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Advance Program Speaker Index | Scientific & Clinical Abstracts

  

Thursday, September 4

213

11:30 AM – 12:30 PM

Scientific and Clinical Abstract Poster Presentations 

 
POSTER 01
SCIENTIFIC SUBMISSION
PRESENTER: Alexis Beatty
AUTHORS: Beatty, Alexis L.1; Fukuoka, Yoshimi4; Moskowitz, Judith T.1, 5; Whooley, Mary A.2, 3
INSTITUTIONS: 1. Medicine, UCSF, San Francisco, CA, United States. 
2. General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States. 
3. Epidemiology and Biostatistics, UCSF, San Francisco, CA, United States. 
4. Social and Behavioral Sciences, UCSF, San Francisco, CA, United States. 
5. Osher Center for Integrative Medicine, UCSF, San Francisco, CA, United States. 
ABSTRACT BODY: 
Introduction: 
Cardiac rehabilitation is one of nine performance measures for secondary prevention after acute myocardial infarction or revascularization. However, for a variety of reasons, it is vastly underutilized. A mobile application could promote access, participation, and adherence among patients in cardiac rehabilitation programs.

Purpose: 
To develop and test a novel mobile application for cardiac rehabilitation.

Design: 
Usability testing of a mobile application for cardiac rehabilitation. 

Methods: 
Based on behavior change theory, we developed an iOS-based mobile application (“FitHeart”) to improve the delivery of cardiac rehabilitation. The mobile application has 4 main sections: physical activity, risk factor management (blood pressure, glucose, cholesterol), nutrition (weight, calories), and mood. The mobile application enables patients to record and track physical activity, diet, and blood pressure. It also provides educational modules and programmed reminders that encourage the patient to set and track progress toward goals. We recruited participants with ischemic heart disease (prior myocardial infarction or revascularization) to conduct usability testing of the first design iteration of the mobile application. We observed participant use of the mobile application in a clinical research laboratory setting, measured task completion success rate, administered questionnaires about mobile application use, and conducted a semi-structured interview about use of the mobile application. Based on participant feedback, iterative revisions to the mobile application were made.

Results: 
Mobile application task completion success rate was 6/7 (86%). Participant rating of likelihood of using the mobile application was 97/100. Participant comments about the mobile application included “the visual representation of working towards goals is great” and “good that you have one that has everything in one place.” Features that were favorably received included ease of use of goal setting interface, educational modules, and mood section. Suggestions for improvement included the ability to automatically link with mobile device-based or peripheral sensors.

Conclusions: 
We created a mobile application for cardiac rehabilitation that demonstrates preliminary usability and acceptability. The potential for this mobile application to improve participation and adherence in cardiac rehabilitation deserves further study. 
 
POSTER 02
CLINICAL SUBMISSION
PRESENTER: Kim Bloch
AUTHORS (LAST NAME, FIRST NAME): Bloch, Kim K.1; Nystrom, Perry3; Wetzel, Steve2; Sampsell, Debi4; Gauder, Robert4
INSTITUTIONS (ALL): 1. Rehabilitation, Dayton VAMC, Dayton, OH, United States. 
2. Respiratory, Daytonc VAMC, Dayton, OH, United States. 
3. Medicine, Dayton VAMC, DAytonc, OH, United States. 
4. Nursing, Dayton VAMC, DAyton, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Patient education about chronic illness is best performed by a multidisciplinary team and should be part of routine visits to healthcare providers. Traditionally, teaching is static. In Patient Centered Care, interactive human patient simulators (HPS) can be incorporated into educational sessions to create a nonthreatening, interactive and realistic environment to enhance information transfer.

Purpose: 
To improve patient understanding about COPD and COPD self-management by using a human patient simulator in an educational session by a multidisciplinary team.

Significance: 
The amount of healthcare resources and finances for COPD care continues to increase. More effective interventions are needed to improve patient understanding of COPD and self-management proficiencies.

Design:
A multidisciplinary team conducted a prospective randomized IRB approved pilot study in veterans with severe COPD to participate in a three hour education session on self-management of COPD utilizing HPS. The study was IRB approved. Participants were asked to complete a pre/post session questionnaire. The 3 hour session consisted of a brief introduction to human patient simulator technology, an interactive clinic visit scenario, inhaled therapies, medications, and breathing devices, breathing techniques and exercises, aerobic exercises and strength training.

Methods:
Twenty three veterans provided informed consent to participate. All subjects have severe COPD by FEV1 criteria (FEV1<50% predicted). Subjects were randomized to routine care or a small group education class with HPS. A three hour educational session incorporated HPS in clinical scenarios and interactive teaching sessions by a multidisciplinary team.

Results:
8 subjects attended the education class with HPS. All participants rated the class as good to excellent; 7/8 reported HPS was an effective learning tool which they would recommend to others. 6/8 reported increased understanding about COPD, and 7/8 reported improved understanding about correct inhaled medication use, the importance of activity and plans to incorporate more activity and exercise into their daily routine. Five asked for devices to use at home.

Conclusions:  
Using HPS during small group education about COPD and COPD self-management appears to improve understanding about the disease, inhaled therapies, and the importance of activity. 

Implications:
Larger studies are needed to validate this conclusion and assess whether HPS interactive education with HPS is associated with a reduction in utilization of healthcare resources for COPD.
 
POSTER 03
CLINICAL SUBMISSION
PRESENTER: Melissa Bowman
AUTHORS (LAST NAME, FIRST NAME): Bowman, Melissa J.1; Hayes, Sharonne N.1; Thomas, Randal J.1; Squires, Ray W.1
INSTITUTIONS (ALL): 1. Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN, United States. 
ABSTRACT BODY: 
Introduction: 
Spontaneous coronary artery dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndromes (ACS) affecting primarily young, otherwise healthy women. Single or multivessel dissections may be present on coronary angiography. In-hospital and early outpatient outcomes are generally favorable, although recurrent dissection is not uncommon. The optimal management of SCAD remains uncertain.

Purpose: 
To describe the participation of two patients with three episodes of SCAD in Phase II early outpatient cardiac rehabilitation (CR).

Significance: 
Participation in CR after SCAD has not been previously reported.

Design:
We identified two female patients, ages 38 and 55 years, in whom SCAD was the cause of their three ACS (two non-ST-segment elevation [NSTEMI] and one ST-segment elevation myocardial infarctions [STEMI] in 2010, 2012, and 2013) and participated in CR after each event. One patient had two events (NSTEMI and STEMI 27 months apart; affecting three separate coronary arteries). The other had a single vessel dissection. All dissections were managed medically. Echocardiography in both patients revealed preserved left ventricular systolic function with regional wall motion abnormalities.

Methods:
CR began an average of 10 days post event (range 8-14 days). Patients completed an average of 32 CR sessions (range 28-36) over an interval of 3.2 months (range 2-4.5 months). Assessments at baseline and program completion included direct measurement of VO2peak, body composition via plethysmography and depression (PHQ-9). Patients received our standard education/counseling, including nutrition education. Exercise prescription followed our usual practice and included intensity at 60% to 70% of heart rate reserve and/or 12-14 on the Borg Perceived Exertion Scale (RPE) and goal session duration of 30-45 minutes. The following weekly session frequency and type was recommended: 2-4 supervised aerobic, 2-3 independent aerobic, 2-3 resistance training, and high-intensity aerobic exercise (RPE 15-17) included in 2-3 sessions/week.

