Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients.

BACKGROUND: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its' worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting. METHODS: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. RESULTS: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). CONCLUSIONS: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.

Validation of a Scale to Assess Patients' Comprehension of Frequently Used Cardiology Terminology: The Cardiac TERM Scale in Brazilian Portuguese.

PURPOSE: The aim of this study was to psychometrically validate the translation of a questionnaire on patient understanding of cardiology terminology (TERM) to Brazilian Portuguese. DESIGN: After piloting the translation and cross-cultural adaptation, the 16-item TERM questionnaire was psychometrically tested. METHODS: Internal and test-retest reliability, as well as validity, were assessed in 322 cardiac patients. FINDINGS: Internal (α = .88) and test-retest reliability (all weighted Kappa > 0.63) exceeded the minimum recommended standards. Criterion validity was supported by significant differences in mean scores by socioeconomic indicators (p < .01). Discriminant validity was supported in that cardiac rehabilitation participants had significantly higher TERM scores (p < .001). Participants did not correctly define any of the terms, and a floor effect was identified in all terms. CONCLUSIONS: The Cardiac TERM Scale was demonstrated to have good reliability and validity. CLINICAL RELEVANCE: The scale can be used by healthcare professionals, such as nurses. Results can be used to inform patient education, which could in turn impact patient adherence to medical advice and hence outcomes.

Availability and characteristics of cardiac rehabilitation programs in one Brazilian state: a cross-sectional study.

BACKGROUND: Cardiac rehabilitation (CR) is a recommended model of care for cardiovascular diseases; however, is not widely available and is underutilized, especially in low- and middle-income countries. OBJECTIVES: To identify the CR programs available in one Brazilian state (Minas Gerais; MG) and describe their characteristics by funding type. METHODS: In this multi-center descriptive study, CR programs were identified in four MG regions and 41 CR coordinators were sent a survey to report the characteristics of their programs, including CR components described in guidelines and barriers to patients' participation. Descriptive and comparative analysis between public and private programs were carried out. RESULTS: Forty-one CR programs were identified, only 21.9% public. Nineteen completed the survey. The majority of CR programs offered initial assessment and physical training. Components of comprehensive CR programs that were rarely offered included treatment of tobacco dependence, psychological support and lipid control. Physical therapists were present in all CR programs. The six-minute walk test was used in most programs to assess functional capacity. Programs were located intra-hospital only in public hospitals. Phase 2 (initial outpatient) and phase 4 (maintenance) were offered significantly more in private programs when compared to public ones. The main barrier for CR participation was the lack of referral. CONCLUSIONS: The availability of CR programs in MG state is low, especially public programs. Most programs do not offer all core components of CR.

Perceptions of Cardiology Administrators About Cardiac Rehabilitation in South America and the Caribbean.

BACKGROUND: Cardiac rehabilitation (CR) programs can address the cardiovascular disease epidemic in South America. However, there are factors limiting CR access at the patient, provider, and system levels. The latter 2 have not been extensively studied. The objective of this study was to investigate cardiology administrator's awareness and knowledge of CR and perceptions regarding resources for CR. METHODS: This study was cross-sectional and observational in design. Cardiology administrators from South American and Caribbean countries were invited to participate by members of a professional association. Participants completed a questionnaire online. Descriptive analysis was performed and differences in CR knowledge, awareness, perception, and attitudes regarding CR were described overall, by institution funding source (private vs public) and presence of within-institution CR (yes vs no). RESULTS: Most of the 55 respondents from 8 countries perceived CR as important for outpatient care (mean ± SD = 4.83 ± 0.38 out of 5; higher scores indicating more positive perceptions), with benefits including reduced hospital readmissions (4.31 ± 0.48) and length of stay (4.64 ± 0.71 days), not only for cardiac patients but for those with other vascular conditions (4.34 ± 0.68 days). Those working in public institutions (50.9%) and in institutions without a CR program (25.0%) were not as aware of, and less likely to value, CR services (P < .05). Only 13.2% of programs had dedicated funding. CONCLUSIONS: Similar to findings from high-income settings, cardiology administrators and cardiologists in South America value CR as part of cardiac patient care, but funding and availability of programs restrict capacity to deliver these services.

Intensidade do treinamento durante a reabilitação física em hemiparéticos pós-acidente vascular encefálico e estresse cardiorrespiratório: uma revisão / Training intensity during conventional rehabilitation for post-stroke patients with hemiparesis and cardiorespiratory stress: a review

Introdução: A reabilitação física deveria ser realizada em intensidades capazes de promover estresse cardiorrespiratório adequado para minimizar o descondicionamento apresentado por indivíduos após Acidente Vascular Encefálico (AVE). Objetivo: Revisar a literatura acerca da intensidade das sessões de reabilitação física capazes de proporcionar estresse cardiorrespiratório em indivíduos pós-AVE. Métodos: Selecionaram-se estudos onde se avaliou o estresse cardiorrespiratório por meio da frequência cardíaca-alvo de indivíduos pós-AVE. A busca dos artigos foi realizada nas bases de dados Medline, SciELO, Embase e PEDro. Resultados: Foram encontrados três trabalhos transversais, e um longitudinal, com a amostra total de 78 hemiparéticos pós-AVE, totalizando 267 atendimentos. Em nenhuma das pesquisas a intensidade das sessões foi capaz de proporcionar estresse cardiorrespiratório adequado. A atividade com maior estresse cardiorrespiratório foi a marcha. Conclusões: A intensidade do exercício durante a reabilitação física não foi capaz de provocar efeitos cardiorrespiratórios adequados em indivíduos pós-AVE.

