Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs

Objective: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR. Design: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team. Setting: Six regional hospitals in south-west Victoria offering hospital-based CR programs. Participants: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs. Main outcomes measures: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery. Results: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook. Conclusions: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.     

A systematic review of economic evaluations of cardiac rehabilitation

ABSTRACT: BACKGROUND: Cardiac rehabilitation (CR), a multidisciplinary program consisting of exercise, risk factor modification and psychosocial intervention, forms an integral part of managing patients after myocardial infarction (MI), revascularization surgery and percutaneous coronary interventions, as well as patients with heart failure (HF). This systematic review seeks to examine the cost-effectiveness of CR for patients with MI or HF and inform policy makers in Singapore on published cost-effectiveness studies on CR. METHODS: Electronic databases (EMBASE, MEDLINE, NHS EED, PEDro, CINAHL) were searched from inception to May 2010 for published economic studies. Additional references were identified through searching bibliographies of included studies. Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Quality assessment of economic evaluations was undertaken using Drummond's checklist. RESULTS: A total of 22 articles were selected for review. However five articles were further excluded because they were cost-minimization analyses, whilst one included patients with stroke. Of the final 16 articles, one article addressed both centre-based cardiac rehabilitation versus no rehabilitation, as well as home-based cardiac rehabilitation versus no rehabilitation. Therefore, nine studies compared cost-effectiveness between centre-based supervised CR and no CR; three studies examined that between centre- and home based CR; one between inpatient and outpatient CR; and four between home-based CR and no CR. These studies were characterized by differences in the study perspectives, economic study designs and time frames, as well as variability in clinical data and assumptions made on costs. Overall, the studies suggested that: (1) supervised centre-based CR was highly cost-effective and the dominant strategy when compared to no CR; (2) home-based CR was no different from centre-based CR; (3) no difference existed between inpatient and outpatient CR; and (4) home-based programs were generally cost-saving compared to no CR. CONCLUSIONS: Overall, all the studies supported the implementation of CR for MI and HF. However, comparison across studies highlighted wide variability of CR program design and delivery. Policy makers need to exercise caution when generalizing these findings to the Singapore context.     

Waiting time for rehabilitation services for children with physical disabilities

BACKGROUND: Early rehabilitation may minimize disability and complications. However, children often wait a long time to gain admission to rehabilitation centres. OBJECTIVES: To describe waiting times for paediatric physical and occupational therapy and to determine factors associated with these waiting times. RESEARCH DESIGN: The study was a prospective cohort design. Patients were followed from 1 January 1999 to 1 March 2000. SUBJECTS: All children with physical disabilities, aged 0-18 years, referred in 1999 from the Montreal Children's Hospital to paediatric rehabilitation centres. MEASURES: Data on date of referral, date of first appointment at the rehabilitation centre, age, gender, diagnosis, region and language were obtained from the rehabilitation transfer database. Primary family caregivers of children who were transferred to a rehabilitation facility participated in a telephone interview regarding their perceptions of the transfer process. RESULTS: There were 172 children referred to rehabilitation facilities. The mean age of the children was 2.5 years. Average waiting time was 157.4 days (SD 57.1) for occupational therapy and 129.4 days (SD 51.6) for physical therapy. Decreased waiting time was associated with living in the city as opposed to the suburbs (hazard ratio=1.77; 95% confidence interval=0.92-3.41) and inversely associated with age (hazard ratio=0.46; 95% confidence interval=0.34-0.62). Among the 41 primary family caregivers who participated in the survey, higher empowerment scores were associated with shorter waits for rehabilitation. CONCLUSION: Waiting time for rehabilitation services needs to be reduced. Empowered parents appear to manoeuvre within the system to reduce waiting times for their children.     

