14:00 PM-15:00 PM
Saturday, October 27, 2012
Concurrent Scientific
Oral Presentations
Oral #1
EFFECT OF CARDIAC REHABILITATION REFERRAL STRATEGIES ON UTILIZATION AMONG MEN AND WOMEN
Shannon Gravely,1 Sonia S. Anand,2 Donna E. Stewart,1,3 Sherry L. Grace,1,3,4 on behalf of the CRCARE Investigators
1University Health Network, Toronto, Ontario; 2McMaster University, Hamilton, Ontario; 3University of Toronto, Ontario; 4York University, Toronto, Ontario
BACKGROUND AND AIMS: Despite its proven benefits and need, women are significantly less likely to be referred and enrolled in cardiac rehabilitation (CR) compared to men. Referral strategies, such as systematic referral, have been advocated to improve access to CR. This study examined sex differences in CR referral and enrollment by referral strategies; and the impact of referral strategies for referral and enrollment concordance among women.
METHODS: In this prospective study, 2635 coronary artery disease inpatients from 11 Ontario hospitals that utilized 1 of 4 referral strategies completed a sociodemographic survey, and clinical data were extracted from charts. One year later, 1809 participants (452 [25%] women) completed a mailed survey that assessed CR utilization. Referral strategies were compared using generalized estimating equations to control for effect of hospital.
RESULTS: Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p < .001), and enrolled in CR (58.6% and 49.3% respectively, p = .001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (Odds Ratio [OR] = 10.3, 95% Confidence Interval [CI] = 4.11-25.58) and enrollment (OR = 6.6, 95% CI = 4.34-9.92) among women when compared to usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (Kappa = .85), and decreased with referral intensity.
CONCLUSION: While a lower proportion of referred patients enroll, systematic and liaison-facilitated inpatient referral strategies result in the greatest CR enrollment rates among women. Such strategies have the potential to eradicate sex bias in CR access, and reduce "cherry picking" of patients for referral.
Oral #2
CARDIAC REHABILITATION PROGRAM OUTCOMES: PRELIMINARY FINDINGS FROM A SYSTEMATIC "DILLMAN"-BASED FOLLOW-UP PILOT PROJECT
P O'Farrell, P Turton, H Tulloch
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
BACKGROUND & PURPOSE: The Division of Prevention and Rehabilitation at the University of Ottawa Heart Institute has been providing a multi-disciplinary Cardiac Rehabilitation (CR) program for approximately 20 years. Today, outpatients referred to CR have the choice of participating in the following program options: (1) a 2-3 month on-site supervised program, (2) a case-managed home program (CMHP), or (3) a brief program (no supervised exercise sessions). In April 2011, a program evaluation initiative was launched with the aim of obtaining long-term clinical and program outcomes and improving follow-up rates.
METHODS: A systematic process based on the Dillman protocol is being piloted among a random sample of 550 participants enrolled in CR. Data for this pilot project is collected by program staff and by self-reported questionnaires at program entry, and again at 3 months and 12 months post-program entry. Nine key outcomes have been selected for evaluation including CR exercise adherence rates, anthropometric measures, exercise history (modified Godin), smoking, and anxiety and depression (HADS).
RESULTS: The present analysis includes 123 CR participants who have completed their 3-month follow-up, representing a 66.5% response rate (123/185 participants). Participants were mostly male (73.2%) and mean age was 63.4 +/- 10.3 yrs (age range 39 to 85 yrs). The overall CR exercise adherence rate was 87.0%; by program option 85.4% for on-site, 91.4% for CMHP and 89.6% for brief. There were no significant changes in weight and BMI at 3 months post-program entry, however, waist circumference significantly increased at 3 months compare to program entry (96.0 +/- 11.8 cm vs. 91.8 +/- 11.7 cm; P < 0.001). With respect to reported total number of moderate-to-vigorous minutes of exercise per week, only 21.9% of participants were achieving 200 minutes or more per week at program entry compared to 44.2% at 3 months. At program entry, 8.9% of participants were self-reported daily smokers vs. 4.1% at 3-month follow-up, which is a 54.5% quit rate. Finally, anxiety and depression scores improved at 3 months compare to program entry (P < 0.001 and P = 0.056 respectively).
CONCLUSIONS: Implementation of the Dillman protocol led to a 20% increase in patient response rates at 3 months post-program entry. Exercise adherence was excellent for all program options. Participation in CR led to improvements in exercise, smoking cessation and mental health. The absence of positive changes for weight-related variables was unexpected, and will be explored further upon the full analysis of CR program outcomes at 12 months.
Oral #3
DISTINCT TRAJECTORIES OF STEPS PER DAY DURING AND AFTER CARDIAC REHABILITATION: RESULTS FROM THE SOCIAL ECOLOGICAL CORRELATES DURING AND AFTER CARDIAC REHABILITATION (SEARCH) TRIAL
CM Blanchard, N Giacomantonio, R Lyons, Dalhousie University, Halifax, Nova Scotia; C Cyr, R Stevenson, Saint John Regional Hospital, Saint John, New Brunswick; RE Rhodes, University of Victoria, Victoria, British Columbia; R Reid, Ottawa Heart Institute, Ottawa, Ontario; JC Spence, University of Alberta, Edmonton; Alberta, K McGannon, Luarentian University, Sudbury, Ontario
BACKGROUND: Little is known about the physical activity (PA) trajectories of cardiac rehabilitation (CR) patients utilizing an objective PA measure. The present study's purpose was to shed light on this issue in order to identify groups/classes of patients that had similar PA trajectories and then identify the key demographic/clinical predictors of these trajectories.
PROCEDURE: Patients were approached during their first PA session of the 3rd week of their CR. If interested, they were consented and completed a baseline survey. Patients completed the same survey during the 2nd last week of their program and were also fitted with a pedometer. They were asked to wear the pedometer for 7 days and recorded their daily steps in PA log. They returned the pedometer, PA log, and survey the following week. They completed the same survey and wore the pedometer at 3, 6, and 9 months after completing CR.
RESULTS: 355 patients agreed to participate, however, 114 patients dropped out of CR and became ineligible. The final sample was 241 patients who had a mean age of 60.99 (SD = 9.31), a BMI of 30.06 (SD = 8.42), averaged 12.61 years (SD = 3.41) of school, and were primarily male (66%), married (78.4%), white (98.3%), retired (46.5%), and had an income >== $40,000 (53.3%). Latent class growth analyses showed 3 classes / groups emerged. The Highly Active Maintainers (n = 60) averaged 10,831 (SD = 2650.25) steps per day at the end of CR, the Active Maintainers (n = 102) averaged 6995.71 (SD = 1513.78) steps per day, whereas the Inactive Maintainers (n = 62) averaged 2862.83 (SD = 149.62) steps per day. All 3 groups / classes' steps per day remained stable up to 9 months after CR. Follow-up analyses showed that Inactive Maintainers were the oldest F(2, 238) = 8.16, p < .05, had the highest BMI F(2,238) = 4.03, p < .05, # of comorbidities F(2,238) = 16.73, p < .05, and lowest income [chi]2 (2) 13.9, p < .05, whereas the Highly Active Maintainers had the most education F(2, 238) = 8.67, p < .05. Active Maintainers were most likely to be married [chi]2 (2) 10.65, p < .05 and had a recurring heart-related event [chi]2 (2) 11.42, p < .05.
CONCLUSION: PA trajectories for CR patients vary as a function of the demographic / clinical predictors of these trajectories.
Oral #4
IS SOCIAL DESIRABILITY ASSOCIATED WITH SELF-REPORTED PHYSICAL ACTIVITY IN CARDIAC PATIENTS?
Darren A Mercer,1,3,4 Sandra Pelaez,1,2,4 Blaine Ditto,3 Kim L Lavoie,1,4,5 Andre Arsenault,1,4 Simon L Bacon1,4,6
1Montreal Behavioural Medicine Centre, Montreal, Canada; 2Department of Educational and Counseling Psychology, McGill University, Montreal, Canada; 3Department of Psychology, McGill University, Montreal, Canada; 4Research Centre, Montreal Heart Institute-a University of Montreal affiliated hospital, Montreal, Canada; 5Department of Psychology, University of Quebec at Montreal, Montreal, Canada; 6Department of Exercise Science, Concordia University, Montreal, Canada
BACKGROUND AND AIMS: Social desirability (SD) bias represents a tendency for individuals to over-report perceived good behaviour and under-report perceived bad behaviour, when portraying themselves to others. It has been suggested that SD may be associated with self-reported leisure time physical activity (LTPA), representing a source of error, but literature is inconclusive. Health locus of control (HLOC), the extent to which individuals believe control of their health rests with themselves or other individuals, may moderate this relationship. High SD cardiac patients who believe they control their health (Internal HLOC) may self-report more LTPA, due to a personal responsibility felt for their health, and a belief that LTPA is a desirable activity. High SD cardiac patients who believe others (such as doctors) control their own health may over-report LTPA in order to more positively portray themselves to other individuals. This study aimed to assess the association of SD with LTPA in cardiac patients, and examine the potential moderating effect of HLOC.
