Louise J. Beaton

Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study

Background Little is known about physical activity levels in patients with coronary artery disease (CAD) who are not engaged in cardiac rehabilitation. We explored the trajectory of physical activity after hospitalization for CAD, and examined the effects of demographic, medical, and activity-related factors on the trajectory. Design A prospective cohort study. Methods A total of 782 patients were recruited during CAD-related hospitalization. Leisure-time activity energy expenditure (AEE) was measured 2, 6 and 12 months later. Sex, age, education, reason for hospitalization, congestive heart failure (CHF), diabetes, and physical activity before hospitalization were assessed at recruitment. Participation in cardiac rehabilitation was measured at follow-up. Results AEE was 1948 ± 1450, 1676 ± 1290, and 1637 ± 1486 kcal/week at 2, 6 and 12 months, respectively. There was a negative effect of time from 2 months post-hospitalization on physical activity (P<0.001). Interactions were found between age and time (P = 0.012) and education and time (P = 0.001). Main effects were noted for sex (men more active than women; P<0.001), CHF (those without CHF more active; P<0.01), diabetes (those without diabetes more active; P<0.05), and previous level of physical activity (those active before hospitalization more active after; P<0.001). Coronary artery bypass graft patients were more active than percutaneous coronary intervention (PCI) patients (P = 0.033). Conclusions Physical activity levels declined from 2 months after hospitalization. Specific subgroups (e.g. less educated, younger) were at greater risk of decline and other subgroups (e.g. women, and PCI, CHF, and diabetic patients) demonstrated lower physical activity. These groups need tailored interventions.

Economic evaluation of cardiac rehabilitation: a systematic review.

Background Economic evaluation is an important tool in the evaluation of competing healthcare interventions. Little is known about the economic benefits of different cardiac rehabilitation program delivery models. Design The goal of this study was to review and evaluate the methodological quality of published economic evaluations of cardiac rehabilitation services. Methods Electronic databases were searched for English language evaluations (trials, modeling studies) of the economic impact of cardiac rehabilitation. A review of study characteristics and methodological quality was completed using standardized tools. All costs are adjusted to 2004 US dollars. Results Fifteen economic evaluations were identified which met eligibility criteria but which displayed wide variation in the use of comparators, evaluation type, perspective and design. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation in myocardial infarction and heart failure patients was identified. The range of cost per life year gained was estimated as from

Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease

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Cost-effectiveness of cardiac rehabilitation program delivery models in patients at varying cardiac risk, reason for referral, and sex:

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Barrier Self-Efficacy and Physical Activity Over a 12-Month Period in Men and Women Who Do and Do Not Attend Cardiac Rehabilitation

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Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation

16118 per quality adjusted life year gained. The level of evidence supporting the economic value of home-based cardiac rehabilitation interventions is limited to partial economic analyses. Conclusions Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. Further trials are required to support the cost-effectiveness of cardiac rehabilitation in cardiac patients who have under gone revascularization. The literature evaluating home-based and alternative delivery models of cardiac rehabilitation was insufficient to draw conclusions about their relative cost-effectiveness. The overall quality of published economic evaluations of cardiac rehabilitation is poor and further well-designed trials are required.

Who will be active? Predicting exercise stage transitions after hospitalization for coronary artery disease

Background: The CardioFit internet-based expert system was designed to promote physical activity in patients with coronary heart disease (CHD) who were not participating in cardiac rehabilitation. Design: This randomized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes. Methods: A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and randomly assigned to either CardioFit (n = 115) or usual care (n = 108). The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking. They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist. Usual care consisted of physical activity guidance from an attending cardiologist. Physical activity was measured by pedometer and self-reported over a 7-day period, 6 and 12 months after randomization. Results: The CardioFit internet-based physical activity expert system significantly increased objectively measured (p = 0.023) and self-reported physical activity (p = 0.047) compared to usual care. Emotional (p = 0.038) and physical (p = 0.031) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care. Conclusions: Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care. Use of the CardioFit program could extend the reach of rehabilitation and secondary-prevention services.

Correlates of physical activity change in patients not attending cardiac rehabilitation.

Background Little is known about the relative cost-effectiveness of different secondary prevention cardiac rehabilitation (CR) program designs or how cost-effectiveness is influenced by patient clinical and demographic characteristics. The purpose of the study was (i) to evaluate the incremental cost-effectiveness of a standard 3-month CR program (SCR) versus a program distributed over 12 months (distributed CR, DCR); and (ii) to determine the effect of patient demographic characteristics (cardiac risk, cardiac diagnosis, sex) on incremental cost-effectiveness. Methods A two group cost-effectiveness analysis was conducted alongside a randomized controlled trial. Patients with coronary artery disease (mean age = 58 years, SD ± 10) were randomized to either SCR (n = 196) or DCR (n = 196) and followed for 24 months. Program delivery costs, cardiac healthcare use, morbidity, mortality, and quality-adjusted life years were assessed. Cost-effectiveness was evaluated with incremental cost-utility analysis. Results In the pooled analysis, we found the probability of SCR being more cost-effective than DCR was 63–67%. The subanalysis found SCR to be the more cost-effective intervention for patients at high risk, patients with previous coronary artery bypass graft and for male patients. The DCR program was more cost-effective for patients with lower risk of disease progression and for female patients. Conclusion Differences were noted in the cost-effectiveness of CR models based on cardiac risk level, reason for referral, and demographic characteristics. Our results suggest improved cost-effectiveness may be gained by triaging patients to different CR intervention models, however, further investigation is required.

Universal access: But when? Treating the right patient at the right time: Access to cardiac rehabilitation

Objectives: Two primary objectives were to examine (a) changes in physical activity (PA) over a 12-month period in people living with cardiac disease who did not attend cardiac rehabilitation (CR), and (b) the role of barrier self-efficacy in explaining these changes from a gender perspective. A secondary objective was to examine whether attending CR (or not) moderated the gender‐barrier self-efficacy relationship with PA. Design and Setting: Participants (N 801) completed a questionnaire in the hospital and at 2, 6, and 12 months after hospitalization, as well as a telephone-administered 7-day PA recall at 2, 6, and 12 months. Main Outcome Measures: PA and barrier self-efficacy. Results: Hierarchical linear modeling showed significant declines in PA over time, which were especially pronounced for women. Moreover, the association between barrier self-efficacy and PA became significantly weaker over time, especially for women. This trend was similar for participants who did and did not attend CR. Conclusion: Interventions that focus on increasing barrier self-efficacy in people living with heart disease after hospitalization will likely equally benefit men and women in the short term but may disproportionately benefit men in the longer term regardless of participation in CR.

Impact of program duration and contact frequency on efficacy and cost of cardiac rehabilitation: results of a randomized trial.

Background: Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. Design: A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. Method: One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. Results: Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µadd = 0.69, p < 0.05). Conclusion: Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.