Social Smoking Environment and Associations With Cardiac Rehabilitation Attendance.

PURPOSE: Continued cigarette smoking after a major cardiac event predicts worse health outcomes and leads to reduced participation in cardiac rehabilitation (CR). Understanding which characteristics of current smokers are associated with CR attendance and smoking cessation will help improve care for these high-risk patients. We examined whether smoking among social connections was associated with CR participation and continued smoking in cardiac patients. METHODS: Participants included 149 patients hospitalized with an acute cardiac event who self-reported smoking prior to the hospitalization and were eligible for outpatient CR. Participants completed a survey on their smoking habits prior to hospitalization and 3 mo later. Participants were dichotomized into two groups by the proportion of friends or family currently smoking ("None-Few" vs "Some-Most"). Sociodemographic, health, secondhand smoke exposure, and smoking measures were compared using t tests and χ2 tests (P < .05). ORs were calculated to compare self-reported rates of CR attendance and smoking cessation at 3-mo follow-up. RESULTS: Compared with the "None-Few" group, participants in the "Some-Most" group experienced more secondhand smoke exposure (P < .01) and were less likely to attend CR at follow-up (OR = 0.40; 95% CI, 0.17-0.93). Participants in the "Some-Most" group tended to be less likely to quit smoking, but this difference was not statistically significant. CONCLUSION: Social environments with more smokers predicted worse outpatient CR attendance. Clinicians should consider smoking within the social network of the patient as an important potential barrier to pro-health behavior change.

The effect of executive function on adherence with a cardiac secondary prevention program and its interaction with an incentive-based intervention.

Participation in secondary prevention programs such as cardiac rehabilitation (CR) reduces morbidity, mortality, and hospitalizations while improving quality of life. Executive function (EF) is a complex set of cognitive abilities that control and regulate behavior. EF predicts many health-related behaviors, but how EF interacts with interventions to improve treatment adherence is not well understood. The objective of this study is to examine if EF predicts CR treatment adherence and how EF interacts with an intervention to improve adherence. Data were collected from 2013 to 2018 in Vermont, USA. 130 Medicaid-enrolled individuals who had experienced a qualifying cardiac event were enrolled in a controlled clinical trial and randomized 1:1 to receive financial incentives for completing secondary prevention sessions or to usual care. In this secondary analysis, effects of EF on CR adherence (defined as completing ≥30/36 sessions) were examined in 112 participants (57 usual care, 55 intervention) who completed an EF battery. Delay-discounting, a measure of impulsivity, predicted CR adherence (p = 0.01) and interacted with the incentive intervention, such that those who exhibited greater discounting of future rewards benefitted more from the intervention than those who discounted less (F(1, 104) = 5.23, p = 0.02). Better cognitive flexibility, measured with the trail-making-task, also predicted CR adherence (p = 0.02). While EF has been associated with adherence to a variety of treatment regimens, this interaction between an incentive-based intervention to promote treatment adherence and EF is novel. This work illustrates the value of considering individual differences in EF when designing and implementing interventions to promote health-related behavior change.

Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products.

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial.

OBJECTIVES: This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR). BACKGROUND: Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events. METHODS: A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO2) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year. RESULTS: Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079). CONCLUSIONS: Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).

A Systematic Review of the Diagnostic Accuracy of Depression Questionnaires for Cardiac Populations: IMPLICATIONS FOR CARDIAC REHABILITATION.