METHODS AND MATERIALS: Outpatients undergoing exercise stress testing at the Montreal Heart Institute were recruited (n = 901). Patients completed the Marlowe-Crowne Social Desirability Scale, and a modified physical activity recall questionnaire assessing LTPA (converted to MET-hr/wk). At a two-year follow-up, patients completed the Multidimensional Health Locus of Control scale, form C, featuring internal, doctor, and other sub-scales.
RESULTS: SD was not associated with LTPA ([beta] = -.06,SE = .11, p = .581), after adjusting for stress test derived objective fitness levels, age, sex, and CVD. Internal HLOC sub-scale scores were associated with higher levels of self-reported LTPA ([beta] = .28,SE = .07, p < .001), however there was no significant interaction between SD and internal HLOC ([beta] < .01,SE = .02, p = .971). Doctor ([beta] = .31,SE = .20, p = .128), and Other ([beta] = .26,SE = .16, p = .106) sub-scale scores were not associated with self-reported LTPA, and there was no significant interaction between either of these sub-scales and SD ([beta] = -.05,SE = .04, p = .212; [beta] = -.02,SE = .04, p = .671 respectively).
CONCLUSIONS: SD was not associated with elevated LTPA, suggesting that individuals with high SD ratings may not over-report LTPA compared to individuals less concerned with SD. No association was found even when examining the potential moderating effects of individuals who take control of their health (Internal HLOC sub-scale), or individuals who place health control on others (Doctor & Other HLOC sub-scales). Increasing internal HLOC scores were found to be associated with more LTPA, suggesting that individuals who accept control of their health are more likely to engage in increased LTPA.
Oral #5
THE EFFECT OF CARDIAC REHABILITATION ON HEART RATE RECOVERY DIFFERS ACCORDING TO SEX
A Corcelli,1 BJ Martin,1-3 T Hauer,1 LD Austford,1 JA Stone,1-3 R Arena,1,4 B Marra,1 S Aggarwal1-3
1Cardiac Wellness Institute of Calgary, 2University of Calgary, 3Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada; 4University of New Mexico, Albuquerque, New Mexico
INTRODUCTION: Heart rate recovery (HRR) is now recognized as an important marker of health and prognosis. Less is known about the effects of exercise training on HRR in patients with coronary artery disease (CAD), particularly the potential for a sex-based influence. The purpose of the present study was to therefore examine the effect of cardiac rehabilitation (CR) on HRR in a large CAD cohort.
METHODS: Nineteen hundred and forty-two patients (age: 60.0 +/-10.6 years; 1563 male/379 female) with CAD were included in this study. All subjects underwent a baseline graded exercise test, attended a 12 week multidisciplinary CR program, and then underwent repeat treadmill testing. Peak metabolic equivalents (METs), calculated from the speed and grade of the last stage of the graded exercise testing, and HRR at 1 minute post exercise were determined pre and post CR.
RESULTS: Peak MET and HRR values are listed in Table 1. There were significant improvements in peak METs and HRR following CR in both male and female subgroups. Peak MET level was significantly lower in females compared to males prior to and following CR with a parallel improvement following the intervention (males: 0.86 +/-0.94 vs. females: 0.85 +/-1.0 METs, p = 0.88). However, while HRR was significantly lower at baseline in females compared to males, values were similar following CR as the mean improvement was significantly greater in the female subgroup (males: 1.0 +/-9.9 vs. females: 2.4 +/-12.3 beats, p < 0.05).
CONCLUSIONS: The results of the present study are consistent with previous research that has found: 1) A significant improvement in peak METs following CR irrespective of sex and 2) peak METs remain significantly higher in males prior to and following CR compared to females. However, it appears the impact of CR on HRR, while positive for both men and women, is more pronounced in the latter sex. Our findings may therefore have sex-based implications for how HRR is interpreted both as a cross-sectional and longitudinal marker of health and prognosis.
Oral #6
THE ASSOCIATION BETWEEN PHYSICAL ACTIVITY AND DEPRESSION AFTER CARDIAC SURGERY
D Scott Kehler,1,2,+ David Horne,3,+ Brett Hiebert,1 George Kaoukis,3 Eric Garcia,1,2 Soyun Chapman,1,2 Rakesh C Arora,2,3,++ Todd A Duhamel1,2,++
1Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre; 2Faculty of Kinesiology and Recreation Management, 3Faculty of Medicine, University of Manitoba; +Co-first author; ++Co-principal investigators. Winnipeg, MB, Canada.
RATIONALE: Physical activity is associated with a lower prevalence of depressive symptoms amongst patients with cardiovascular disease. However, little is known about the benefits of physical activity on depression in cardiac surgery patients peri-operatively. Therefore, this prospective, observational trial sought to determine if daily physical activity is associated with symptoms of depression before and after cardiac surgery.
METHODS: Four hundred and thirty six non-emergent cardiac surgery patients were recruited. Data was collected pre-operatively (Q1), at discharge (Q2) and three (Q3) and six (Q4) months post-operatively. Physical activity was assessed using the short form International Physical Activity Questionnaire (IPAQ) and a sub-set of 52 patient responses were validated using accelerometers. Symptoms of depression were assessed using the Patient Health Questionnaire-9 (PHQ-9).
RESULTS: Complete data sets were obtained for 364 patients. IPAQ data indicated that 31% (Q1), 43% (Q3) and 51% (Q4) of patients reported being physically active enough to meet Canadian Physical Activity Guidelines. Median IPAQ scores were 420 (140-914; interquartile range) total minutes of physical activity/week, which compared to a median of 29 (0-81) total minutes of physical activity/week based on accelerometry (i.e. the total number of minutes of light, moderate or vigorous activity completed in 10 minute bouts). PHQ-9 scores indicated that 24% of patients had depressive symptoms at baseline. Inactivity (i.e. IPAQ <600 MET-min/week) at Q1 was independently predictive of depressive symptoms at Q2 (OR: 2.03; 95%CI, 1.26-3.28; P < 0.005). At baseline, 49% of the depressed cohort was classified as inactive, whereas, only 27% of the non-depressed cohort was inactive. Over time, the number of patients classified as inactive based on self-report data declined but was always highest amongst the depressed cohort. Amongst the patients depressed at baseline, the group who reduced their symptoms of depression at Q4 were more active (82% were active) than the group who did not improve their symptoms of depression (53% were active; P < 0.05). Pooled data showed an inverse relationship between depressive symptoms and self-reported physical activity (Spearman r = -0.211, p < 0.001) as well as self-reported physical activity-based energy expenditure (MET-min/week; spearman r = -0.219, p < 0.001). Accelerometer data supported and strengthened these correlations (total physical activity, Spearman r = -0.235, p < 0.05; energy expenditure, Spearman r = -0.260, p < 0.001).
CONCLUSION: These data indicate that less active people experience more depression following cardiac surgery. Furthermore, increased physical activity is associated with less depression over time after cardiac surgery.
Oral #7
DIFFERENCES IN SOCIAL COGNITIVE CORRELATES OF CARDIAC REHABILITATION EXERCISE ADHERENCE AS A FUNCTION OF PROBLEM-SOLVING STYLE
Parminder K Flora, Lawrence R Brawley
College of Kinesiology, University of Saskatchewan, Saskatoon.
Exercise therapy is an integral component of cardiac rehabilitation (CR) yet non-adherence to exercise continues to be problematic. Evidence-based self-regulatory strategies are important for adoption and maintenance of exercise behaviour (Artinian et al, 2010). Problem-solving (PS) skills are recommended for exercise self-regulation within the CR population (e.g., Ewart, 1990). A recent scientific statement from the AHA provides evidence for the use PS in behaviour change interventions for cardiac risk reduction (Artinian et al, 2010). While PS training has repeatedly been included in behaviour change interventions, the process by which PS influences adherence to exercise therapy remains unexamined, limiting our understanding of how PS facilitates adherence to CR exercise. Despite recommendations to use PS strategies in the CR exercise therapy context (Ewart 1990) no studies have examined how individuals' PS style affects factors related to lapses from adherence. We focused on initiates to CR exercise therapy to examine the question of whether PS style affects social cognitive beliefs and markers of process related to exercise adherence. Based upon previous research and theory (Social Cognitive Theory and Model of Social Problem Solving), we hypothesized that when CR initiates are faced with an exercise lapse-related problem, participants' with Rational (RPS) and Impulsive-careless (ICS) PS styles would differ on markers of PS process and persistence. CR initiates (N = 51, Mage = 65.6) first completed measures of RPS and ICS style before being presented with a pre-tested, relevant problem about an exercise lapse. Next, their self-efficacy (SE) for a) problem-solving (SEPS), b) solution implementation (SESI), and persistence with c) PS and d) SI were assessed. MANOVA's comparing Rational and Impulsive-careless groups revealed significant main effects where higher RPS and ICS styles reported greater SEPS and SESI as well as greater persistence with PS and SI, RPS: Wilk's [lambda] = .70, F (4, 46) = 4.88, P < .01, observed power = .94 and ICS: Wilk's [lambda] = .64, F (4, 46) = 6.41, P < .001, observed power = .98) compared to their respective lower counterparts. More effective problem solvers are more confident in and persistent in dealing with a CR lapse-related problem than less effective problem-solvers. These findings provide a first demonstration of the social-cognitive factors in self-regulation that differ among CR initiates varying in PS styles. The findings suggest a possible moderating effect of PS style and implications for strategies to counter lapses in exercise therapy.