Results:
CR was well-received. Patients did not report cardiac symptoms and there were no adverse events during exercise testing or training. VO2peak increased by an average of 5.5 ml/kg/min (23.5%). Changes in body composition included: ↓1.9kg body mass, ↓2.7kg fat mass, and ↑1.0kg lean mass. Mean PHQ-9 depression scores were 3.5 (minimal depression) at baseline and at program completion.

Conclusions:  
Standard CR beginning 1-2 weeks after SCAD appears to be feasible and safe and results in improved aerobic capacity and body composition. Patients did not show evidence of depression.

Implications:
Patients with SCAD should be referred to CR.
 
POSTER 04
CLINICAL SUBMISSION
PRESENTER: Jenna Brinks
AUTHORS (LAST NAME, FIRST NAME): Brinks, Jenna1; Franklin , Barry A.1; Boura, Judith1; Fowler, Amy1; Balagna, Emily1
INSTITUTIONS (ALL): 1. Preventive Cardiology and Rehabilitation, Beaumont Health System, Royal Oak, MI, United States. 
ABSTRACT BODY: 
Introduction: 
Traditional Phase 2 cardiac rehabilitation (P2CR) employs an entry exercise test (GXT). Patients are increasingly being referred without a GXT. 

Purpose: 
To evaluate if P2CR patients with or without an entry GXT demonstrate different selected outcomes and responses. 

Significance: 
Foregoing a GXT prior to P2CR may reduce healthcare costs and accelerate enrollment.

Design:
A retrospective analysis comparing outcomes in P2CR patients with and without a GXT.

Methods:
P2CR patients (n = 201) who completed ≥ 18 sessions were reviewed. Relevant data included GXT status, entry/exit training workloads and clinical responses. Pearson's Chi-square tests were used for analyses.

Results:
No differences were observed for patients who had a GXT (n = 57) as compared with those without a GXT (n = 144) for abnormal ECG findings (p = 0.32), cardiac symptoms (p = 0.62), hyper/hypotension (p = 0.60), and exertional hypoglycemia (p = 0.42). Patients with and without a GXT demonstrated 1.1- and 1.2-MET improvements in training workloads, respectively, with no major complications. 

Conclusions:
Foregoing an entry GXT had no significant adverse implications in P2CR. 

Implications:
Eliminating an entry GXT may be an effective method for delivering P2CR. 
 
POSTER 05
CLINICAL SUBMISSION
PRESENTER: Michelle Brown
AUTHORS (LAST NAME, FIRST NAME): Brown, Michelle R.1; Hester, Melinda A.2, 1; Schuller, Dan4, 3; Shehan, John C.3, 5; Haave, Scott H.2, 1
INSTITUTIONS (ALL): 1. Pulmonary Rehab, Bellevue Medical Center, Bellevue, NE, United States. 
2. Respiratory Care Services, Bellevue Medical Center, Bellevue, NE, United States. 
3. Pulmonary Medicine, Bellevue Medical Center, Bellevue, NE, United States. 
4. Pulmonary Medicine, Baylor University, Dallas, TX, United States. 
5. Pulmonary, Critical Care Medicine, Nebraska Methodist Hospital, Omaha, NE, United States. 
ABSTRACT BODY: 
Introduction: 
As healthcare goals realign with the Affordable Healthcare Acts Medicare Readmission Reduction Program (MRRP) and its penalty for 30 day hospital readmissions, a strategy to utilize the resources of PR to not only strengthen and improve patient outcomes, but also to decrease 30 day readmission rates was evaluated.

Purpose: 
The outcomes of an outpatient pulmonary rehab program (PR) in a small community hospital for stable patients with lung disease which has compromised their overall quality of life were evaluated. The hospital 30 day readmission rates were observed in the entire PR referral group to correlate the impact PR participation presents on readmissions.

Significance: 
Commitments to improved patient outcomes, reduced readmission in alignment with MRRP by encouraging participation in pulmonary rehab.

Design:
Inclusion criteria for the program consisted of a decreased ability to perform activities of daily living, or a decline in clinical, nutritional, psychosocial or strengthening status due to lung disease. Care plans included aerobic exercise, strengthening strategies, education, nutritional and psychosocial support. Program duration of 18 to 36 sessions, was relative to diagnosis. All program referrals to the program were monitored for hospital readmissions for 6 months before and after program initiation. 

Methods:
Health related quality of life (HRQOL) was assessed using the St. George Respiratory Questionnaire (SGRQ), which was administered at the initial and final PR sessions. A minimal clinically important difference (MCID) of 4 units SGRQ total score was measured. Patient outcomes were evaluated with standard EXCEL (2010 Microsoft, Redmond, WA) applications using histogram analysis of the data. 30 day readmissions were compared with the referral group using Excel Q1Macros 2013 Chart Analysis. Six month pre-post program readmission data was collected. Control group consisted of referrals that met criteria but declined.

Results: The number needed to treat (NNT) was 4.57 showing the number of participants in PR to prevent one readmission in 30 days. The control group were those referred, meeting criteria, but declined participation. 60% of the participants showed a MCID > 4 units on their SGRQ total score. 

Conclusions:  
PR participation can improve the patients’ quality of life, and also adds the potential financial benefit to the healthcare system associated with the reduction in 30 day hospital readmissions

Implications:
MRRP has strengthened our resolve as healthcare providers to improve PR as a tool to accomplish our commitment to our patients as well as address 30 day readmissions.

 
 
POSTER 06
SCIENTIFIC SUBMISSION
PRESENTER: Chris Garvey
AUTHORS: Ryan, Coleman 3, 2; Pliam, Michael3, 2; Garvey, Chris1, 3; Constantino, Richard 3, 1; Zierke, Jennifer 3, 1; Cavalieri, Michelle 3, 1; Rigler, Julia1, 3
INSTITUTIONS: 1. Pulmonary Rehabilitation, Seton Medical Center, Daly City , CA, United States. 
2. Cardiology , Seton Medical Center, Daly City , CA, United States. 
3. Cardiac Rehabilitation , Seton Medical Center, Daly City , CA, United States. 
ABSTRACT BODY: 
Introduction: 
Limited evidence is available of the impact of Cardiac Rehabilitation (CR) in ethnic subpopulations including Asian Americans. 

Purpose: 
This study describes CR outcomes with subanalysis of Asian American attendees. 

Design: 
A database analysis comparing aggregate pre and post CR findings and outcomes with t-Test of paired data using SPSS 12.0 statistical software.

Methods: 
Data from 426 CR patients [n = 234 (54.9%) males] from 2010 through 2012: mean age 66 (+/- 12.19), range 26 to 92] yrs. Ethnicity: 164 (38.5%) Asian, 138 (32.4%) Caucasian, 8 (1.9%) Hispanic, 34 (8.0%) other. 338 (79.3%) had coronary artery disease (CAD) and 88 (20.7%) had valvular heart disease and / or heart failure. Of CAD patients, 7 had MI, 25 had MI + CABG, 59 had MI and PTCA, 144 (33.8%) had diabetes. Self-administered Duke Activity Status Index (DASI), Short Form 36 and Patient Health Questionnaire (PHQ-9) were colledted pre and post CR. 