Introduction: Physical rehabilitation should have adequate intensities to provide cardiopulmonary stresses to minimize deconditioning presented by individuals post stroke. Objective: To review the literature regarding the intensity of the physical rehabilitation sessions, which were able to provide cardiorespiratory stresses in stroke subjects. Methods: This literature review included studies which evaluated cardiorespiratory stresses based upon the target heart rates of stroke subjects. A search of the literature was conducted in the Medline, SciELO, Embase, and PEDro databases. Results: Three cross-sectional and one longitudinal study were found, with the total sample of 78 stroke individuals; totalling 267 sessions. The results of all studies showed that the intensity of the sessions was not capable of providing adequate cardiopulmonary stresses. The activity which provided higher cardiorespiratory stresses was gait. Conclusion: Exercise intensity during physical rehabilitation is not able to provide adequate cardiorespiratory stresses in stroke individuals.

Study on functional cardiorespiratory changes after laparoscopic Nissen fundoplication.

PURPOSE: To analyze the behavior of cardiopulmonary function in postoperative of laparoscopic Nissen fundoplication. METHODS: Thirty-two patients, 13 males (41%) and 19 females (59%), were evaluated. Their age ranged from 25 to 67 years, with a mean of 44.4 ± 10.9. Pulmonary volumes, respiratory pressures and exercise tests were performed in the preoperative period (PRE) and in the first (PO1), second (PO2), fifth (PO5) and thirtieth (PO30) postoperative periods. RESULTS: Thirty-two patients were evaluated, of whom 59% were females. Mean age was 44.4 ± 10.9 years. Lung volumes had significant decrease at PO1 and PO2 and were similar to PRE values at PO5. Respiratory pressures were altered only at PO1. The distance covered in the 6-minute walk test had significant reduction until PO2, and climbing time in the stair-climbing test significantly increased at PO2. CONCLUSION: Patients submitted to LNF surgery have decreased cardiorespiratory function in the early postoperative period; however, they soon return to preoperative conditions.

Study on functional cardiorespiratory changes after laparoscopic Nissen fundoplication / Estudo das alterações funcionais cardiorrespiratórias após a fundoplicatura laparoscópica à Nissen

PURPOSE: To analyze the behavior of cardiopulmonary function in postoperative of laparoscopic Nissen fundoplication. METHODS: Thirty-two patients, 13 males (41%) and 19 females (59%), were evaluated. Their age ranged from 25 to 67 years, with a mean of 44.4 ± 10.9. Pulmonary volumes, respiratory pressures and exercise tests were performed in the preoperative period (PRE) and in the first (PO1), second (PO2), fifth (PO5) and thirtieth (PO30) postoperative periods. RESULTS: Thirty-two patients were evaluated, of whom 59% were females. Mean age was 44.4 ± 10.9 years. Lung volumes had significant decrease at PO1 and PO2 and were similar to PRE values at PO5. Respiratory pressures were altered only at PO1. The distance covered in the 6-minute walk test had significant reduction until PO2, and climbing time in the stair-climbing test significantly increased at PO2. CONCLUSION: Patients submitted to LNF surgery have decreased cardiorespiratory function in the early postoperative period; however, they soon return to preoperative conditions.

OBJETIVO: Analisar o comportamento da função cardiopulmonar no pós-operatório de fundoplicatura Nissen laparoscópica. MÉTODOS: Trinta e dois pacientes, 13 homens (41%) e 19 mulheres (59%) foram avaliados. A idade variou de 25 to 67 anos, com media de 44.4 ± 10.9. Os volumes pulmonares, as pressões respiratórias e testes de exercício foram realizados no período pré-operatório (PRE) e no primeiro (PO1), segundo (PO2), quinto (PO5) e trigésimo (PO30) períodos pós-operatórios. RESULTADOS: Trinta e dois pacientes foram avaliados, dos quais 59% eram do sexo feminino. A média de idade foi de 44,4 ± 10,9 anos. Os volumes pulmonares apresentaram diminuição significativa no PO1 e PO2 e foram semelhantes aos valores PRE no PO5. As pressões respiratórias estiveram alteradas apenas no PO1. A distância percorrida no teste da caminhada de 6 minutos apresentou redução significativa até o PO2, e o tempo de subida no teste de escada aumentou significativamente no PO2. CONCLUSÃO: Pacientes submetidos à FLN apresentaram diminuição da função cardiorrespiratória no início do período pós-operatório, no entanto, elas rapidamente regressaram às condições pré-operatórias.