Delayed access to health care and mortality

OBJECTIVE: To measure the relationship between time spent waiting for health care services and patients' mortality. DATA SOURCE: Data on the number of days until the next available appointment at 89 Veterans Affairs (VA) medical centers in 2001 were extracted from a VA administrative database. These facility-level data were merged with individual-level data for a sample of veterans who visited a VA geriatric outpatient clinic in 2001. The merged dataset includes facility-level data on waiting times and individual-level data on demographics, health status (e.g., diagnoses), and mortality. STUDY DESIGN: This was a retrospective observational study using secondary data from administrative sources. The dependent variable was mortality within a 6-month follow-up period. The main explanatory variable of interest was VA facility-level wait times for outpatient visits measured in number of days. Random effects logistic regression models were risk adjusted for prior individual health status and facility-level differences in case mix. PRINCIPAL FINDINGS: Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality (odds ratio=1.21, p=0.027) compared with veterans who visited a VA medical center with facility-level wait times of <31 days. CONCLUSIONS: Our findings support the largely assumed association between long wait times for outpatient health care and negative health outcomes, such as mortality. Future research should focus on the causes of long waits for health care (e.g., physician reimbursement levels), the consequences of long waits in other populations, and effective policies to decrease long waits for health care services.     

Ontario's wait time strategy: part 1

Ontario's Wait Time Strategy was designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas-cancer surgery, cardiac revascularization procedures (cardiac surgery, percutaneous coronary intervention, diagnostic catheterization), cataract surgery, hip and knee total joint replacements and MRI and CT scans. These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services.     

Assessing Medicaid recipient access and satisfaction. Fee-for-service, case management, and capitation

Medicaid increasingly requires enrollment in managed care programs. This study assessed access to care, satisfaction with care, and appointment wait times during the transition from fee for service to managed care using three annual Medicaid recipient surveys. There was little evidence of dissatisfaction or poorer access among managed care recipients. Fee-for-service recipients, compared to primary care case management, reported greater general (91 vs. 78%, p < .01) and specialty care access (92 vs. 80%, p < .01). When appointments were required, adult HMO enrollees, compared to case management, had longer waits for routine care in the second (5.8 +/- 8.2 days vs. 4.0 +/- 6.6) and third surveys (5.5 +/- 6.9 days vs. 3.8 +/- 7.3); waits for other appointments did not consistently differ by program. There were no significant program differences in overall satisfaction. Findings are tempered by the potential for response bias and geographic confounding. Continued monitoring is crucial to assure that access and satisfaction remain high in Medicaid managed care.     

A randomized control trial of cardiac rehabilitation

A randomized trial using controls tested whether psycho-social rehabilitation of acute myocardial infarction (MI) patients would improve significantly their return to work rate and assessed the importance of various psychological, social, occupational, socio-demographic, and medical factors in facilitating or impeding rapid return to work. Eighty-nine patients were assigned randomly to participate in an experimental cardiac rehabilitation program (rehab care), and 91 patients were controls who received conventional hospital rehabilitation (usual care). By the first follow-up interview at three months, patients assigned to experimental treatment were significantly less distressed psychologically and less dependent on family support than controls (P = 0.04 and P = 0.05, respectively). By the final follow-up interview at 13 months, there was a marginally significant difference in favor of the experimental group in the frequency of reported deterrents to work resumption (P = 0.07). However, the intervention did not result in a statistically significant difference in the return to work rate (P greater than 0.10). In each group, 88% were back at work by approximately the first year after infarction. In addition, the two groups were similar in the amount of time patients remained out of the workforce (median days rehab care = 75, usual care = 81; P greater than 0.10). A multi-stage data analysis procedure utilizing the Cox regression technique indicated that while several independent variables had significant univariate associations with the length of time patients convalesced, outcome was most influenced by the patient's initial cardiological status and clinical course, by the patterns of family support, and by the several variables measuring the presence of obstacles to resuming work. Our findings suggest that rehabilitation programs intervening on multiple levels (psychological, social, occupational, and physical) may best meet the needs of chronically ill cardiac patients. Results indicate that implementing measures addressing the patient's general psycho-social adjustment to MI may improve existing programs.     