Results: 
For all 426 patients there was significant differences pre and post CR DASI (22.7 (+/- 12.7) vs. 29.5 (+/- 14.8), p < 0.000), SF36_Phys 40.7 (+/- 8.4) vs. 44.9 (+/- 8.4), p < 0.000), SF36_Ment 47.4 (+/- 11.1) vs. 51.0 (+/- 10.2), p < 0.000), and PHQ9 4.9 (+/- 4.5) vs. 3.3 (+/- 3.3), p < 0.000). Weight was reduced (173.5 lbs (+/- 42.0) vs. 172.7 lbs (+/- 41.7), p < 0.013) and BMI (28.26 (+/- 5.68) vs. 28.13 (+/- 5.66) p < 0.000). 100 patients failed to complete CR due to: high co- pay (12), hospital readmission (12), return to work (17), other (59). Compared to non-Asians, Asians were younger [64.6 yrs (+/- 11.94) vs. 67.64 yrs (+/- 12..25), p < 0.017], improved more on SF36_Phys [5.48 (+/- 7.39) vs. 2.95 (+/- 7.49), p < 0.024], did slightly better on DASI [7.68 (+/- 12.93 vs. 6.01 (+/-11.62), p = 0.397] and PHQ-9 [2.41 (+/- 0 .71) vs. -0.90 (+/- 3.36), p - 0.073], but showed no differences in weight, BMI, or mean BP. 

Conclusions: 
The analysis demonstrates significant benefits of CR. Asian patients tended to be younger and showed more improvement in physical capability. These observations validate those of others that CR is an important adjunct for patients with cardiac disease in an ethnically heterogeneous patient population.
 
POSTER 07
SESSION SUBMISSION
PRESENTER: Donna Donakowski
AUTHORS (LAST NAME, FIRST NAME): Donakowski, Donna1
INSTITUTIONS (ALL): 1. Henry Ford Macomb Hospital, Rochester Hills, MI, United States. 
ABSTRACT BODY: 
Detailed Description:
Create an atmosphere for your customers and staff that ROCKS! The key is to provide a comprehensive, quality program specifically designed for "sellout" audiences. In this session participants will learn techniques to insure your cardiac and pulmonary rehab program delivers the highest quality, most comprehensive service available in regards to AACVPR certification, CMS reimbursement and Continuous Quality Improvement (Outcomes).
Envision "Rock Star" treatment for your patients and staff to create long term loyal fans, encore after encore! This motivating program will provide useful resources, comprehensive reimbursement information and the latest trends in process improvements, customer service and employee satisfaction.


Session Objectives:
Understand how AACVPR certification improves staff and customer satisfaction.
Discuss CMS reimbursement regulations and how to optimize program policies to insure compliance with CMS requirements.
Demonstrate the use of PDCA cycles to insure Continuous Quality Improvement (Outcomes) utilization.
 
POSTER 08
CLINICAL SUBMISSION
PRESENTER: Kariann Drwal
AUTHORS (LAST NAME, FIRST NAME): Drwal, Kariann R.1, 2; Wakefield, Bonnie 1, 2; Scherubel, Melody 1, 2; Kaboli, Peter 1, 2
INSTITUTIONS (ALL): 1. Veterans Rural Health Resource Center-Central Region, VA Office of Rural Health, Iowa City VA Healthcare System, Iowa City , IA, United States. 
2. The Comprehensive Access and Delivery Research and Evaluation Center, Iowa City VA Healthcare System, Iowa City , IA, United States. 
ABSTRACT BODY: 
Introduction: 
A home-based cardiac rehabilitation (CR) model has been implemented within some Veterans Affairs (VA) Medical centers.

Purpose: 
To address access and attendance in CR, we developed and evaluated a home-based CR program in 2011. We are now disseminating the program to additional VA sites. 

Significance: 
Very few VA medical centers offer on-site CR. Patients at facilities without CR have the option to travel to a non-VA Hospital for center-based CR. However, barriers such as lack of transportation, employment conflicts, geographic location, and family obligations often prevent attendance. Therefore, following the successful implementation and evaluation of this home-based CR Program at one VA site, the Office of Rural Health (ORH) has funded the dissemination and implementation to additional VA sites. 

Design:
A blended facilitation implementation approach is being used as four additional VA sites adopt and implement the home-based CR model.

Methods:
Tool kit materials are provided to each site including an implementation manual and patient education workbook. There are scheduled monthly teleconference meetings including program training, guidance with implementation, and discussion addressing concerns and questions. Other meetings and individual consultation occur as needed. Each site’s program director is responsible for overseeing the implementation of the twelve week telephone based CR program. In addition to evaluating enrollment numbers, a qualitative analysis will be conducted to assess barriers and facilitators of implementation. 

Results:
Four of the sites have hired program staff. All sites have received the program tool kit including guidance and counseling on the use of the materials and the implementation timeline and process. Active monthly teleconference meetings, site meetings and communication, and one site visit has taken place. Development of the clinic structure, note templates, scheduling, coding, and the consult process has occurred. Two sites are actively enrolling patients. In addition there will be a completed qualitative analysis addressing barriers, facilitators, and solutions to implementation. Enrollment rates addressing referral, participation, completion, and drop-out, and number of rural participants will be assessed.

Conclusions:  
The Home-based CR program has provided additional VA sites with an alternative addressing access to care especially for rural veterans.

Implications:
Five VA sites are actively adopting and implementing a home-based CR program. There is support for expansion of this program to additional VA sites within the next year. This program has been able to help serve a greater number of patients and has brought care closer to the veteran. 
 
POSTER 09
SCIENTIFIC SUBMISSION
PRESENTER: Edward Davila
AUTHORS: Davila, Edward1, 2; Wishman, Ashley1; Henslee, Kiersten1; McNamara, Mike3
INSTITUTIONS: 1. Cardiac and Pulmonary Rehabilitation, Bozeman Deaconess Hospital, Bozeman , MT, United States. 
2. Recreational Sports and Fitness, Montana State University, Bozeman, MT, United States. 
3. Montana Department of Public Health and Human Services , , Helena, MT, United States. 
ABSTRACT BODY: 
Introduction: 
Cardiac rehabilitation exercise training has been shown to confer many clinical benefits in patients with heart failure (HF). With more than 650,000 new cases diagnosed each year the importance of continuing to elucidate the benefits of exercise training in this population will continue to rise. 

Purpose: 
The aim of the current study was to evaluate the effectiveness of 13 cardiac rehabilitation sessions on function capacity, physical and mental health, quality of life, and dietary habits in a group of HF patients. Our hypothesis was that 13 sessions of contemporary cardiac rehabilitation would significantly improve functional capacity, physical and mental health, quality of life, and dietary habit scores when compared to baseline. 

Design: 
The current study was a retrospective cohort study. 

Methods: 
Data from 13 adults (Mean ± SD: 66.9 ± 11.7 yr, 171.7 ± 12.4 cm, 84.8 ± 12.6 kg) with diagnosed HF were used in the current analyses. Patients underwent clinically supervised exercise training in cardiac rehabilitation two times a week for a total of 13 sessions. Prior to starting the program, and at the end, all patients completed a 6MWT and five qualitative outcome surveys; the Duke Activity Status Index (DASI), Dartmouth COOP, Patient Health Questionnaire (PHQ-9), Dietary Fat Screener, and Sodium Intake Screener. The DASI questionnaire was used to measure functional capacity whereas the Dartmouth COOP and PHQ-9 questionnaires were used to measure quality of life/health status and mental health, respectively. The Dietary Fat Screener and Sodium Intake Screener were used to measure dietary behaviors. Data were analyzed using paired t-tests to compare pre- and post-assessment values in order to determine statistical significance. A Bonferroni correction was applied to the statistical comparisons to correct for potential inflation of the overall type I error rate, resulting in an alpha level of <0.008 being required for statistical significance. 

Results: 
6MWT and DASI results significantly improved after 13 sessions of cardiac rehabilitation when compared to baseline (p < 0.008). In contrast, the Dartmouth COOP, PHQ-9, Sodium Intake Screener, and Dietary Fat Screener values were statistically similar between pre-and post-assessments after 13 cardiac rehabilitation sessions.