Oral #8
RANDOMIZED CONTROL TRIAL TO ASSESS THE EFFICACY OF AUTOMATED TELEPHONE FOLLOW UP FOR SMOKING CESSATION FOLLOWING HOSPITALIZATION: MAIN OUTCOMES AND PREDICTORS OF LONG-TERM CESSATION
Kerri-Anne Mullen,1,2 Ashley Armstrong,1 Laura A Jones,1 Debbie A Aitken,1 Andrew L Pipe,1 Robert D Reid,1
1University of Ottawa Heart Institute, Ottawa, Ontario; 2University of Ottawa
RATIONALE: For smokers with coronary heart disease (CHD), smoking cessation is essential. Hospital-initiated cessation interventions are effective, only if support continues after discharge.
OBJECTIVE: The main objective of this randomized control trial was to determine if long-term quit rates were higher for smokers with CHD who received automated telephone follow-up with triage to nurse counseling after hospitalization compared to standard care. A second objective was to determine the predictors of smoking cessation at 26 and 52 weeks.
METHODS: Smokers hospitalized with CHD (n = 401) were randomized to either standard care or automated telephone follow up (ATF). Standard care included brief, in-hospital nurse counseling and nicotine replacement therapy (NRT) during hospitalization. In addition to standard care, the ATF group received eight automated calls over six months following hospital discharge. The telephone system posed questions concerning smoking status, confidence in staying smoke-free, and need for additional support. Nurse counselors monitored the system and, if flagged, called patients back to provide additional assistance. Abstinence rates were compared between groups using 2 x 2 contingency table analyses. Odds ratios with 95% confidence intervals were calculated. Logistic regression was used to determine the predictors of smoking cessation at 26 and 52 weeks.
RESULTS: The ATF group had a higher rate of continuous abstinence, adjusted for potential misreporting, during weeks 1-26 (38.2% vs. 26.6%; OR = 1.70; 95% CI: 1.09-2.66; P = .013), but not for weeks 27-52 (32.4% vs. 27.1%; OR = 1.29; 95% CI: 0.82-2.03); P =.24). In the logistic regression, diagnosis of acute coronary syndrome (p = .04), having a post-secondary education (OR = 1.58; 95% CI: 1.02-2.45; P = .04), smoking the first cigarette after 30 minutes of waking (OR = 1.68; 95% CI: 1.02-2.77; P = .04), using a quit smoking medication (OR = 1.95; 95% CI: 1.26-3.04; P = .003), and being older (OR = 1.03; 95% CI: 1.01-1.06; P = .02) predicted 26 week continuous abstinence. Post-secondary education (OR = 1.69; 95% CI: 1.08-2.64; P = .02) and use of quit smoking medications (OR = 2.78; 95% CI: 1.63-4.75; P < .001) were the only predictors of continued cessation at 52 weeks.
CONCLUSIONS: Automated telephone follow-up and triage to nurse counseling result in statistically and clinically significant increases in smoking abstinence following hospitalization with CHD. The most important predictor of long-term abstinence appears to be the use of quit smoking medications. ATF offers an efficient way to direct limited hospital resources to smokers in need of ongoing support after discharge; the approach used in this study is a fundamental component of the Ottawa Model for Smoking Cessation.
Oral #9
DEVELOPMENT AND PSYCHOMETRIC VALIDATION OF A NEW TOOL TO ASSESS EDUCATIONAL NEEDS IN CARDIAC REHABILITATION PATIENTS.
GLM Ghisi,1,2 S Grace,1,2,3 MF Evans,1,4 S Thomas,1 P Oh2
1Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada; 2Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; 3School of Kinesiology and Health Science, York University, Toronto, Canada; 4Health Design Lab, St. Michael's Hospital, Toronto, Canada.
INTRODUCTION: Good patient education involves assessing needs, setting goals and objectives, implementing a teaching plan, and evaluating outcomes. The identification of information needs is considered the first step to improve knowledge that ultimately improves health outcomes. There is no tool in the literature that addresses the educational needs of cardiac rehabilitation (CR) patients. The aim of this study was to develop and psychometrically validate a new tool to assess educational needs in CR patients.
METHODS: after an extensive literature search, 61 educational items were collected and reviewed by an expert panel (n = 10). Items were rated on a 5-point Likert-type scale that ranged from 1 = really not important to 5 = very important. High scores indicated high educational needs of each topic identified by the subjects. The items were put together as an Educational Needs Assessment Questionnaire, had "clarity" and "compatibility" checked, and pilot tested in 34 coronary patients (15 [44%]female, 69 +/- 8.4 years old) that completed the 6-month CR program. A final version was generated and psychometrically tested in a sample of 204 CR patients (49 [24%]female, 64 +/- 11.8 years old). The internal consistency was assessed using Cronbach's alpha, the test-retest reliability using intraclass correlation coefficient (ICC), and the construct validity was assessed through factor analysis. T-tests were used to assess the discriminant validity with regard to age, sex, educational level and family income.
RESULTS: Cronbach's alpha was 0.956 and ICC was 0.851. Factor analysis revealed six factors all internally-consistent and well-defined by the items: risk factors/exercise and physical activity/stress and psychological factors (Alpha = 0.930); the heart/work, vocational and social/general and social concerns (Alpha = 0.844); medication (Alpha = 0.933); diagnosis and treatment/emergency and safety (Alpha = 0.877); nutrition (Alpha = 0.870); and barriers and goal setting (Alpha = 0.695). The mean total score was 4.08 +/- 0.53. Criterion validity was supported by significant differences in mean scores by gender (p = 0.27), and educational level (p < 0.01). Patients rated emergency/safety (mean = 4.53 +/- 0.71), the heart (mean = 4.32 +/- 0.63), and stress/psychological factors (mean = 4.29 +/- 0.7) as their greatest educational needs; and work/vocational/social (mean = 3.61 +/- 1.09), general/social concerns (mean = 3.83+/-1.13) and risk factors (mean = 3.83 +/- 0.79) as their lowest educational needs.
CONCLUSIONS: The Educational Needs Assessment Questionnaire was demonstrated to have sufficient reliability and validity, supporting its use in further studies. The nature of the needs identified suggest cardiac patients have higher expectations of outpatient care, and that different strategies would be required to promote education in this setting. Future research is needed to administer this scale to non-enrolees in CR programs, so that key educational needs can be compared.
Scientific Poster Presentations
Saturday, October 27, 2012
CACR Showcase
Posters available for viewing:
9:30 AM-4:30 PM
Authors present:
9:30 AM-10:00 AM
Sunday, October 28, 2012
CACR Showcase
Posters available for viewing:
9:30 AM-1:00 AM
Authors present:
10:00 AM-10:30 AM
Scientific Posters
Poster #1
A PATIENT NAVIGATION INTERVENTION IMPROVED ENROLLMENT IN OUTPATIENT CARDIAC REHABILITATION: RESULTS FROM A RANDOMIZED CONTROLLED TRIAL
Shannon Gravely,1,2 Lisa Benz Scott,2 Thomas R. Sexton,3 Sabrina Brzostek,4 Ceylan Cizmeli,5 David L Brown4
1Peter Munk Cardiac Centre & Women's Health Program, Toronto General Hospital University Health Network, Toronto, Canada; 2Graduate Program in Public Health, Stony Brook University Health Sciences Center, Stony Brook, NY, USA; 3College of Business, Stony Brook University, Stony Brook, NY, USA; 4School of Medicine, Stony Brook University Health Sciences Center, Stony Brook, NY, USA
BACKGROUND AND AIMS: Enrollment into outpatient cardiac rehabilitation (OCR) among eligible patients is suboptimal. Thus, it is important to identify new approaches to improving enrollment in OCR. This study examined the effect of cardiac patient navigation intervention (PN) on OCR enrollment rates compared to usual care (UC).
METHODS: Patients with myocardial infarction (MI), stable angina or having undergone revascularization were consented during inpatient care at a participating academic medical center in the United States, and randomly assigned to either PN (n = 90) or UC (n = 91). The PN group was provided with a trained lay health advisor (non-clinician) who delivered OCR-focused education/support at the bedside, and/or telephone-based education to facilitate the patient's selection of an OCR program. PN patients discharged prior to navigation were mailed information to their home which was reviewed by telephone with a navigator within 1 week. Navigators contacted the OCR program selected by each patient to provide staff with pertinent information to facilitate patient contact. All study participants were interviewed by phone at 1 and 3 months post-discharge to assess self-reported OCR enrollment. Study personnel verified enrollment (defined as >= 1 OCR session). After the 3-month interview, UC were also mailed educational information about OCR in the event they did not learn about it from a provider. Group differences in enrollment rates were assessed using Fisher's Exact Test (one-tailed, alpha .05). Patients who died <= 1 month after hospitalization (1 PN, 2 UC) were removed from analysis.