Behavior change outcomes in an outpatient cardiac rehabilitation program

OBJECTIVE: To evaluate the effectiveness of nutrition education within an outpatient cardiac rehabilitation program. DESIGN: Subjects were assigned, according to participation in cardiac rehabilitation programs in two community hospitals within an integrated healthcare system, to either a treatment (n=54), or a control group (n=50). SUBJECTS/SETTING: One hundred four men and women, age range 35 to 85 years, participating in a 6-week cardiac rehabilitation program. Most were men (80%) and overweight. The majority presented with the diagnosis of myocardial infarction followed by coronary artery bypass surgery or percutaneous transluminal coronary angiography procedure. INTERVENTION: Subjects in the control group received usual nonindividualized nutrition education from cardiac rehabilitation therapists. Subjects in the treatment group attended two group nutrition education classes and one individual diet counseling session, all led by the same dietitian. MAIN OUTCOME MEASURES: Changes in fat, saturated fat, cholesterol, and carbohydrate intake, and restaurant eating habits as assessed by the Diet Habit Survey; changes in cardiac diet self-efficacy; and changes in health-related quality of life. Statistical analyses performed Group-by-time analysis of variance with repeated measures, chi2 test. RESULTS: The treatment group had greater improvement in Restaurant and Recipes scores on the Diet Habit Survey (2.6 vs 1.0) and a greater cardiac diet self-efficacy mean score (4.3) compared with the control group (3.8), with the greatest change in items related to eating in restaurants, away from home, or when alone. From entry into the program to discharge, the cholesterol-saturated fat index decreased significantly in the control group (from 57 to 48), and in the treatment group (from 51 to 42). The percent of energy from carbohydrate increased significantly in the control group (from 51% to 55%) and in the treatment group (from 53% to 57%). There were no differences between groups over the 3 time periods (baseline, 6 weeks, and 3-month follow-up) (n=39 for control group and n=47 for treatment group for all 3 time periods). APPLICATIONS/CONCLUSIONS: Nutrition education within an outpatient cardiac rehabilitation program can improve dietary choices at restaurants and boost self confidence in the ability to adhere to a lipid-lowering diet.     

A research of service outcomes in Taiwan: the role of patients' quality perceptions and wait time

Wait time is a continuing issue in healthcare services. U.S. studies reveal wait time is inversely related to healthcare service outcome as well as patient behavior and attitudes. However, Taiwan, despite being an important center for global healthcare services, has not been the subject of much research attention regarding wait time and its impact on patient perceptions and behavior. In the authors' exploratory study, patients in Taiwan completed a self-report questionnaire on how wait time and service quality characteristics relate to service outcome. Results indicate the influence of healthcare service quality and wait time on service outcome. Contributions, limitations, and research and managerial implications are discussed.     

Contract management of Ontario's cancer surgery wait times strategy

The province of Ontario, as a result of the First Ministers' Meeting, was committed to addressing surgery wait times in Ontario. The Ministry of Health and Long-Term Care's response to this commitment was the Wait Times Strategy (WTS) initiative, which addressed access issues with the aim of positively impacting wait times in cancer surgery. Cancer Care Ontario (CCO) was tasked with managing the cancer surgery WTS. CCO engaged in accountability agreements with Ontario hospitals to provide incremental cancer surgery volumes, in return for one-time funding. Through the use of accountability agreements, CCO was able to tie service volume delivery, quality care initiatives and reporting requirements to funding. Other elements of the cancer surgery WTS implementation included the development of wait times definitions, guidelines and targets; the use of a performance management system; facilitation by existing regional cancer leads and continued development of regional cancer programs. Eight key lessons were learned: (1) baseline volume guarantees are critical to ensuring that wait times are positively impacted; (2) there is a need to create a balance between accountability and systems management; (3) clinical quality initiatives can be tied to funding initiatives; (4) allocations of services should be informed by many factors; (5) regional leadership is key to ensuring that local needs are met; (6) data are invaluable in improving performance; (7) there is regional disparity in service delivery, capacity and resources across the province; and (8) program sustainability is an underlying goal of the WTS for cancer surgery. The implication is that accountability agreements can be leveraged to create sustainable health management systems.     

Public views on a wait time management initiative: a matter of communication

Background  

Many countries have tried to reduce waiting times for health care through formal wait time reduction strategies. Our paper describes views of members of the public about a wait time management initiative - the Ontario Wait Time Strategy (OWTS) (Canada). Scholars and governmental reports have advocated for increased public involvement in wait time management. We provide empirically derived recommendations for public engagement in a wait time management initiative.     