Conclusions: 
Findings from the current study suggest that 13 sessions of cardiac rehabilitation may improve functional capacity in HF patients. However, additional visits may be necessary to impact other key outcome indicators.
 
POSTER 10
CLINICAL SUBMISSION
PRESENTER: Kathy Harris
AUTHORS (LAST NAME, FIRST NAME): Harris, Kathy N.1
INSTITUTIONS (ALL): 1. C-P Rehab, Robinson Memorial Hospital, Ravenna, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Stress reduction is an important aspect of cardiac rehabilitation (CR), yet most programs do not provide adequate tools for stress reduction. 

Purpose: 
This evidence-based project was designed to address whether routinely incorporating a stress reduction technique during CR would improve patients’ stress coping and increase educator satisfaction. 

Significance: 
CR patients often experience stress, worry, and anxiety, which can lead to depression. Depression can inhibit healing, decrease patient compliance, and is an independent risk factor for coronary artery disease. By providing stress reduction techniques in CR we may be able to help patients cope with stress, potentially reducing depression, increasing compliance and improving outcomes. 

Design:
In RMH’s CR, the three minute mindfulness technique (3MMT; a stress reduction tool), was traditionally provided once during the 9-week series. Based on an extensive literature search, data support that the 3MMT is beneficial for decreasing pain, depression and anxiety, but is seldom used in CR. To increase expose and usage we began offering it weekly. As an outcome variable, we measured whether patients were using the 3MMT out of class and patients’ overall health. Additionally, we surveyed CR educators about patient participation in class and about their own in-class stress. 

Methods:
From April to November 2013, we incorporated the 3MMT in CR one time per week for 9 weeks. At every CR session, patients were surveyed about 3MMT use outside of class and overall health; qualitative data were analyzed using content analysis to determine themes. Educators provided periodic feedback on the 3MMT implementation.

Results:
Out of the 58 patients who completed the 9-week series 42 (72%) reported using the 3MMT daily, outside of class, with positive outcomes. Patients reported using 3MMT for sleep and to cope with unexpected stressful events. Educators felt less stressed during class and reported that the weekly 3MMT protocol promoted a calm atmosphere which increased patient engagement. 

Conclusions:  
With minimal financial and time commitments this project has demonstrated positive outcomes for patients and staff. This technique can be incorporated easily and has potential to be incorporated into other areas of health care. 

Implications:
We have anecdotally shown that weekly 3MMT education can aid in patients’ stress coping. Due to the link between stress and depression, increased coping may benefit mental health status, increase healing, and increase patient compliance. In light of these results, we have approval from the human subjects review board to conduct a larger retrospective chart review project.
 
POSTER 12
SCIENTIFIC SUBMISSION
PRESENTER: Jae-Young Han
AUTHORS: Han, Jae-Young1; Seon, Hyo-Jeong1; Yun, Hyun-Sik1; Choi, In-Sung1; Lee, Sam-Gyu1
INSTITUTIONS: 1. Physical and Rehabilitation Medicine, Research Institute of Medical Sciences, Cardiovascular Research Institute, Chonnam National University Medical School & Hospital, Gwangju , Korea, Republic of. 
ABSTRACT BODY: 
Introduction: 
Obesity is strongly associated with coronary heart disease and it is known as an independent risk factor. A few study of the effectiveness of cardiac rehabilitation (CR) among the obesity were published. And, little is known about the effects between obese and non-obese patients for Asian. 

Purpose: 
To compare the effect of CR on functional capacity between obese and non-obese patients with AMI in Asian.

Design: 
case-control study

Methods: 
One hundred sixty three AMI patients referred for CR after PCI. These patients were divided into two groups, Obese group (BMI≥25) and non-obese group (BMI<25). All patients were evaluated to statistic analysis about HRrest, HRmax, SBPrest, METs, total exercise duration (TED) and VO2max.

Results: 
1) Obese groups had significant improvement between before and after in HRrest (p=0.005), METs (p=0.047), TED (p=0.001). 2) Non-obese groups had significant improvement between before and after in HRrest (p=0.001), SBPmax (p=0.024), METs (p=0.001), TED (p=0.001), VO2max (p=0.000). 3) There was no significant difference in changing ratio of cardiopulmonary exercise capacity between obese and non-obese groups.

Conclusions: 
Our study revealed that CR result in significant improvement in functional capacity at all levels of BMI in patients with AMI. 
 
POSTER 13
SCIENTIFIC SUBMISSION
PRESENTER: Jenny Adams
AUTHORS: Adams, Jenny1; Shock, Tiffany1; Qin, Huanying2; Bilbrey, Tim1
INSTITUTIONS: 1. Cardiac Rehabilitation, Baylor Hamilton Heart and Vascular Hospital, Dallas, TX, United States. 
2. Quantitative Sciences, Baylor Health Care System, Dallas, TX, United States. 
ABSTRACT BODY: 
Introduction: 
The loss of shoulder flexibility (abduction in particular) during aging is likely to reduce independence by impairing the performance of everyday activities such as washing hair, reaching objects in overhead cabinets, and changing light bulbs. Inclinometry is a straightforward way of measuring shoulder abduction that can be used not only to capture outcomes data in the cardiac rehabilitation setting but also to study the factors that are associated with reduced shoulder flexibility.

Purpose: 
To measure and compare the degrees of shoulder abduction in sternotomy and non-sternotomy patients in a cardiac rehabilitation setting.

Design: 
In a pilot study, inclinometry was used to measure right and left shoulder abduction in 36 cardiac rehabilitation patients (12 women and 24 men, aged 25 to 86 years), enabling the comparison of data from those with and without a sternotomy.

Methods: 
During a cardiac rehabilitation session, an exercise physiologist used an inclinometer to measure right and left shoulder abduction. A t test was utilized to evaluate the difference in shoulder abduction between sternotomy patients and non-sternotomy patients. 

Results:
Sternotomy patients had fewer degrees of abduction than non-sternotomy patients in both the right and left shoulders, but the differences were not significant. Sternotomy patients also showed fewer degrees of abduction in the right shoulder than in the left. A multivariable regression analysis revealed that age (p = 0.03) was significantly associated with degrees of right shoulder abduction when adjusting for sternotomy status. Further subgroup analysis suggested that age only significantly affected sternotomy patients (p = 0.007). 

Conclusions:
Inclinometry testing is an effective and well-tolerated way to quantify degrees of shoulder abduction in a cardiac rehabilitation setting. Even though the differences between the sternotomy and non-sternotomy patients were not significant in this pilot study, the variables of patient age and arm dominance may be relevant. Further studies are needed to assess the benefit of measuring shoulder abduction in the course of cardiac rehabilitation.
 
POSTER 14
SCIENTIFIC SUBMISSION
PRESENTER: Joel Hughes
AUTHORS: Hughes, Joel1; Dolansky, Mary A.3; Hawkins, Misty1; Redle, Joseph2; Gunstad, John1; Fulcher, Michael2; Moore, Shirley M.3; Josephson, Richard A.4
INSTITUTIONS: 1. Kent State University, Kent, OH, United States. 
2. Center for Cardiopulmonary Research, Summa Health System, Akron, OH, United States. 
3. Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, United States. 
4. Harrington Heart & Vascular Institute, University Hospitals Health System, Cleveland, OH, United States. 
ABSTRACT BODY: 
Introduction: 
CMS has proposed a coverage policy for cardiac rehabilitation (CR) among patients with heart failure (HF). Eligible patients were defined as Medicare beneficiaries with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal HF therapy for at least six weeks. CR is an ideal venue for addressing the unique needs of these patients. As CR enrollment increases with newly referred HF patients, understanding characteristics of eligible HF patients may help in defining appropriate targets for intervention. 

