Temporal Trends and Factors Associated With Cardiac Rehabilitation Participation Among Medicare Beneficiaries With Heart Failure

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Background Heart failure (HF) places a large burden on patients and society as a major cause of morbidity, mortality and healthcare costs. Participation in exercise-based cardiac rehabilitation (CR) in people with HF is a clinically and cost-effective strategy and recommended in international clinical guidelines. Purpose The aims of this study were to: (1) examine the temporal trends and predictors of national CR referral, and (2) compare the risk of hospital readmission and mortality in those referred for CR compared to no referral. Methods All patients in Denmark with incident HF were identified by the Danish Heart Failure Register in the period 2010 to 2018 (n = 33,257) and CR referral assessed within 120 days of hospital admission. Multivariable logistic regression models were used to evaluate the association between CR referral and predictors and to compare risk of hospital readmission and mortality until 1 year between referred and not referred patients. Results Overall, 45.0% of HF patients were referred to exercise-based CR, increasing from 31.7% in 2010 to 52.2% in 2018. Factors independently associated with higher CR referral were: NYHA functional class II, LVEF <50%, diagnosis of myocardial infarction and use of ACE inhibitor. Male gender, older age, region, unemployment, retirement, living alone, non-Danish ethnic origin, lower educational level, NYHA class IV, treatment for hypertension, existing chronic obstructive lung disease and stroke were associated with lower CR referral. CR referral was associated with lower risk of readmission (adjusted odds ratio: 0.90;95%CI: 0.85-0.95), HF-specific mortality (0.61; 0.39-0.95) and all-cause mortality (0.61; 0.55-0.69) as compared to no referral. Conclusions Although CR referral has increased over time, only some 1 in 2 diagnosed HF patients in Denmark are referred to exercise-based CR. CR referral is associated with lower risk in readmissions and mortality. Strategies to promote CR referral including healthcare professional education on the benefits of CR and alternative methods of CR delivery are urgently needed to improve access to CR, especially for high-risk groups.

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Early Increased Physical Activity, Cardiac Rehabilitation, and Survival After Implantable Cardioverter-Defibrillator Implantation

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.007580 ◽

2021 ◽

Author(s):

Brett D. Atwater ◽

Zhen Li ◽

Jessica Pritchard ◽

Melissa A. Greiner ◽

Yelena Nabutovsky ◽

...

Keyword(s):

Physical Activity ◽

Heart Failure ◽

Cardiac Rehabilitation ◽

Propensity Scores ◽

Time Frame ◽

Hazard Ratio ◽

Implantable Cardioverter Defibrillators ◽

Medicare Beneficiaries ◽

Icd Implantation ◽

All Cause Mortality

Background: Increased physical activity (PA) through cardiac rehabilitation (CR) improves outcomes in patients with heart failure and coronary disease, but CR referral remains infrequent. Implantable cardioverter-defibrillators (ICDs) can provide daily PA measurements to patients that may motivate them to increase PA, but it remains unclear if increased ICD measured PA is associated with improved outcomes with and without CR. Methods: This is a retrospective observational study of 41 731 Medicare beneficiaries with ICD implantation between January 1, 2014 and December 31, 2016. We linked daily ICD PA measurements and Medicare claims data to determine if increased PA is associated with a reduction in the likelihood of death or heart failure hospitalization. To determine if CR participation altered the effect of PA on outcomes, we performed two additional analyses matching CR participants and nonparticipants using propensity scores. The first match included demographics, comorbidities, and baseline PA measurements. The second match also included the change in PA measured during CR or the same time frame after ICD implant among nonparticipants. Results: The mean age was 75 (SD, 10) years, 30 182 beneficiaries (72.3%) were male, and 1324 (3%) participated in CR. Increased ICD detected PA was associated with improved survival. CR participants had a mean PA change of +9.7 (SD, 57.8) min/d, whereas nonparticipants had a mean change of −1.0 (SD, 59.7) min/d ( P <0.001). After matching for demographics, comorbidities and baseline PA, CR participants had significantly lower 1- to 3-year mortality (hazard ratio, 0.76 [95% CI, 0.69–0.85], P =0.03). After additionally matching for the ICD measured change in PA during CR there were no differences in mortality with and without CR (hazard ratio, 1.00 [95% CI, 0.82–1.21], P =0.87). Every 10 minutes of increased daily PA was associated with a 1.1% reduction in all-cause mortality in both groups. Conclusions: Among Medicare beneficiaries with ICDs, small increases in PA were associated with significant reductions in all-cause mortality.

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Factors Associated With Racial and Ethnic Diversity Among Heart Failure Trial Participants: A Systematic Bibliometric Review

Circulation Heart Failure ◽

10.1161/circheartfailure.121.008685 ◽

2021 ◽

Author(s):

Sunny Wei ◽

NhatChinh Le ◽

Jie Wei Zhu ◽

Khadijah Breathett ◽

Stephen J. Greene ◽

...

Keyword(s):

Heart Failure ◽

Ethnic Diversity ◽

Race And Ethnicity ◽

Temporal Trends ◽

People Of Color ◽

Unique Identifier ◽

Factors Associated ◽

Bibliometric Review ◽

Multivariable Regression ◽

Ethnicity Data

Background: Heart failure has a disproportionate burden on patients who are Black, Indigenous, and people of color (BIPOC), but not much is known about representation of these groups in randomized controlled trials (RCTs). We explored temporal trends in and RCT factors associated with the reporting of race and ethnicity data and the enrollment of BIPOC in heart failure RCTs. Methods: We searched MEDLINE, EMBASE, and CINAHL for heart failure RCTs published in journals with an impact factor ≥10 between January 1, 2000 and June 17, 2020. We used the Cochran-Armitage and Jonchkeere-Terpstra tests to examine temporal trends, and multivariable regression to assess the association between trial characteristics and outcomes. Results: Of 414 RCTs meeting inclusion criteria, only 157 (37.9% [95% CI, 33.2%–2.8%]) reported race and ethnicity data. Among 158 200 participants in these 157 RCTs, 29 512 (18.7% [95% CI, 18.5%–18.9%]) were BIPOC. There was a temporal increase in reporting of race and ethnicity data (29.5% in 2000–2003 to 54.7% in 2016–2020, P <0.001) and in enrollment of BIPOC (14.4% in 2000–2003 to 22.2% in 2016–2020, P =0.038). Trial leadership by a woman was independently associated with twice the odds of reporting race and ethnicity data (odds ratio, 2.0 [95% CI, 1.1–3.8]; P =0.028) and an 8.4% increase (95% CI, 1.9%–15.0%; P =0.013) in BIPOC enrollment. Conclusions: A minority of heart failure RCTs reported race and ethnicity data, and among these, BIPOC were under-enrolled relative to disease distribution. Both reporting of race and ethnicity as well as enrollment of BIPOC increased between 2000 and 2020. After multivariable adjustment, trials led by women had greater odds of reporting race and ethnicity and enrolling BIPOC. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42021237497.

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