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Effect of Early Enrollment on Outcomes in Cardiac Rehabilitation

https://doi.org/10.1016/j.amjcard.2014.09.036Get rights and content

Outpatient cardiac rehabilitation (CR) is most beneficial when delivered 1 to 3 weeks after the index cardiac event. The effects of delayed enrollment on subsequent outcomes are unclear. A total of 1,241 patients were enrolled in CR after recent (<1 year) treatment of cardiac events or postcardiac surgery. Risk factors and metabolic equivalent levels (METs) during aerobic exercise were calculated before and after CR. The mean CR delay time was 34 days (maximum of 327). Delay time >30 days was associated with older age, female gender, nonwhite race, being unemployed, and increased length of hospital stay before CR after index cardiac event (p <0.05 vs 0 to 15 and 16 to 30 days for all comparisons). Patients with delay time >30 days had significant improvements in all CR metrics, but peak METs and weight improvements were lesser in magnitude compared with patients with CR delay times 0 to 15 and 16 to 30 days. After multivariate adjustment, delay time >30 days remained an independent predictor of decreased MET improvement compared with delay time 0 to 15 days (β = −0.59, p <0.001). In conclusion, time to enrollment in CR varies substantially and is independently linked to demographics and length of index hospital stay. Delayed enrollment in CR is directly related to patient outcomes. Although all patients showed improvements in key metrics regardless of delay time, CR was of greatest benefit, particularly for weight and exercise capacity, when initiated within 15 days of the index event.

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Methods

From January 2004 to August 2012, 1,241 consecutive patients were enrolled in the outpatient CR program at Wake Forest Baptist Medical Center within 1 year after interventions for coronary artery disease and/or valvular heart disease, including cardiothoracic surgery. Clinical data for this study were taken from patient records, and the study was approved by our institutional review board.

The details of our CR program have been previously outlined.4 Briefly, it consists of 3 sessions per week

Results

The distribution of time to enrollment in days was as follows: mean = 34.1 ± 34.8, median = 24, interquartile range = 16 to 37, ninety-ninth percentile = 197. Patients who enrolled >30 days after treatment of the index cardiac event were more often women, nonwhite, and older compared with those enrolling within 30 days (p <0.05 vs 0 to 15 days and 16 to 30 days for all comparisons; Table 1). Compared with those enrolling within 15 days, those who enrolled later than 30 days also had a higher

Discussion

As few as 30% of eligible subjects in the US participate in CR.2, 11 The strength of the primary physician's recommendation is a powerful predictor of enrollment,3 but co-morbidities, financial and/or insurance issues, travel times, and occupational considerations are also factors.2, 3, 11 In our study, later enrollees were more likely to be women, nonwhite, and have a lesser income, suggesting social factors also may determine the time to CR participation.

In a previous study of nearly 600

Acknowledgment

We are very grateful to Karen Klein of the Translational Science Institute, Wake Forest University Health Sciences, for editing the manuscript.

References (13)

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