Purpose: 
To describe a cross-sectional sample of HF patients who would be eligible for CR under the proposed coverage with respect to basic demographics, BMI, depression, social support, cognitive status, knowledge of HF, and sodium excretion. 

Design: 
This is an observational, cross-sectional study from a larger prospective cohort study enrolling patients with HF.

Methods: 
Participants were 212 predominantly Caucasian (79%) English-speaking HF patients (59% male) aged 50-85 years. Cognitive status was measured with the 3MS. Depression, social support, and HF knowledge were measured with self-report measures (see Table 1). Sodium excretion was measured with a 24-hour urine collection. Descriptive statistics were used for analyses.

Results: 
Patient characteristics are presented in Table 1. Patients were generally overweight or obese. Most (63%) were consuming more sodium than recommended by AHA guidelines, 36% evidenced cognitive impairment, and 14% had elevated depression symptoms.

Conclusions: 
Most patients were overweight and consuming too much sodium. Many had mild cognitive impairment, and some evidenced psychosocial stress. Screening HF patients for some of these clinical targets could aid treatment planning. Most HF patients would benefit from focused dietary education (i.e., weight loss, sodium restriction). These patients were volunteers in a larger study, and may reflect more motivated individuals. Not all eligible HF patients will enroll in CR, and future studies should evaluate how CR enrollees with HF may differ from the broader HF population. 
 
POSTER 15
SCIENTIFIC SUBMISSION
PRESENTER: Joel Hughes
AUTHORS: Hawkins, Misty1; Dolansky, Mary A.2; Shaefer, Julie T.1; Fulcher, Michael3; Gunstad, John1; Redle, Joseph3; Josephson, Richard A.4, 5; Hughes, Joel1, 3
INSTITUTIONS: 1. Kent State University, Kent, OH, United States. 
2. School of Nursing, Case Western Reserve University, Cleveland, OH, United States. 
3. Cardiovascular Research, Summa Health System, Akron, OH, United States. 
4. School of Medicine, Case Western Reserve University, Cleveland, OH, United States. 
5. Harrington Heart & Vascular Institute, University Hospitals Health System, Cleveland, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Patients with heart failure (HF) have high rates of cognitive impairment and depressive symptoms. Depressive symptoms have been associated with greater cognitive impairments in HF; however, it is not known whether particular clusters of depressive symptoms are more detrimental to cognition than others. 

Purpose: 
To identify whether somatic and/or nonsomatic depressive symptom clusters were associated with cognitive function in persons with HF.

Design: 
This is an observational, cross-sectional study from a larger prospective cohort study enrolling patients with HF.

Methods: 
Participants were 326 HF patients (40.5% female, 26.7% minority status, aged 68.6±9.7 years). Depressive symptoms were measured using a depression questionnaire commonly used in medical populations: the Patient Health Questionnatire-9 (PHQ-9). Somatic and Nonsomatic subscales scores were created using previous factor analytic results. A neuropsychological battery tested attention, executive function, and memory. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and medical factors were conducted. 

Results:
Regressions revealed that PHQ-9 Total was associated with Attention (β=-.14, p=.008) and Executive Function (β=-.17, p=.001). When analyzed separately, the Nonsomatic subscale – but not the Somatic symptoms subscale (ps≥.092) – was associated with Attention scores (β=-.15, p=.004) and Memory (β=-.11, p=.044). Both Nonsomatic (β=-.18, p<.001) and Somatic symptoms (β=-.11, p=.048) were related to Executive Function. When included together, only the Nonsomatic symptom cluster was associated with Attention (β=-.15, p=.020) and Executive Function (β=-.19, p=.003). 

Conclusions: 
Greater overall depressive symptom severity was associated with poorer performance on multiple cognitive domains, an effect driven primarily by the nonsomatic symptoms of depression.
 
POSTER 16
CLINICAL SUBMISSION
PRESENTER: Patti Killingsworth
AUTHORS (LAST NAME, FIRST NAME): Killingsworth, Patti 1
INSTITUTIONS (ALL): 1. Cardiac Rehabilitation, Banner Health, Phoenix, AZ, United States. 
ABSTRACT BODY: 
Introduction: 
Frequently restrictions given to patients (sternal precautions), and activity progression are based on tradition and belief rather than clinical evidence.

Purpose: 
Overly restricting physical activity may hinder optimal sternal healing and physiologic recovery. A progressive, evidence based, precautionary approach rather than restrictive approach will facilitate optimal sternal healing and functional recovery. 

Significance: 
A review of practices in a large hospital system found patient education of sternal precautions and activity progression was highly varied. Instruction was provided by numerous clinical staff including physicians, nurses, therapists, and others, and at times was contradictory. Written instruction was often not evidence-based, occasionally teaching was solely verbal. In some hospitals no formal written guidelines existed. Activity progression and home exercise guidance also varied. 

Design:
An interdisciplinary and interhospital partnership was created to develop and implement a Midline Sternotomy Recovery Plan, ensuring all health system patients receive simplified, consistent, evidence based education and activity guidelines from all caregivers. 

Methods:
Initially a Midline Sternotomy Management Survey was sent out regarding care and patient instruction. A thorough literature review regarding activity guidelines was conducted. Existing clinical practice guidelines and patient and staff education materials were reviewed in addition to review of actual clinical practices in all facilities. A Clinical Practice Guideline was created based on clinical evidence in the literature, existing guidelines, and best practices within the hospital system. A simplified Midline Sternotomy Recovery Plan (MSRP) was developed. Standardized protocols including ROM exercises and progressive ambulation were created. Standardized patient education materials were developed and rolled out system-wide. 

Results:
The Clinical Practice Guideline and Midline Sternotomy Recovery Plan was adopted and fully implemented in 9 hospitals in 2 states.

Conclusions:  
Creation of a multi-disciplinary, multi-factility standardized practice is truly challenging and time-consuming. All participants must commit to the idea that a progressive, evidence based, and precautionary approach to post sternotomy care is in the best interest of staff and patients.

Implications:
Education of providers to ensure consistency in education and continued care for patients in transition from hospital to home to out-patient cardiac rehabilitation. Work is ongoing on standardized documentation of education and activity in the EMR. Data collection is ongoing to measure the effect on length of stay, rate of complications, and patient satisfaction. 

 
POSTER 17
CLINICAL SUBMISSION
PRESENTER: Jong-Young Lee
AUTHORS (LAST NAME, FIRST NAME): Lee, Jong-Young1
INSTITUTIONS (ALL): 1. asan medical center, Seoul, Korea, Republic of. 
ABSTRACT BODY: 
Introduction: 
Cardiac rehabilitation (CR) could reduce cardiovascular mortality and morbidity in coronary artery disease. Long coronary artery lesions may be associated with adverse outcomes after drug-eluting stent (DES) implantation.

Purpose: 
The purpose of this study was to evaluate angiographic outcomes after a comprehensive CR program in patients with DES for long coronary artery lesions.

Significance: 
After stenting, the role of cardiac rehabilitaiton might be underestimated.

Design:
Prospective cohort analysis of CR participation was used.

Methods:
A total of 576 patients with long coronary lesions (≥25 mm) were enrolled. Comprehensive CR programs were successfully performed on 288 (50%) patients. The primary endpoint was in-stent late luminal loss at the 9-month angiographic follow-up. 