RESULTS: The sample was primarily male (n = 119, 65.7%), white, non-Hispanic (n = 163, 90%), insured (n = 153, 85%), and recovering from MI (n = 108). Mean age was not significantly different between PN (60.44 +/-10.21 years) and UC groups (61.04 +/-11.17 years). Only 5/89 UC (6%) and 16/89 PN (18%) enrolled in OCR (p = 0.009). Gender analyses showed that 15% of women in PN enrolled in OCR (5 of 32), vs. 7.1% of women in UC (2 of 28), p = 0.272. Among men, 19.3% in PN enrolled in OCR (11 of 57) vs. 4.8% in UC (3 of 62), p = 0.016. Only 2 PN patients refused navigation and 7 PN patients declined to select an OCR program after learning about the benefits.
CONCLUSION: Although still suboptimal, OCR enrollment rates within 3 months of hospitalization were significantly higher among patients assigned to navigation compared to UC. These findings are encouraging and suggest that an innovative cardiac Patient Navigation program implemented in a real world hospital setting can improve OCR enrollment rates among clinically eligible patients.
Poster #2
CORRELATES OF SMOKING CESSATION IN SMOKERS WITH CEREBROVASCULAR DISEASE
R Edjoc,1 RD Reid,1 M Sharma,2 L Balfour3
1Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, Ottawa, Canada; 2Regional Stroke Prevention Program, The Ottawa Hospital, Ottawa, Ontario, Canada; 3The Ottawa Hospital, Ottawa, Ontario, Canada
BACKGROUND: Despite the benefits of smoking cessation in secondary stroke prevention many patients continue to smoke after their event. The purpose of this study is to determine multi-level correlates of smoking cessation in this high risk group of smokers.
METHODS: We used data from the 2007-2008 Canadian Community Health Survey. Logistic regression examined the association between respondents who reported to suffer from stroke symptoms and who quit smoking while controlling for multi-level correlates of smoking cessation. Proportions were weighted to the Canadian Population.
RESULTS: There were 109 395 respondents who quit smoking. This cohort was largely male (62.9%), older (70-80+ yrs: 46.1%), had mostly post-secondary education (55.3%), consumed less alcohol than smokers (45.9% vs. 49.1%; p < 0.0001) and reported less cases of depressive episodes (35.6% vs. 41.7%; p < 0.0001). Male sex (OR 2.2; 95% CI: 2.18 - 2.32), household (OR 1.1; 95% CI: 1.06 - 1.09) and vehicle (OR 7.7; 95% CI: 7.04 - 8.48) smoking restrictions as well as the use of Bupropion (OR 18.4; 95% of CI: 16.6 - 20.3) and counselling (OR 1.8; 95% CI: 1.64 - 1.96) were significant correlates of smoking cessation. Alcohol consumption (OR 0.96; 95% CI: 0.95 - 0.98) and depression (OR 0.87; 95% CI: 0.86 - 0.88) reduced the likelihood of smoking cessation.
CONCLUSION: Future interventions should be tailored with these correlates in mind to increase the likelihood of cessation for this group of smokers.
Poster #3
REFERRAL TO CARDIAC REHABILITATION FOLLOWING REVASCULARIZATION IN ONTARIO
S Brady,1 D Purdham,2 P Oh,1,3 SL Grace1,3,4
1University of Toronto, Toronto, Canada; 2Cardiac Care Network of Ontario, Toronto, Canada; 3University Health Network, Toronto, Canada; 4York University, Toronto, Canada
BACKGROUND: Cardiac rehabilitation (CR) is a proven intervention for reducing morbidity and mortality following cardiac revascularization. However, it is largely underutilized, in Ontario and beyond. The objectives of this study were to: (1) describe rates of CR referral post-revascularization in Ontario, and (2) examine sociodemographic and clinical factors related to referral.
METHODS: In this retrospective study, the sample was comprised of all CR-indicated patients who had undergone revascularization at the member hospitals of the Cardiac Care Network of Ontario (CCN) between October 2011 (when CR referral was introduced as a field in the administrative database), through March 2012. The sample focused on the 10 of the total 18 CCN hospitals that reported on CR referral. Referral rates were described, and multivariate analyses were performed.
RESULTS: There were 3,773 patients revascularized across the 10 sites. 34 (0.9%) patients who did not survive to discharge were excluded. Of the 3,739 (99.1%) patients included in the analysis, the mean age was 66.8+/-10.9, and 2,838 (75.9%) were male. 1,936 (51.8%) patients were referred to CR: 810 (42.6%) following percutaneous coronary intervention and 1,126 (61.3%) after coronary artery bypass graft +/- valve intervention (OR = 2.25; 95%CI = 1.96-2.57). Sex and BMI were unrelated to referral. Patients with hyperlipidemia (OR = 0.80; 95%CI=0.68-0.94), COPD (OR = 0.74; 95%CI = 0.57-0.96), comorbid renal (OR = 0.36; 95%CI = 0.24-0.56) or peripheral vascular disease (OR = 0.61; 95%CI = 0.47-0.79), and heart failure (OR = 0.58; 95%CI = 0.37-0.93), as well as patients aged 85 and older (OR=0.58; 95%CI = 0.38-0.87) or who required a translator (OR = 0.53; 95%CI = 0.29-0.98), were significantly less likely to be referred. Patients with a history of smoking (OR = 1.54; 95%CI = 1.34-1.77) or myocardial infarction (OR = 1.29; 95%CI = 1.10-1.51) were more likely to be referred to CR than those without.
CONCLUSIONS: This is the first report of the new CR referral data field in the CCN database. A national policy statement recommends 85% referral of indicated patients to CR, and therefore we are missing this target by almost 35%. It is promising that there was no sex bias in referral, and that smokers were more likely to be referred than non-smokers. However some patients at higher clinical risk who might arguably benefit more from CR participation, were particularly less likely to be referred. More study is warranted.
Poster #4
SATISFACTION AND PREFERENCE FOR CARDIAC REHABILITATION PROGRAM MODELS AMONG FEMALE PARTICIPANTS
M Cahill,1 HM Arthur,2,3 P Oh,4,5 C Chessex,4,5 S Brister,4,5 SL Grace1,4,5,6
1York University, Toronto, Canada; 2McMaster University, Hamilton, Canada; 3Hamilton Health Sciences, Hamilton, Canada; 4University Health Network, Toronto, Canada; 5University of Toronto, Toronto, Canada; 6York Central Hospital, Richmond Hill, Canada
BACKGROUND: Women are under-represented in cardiac rehabilitation (CR), and more likely to dropout than men. Previous research has established that women may perceive CR as male-orientated and not meeting their needs. This study examined women's satisfaction with CR, and preference for CR program models such as home-based and women-only programs.
METHODS: Within an ongoing trial of female outpatients randomized to one of 3 CR models (i.e., home-based, women-only, co-ed), patients are recruited from several inpatient and outpatient cardiac settings in Ontario. Consenting participants are asked to complete a survey pre and post-CR, and clinical data are extracted from charts. This study presents secondary analysis of elements of the mailed post-test survey, which included investigator-generated items assessing satisfaction and model preference through closed and open-ended questions. A descriptive examination was performed.
RESULTS: To date, 50 (49.5% response rate among eligible patients) participants have completed the final survey. Their mean age was 65.1 +/- 9.5, and their most-frequent cardiac indication was percutaneous coronary intervention (n = 26; 53.1%). 7(14.0%) patients did not attend CR despite being referred. Of attendees, when asked to rate their degree of program satisfaction from 1'very unsatisfied' to 5'very satisfied', the mean rating was 4.19 +/- 1.25. When asked why, open-ended responses included knowledgeable staff who provided guidance (n = 21;48.8%), and helpfulness of the exercise prescription (n = 11;25.5%). When rating specific aspects of CR (scores range from 1'strongly disagree' to 5'strongly agree'), participants most strongly agreed that they felt comfortable in their workout clothes (mean = 4.4 +/- .57). In addition, they were satisfied with the nature of the education they received (3.8 +/- .93), the discussion of psychosocial issues in CR (3.7 +/- 1.00), information regarding life role resumption (3.6 +/- .88), discussion of women's health issues (3.2 +/- 1.1), and finally they felt the behaviour change counselling was applicable to them (3.2 +/- .99). Overall when asked to rate which of 3 program models they would prefer to attend, 20(44.4%) participants preferred co-ed, followed by 19(42.2%) preferring women-only and 6(13.3%) home-based CR. Open-ended reasons why included that they enjoyed interacting with people experiencing the same issues (n = 11; 23.9%) and felt more comfortable exercising and discussing issues with women only (n = 10; 21.7%).
CONCLUSION: Preliminary results suggest that female participants are highly satisfied with CR, but mean satisfaction ratings in regards to women specific content are somewhat low. While the study is ongoing, preliminary results suggest that women seem to prefer to attend supervised programs, whether they are sex-specific or not.