Investigating patients' preferences for cardiac rehabilitation in Denmark

OBJECTIVES: The objective of this study was to analyze preferences for activities comprised in comprehensive cardiac rehabilitation programs among former cardiac patients from three different hospitals in Copenhagen County, Denmark. METHODS: A discrete choice experiment was applied to elicit the preferences for the offer of participation in various cardiac rehabilitation program activities: smoking cessation course, physical exercise program, personal meetings with cardiac nurse, group meetings managed by cardiac nurses, and nutritional counseling guidance. The questionnaire was sent to 742 former cardiac patients. We had a response rate of 69 percent. RESULTS: We found that preferences differed with respect to gender and age and that the offer of participation in cardiac rehabilitation activities was not highly valued by older patients, in particular among older men. CONCLUSIONS: The discrete choice experiment proved a valuable instrument for the measurement of preferences for cardiac rehabilitation. The study provides important information on patients' preferences for cardiac rehabilitation for healthcare professionals and decision makers.     

Waiting times and hospitalizations for ambulatory care sensitive conditions

Long waits for health care are hypothesized to cause negative health outcomes due to delays in diagnosis and treatment. This study uses administrative data to examine the relationship between time spent waiting for outpatient care and the risk of hospitalization for an ambulatory care sensitive condition (ACSC). Data on the number of days until the next available appointment were extracted from Veterans Affairs (VA) medical centers. Two methodological issues arose. First, the simultaneous determination of individual health status and wait times due to medical triage was overcome by developing an exogenous wait time measure. Second, selection bias due to unobserved case mix differences was minimized by separating in time the sample selection period from the period when wait times and outcomes were measured. Exogenous facility-level wait time was the main variable of interest in a fixed effects stacked heteroskedastic probit regression model that predicted the probability of ACSC hospitalization in each month of a six-month period. There was a significant and positive relationship between facility-level wait times and the probability of experiencing an ACSC hospitalization, especially for facility-level wait times of 29 days or more. Further research is needed to replicate these findings in other populations and among those with different clinical histories. As well, policymakers and researchers need an improved understanding of the causes of long wait times and interventions to decrease wait times.

Improving access to cardiac rehabilitation for remote Indigenous clients

OBJECTIVE: To identify barriers to Indigenous patients taking up a rural general practice-based cardiac rehabilitation program. We investigated the accessibility and appropriateness of the program and the role of Indigenous health workers (IHWs) in caring for Indigenous cardiac patients. METHODS: A cross-sectional survey of knowledge and views relating to cardiac rehabilitation was undertaken with 47 Indigenous cardiac patients and 41 health professionals in remote Queensland. RESULTS: Only three patients were fully engaged in the program. Reasons for non-participation included: lack of knowledge about rehabilitation, low income, and having a large extended family. Although the program incorporated a training component for IHWs covering prevention and follow-up, most did not monitor patients specifically for their heart problems and thought they did not have adequate skills. Shared care was occurring in some settings but without the participation of IHWs. CONCLUSIONS: There was general agreement that IHWs do have a role in cardiac rehabilitation. There is a need for ongoing in-service education or inclusion in training programs. Lack of understanding of the role of IHWs is a barrier to shared care. Cardiovascular disease needs to be addressed as part of the raft of chronic illnesses. IMPLICATIONS: Training about chronic illnesses and their management needs to be linked to structural adaptations in the delivery of health services to allow efficient use of each professional's skills. Clear role delineation needs to be negotiated to allow all health professionals to carry out their job effectively.     

Improving substance abuse data systems to measure 'waiting time to treatment': lessons learned from a quality improvement initiative

Robust data measurement systems assess health care performance and monitor population-level treatment trends. A key challenge in the assessment of substance abuse treatment is the development of systems to accurately monitor service delivery indicators. Wait time to treatment, as defined by the days between first request for service and first treatment, is an important measure of organizational process and delivery of care. The Network for the Improvement of Addiction Treatment emphasizes wait time as a primary outcome in their study of 201 addiction treatment agencies in the USA. This article describes the changes made in five state data systems to monitor wait times and outlines lessons learned that could be applied to other health data tracking systems.     