Results:
There were few significant differences in baseline characteristics between the CR and non-CR group, including clinical, angiographic, and procedural variables. The CR group showed a rate of in-stent late luminal loss that was 35% less than that for the usual care group (0.19±0.33 mm in CR vs. 0.29±0.45 mm in non-CR; difference, 0.08 mm; 95% confidence interval, 0.01 to 0.16; P=0.02) at the 9-month follow-up. After a propensity-matched analysis (224 pairs), the results were consistent (0.18±0.31 mm in CR vs. 0.28±0.41 mm in non-CR; difference, 0.10 mm; 95% confidence interval, 0.02 to 0.18; P=0.02). The CR group showed a highly significant improvement in the overall risk profile compared to the non-CR group, including current smoking, HDL, hsCRP, HbA1C, depression, obesity, and exercise capacity. 

Conclusions:  
The comprehensive CR program could significantly reduce late luminal loss after DES implantation for long coronary lesions, which might be associated with a significant improvement in exercise capacity and overall risk profile.

Implications:
We can manage intensively using cardiac rehabilitation even after long-coronary artery stenting. This study can light a road for future trials using cardiac rehabilitation.
 
POSTER 18
SCIENTIFIC SUBMISSION
PRESENTER: Mike McNamara
AUTHORS: Green, Amber1; McNamara, Mike2; Oser, Carrie2; Vella, Chantal 1
INSTITUTIONS: 1. Movement Sciences, University of Idaho, Moscow, ID, United States. 
2. Cardiovascular Health Program, Montana Department of Public Health & Human Services, Helena, MT, United States. 
ABSTRACT BODY: 
Introduction: 
Research suggests physical and psychological health outcomes are improved with participation in cardiac rehabilitation (CR). Despite this evidence, patient drop out is common. Most studies investigating reasons for non-completion of CR have small sample sizes and few have compared differences between men and women. 

Purpose: 
To investigate gender differences in reasons why patients do not complete CR. 

Design: 
We used a cross-sectional study design for CR facilities participating in the Montana Outcomes Project. 

Methods: 
The sample included patients seen in CR programs participating in the Montana Outcomes Project from October 2011 through September 2012. Comprehensive outcomes data were collected using an Excel spreadsheet and reported quarterly. The reporting spreadsheet utilized a drop-down menu that included pre-defined reasons for non-completion of CR. Statistical analysis included ANOVA and Chi-square tests with p-value of ≤ 0.05 indicating significance.

Results: 
The sample consisted of 3714 patients (2506 men vs. 1208 women). There was a significant difference in age between men and women (62.8 vs. 65.1 years). Overall, the most common primary diagnoses for both genders included percutaneous transluminal intervention (PCI) (29%), myocardial infarction (MI)/PCI (24%) and coronary artery bypass graft (CABG) (21%). Significant differences between men and women were noted among MI (5% vs. 8%), MI/CABG (5% vs. 3%) and CABG (23% vs. 17%). In addition, women had a significantly higher prevalence of diabetes compared to men (31% vs. 25%). No significant difference between men and women was noted among MI/PCI, PCI, angina, valve surgery and heart failure diagnoses. Common reasons for non-completion for both men and women included return to work, financial burden (e.g., high co-pay, not a covered benefit, no insurance), hospital readmissions, transportation issues and “other”. Among men, “return to work” was a significant cause for non-completion compared to women (17 and 9%, respectively). Among women, “hospital readmission” was significant cause for not completing CR compared to men (6 and 5%) respectively. 

Conclusions: 
Our findings suggest that there are gender differences in reasons for non-completion of CR. Key differences may be the result of age differences among those attending CR as men tended to be younger and not of retirement age. In addition, differences in the complexity of disease presentation related to women such as higher rates of diabetes and MI (without PCI) prior to CR initiation. Our findings suggest that gender specific strategies may be needed in order to effectively reduce non-completion rates.
 
POSTER 19
SCIENTIFIC SUBMISSION
PRESENTER: Monica Rincon
AUTHORS: Rincon, Monica1; Dennis, Rodolfo2; Rojas, Maria Ximena3; Tamayo, Diana C.3; Brophy, James4; Rodríguez, Viviana A.3; Oyuela, Martha5; Franco, Camilo6; Castro, Hector3; Rodriguez, Alfredo1
INSTITUTIONS: 1. Cardiac Rehabilitation, Fundación Cardioinfantil Instituto de Cardiología, Bogota, Colombia. 
2. Research Department, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia. 
3. Epidemiology and Biostatistics , Pontificia Universidad Javeriana, Bogota, Colombia. 
4. Department of Clinical Epidemiology and Biostatistics, Royal Victoria Hospital and McGill University, Montreal, QC, Canada. 
5. Radiology Department, Instituto de Ortopedia Infantil Roosevelt, Bogotá, Colombia. 
6. Cardiology Department, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia. 
ABSTRACT BODY: 
Introduction: 
Cardiac rehabilitation in patients with chronic heart failure has met with resistance from third-party payers in Colombia due to lack of evidence on its efficiency. We aimed to provide information on its cost-effectiveness.

Purpose: 
This study aims to compare the ratio of cost-effectiveness of two strategies of outpatient management of heart failure with low ejection fraction; usual care (which does not include cardiac rehabilitation) versus usual care plus a cardiac rehabilitation program based on exercise .

Design: 
An analysis of cost-effectiveness and cost-utility was conducted to compare the effects on morbidity and mortality of two strategies for outpatient management of patients with compensated heart failure: usual care (which currently does not include Cardiac Rehabilitation) and usual care plus Cardiac Rehabilitation program.

Methods: 
We estimated the costs associated with a running a three month rehabilitation program for patients with chronic heart failure. We collected all medical resource data used in ambulatory care and data on hospital costs incurred in the attention of patients with uncompensated heart failure. We conducted a literature search to establish the rates associated with hospitalization due to uncompensated heart failure and death due to Heart Failure, and potential reductions due to the utilization of Cardiac Rehabilitation. We modeled the incremental costs and effectiveness associated with the use of Cardiac Rehabilitation over a time horizon of 5 years, from the point of view of the third-party payer. 

Results: 
Results: For an exercise-based program with 10 patients per session, its costs may range from USD$265.42 to USD$369.89. Monthly costs associated with ambulatory care of chronic heart failure were USD$128.58 (SD 321.49) per patient, and hospitalization costs were of USD$3621.34 (SD 5444.04) per event. Yearly hospitalization rates with Cardiac Rehabilitation and without were 0.0138 and 0.0180 respectively. The incremental cost of Cardiac Rehabilitation would be USD $998.7 per additional quality-adjusted life year gained. Sensitivity analysis did not change results meaningfully.

Conclusions: 
Cardiac Rehabilitation in patients with chronic heart failure in Colombia can be a cost-effective strategy, as it is associated with minimal incremental costs and better quality of life, mainly due to decreased rates of hospitalization.
 
POSTER 20
SCIENTIFIC SUBMISSION
PRESENTER: Monica Rincon
AUTHORS: Rincon, Monica1; Trujillo, Heidy2; Vásquez, Ana3
INSTITUTIONS: 1. Cardiac Rehabilitation, Fundación Cardioinfantil Instituto de Cardiología, Bogota, Colombia. 
2. Nursing Department, Fundación Cardioinfantil Instituto de Cardiología , Bogotá, Colombia. 
3. Independent Research, Bogotá, Colombia. 
ABSTRACT BODY: 
Introduction: 
The benefits of Cardiac Rehabilitation Programs (CRP) for the treatment of patients with cardiac disease are well established. However, it is important to consider the potential risk and complications arising from these programs.

Purpose: 
To describe the proportion of complications before, during and after an exercise session in patiens attending a CRP in a health institution, during 6 years.