Poster #5
BURDEN, SCREENING, AND TREATMENT OF PSYCHOSOCIAL DISTRESS AMONG WOMEN IN CARDIAC REHABILITATION
M Cahill,1 HM Arthur,2,3 A Kovacs,4 C Chessex,4,5 SL Grace1,4,5
1York University, Toronto, Canada; 2McMaster University, Hamilton, Canada; 3Hamilton Health Sciences, Hamilton, Canada; 4University Health Network, Toronto, Canada; 5University of Toronto, Toronto, Canada
BACKGROUND: Women with cardiovascular disease (CVD) experience a significantly greater burden of psychosocial distress than men. Specifically, they experience 2-times greater depression, and comorbid depression has been shown to relate to 2-times greater mortality. Practice guidelines promote depression screening in cardiac rehabilitation (CR). The objective herein was to describe the burden of psychosocial distress among women at CR completion, whether they were screened during CR, and the outcome of such screening.
METHODS: Within an ongoing trial of female outpatients randomized to one of 3 CR models, patients are recruited from several inpatient and outpatient cardiac settings in Ontario. Consenting participants are asked to complete a survey pre and post CR, and clinical data are extracted from charts. This study presents secondary analysis of elements of the mailed post-test survey, which included investigator-generated items assessing screening and treatment of mood and anxiety, and the Hospital Anxiety and Depression Scale (for which scores of >=8 on either the depression or anxiety subscale represent elevated scores). A descriptive examination was performed.
RESULTS: To date, 50 (49.5% response rate among eligible patients) women have completed the final survey, of which 43(86.0%) enrolled in CR. Their mean age was 65.1 +/- 9.5, and their most frequent cardiac indication was percutaneous coronary intervention (n = 26; 53.1%). The overall mean depression score was 6.9 +/- 3.4 (n = 13; 28.8% elevated) and anxiety score was 5.0 +/- 2.9 (n = 9; 20.0% elevated).17 (39.5%) participants reported experiencing distress during CR, specifically depressed mood (n = 3; 17.6%), anxiety (n = 7; 41.2%) or both (n = 7; 41.2%), for which 7 (38.6%) participants reported they were not receiving treatment. 21(55.2%) reported being screened since CR initiation, of which 3 (14.3%) reported that someone discussed the results with them. The most frequently-reported outcome of screening was psychotherapy (n = 5; 25.5%), followed by pharmacotherapy prescription (n = 2; 10.0%). Women who reported accessing treatment received this most frequently from a primary care physician (n = 7; 41.2%).
CONCLUSION: While the non-randomized design precludes inferences regarding the impact of CR on psychosocial distress, preliminary findings convey a continued burden of untreated emotional distress in female cardiac patients post-program. Almost half of female participants recall being asked about psychosocial distress which is encouraging, given that some recall failure is likely with self-report. Of the women who recall being formally screened, only approximately 15% were informed of the results suggesting more time to discuss psychosocial wellbeing within CR may be needed, particularly when considering its negative impact on health outcomes and quality of life.
Poster #6
EXERCISE AND CARDIAC REHABILITATION AWARENESS, KNOWLEDGE AND BEHAVIOUR AMONG AMBULATORY HEART FAILURE PATIENTS
Vicki N Wang,1 Sherry L Grace,1,2,3 Susanna Mak1,4
1Faculty of Medicine, University of Toronto, Toronto, Ontario; 2Cardiovascular Rehabilitation and Prevention Program, University Health Network, Toronto, Ontario; 3Faculty of Health, York University, Toronto, Ontario; 4Division of Cardiology, Department of Medicine, Mount Sinai Hospital, Toronto, Ontario
BACKGROUND: Clinical recommendations for heart failure (HF) patients include physical activity and participation in comprehensive risk reduction programs such as cardiac rehabilitation (CR). CR is established as beneficial for HF, yet exercise behaviour and CR participation are particularly low in this population. The objectives of this study were to assess (1) exercise knowledge, perceptions and behaviour, and (2) CR awareness, use and factors related to such use in HF outpatients.
METHODS: In this cross-sectional study, HF patients were approached for informed consent in a subspecialty heart function clinic and asked to complete a survey. Inclusion criteria were NYHA class I-III. Exclusion criteria were inability to ambulate and other contraindications to exercise, and HF of non-cardiac cause (e.g. anemia, fluid overload secondary to renal disease). Activity status and behaviour were assessed using the Duke Activity Status Index and the Godin Leisure-Time Exercise questionnaire, respectively. Awareness and knowledge regarding exercise and CR were assessed using investigator-generated questions, and the Cardiac Rehabilitation Barriers Scale.
RESULTS: 35 patients participated in the study (n = 23, 67% male; age = 59 +/- 16; activity status = 33 +/- 17), of which 8 (23%) met recommended levels of physical activity (Godin > 24; mean = 12 +/- 18). 9 (25%) reported receiving medical advice to exercise. The entire cohort reported maximum HR (0%), inability to talk (14%), set time (33%), fatigue (44%), and breathlessness (50%) as reasons for ceasing exercise. 21 (58%) had heard of CR, and 12 (33%) were offered and attended CR. Those who did not attend CR were significantly less likely to have heard of CR than those who attended (41% vs. 100% respectively, p < 0.01). The most highly-endorsed CR barriers were time constraints (2.9 +/- 1.4/5), distance (2.6 +/- 1.7/5), preference to take care of health alone versus in a group (2.6 +/- 1.7/5), and family responsibilities (2.6 +/- 1.4/5).
CONCLUSIONS: Although patients were recruited from a specialized heart function clinic at an academic centre with CR availability, few received medical advice to exercise or had heard of CR. All subjects in this study were eligible for and would have benefited from participation in CR. While caution is warranted due to the small sample size and study design, these findings suggest that more investigation regarding exercise counselling and CR referral rates in the context of HF clinics is warranted.
Poster #7
CARDIOVASCULAR CONDITIONS AND NON-CARDIAC MEDICAL COMORBIDITIES RESPOND LESS FAVOURABLY TO STRESS REDUCTION PROGRAMS
G Dashi,1 L Finkler,2 P Oh,3 D Alter,3 J Reitav3
1University of Toronto, Toronto, Canada; 2York University, Toronto, Canada; 3Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
RATIONALE: Stress is one of nine modifiable risk factors for myocardial infarction (MI). Stress Reductions Programs (SRPs) reduce distress and mortality among some patients with cardiovascular disease (CVD), but not all. Yet, it is unclear whether patients with CVD conditions respond differently from patients with other medical comorbidities to SRP.
OBJECTIVE: We examined whether patients with CVD have similar SRP outcomes when compared to patients with other non-cardiac medical comorbidities.
METHODOLOGY: We conducted an exploratory study of the effects of a SRP, which included in-class and at-home components. 28 participants voluntarily enrolled and completed an 8-week program. Participants completed validated self-report questionnaires at the start and end of the program, which were used to assess their initial mental stress status and any benefits gained from the SRP. Benefit was objectively measured depending on the presence and severity of four outcomes associated with both stress and CVD: distress, depression, anxiety, and insomnia. CVD was defined as diagnosed cardiovascular disease, experience of MI, or previous cardiac surgery. Medical comorbidity was defined as two or more diagnosed, non-cardiovascular, medical conditions.
RESULTS: By the end of the SRP, participants showed significantly lower levels of distress (p < .05), subjective anxiety (p < .05), and insomnia (p < .01), as well negative mood and somatic symptoms associated with depression (p < .05). However, sub-group analysis showed that CVD conditions responded less favourably to the SRP. Participants without CVD conditions (n=13) improved significantly more in terms of distress, insomnia, and negative mood associated with depression (p < .05) than those with CVD conditions (n = 15). On the other hand, non-cardiac medical comorbidities did not have as strong of a negative impact on outcomes as did CVD. Participants without non-cardiac medical comorbidities (n = 17) improved significantly more than their counterparts only with respect to insomnia (p < .05). Despite these results, a power analysis demonstrated that our pilot study of 28 patients was underpowered. Additional data has been collected and is currently being analysed.
CONCLUSION: While patients with CVD and those with non-cardiac medical comorbidities both benefited from the SRP, provision of effective SRP to the cardiac population presents additional complexities. Further research into the clinical challenges of tailoring SRP to cardiac patients is warranted.
Poster #8
THE PREVALENCE AND IMPACT OF ADHD AMONG CARDIAC REHABILITATION PATIENTS: A PILOT STUDY
L Finkler,1 G Proulx,1 G Dashi,2 P Oh,3 D Alter,3 J Reitav3
1Glendon College-York University; 2University of Toronto; 3Toronto Rehabilitation Institute-University Health Network
BACKGROUND AND AIMS: Cardiovascular Disease (CVD) is the second leading cause of death among Canadians, accounting for 21.3% of all deaths. It has been proven that psychological treatment such as a Stress Reduction Program (SRP) combined with usual care reduces mortality in the first two years post cardiac event for some patients, and improves quality of life. Adult ADHD is commonly undiagnosed in the CR context, and adults with this disorder are more vulnerable to distress, anxiety and depression. The goals of this study are: 1) evaluate the prevalence of ADHD among patients enrolling in an SRP, and 2) to examine whether the presence of ADHD impacts the outcomes achieved by these patients.
METHODS: The participants of this study were those who enrolled in Toronto Rehabilitation Institute's SRP. All 46 of these patients were screened for adult ADHD using the World Health Organization (WHO) Adult ADHD Self Report Scale. Dependent measures included measures of anxiety (BAI), depression (CES-D) and stress (K6).
