significantly greater than the change in the control group at six weeks, after adjusting for baseline differences. However, these differences did not remain significant at six months. Conclusion This research showed that participation in a six week pedometer based intervention significantly increased the physical activity level and psychosocial status of people with heart disease. These findings suggest the pedometer based intervention could be offered as an effective and accessible option for those who do not attend cardiac rehabilitation to increase their physical activity levels. This intervention could also be promoted as an important adjunct to existing cardiac rehabilitation programs to promote adherence to physical activity after cardiac rehabilitation attendance. These studies provide community based evidence of an effective physical activity intervention for those eligible for cardiac rehabilitation, including those who do not attend. This provides a public health approach to cardiac rehabilitation programs and has the potential to improve health outcomes in this population.