Design: 
Cross-sectional study. 

Methods: 
A six years follow-up was conducted in patients attending a CRP to establish cardiovascular and non-cardiovascular complications before, during and after an exercise session. The demographic and clinical data was extracted from medical record and the complications were recorded by the patient physician.
Data analysis included univariated analysis, results are presented with means and proportions. 

Results: 
42000 exercise hours were analyzed in an average of 24412 patients during a six years period. Patients age was 58 years, 62% males. Cardiac risk was moderated in 47% and high in 36% patients. 29% patients attending to RC program had valve replacement, the other percentage of patients had coronary disease with medical treatment or after coronary angioplasty or coronary artery bypass graft. The incidence of complications was 0.7%. 44% patients presented cardiovascular complications; the most frequent was High Blood Pressure. 67% patients presented a complication before exercise session, which implies that attending to CR is a way to prevent major complications, since patient can be assisted by the interdisciplinary team of the program. 

Conclusions: 
Cardiac rehabilitation programs are an efficient treatment for cardiovascular patients. Despite the moderate to high cardiovascular risk of the patients included in this study, there was a low incidence of complications and these happened before exercise session, from non-cardiovascular causes. This denotes the relevance of having an interdisciplinary team and medical supervision during the exercise sessions. 
 
POSTER 21
SCIENTIFIC SUBMISSION
PRESENTER: Nathan Boehlke
AUTHORS: Boehlke, Nathan1; Corbisiero, Teresa M.1; Stackpool, Caitlin1; Bon-Wilson, Andrea1; Meyers, Mary S.3; Oster, Cynthia A.2
INSTITUTIONS: 1. Cardiac Rehabilitation, Porter Adventist Hospital, Denver, CO, United States. 
2. Critical Care and Cardiovascular Services, Porter Adventist Hospital, Denver, CO, United States. 
3. Quality Improvement and Research, Centura Health, Littleton, CO, United States. 
ABSTRACT BODY: 
Introduction: 
Cardiac Rehabilitation (CR) services continue to be underutilized despite evidence these services are associated with significant benefits. Few studies have explored the relationship between stress management (SM) education and clinical outcomes. Studies indicate psychosocial intervention can positively affect stress behavior in patients with coronary artery disease. The importance of a licensed professional counselor (LPC) in CR was reviewed to improve behavioral outcomes and sustain ancillary services.

Purpose: 
The study aimed to compare pre/post Patient Health Questionnaire (PHQ -9) depression scores among Phase II CR participants who attended three 1.5 hour SM education sessions provided by a LPC. 

Design: 
A retrospective comparative design compared 153 participants of a Phase II CR program completing ≥ 12 sessions between December 2011 and January 2014 at a hospital-based nationally certified CR program located in a western mountain region. 

Methods: 
The PHQ-9 questionnaire, a tool for initial treatment selection for depression, was administered during the initial CR session and two CR sessions prior to program discharge. Severity scores of 5 to ≥20 represent minimal to severe symptoms of depression. Individual PHQ-9 scores were compared among participants attending and not attending three 1.5 hour SM sessions. A medical record review was conducted to collect completed PHQ-9 scores, attendance of SM sessions, gender, and age. The t-test determined statistical significance. PHQ-9 scores were regressed on session participation, age and gender using Ordinary Least Squares (OLS).

Results: 
One hundred twenty males (mean age = 63.4 years) and 33 females (mean age = 68.8 years) participated. Fifty eight participants attended the SM sessions and 77 did not. Mean pre (5.49) and post (2.28) PHQ-9 scores for SM participants significantly improved (mean difference = 3.20: p= 0.000, t = 6.17). Adjusting for age and gender, significantly lower depression scores were associated with session attendance (β = 1.65, t =-2.68, p = 0.016, 95%CI (2.99, 0.313)).

Conclusions: 
All patients attending CR improved PHQ-9 scores with participants attending SM sessions achieving the greatest improvement. Preliminary data suggest attending structured SM sessions affect depression in this patient population. SM sessions by a LPC are an integral part of a CR program. The accurate identification of depressed CR patients utilizing a multidisciplinary approach contributes to improved clinical outcomes.
 
 
POSTER 22
SESSION SUBMISSION
PRESENTER: Richard Novitch
AUTHORS (LAST NAME, FIRST NAME): Novitch, Richard1; Wilkins, Victoria2; Friedman, Susan1
INSTITUTIONS (ALL): 1. Burke Rehabilitation Hospital, White Plains, NY, United States. 
2. Cornell Institute of Geriatric Psychiatry , White Plains, NY, United States. 
ABSTRACT BODY: 
Detailed Description:
Depression is a common co morbidity in COPD and has been identified in 18-35% of patients in various studies. However, the medical literature has been lacking with regard to evidence based standards for identification and treatment of depression in COPD. In addition, depression can have adverse consequences in rehabilitation outcomes in COPD because of increased failure to adhere to medical and exercise recommendations.

We have developed a rigorous but easy to employ method for screening patients in pulmonary rehabilitation programs for depression and developed a method to administer a personalized intervention based on expert knowledge of depression and COPD treatment. This personalized psychotherapeutic intervention has demonstrated success in a population of patients with severe COPD undergoing inpatient rehabilitation and in follow up for 1 year with regard to depressed mood, were more adherent to medication and exercise and were less dyspneic at 28 weeks and 52 weeks..

Session Objectives:
Review COPD and Depression in Rehabilitation  
Review Screening Tools
Describe an Intervention method
 
POSTER 23
SCIENTIFIC SUBMISSION
PRESENTER: Pedro Recalde
AUTHORS: Recalde, Pedro1; Myers, Heather1; Ramirez, Aleyda1; Beauchene, Alex1; Xing, Rachael1; Diez, Jose1
INSTITUTIONS: 1. Non Invasive Cardiology, Baylor St. Lukes Health Medical Center, Houston, TX, United States. 
ABSTRACT BODY: 
Introduction: 
Prescribing exercise is often referred to as “more art than science”. The use of metabolic equivalents (METs) enables quantifiable categorization and comparison of non-related exercise activities (e.g. treadmill, cycle ergometry). When using MET calculations for prescribing cycle ergometry, the inherent assumption is that increased weight is equal to increased muscle mass (i.e. increased ability to do work). This assumption does not consider the relationship between increased weight and fat mass for aging populations, or the exponential decrease in strength and endurance for diseased populations. Anecdotal evidence reveals that the straight translation of METs from treadmill first ventilatory threshold (1st VT) estimations to cycle ergometry results in non-sustainable prescriptions. 

Purpose: 
The purpose of the presentation is to evaluate two scenarios for standardized patient weight adjustment when converting workloads from treadmill to cycle ergometry. In the first scenario a patient’s weight is calculated when percent body fat is adjusted to “healthy” recommendations. In the second scenario the individual’s body weight is adjusted by using the “healthy” weight associated with height in the BMI calculation. 

Design: 
We used paired t-tests to compare the means of three separate cycle ergometry workloads which were derived from typical % body fat and weight as seen in outpatient cardiac rehabilitation.

Methods: 
A cohort of 55 unique database entries was created that consisted of weight, MET level for estimated 1st VT on a treadmill, and entry % body fat using the 3-site skin fold method. Using the 1st VT MET intensity, three cycle ergometry workloads were calculated at current body weight, body weight with an adjusted body fat to “healthy range”, and body weight based on an adjusted “healthy range” BMI.

Results: 
The prescribed watt intensity was lower for adjusted BMI (p<0.01) and for adjusted % body fat (p<0.01) when compared to the prescribed ergometry watts based on actual body weight. When adjusted BMI and adjusted % body fat prescriptions are compared to one another, the adjusted BMI prescription is lower (p<0.01). 