RESULTS: Results showed that 28% of the patients enrolling for SRP screened positively for adult ADHD. Three separate 2 (ADHD or non-ADHD) x 2 (Pre-Training and Post-Training) mixed measures analysis of variances were conducted. The ADHD group had higher mean scores on anxiety (21.034 vs. 12.037, p < 0.016), depression (23.878 vs. 16.114, p < 0.016), and stress (10.833 vs. 6.818, p < 0.016) at pre-training than the non-ADHD group. At post-training, the ADHD group's mean scores on the dependent measures were all still in the 'moderate' range while the mean scores for the non-ADHD group were reduced to minimal anxiety, no depression and mild distress. The main effects of SRP training were significant for reducing distress, anxiety, and depression. The main effect of ADHD was significant for reducing anxiety and psychological distress but not depression. No interactions were statistically significant.
CONCLUSION: These results confirm that SRP successfully reduces levels of stress, anxiety and depression for most SRP participants. However, the higher levels of symptoms present in adult ADHD patients were clinically significant and the high prevalence of ADHD in our sample suggest that SRPs in CR settings should routinely screen for ADHD and that SRP may need to be modified for some patients.
Poster #9
CHANGE IN BLOOD LIPID PROFILE IMMEDIATELY FOLLOWING CARDIAC REHABILITATION AND AT ONE YEAR FOLLOW-UP
B Marra,1 BJ Martin,1-3 T Hauer,1 LD Austford,1 JA Stone,1-3 A Corcelli,1 S Aggarwal,1-3 R Arena,1,4
1Cardiac Wellness Institute of Calgary; 2University of Calgary; 3Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada; 4University of New Mexico, Albuquerque, New Mexico
INTRODUCTION: Cardiac rehabilitation (CR) produces a number of positive health benefits, including favorable modifications to blood lipids. The mechanism for the improvement in blood lipid profile among CR participants in likely to be multifactorial. The purpose of the present investigation is to assess change in blood lipid profile immediately following completion of CR and at one year follow-up.
METHODS: One thousand three hundred and fifty patients (1124 males and 226 females, age = 61.4 +/-10.2) diagnosed with coronary artery disease participated in a 12 week comprehensive CR program. A fasting blood lipid analysis was performed immediately prior to initiation and completion of CR as well as at one year follow-up.
RESULTS:Table 1 lists the results from the repeated measures analysis of variance. Total cholesterol, LDL and triglycerides were significantly lower while HDL was significantly higher immediately following CR. At one year follow-up, LDL and triglyceride levels were comparable to baseline values while total cholesterol and HDL were significantly higher.
DISCUSSION: The majority of reported positive benefits derived from CR are supported by data collected immediately following completion of the supervised program. Patients are then expected to adhere to the positive health behavior modifications taught in CR with minimal to no supervision. The long-term change in lipid profile following CR warrants further investigation.
Poster #10
EXERCISE AND HEMODIALYSIS: DETERMINING THE AVAILABILITY OF EXERCISE REHABILITATION PROGRAMS IN DIALYSIS CENTRES ACROSS CANADA
J Lui,1 S Ma,1 D Brooks,2 TL Parsons1
1Queen's University, Kingston, Canada; 2University of Toronto, Toronto, Canada
BACKGROUND: Exercise training has been demonstrated to be a safe and effective strategy for improving physical fitness, cardiovascular outcomes, and quality of life amongst persons with chronic kidney disease. When performed during hemodialysis, exercise is also known to improve dialysis efficacy by enhancing solute removal and reducing symptoms associated with dialysis. When performed off dialysis, exercise can improve cardiac responses and help manage co-morbidities associated with renal failure. Currently, no published data exists on the prevalence and nature of exercise programs offered to Canadians with chronic kidney disease.
OBJECTIVES: To (1) determine the availability of exercise rehabilitation programs for patients undergoing dialysis, (2) identify the barriers of implementing an exercise rehabilitation program, and (3) develop and pilot an online survey tool.
METHODOLOGY: An online survey was created through FluidSsurveys. An invitation letter containing the link to the online survey and an embedded online consent form was then distributed via email to 93 dialysis facilities across Ontario, as identified from the Canadian Organ Replacement Registry (CORR).
RESULTS: Reponses were received from 46 dialysis facilities, yielding a 49% response rate. Most commonly reported co-morbidities in patients undergoing dialysis include hypertension, diabetes, and cardiovascular diseases. Of the 46 facilities who responded, only five facilities had an exercise program for patients on hemodialysis. The exercise programs were mostly carried out during dialysis, with two of the five facilities offering programs similar to an in-centre cardiac rehabilitation model for patients to attend on non-dialysis days. The remaining 41 facilities who indicated the lack of an exercise program reported that the most commonly perceived barriers by the facility staff were lack of funding (n = 21), lack of human resources (n = 17), and lack of equipment (n = 16). Less common barriers include lack of patient interest and concerns regarding patient safety. Four facilities who did not offer an exercise program expressed strong interest in implementing an exercise program for their patients.
CONCLUSION: Despite low prevalence (11%) of exercise rehabilitation programs offered by dialysis facilities across Ontario, there is interest expressed for such a program. The main barriers to establishing exercise programs were lack of funding, human resources, and equipment. Current work is underway to investigate the prevalence of exercise programs for dialysis patients across Canada.
Poster #11
EXERCISE ADHERENCE IN PEOPLE WITH HEART FAILURE: APPLYING THE THEORY OF PLANNED BEHAVIOUR
LN Wilson,1 J Ezekowitz,2 K Courneya,3 JC Spence3
1Northern Alberta Cardiac Rehabilitation Program, Glenrose Site, University of Alberta Centre for Health Promotion Studies, Edmonton, Canada; 2Univeristy of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Division of Cardiology, Edmonton, Canada Edmonton, Canada; 3University of Alberta, Faculty of Physical Education and Recreation
RATIONALE: Despite advances in heart failure (HF), mortality rates remain high and the affected population continues to grow. Improvement in symptomology, and quality of life is noted when exercise is included in the treatment plan. Despite this, exercise adherence is a challenge for people with HF. Objectives: To understand the factors that drive exercise, this study examined the utility of the theory of planned behaviour (TPB).
METHODS: Eighty-one participants completed a questionnaire at: baseline to establish demographic and TPB construct data; and, 3 months to assess exercise.
RESULTS: Hierarchical regression analyses determined that a) attitude, subjective norm and perceived behavioural control (PBC) accounted for 20% of the variance in exercise intention with PBC making the only significant contribution; b) intention explained 26% of the variance in exercise at baseline; and, c) intention was a significant contributor to exercise at 3 months.
CONCLUSION: The TPB may inform interventions for HF which may translate into an improved future for those affected.
Poster #12
PSYCHOSOCIAL TRIAGE SYSTEM FOR CARDIAC REHABILITATION: SAVE TIME AND RESOURCES
H Tulloch, L Cupper, R Pelletier, F Zachariades, P O'Farrell
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
BACKGROUND & PURPOSE: Depression and anxiety have been identified as risk factors for cardiovascular disease and are related to morbidity, mortality and reduced quality of life. Treatment for these disorders may lead to improvement in symptoms, quality of life, and positive lifestyle changes that influence cardiac outcomes. However, funding for psychosocial resources is limited. Therefore, a systematic method for assessing and triaging patients for these services is required. We have implemented a new psychsocial referral triage protocol at the University of Ottawa Heart Institute's cardiac rehabilitation (CR) program that includes standard administration of the Hospital Anxiety and Depression Scale (HADS) at CR intake and, if elevated (>=11 Anxiety; >=8 Depression), intake staff notify the psychosocial team, who then re-administers the HADS 4 weeks later. Scores >= 16 receive an immediate referral to psychology. In the past, almost all patients with elevated scores at intake were screened and triaged by social work. The purpose of the present research is to evaluate the feasibility and efficacy of the new triage protocol.
METHOD: From July, 2011 to April, 2012, we tracked HADS scores of patients attending CR, the number of patients with elevated scores, and the psychosocial referrals made.
RESULTS: Of 804 patients attending intake for the on-site program, 114 patients (14%) had elevated HADS scores. We found that approximately 4 patients per intake were not triaged as per the protocol (i.e., not referred for re-administration despite high scores) during the first six months of implementation, but after increased staff training, adherence to the protocol was excellent. Fourteen patients were lost to follow-up. Many patients (27%) no longer required intervention as their HADS scores had dropped below clinical levels at 4 weeks. All other patients were referred to services within our program (social work, vocational counselling, psychology, stress management) or community resources.
CONCLUSIONS: The new triage protocol was found to be feasible, however, strategies to ensure adherence to the protocol and to improve loss to follow-up were required. Implementation of the protocol led to a significant reduction in the number of referrals for psychosocial services. As a result, patients who no longer needed psychosocial services were not burdened with another health-related appointment. Clinician time was saved, leading to a reduction in wait-times.
