ABSTRACT
Common concerns with the traditional protocol (TP) for cardiac rehabilitation include suboptimal program participation, poor facilitation of independent exercise, the use of costly continuous electrocardiographic (ECG) monitoring, and lack of insurance reimbursement. To address these concerns, a reduced cost-modified protocol (MP) was developed to promote independent exercise. Eighty low- to moderate-risk cardiac patients were randomized to a TP (n = 42) or a MP (n = 38) and were compared over 6 months on program participation, exercise adherence, cardiovascular outcomes, and program costs. During month 1, patients followed identical regimens, including 3 ECG-monitored exercise sessions/week, with encouragement to achieve >/=5 thirty-minute sessions/week. In week 5, the TP continued with a facility-based regimen including 3 exercise sessions/week for 6 months and used ECG monitoring the initial 3 months. The MP discontinued ECG monitoring in week 5 and were gradually weaned to an off-site exercise regimen that was complemented with educational support meetings and telephone follow-up. Compared with TP patients, MP patients had higher rates of off-site exercise over 6 months (p = 0.05), and total exercise (on site + off site) during the final 3 months (p = 0.03). Also, MP patients were less likely to drop out (p = 0.05). Both protocols promoted comparable improvements in maximal oxygen uptake (p <0.05), blood lipids (p <0.001), and hemodynamic measurements (p <0.002). The MP cost $738 less/patient than the TP and required 30% less staff (full-time equivalents). These results suggest that a reduced cost MP was as effective as an established TP in improving physiologic outcomes while demonstrating higher rates of exercise adherence and program participation. Thus, the MP or a similar protocol has applicability to hospitals with large capitated or managed care populations to provide cost-effective cardiovascular risk reduction to patients.
Subject(s)
Cardiac Rehabilitation , Exercise Therapy , Health Care Costs , Patient Participation , Adult , Aged , Cardiovascular Diseases/economics , Cardiovascular Diseases/physiopathology , Clinical Protocols , Cost-Benefit Analysis , Electrocardiography/economics , Exercise Therapy/economics , Exercise Therapy/methods , Female , Hemodynamics , Humans , Insurance, Health, Reimbursement , Male , Middle Aged , Patient Participation/economics , Patient Participation/methods , Treatment OutcomeABSTRACT
BACKGROUND AND METHODS: Peak oxygen consumption is a commonly accepted criterion in patient selection for cardiac transplantation. To determine the effect of various gas exchange sampling intervals on the variability of peak oxygen consumption, 15 consecutive patients evaluated for cardiac transplantation performed maximal treadmill testing using a ramped protocol. Oxygen consumption was measured via breath-by-breath analysis of expired air. Peak oxygen consumption was determined for each test using the following sampling intervals: 60-, 30-, and 15-s averages, eight breath rolling average, and true breath by breath. Variability of the mean peak oxygen consumption for each sample average was compared using analysis of variance on repeated measures. RESULTS AND CONCLUSIONS: Measures of peak oxygen consumption differed significantly (p<0.001) between sampling averages. A maximum variability of 20% was noted between the largest and smallest averages (13.8+/-4.2 mL/kg/min for 60 s vs 17.3+/-4.2 mL/kg/min for breath by breath). No significant difference was found between the 30-s, 15-s, and eight breath rolling averages (14.2+/-3.7 vs 14.5+/-3.9 vs 14.7+/-4.3 mL/kg/min), respectively. Results of the study suggest (1) the sampling average can have a significant effect on peak oxygen consumption influencing patient selection for transplantation, and (2) sample averages larger than breath by breath but smaller than 60 s be used for determination of peak oxygen consumption.
Subject(s)
Heart Transplantation , Oxygen Consumption , Exercise Test , Female , Heart Failure/physiopathology , Heart Failure/surgery , Humans , Male , Middle Aged , Respiratory Function Tests/methodsABSTRACT
The diagnosis of coronary artery disease remains a major problem in patients with end-stage renal disease. Screening with conventional noninvasive techniques is limited by the poor exercise capacity of these patients. This study evaluated the accuracy of digital subtraction fluorography in detecting coronary calcification as a noninvasive, nonexercise screening test for coronary artery disease. Eighty-six patients under evaluation for renal transplantation and considered at increased risk of coronary artery disease were studied by coronary arteriography and digital subtraction fluorography for coronary calcification. Significant coronary disease (greater than or equal to 50% obstruction in at least one vessel) was present in 36 (42%) patients. The detection of coronary calcification by digital subtraction fluorography had a sensitivity of 78% and a specificity of 66%. The probability of disease being present in the absence of coronary calcification in this group was 18%. The detection of coronary calcification by digital subtraction fluorography appears to be a satisfactory and inexpensive screening test in this setting.