PURPOSE: Depression is overrepresented in patients with cardiovascular disease and increases risk for future cardiac events. Despite this, depression is not routinely assessed within cardiac rehabilitation. This systematic review sought to examine available depression questionnaires to use within the cardiac population. We assessed each instrument in terms of its capability to accurately identify depressed patients and its sensitivity to detect changes in depression after receiving cardiac rehabilitation. METHODS: Citation searching of previous reviews, MEDLINE, PsycInfo, and PubMed was conducted. RESULTS: The Beck Depression Inventory-II (BDI-II) and the Hospital Anxiety and Depression Scale (HADS-D) are among the most widely used questionnaires. Screening questionnaires appear to perform better at accurately identifying depression when using cut scores with high sensitivity and specificity for the cardiac population. The BDI-II and the HADS-D showed the best sensitivity and negative predictive values for detecting depression. The BDI-II, the HADS-D, the Center for Epidemiological Studies-Depression Scale, and the 15-item Geriatric Depression Scale best captured depression changes after cardiac rehabilitation delivery. CONCLUSIONS: The BDI-II is one of the most validated depression questionnaires within cardiac populations. Health practitioners should consider the BDI-II for depression screening and tracking purposes. In the event of time/cost constraints, a briefer 2-step procedure (the 2-item Patient Health Questionnaire, followed by the BDI-II, if positive) should be adopted. Given the emphasis on cut scores for depression diagnosis and limited available research across cardiac diagnoses, careful interpretation of these results should be done. Thoughtful use of questionnaires can help identify patients in need of referral or further treatment.

Posttraumatic stress disorder and tobacco use: A systematic review and meta-analysis.

Posttraumatic stress disorder (PTSD) and tobacco use are prevalent conditions that co-occur at striking rates in the US. Previous reviews examined prevalence and factors associated with cigarette smoking among individuals with PTSD but have not been summarized since 2007. Moreover, none explored rates and factors associated with the use of other tobacco products. This study aimed to systematically review the most recent literature examining the comorbidity of PTSD and tobacco use to provide prevalence rates, as well as summarize the literature exploring other factors associated with tobacco use among individuals with PTSD. Studies were identified using a systematic search of keywords related to tobacco use and PTSD within the following databases: PubMed, PsycINFO, Web of Knowledge, CINAHL, PsycARTICLES, and Cochrane Clinical Trials Library. The studies included in this review (N = 66) showed that the prevalence of current use of tobacco products in individuals with PTSD was 24.0% and the rate of PTSD among users of tobacco products was 20.2%. Additionally, results demonstrated that individuals with PTSD present with high levels of nicotine dependence and heavy use of tobacco products, as well as underscore the importance of negative emotional states as a contributing factor to tobacco use among individuals with PTSD. It is imperative that future studies continue monitoring tobacco use among individuals with PTSD while also assessing factors identified as having a prominent role in tobacco use among individuals with PTSD. These findings also demonstrate the need for more innovative approaches to reduce the pervasive tobacco use among individuals with PTSD.

Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine.

Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).

Patient Characteristics Predictive of Cardiac Rehabilitation Adherence.

PURPOSE: Cardiac rehabilitation (CR) is a program of structured exercise and interventions for coronary risk factor reduction that reduces morbidity and mortality rates following a major cardiac event. Although a dose-response relationship between the number of CR sessions completed and health outcomes has been demonstrated, adherence with CR is not high. In this study, we examined associations between the number of sessions completed within CR and patient demographics, clinical characteristics, smoking status, and socioeconomic status (SES). METHODS: Multiple logistic regression and classification and regression tree (CART) modeling were used to examine associations between participant characteristics measured at CR intake and the number of sessions completed in a prospectively collected CR clinical database (n = 1658). RESULTS: Current smoking, lower SES, nonsurgical diagnosis, exercise-limiting comorbidities, and lower age independently predicted fewer sessions completed. The CART analysis illustrates how combinations of these characteristics (ie, risk profiles) predict the number of sessions completed. Those with the highest-risk profile for nonadherence (<65 years old, current smoker, lower SES) completed on average 9 sessions while those with the lowest-risk profile (>72 years old, not current smoker, higher SES, surgical diagnosis) completed 27 sessions on average. CONCLUSIONS: Younger individuals, as well as those who report smoking or economic challenges or have a nonsurgical diagnosis, may require additional support to maintain CR session attendance.