Poster #13
THE CHAMPLAIN DECLARATION: MOBILIZING SCHOOL COMMUNITIES IN THE CREATION OF HEALTHY SCHOOL NUTRITION ENVIRONMENTS
Laurie Dojeiji,1 Danielle Simpson,1 Micheline Turnau2
1Champlain Cardiovascular Disease Prevention Network, University of Ottawa Heart Institute, Ottawa, Canada; 2Heart and Stroke Foundation, Ottawa, Canada
BACKGROUND AND AIMS: The Champlain Cardiovascular Disease Prevention Network (CCPN) is a group of health and community partners that has been working to reduce the burden of heart disease and stroke in the Champlain region of Ontario. One of the CCPN's six priority initiatives has been focused on children and youth. A significant milestone was achieved in April 2009 when the nine school boards and four public health units in the Champlain region signed the "Champlain Declaration: A Call to Action for Physically Active & Healthy Eating Environments in Schools". Partners prioritized healthy catered lunches, healthy fundraising, and healthy classroom rewards for immediate action in the over 500 schools in the region. A school baseline survey was conducted in 2010 to better understand the current landscape with respect to school nutrition environments and the three nutrition priorities.
METHODOLOGY: All principals across the nine Champlain school boards were invited to participate in a 15-minute online survey. Response rate was 54.7% (n = 298). Data was analyzed to assess overarching baseline trends related to school nutrition environments, and to inform the types of supportive measures deemed necessary to assist school communities in making positive changes.
RESULTS: Pizza (60.7%), hot dogs and hamburgers (39.9%), and juice that is not 100% juice (31.2%) were reported as the most common foods and beverages sold or served in schools. The majority of schools (85.9%) reported using food for fundraising activities with pizza, bake sale items, and chocolate being the most common fundraising foods. Food was reported as a common reward by teachers for good behaviour (42.3%) with pizza and chocolate ranking as the top food rewards. Nutrition-related training and resources for parents, teachers, and students was cited as the most necessary support. Findings informed the development of a Healthy Schools 2020 workshop module and resource kit to provide school communities with tangible, practical tools to support implementation of the three nutrition priorities. More than 1,200 school board administrators, principals, teachers, and parents across the Champlain region have attended a workshop and/or received a toolkit to date. A one-year follow-up school survey has also been completed with a response rate over 80%. Data will be available in July 2012.
CONCLUSION: The Champlain Declaration has spearheaded concerted, collaborative action for the creation of healthy school nutrition environments and can serve as a model for other regions in Canada.
Poster #14
NEIGHBOURHOOD WALKABILITY AND PHYSICAL ACTIVITY AMONG FAMILY MEMBERS OF PEOPLE WITH HEART DISEASE WHO PARTICIPATED IN A RANDOMIZED CONTROLLED TRIAL OF A BEHAVIOURAL RISK REDUCTION INTERVENTION
Dana L Riley,1 Amy E Mark,1 Elizabeth Kristjansson,2 Mike Sawada,3 Robert D Reid1
1Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, Ottawa, Canada; 2School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, Canada; 3Laboratory for Applied Geomatics and GIS Science (LAGGISS), Department of Geography, University of Ottawa, Ottawa, Canada
This study adds to the current literature investigating the relationship between individuals' physical activity (PA) and the built environment. Self-reported PA from a prospective behavioural risk reduction intervention was explored in the context of objectively measured Walk Scores and neighbourhood walkability in Ottawa, Canada. It was hypothesized that (i) participants living in high walkability neighbourhoods would be more likely to meet the PA guidelines at baseline compared to participants living in low walkability neighbourhoods and (ii) walkability would interact with the intervention arm (Family Risk Reduction (FRR) vs. Standard Care (SC)), with participants allocated to the FRR intervention and living in the highest walkability neighbourhoods having the highest odds of achieving the PA target (150 minutes MVPA/week) at 12-weeks. For the 12-week analyses, participants who met the PA guidelines at baseline (n = 62, 21.2%) were excluded because they did not receive a PA intervention. A series of logistic regression models were used to test for the effect on the dichotomous PA outcome (met guidelines vs. not). The first model examined the effect of the intervention arm (FRR vs. SC); the second model examined the effect of Walk Score (high vs. low); the third model examined the effect of neighbourhood walkability (high vs. low); the fourth model examined the interaction effect of intervention arm x Walk Score; and the final model examined the interaction effect of intervention arm x neighbourhood walkability. Data analyses were performed using SPSS version 19.0. Participants in the FRR intervention arm had significantly higher odds of meeting PA guidelines at 12-weeks compared to the SC control group (OR = 4.42, 95% CI: 2.50 - 7.83, p < .001). This was not influenced by Walk Scores or walkability. This individual-level intervention was effective in assisting participants to overcome potential structural barriers presented by their neighbourhood to meet PA guidelines at 12-weeks.
Poster #15
GENDER DIFFERENCES IN THE ASSOCIATION BETWEEN DEPRESSIVE SYMPTOMS, HEALTH RELATED QUALITY OF LIFE AND SLEEP DIFFICULTIES AMONG PARTICIPANTS OF A CARDIAC REHABILITATION PROGRAM
Hailey R Banack,1,2 Crystal D Holly,2 Ilka Lowensteyn,2,3 Steven Grover,2,3 Deborah Da Costa2,3
1Department of Epidemiology and Biostatistics, McGill University, Montreal, QC; 2Division of Clinical Epidemiology, McGill University, Montreal, QC; 3Faculty of Medicine, McGill University, Montreal, QC
BACKGROUND: Many cardiovascular rehabilitation programs have a narrow scope of treatment, focusing primarily on exercise training. However, recent guidelines (e.g., CACR, AHA) highlight the importance of also addressing psychosocial issues, such as depression and insomnia. Poor sleep quality is a prevalent concern among patients with cardiovascular disease, and recent evidence suggests that 44% of patients with cardiovascular disease experience some degree of insomnia. The purpose of the present study was to explore the relationships between health-related quality of life, depression, and sleep quality in patients enrolled in a structured cardiovascular health prevention and treatment program.
METHODS: The study sample consisted of one hundred and seventy eight (N = 178) enrolled in a cardiac rehabilitation program. The data was collected from participants at baseline. The participants were 137 males and 41 females (mean age 58.97 +/- 11.7 years). Seventy percent of the participants had cardiovascular disease, while thirty percent attended the program for prevention and/or risk factor management. The Beck Depression Inventory (BDI) was used to measure the severity of depressive symptoms, the SF-36 physical and mental component scores were used to measure Health Related Quality of Life, and the Pittsburgh Sleep Quality Index (PSQI) was used to assess participants' subjective sleep quality. Multivariate linear regression was used to examine the association between health related quality of life, depressive symptoms, and sleep quality, while controlling for confounding by age, gender, and cardiovascular disease status.
RESULTS: Poor sleep quality (PSQI > 5) was reported in 70% of participants, and 64% of participants reported having at least mild depressive symptoms (BDI >8). There were significant positive relationships between depressive symptoms and sleep quality among men (p < .001; R2 = .42) and women (p = .003; R2 = .52). The physical functioning (p = .01) and perceived physical role limitations (p = .05) subscales of the SF-36 were significant predictors of sleep quality in females (R2 = .58), while bodily pain (p = .03) and vitality (p = .02) subscales were associated with sleep quality in males (R2 = .36).
CONCLUSION: There is a strong association between depressive symptoms and sleep difficulties among both men and women. Interestingly, different aspects of health related quality of life were associated with sleep difficulties in men and women. Cardiovascular rehabilitation programs must move toward integrating assessment of psychosocial factors such as sleep, depression, and quality of life as well as exercise training.
Poster #16
THE PRE AND POST TEST COMPARATIVE RESULTS OF TWO PREDICTIVE TOOLS USED TO ESTIMATE FUNCTIONAL CAPACITY; THE 6MWT AND THE DASI
JE Silbernagel,1,2 PA Bend,1,2 JL Ruland,1,2 KT Miller,1,2 JM Ludlow,1,2 KD Dorsch,1 JP Neary1,2
1University of Regina; 2Dr. Paul Schwann Applied Health and Research Centre
INTRODUCTION: The Duke Activity Status Index (DASI) is a self-administered, 12-item questionnaire designed to predict functional capacity based on activities of daily living (ADL). Tools designed to estimate functional capacities have utility in cardiac rehabilitation programs where access to exercise stress testing is limited. The DASI is one example of a questionnaire that has a fairly high correlation rate (r = 0.58) between the questionnaire and measured functional capacity. The purpose of this study was to determine if post exercise rehabilitation DASI scores will produce results similar to measured post exercise functional capacity.
METHODS: Our Centre administered the DASI and Borg rating of perceived exertion (RPE) scale before and after a 12-week exercise program. Functional capacity was calculated from the six-minute walk test (6MWT) and applied to three separate regression formulas; American College of Sports Medicine (ACSM) metabolic formula for walking, a formula developed for individuals in a pulmonary rehabilitation program and a formula for individuals with heart failure. These regression formulae were used to eliminate any bias that may have occurred by using one formula. A paired samples t-test was used to test for significance at P <= 0.05.
