Coronary artery disease
Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation

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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.

Section snippets

Study design/population

This 6-month randomized trial was initiated after approval from the institutional review board at a metropolitan hospital in the midwestern USA. The study design and protocol is summarized in Figure 1. Participants included first time referrals to a cardiac rehabilitation program after cardiovascular surgery or event. Patients were recruited within 2 weeks of entering cardiac rehabilitation and included men and women between 35 and 75 years of age who were classified as low to moderate risk7

Descriptive analyses

Baseline characteristics of the 80 randomized patients are listed in Table Iwith reference to those assigned to the TP and MP. The only significant difference between groups was a higher resting systolic blood pressure in the former. Selected demographic and psychosocial measures including socioeconomic status and social support were comparable in the 2 groups at baseline.

Exercise frequency data were obtained in 78 patients, and primary physiologic variables were documented in 67 patients over

Discussion

To date, only 1 randomized clinical trial has demonstrated greater improvements in both functional capacity and blood lipids using an off-site exercise intervention compared with a conventional facility-based traditional cardiac rehabilitation program.21 The present study showed a less staff-intensive, lower-cost MP, which emphasized independent exercise, and elicited comparable improvements in functional capacity and blood lipids when compared with their TP counterparts. Moreover, the MP

Acknowledgements

We are grateful to the following persons for their assistance with data collection and the implementation of the study protocols: Michelle Castro, BS, Lisa Dahlman, MS, MSW, Beverly Graves, RN, Steven Locke, BS, Kahn Nedd, MD, Susan Rozema, RN and Karen Seeling, RN. We would also like to thank Deborah Feltz, PhD, Randall Keyser, PhD, and Douglas Daly, MD, for the review of the proposed study protocol in the early stages, and Allen Shoemaker, PhD, for his statistical assistance.

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    This study was supported in part by Blodgett Memorial Medical Center Research Fund, East Grand Rapids, Michigan; the Kent County Health Department Cardiovascular Mini-Grant, and the Merck Pharmaceutical Educational Grant, Grand Rapids, Michigan. Manuscript received September 19, 1999; revised manuscript received and accepted January 17, 2000.

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