Adherence to a cardiac rehabilitation home program model of care: a comparison to a well-established traditional on-site supervised program

Despite the proven benefits of cardiac rehabilitation (CR), adherence to programs remains suboptimal. To improve adherence, alternative models of care, such as using home programs (HP), have been recommended. Little information exists, however, about its effect on adherence in real-world settings. Therefore, this study's primary objective was to compare adherence of patients in an HP and traditional on-site program (TP) model of CR. The secondary objective was to compare their clinical and demographic profiles and changes in cardiovascular fitness. We implemented a retrospective review of 200 consecutively enrolled patients who chose either a TP or HP model. Profile data was collected at intake assessment. Adherence, defined as attendance to prescheduled contacts or on-site visits in each respective cohort, served as a primary outcome measure. Secondary outcomes included completion of program and cardiopulmonary fitness levels at 6?months. We found that the HP cohort had patients who were significantly younger, male (significantly moreso than female), were more geographically removed from the on-site centre, were employed, and (or) had greater cardiopulmonary fitness at initiation. Similar mean attendance (p = 0.21) and completion rates (p = 0.22) were seen between models. Both groups attained similar gains in cardiovascular fitness (p = 0.79). Analysis of adherence shows the HP to be a suitable option for patients who face barriers for TP-CR participation.     

An audit of the management of melanoma patients at Glasgow Royal Infirmary 1998-2003

BACKGROUND: Melanoma is an important cause of morbidity and mortality. Recently published Scottish Intercollegiate Guideline Network (SIGN) guidelines outline standard management for melanoma patients in Scotland. METHODS: We audited the management of consecutive patients diagnosed with melanoma in Glasgow Royal Infirmary (1998-2003), using the SIGN guidelines as a gold standard. RESULTS: Of 102 patients, 41% were male and 59% were female. The mean ages of men and women were 58 and 50 years respectively. Fifty five per cent of all patients had a superficial spreading melanoma, and the median Breslow thickness was 0.64 mm. The most commonly affected site was the head and neck (29%). Most patients (87%) were referred by their general practitioner, but only 30% were marked as urgent by the referrer, and accordingly the median time to first appointment varied between 20 days (1998) and 52 days (2001). The most frequently noted suspicious feature was irregular pigmentation. The median time to biopsy was 6 days. Seventy-one per cent of patients had an excision biopsy, and of those who did not, most (71%) had lesions on the head and neck. There was poor recording of surgical margins (13%) and histological margins were used to determine the need for re-excision. The SIGN guidelines for re-excision and sentinel lymph node biopsy were closely followed. CONCLUSION: The SIGN guidelines for melanoma have been adhered to in our department, although time to first appointment exceeded national recommendations.     

Quality of life following participation in cardiac rehabilitation programs of longer or shorter than 6 months: does duration matter?

Cardiac rehabilitation (CR) participation results in significant health benefits. However, there is wide variation in program duration, and little is known about the optimal duration of CR for patient outcomes. The objective of this study was to compare quality of life (QoL) of patients who participated in CR programs of??0.0001), and PTGI (P?=?0.007) were significantly greater regardless of CR duration when compared to those who did not attend CR. There were no significant differences in outcomes when comparing patients attending CR programs of?相似文献   

Nutrition information needs during cardiac rehabilitation: perceptions of the cardiac patient and spouse

A survey instrument, which was developed from personal interviews with participants in a cardiac rehabilitation program, was administered at two hospital-based Phase II cardiac rehabilitation programs. Thirty-five patients (28 men, 7 women) and 29 spouses (5 men, 24 women) responded to survey items designed to investigate how subjects perceived themselves dealing with the cardiac diet, what questions they were asking, and how answers to those questions would help them. Subjects in the patient group (which was 80% male) most frequently asked questions dealing with compliance and the diet's benefits. Subjects in the spouse group (which was 83% female) most frequently asked questions relating to food selection. Participants indicated that having their questions answered would help them make decisions, be motivated, feel in control, and plan. Participants' overall attitude toward the diet was positive because patients were willing to make changes in their diet; however, more than half the sample thought food labels were difficult to understand and grocery shopping was difficult. We conclude that nutrition education programs that address individual needs and uses for nutrition information could enhance the learning process in group settings such as cardiac rehabilitation programs.