RESULTS: Data from seventy-six participants were used (M age = 68.2 +/- 9.9 years, 76.3% male). Results from all regression formulae showed significant improvements in functional capacity (P <= 0.001), with no significant difference in RPE (12.94+/-1.21 vs. 13.12 +/- 2.03). The ACSM metabolic formula for walking showed improvements of 6.6% (3.38 +/- 0.50 vs. 3.62 +/- 0.55 METS), the pulmonary rehabilitation formula showed improvements of 6.6% (4.70 +/- 0.69 vs. 5.03 +/- 0.75 METS) and the heart failure formula showed improvements of 9.2% (3.45 +/- 1.06 vs. 3.80 +/- 1.22 METS). The improvements in measured functional capacity varied greatly when compared to pre and post DASI. A significant (P <= 0.05) decline in predictive functional capacity (DASI) of -5.7% (6.76 +/- 1.76 vs. 6.40 +/- 1.86 METS) occurred from commencement to completion.
CONCLUSION: Although the DASI predicts maximal functional capacity and the regression formulas measure sub-maximal work, the observed diverging of variables remain the same. The question remains as to why the significant decrease in DASI scores while there is an obvious increase in actual measured functional capacity. Some possible explanations for the observed results include, individuals over-estimating ADLs at the beginning of the exercise program to appear less fragile, and/or upon completion of the rehabilitation program, individuals realize that they were in poorer shape than originally thought. More research is needed to determine why DASI scores declined and the clinical impact of an overestimation in DASI.
Poster #17
IMPROVING WEIGHT LOSS OUTCOMES IN CARDIAC REHABILITATION
JA Francis,1 K Unsworth,1 PL Prior,1 A Cunningham,1 C Mason-Taylor,1 L Ratsep,1 S Deluca,1 J Lorenzin,1 N Suskin,1 I Hramiak2
1LHSC Cardiac Rehabilitation and Secondary Prevention Program, London, Ontario; 2St. Joseph's Health Care, London, Ontario
BACKGROUND AND AIMS: Approximately 80% of cardiac rehabilitation (CR) patients are overweight (BMI = 25.0-29.9) and 40% of these are obese (BMI >= 30). Modest weight loss of 5-10% of body weight is associated with significant reductions in traditional CAD risk factors even in patients who are already receiving evidence-based medications. However, standard CR programming is usually associated with weight loss of only 1-2%. We describe phased weight loss initiatives that were implemented within our Cardiac Rehabilitation and Secondary Prevention (CRSP) Program to address effectiveness of weight loss interventions that benefit the greatest number of patients in the context of CRSP programming.
METHODS: Phase 1- A convenience sample of 14 obese CR patients (10 male, 4 female) was recruited to participate in a 12 week cognitive behavioral (CBT) weight loss group in addition to participating in the regular 6 month CR program. The CBT program adhered to the 12 week LEARN Program for Weight Management (10th Edition; Brownell, 2004). The group was facilitated by the CRSP program psychologist, dietitian, and kinesiologists. Phase 2- Aspects of phase 1 were incorporated into a phase 2 intervention that could be embedded within the CRSP service delivery model (e.g. consistent monitoring of exercise and eating behavior, goal setting, regular weigh-ins, stimulus control techniques). Phase 2 was implemented by the program dietitian and kinesiologists who provided regular 1-1 counselling at the group-based exercise program. Weight loss results were compared for obese CR patients who were enrolled in the CR program in the year before vs. following implementation of this program.
RESULTS: Phase 1- Eleven of the 14 patients completed the CBT group. Mean weight loss was 3.5 kg (0.7 to 10.3 kg) or 3.36%. Phase 2- No significant difference was found in weight change between obese patients who completed the 6 month CR program prior to implementing phase 2 (N = 90; mean weight gain = 0.08kg) vs. after phase 2 implementation (N = 68; mean weight loss = 0.33kg), t(156) = 0.6, P = 0.5.
DISCUSSION: CR patients who attended the 12 week CBT weight loss group in addition to completing the regular CR program lost more weight than is typically reported for patients completing CR alone. However, the intervention proved to be inefficient, reaching only a fraction of overweight/obese CR patients. We were unsuccessful in helping greater numbers of CR patients lose weight by embedding elements of CBT treatment within regular program. Results highlight difficulties in delivering effective weight loss interventions within CR and the need for further work in this area.
Poster #18
SUSTAINING CARDIAC REHABILITATION OUTCOMES OVER THE LONG TERM: CAN PROGRAM ENTRY MODELS HAVE AN INFLUENCE?
D Kent,1,2 N Wangasekara,1,2 S Chapman,1,2 DS Kehler,1,2 D Luchik,3 D Lamont,3 S Boreskie,3 TA Duhamel1,2
1Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre; 2Faculty of Kinesiology and Recreation Management; 3Reh-Fit Centre, Winnipeg, MB. Canada
RATIONALE: Cardiac rehabilitation (CR) are known to reduce major cardiovascular morbidity and mortality by 20% to 25%. However, patient adherence to physical activity tends to drop off after the completion of CR. This decline in activity adherence may be caused by the loss of the group dynamic that patients have become accustomed to while in CR. A rolling admissions CR program delivery model (ROLL), where patients join a larger CR cohort and are provided the opportunity to interact with more people within the cohort rather than meeting with the same peer group every day, may address this issue. Therefore, this project will determine if a ROLL CR delivery program model is more effective than the traditional (TRAD) CR program for enhancing functional walking ability and the amount of physical activity that CR patients accumulate in daily living.
METHODS: We plan to recruit a total of 64 patients from the TRAD and the ROLL program models at the Reh-Fit Centre (Winnipeg, MB). The primary outcome will assess changes in functional walking ability, as assessed using the 6-Minute Walk Test (6MWT). Secondary outcomes include objectively measured daily physical activity. Data will be collected at baseline, 1, 4, 6 and 12 months after enrollment in CR.
RESULTS: Preliminary data from 43 participants (Age, 61 +/- 2 yrs; GXT peak fitness, 7.9 +/- 0.3 METS) have completed the 1 and 4 month assessments so far and will be described. The length of time between patient referral and entry into the TRAD and ROLL program was 39 +/- 4 days and 40 +/- 5 days, respectively. At baseline, patients in the TRAD program walked 539 +/- 16 meters during the 6MWT, as compared to 545 +/- 24 meters for ROLL. Over time, both groups improved (P < 0.05) their 6MWT performance at 1 month (TRAD, +9%; ROLL, +9%) and had further improvements at 4 months (TRAD, +13%; ROLL, +12%). At baseline, both groups accumulated a similar amount of total physical activity (TRAD, 54 +/- 15 min/wk; ROLL, 64 +/- 11 min/wk). Patients accumulated more physical activity after 1 month (TRAD, +63%; ROLL, +42%), with no further improvements in time spent being physically active observed at 4 months.
CONCLUSION: These preliminary data indicate that both CR delivery models effectively enhance functional walking ability and promote the adoption of a more physically active lifestyle at 1 and 4 months after CR enrollment. The longitudinal effects of the two program models remain to be elucidated when data collection is completed in December 2012.
Poster #19
SENSITIVITY, SPECIFICITY, POSITIVE PREDICTIVE VALUE, AND NEGATIVE PREDICTIVE VALUE OF AN IN-HOSPITAL TEST TO IDENTIFY PREVIOUSLY UNDIAGNOSED DYSGLYCEMIA
J. Kocourek,1 R. Reid,1 J. Malcolm,2 E Keely,2 S Brez,2 R Feibel3
1University of Ottawa Heart Institute, The Ottawa Hospital; 2Division of Endo-crinology and Metabolism, The Ottawa Hospital; 3Department of Orthopedic Surgery, Ottawa, Canada
RATIONALE AND OBJECTIVE: Dysglycemia (including diabetes) is a serious health problem that often goes undiagnosed for several years. Hospitalization affords an opportunity to identify people at risk for diabetes or with previously unrecognized diabetes and attach them to prevention programs or long-term diabetes care. We used thresholds for hemoglobin A1C (>= 5.7%) and random blood glucose (>= 7.8 mmol/L) measured during hospitalization to identify dyslycemia in patients without a previous history of diabetes. The objective of the present study was to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of these thresholds to determine how useful they are to detect dysglyemia post-hospitalization.
METHODOLOGY: Ninety-six patients without a previous history of diabetes admitted to hospital for coronary artery disease (n = 47) or elective orthopedic surgery procedures (n = 49) completed in-hospital tests for HbA1C and random blood glucose. Six weeks following hospitalization, they returned to complete a 2-hr oral glucose tolerance test (OGTT), considered the 'gold standard' for diagnosing dysglyemia/diabetes. In-hospital tests were considered positive if HbA1C was >= 5.7% or RBG >= 7.8 mmol/L.
RESULTS: The sample was predominantly male (60%) with a mean age of 63.8 +/- 9.6 years. In-hospital, 35/96 participants (36.4%) had a positive test for dysglycemia/diabetes. Post-hospitalization, OGTT results indicated 40/96 participants had dysglycemia/diabetes. Results are summarized in Table 1. Sensitivity was 58%. Specificity was 82%. The positive predictive value was 70% and the negative predictive value was 73%.
CONCLUSIONS: The in-hospital testing protocol and thresholds used in the present study more accurately predicted non-cases than cases of dysglycemia. The thresholds utilized in this study had reasonable positive and negative predictive values. Future studies should examine the accuracy of in-hospital screening with HbA1C or RPG alone and of other, potentially lower, thresholds.