Conclusions: 
The analysis provides insight about adjusting exercise prescriptions when translating METs from treadmill to cycle ergometry in a cardiac rehabilitation population. Such adjustments result in decreased workloads which may lead to improved patient response to exercise prescriptions. Further investigation of physiological responses to exercise intensity variations is needed to increase the safety and sustainability of prescribed exercises.
 
POSTER 24
CLINICAL SUBMISSION
PRESENTER: Juan Sarmiento
AUTHORS (LAST NAME, FIRST NAME): Sarmiento, Juan M.1, 2; Camargo, Diana M.1
INSTITUTIONS (ALL): 1. Cardiovascular Prevention Center, Fundacion Clinica Shaio, Bogota, Colombia. 
2. Sports Medicine Residence Program, El Bosque University, Bogota D.C., Colombia. 
ABSTRACT BODY: 
Introduction: 
The 6-minute walk test (6MWT) is a test to assess functional class has become a diagnostic aid and forecasts in recent years in the clinical setting especially in-patient with cardiac or pulmonary diseases

Purpose: 
Correlating functional class by referring patients to the distance in the 6MWT

Significance: 
When comparing functional class referred by the patient to the distance traveled during the six-minute walk, it is shown that a better functional class distance traveled is greater, in order to find a cutoff between the classification of functional class and distance.

Design:
Description study

Methods:
Patients over 12 years of both genders with cardiovascular disease and or lung who performed the 6MWT since the year 2008 until 2013 in the institution. Were divided according to the underlying disease (cardiovascular and respiratory) and NYHA functional class, determining for each group the distances.
The variables described were statistically analyzed using measures of central tendency. To compare the distance and functional class as well as pathologies ANOVA was used with a significance level of 5%. In order to find correlation between functional class referred and walk distance, Spearman correlation was used.


Results:
502 walks ( 220 in men and 282 in women) were evaluated.

The average age was 57.43 ± 16.40 years, being 56.28 ± 16.46 years for men and 58.33 ± 16.32 years for women.

Patients with pulmonary hypertension were 211, 135 heart failure, 39 with dyspnea study, 38 diffuse interstitial lung disease, other diseases 28, 27 chronic obstructive pulmonary disease and coronary heart disease 24.

By correlating with functional class reported distance walked was observed that patients in functional class II and I increased walking distance from others, both men and women. When comparing the distance with functional class is a significant difference between functional class I when compared with the II, III and IV with a significance level of p <0.000, 0.000 and 0.001 respectively 

The correlation of distance with functional class using the Spearman correlation was - 398


Conclusions:  
6MWT is a useful function, which may contribute to an objective assessment of the functional class of patients with cardiopulmonary diseases

Implications:
From the literature reviewed so far no data on distances traveled by patients with cardiovascular disease and / or respiratory functional class 2640 meters above sea level were found
 
POSTER 25
SESSION SUBMISSION
PRESENTER: Charlotte Teneback
AUTHORS (LAST NAME, FIRST NAME): Teneback, Charlotte1
INSTITUTIONS (ALL): 1. University of Vermont, Burlington, VT, United States. 
ABSTRACT BODY: 
Detailed Description:
Cystic Fibrosis is a genetic disease affecting primarily the lungs and GI tract, causing thick mucous that obstructs the lungs and leads to chronic respiratory infections. Most individuals with CF die of respiratory complications. Physical activity is commonly prescribed as a therapy for patients with cystic fibrosis, both to improve airway clearance and to improve cardiovascular fitness. Even though exercise is frequently prescribed in the management of CF, there is relatively little known about the effects of formal excise programs on cardiovascular fitness, lung function, and respiratory symptoms in this population. The purpose of this session will be to review the physiology of exercise in patients with Cystic Fibrosis, the current literature regarding exercise and formal rehabilitation programs in this population, and to review our center’s local experience with enrolling CF patients in Pulmonary Rehabilitation. 

Session Objectives:
1. Understand the role of cardiopulmonary fitness and exercise in the treatment of Cystic Fibrosis
2. Review the current data supporting the use of Pulmonary Rehabilitation in the management of Cystic Fibrosis 
3. Recognize challenges specific to the Cystic Fibrosis population in participation in a group exercise program
 
POSTER 26
CLINICAL SUBMISSION
PRESENTER: Terry Thomas
AUTHORS (LAST NAME, FIRST NAME): Alagona, Peter2; Deron, Scott J.3; Canosa, Roddy P.4; Davis, Tina3; Testa, Heidi L.3; Hudson, Cindy3; Hartranft, Elise4; Kolp, Cindy4; Wilkinson Parmelee, Wendy2; Carrico, Caroline1; Varvel, Stephen1; Thomas, Terry1
INSTITUTIONS (ALL): 1. Health Diagnostic Laboratory, Inc., Richmond, VA, United States. 
2. Penn State Hershey Heart and Vascular Institute, Harrisburg, PA, United States. 
3. Lancaster General Health, Lancaster, PA, United States. 
4. Ephrata Community Hospital, Ephrata, PA, United States. 
ABSTRACT BODY: 
Introduction: 
The goal is to compare the cardiometabolic risk factor profiles of patients entering cardiac rehab using traditional approaches versus a more comprehensive panel of cardiovascular and metabolic biomarkers. It is hypothesized that the comprehensive panel will identify increased risk that would not have been detected using traditional lipid and glucose measures.

Purpose: 
To determine if a greater percentage of the cohort is identified with high-risk levels of LDL particles (LDL-P), and/or ApoB than of LDL-C, and also to determine if the cohort shows higher prevalence of elevated levels of inflammatory and insulin resistance markers when compared to population norms (HDL, Inc. reference data).

Significance: 
Several studies have demonstrated improvements in lipid profiles during cardiac rehab. Multiple statin trials have proven that while LDL-C can be lowered significantly, and often to goal, cardiac events are reduced by only 30% on average. With such an unacceptable level of residual risk (~ 70%) it is imperative to identify and treat the underlying causes of that risk.

Design:
A multi-center, cross-sectional characterization of circulating biomarkers at entry into cardiac rehab for patients who have had an acute coronary event.

Methods:
Risk levels for various cardiometabolic biomarkers were compared among the participants and with national HDL, Inc. reference population data using logistic regression and chi-squared tests.

Results:
Preliminary results for 50 patients show that 28% had elevated LDL-P or ApoB and only 14% had elevated LDL-C upon entering cardiac rehab. When compared to population norms (118k baseline samples from HDL, Inc. nationwide patient database), risk for diabetes and inflammation was markedly higher for the rehab group. The odds of a subject showing risk for developing diabetes was almost three times higher for the rehab group than the overall HDL, Inc. database (95% CI: 1.3-6.8). Rehab subjects were two times more likely to have elevated inflammation markers (95% CI: 1.08-3.88).

Conclusions:  
This preliminary data demonstrates the significant residual cardiometabolic risk that remains largely hidden in the cardiac rehab population. Moreover, uncovering the hidden risk through comprehensive biomarker testing provides an opportunity to improve care by designing more effective individualized treatment plans (ITP), with the goal of preventing secondary events and reducing costly readmissions.

Implications:
Given the recent emphasis on ITPs, comprehensive biomarker testing can be a valuable tool for medical professionals by alerting them of hidden risk and enabling more effective, individualized treatments for better patient outcomes.
 
POSTER 27
SCIENTIFIC SUBMISSION
PRESENTER: Yanlong Li
AUTHORS: Li, Yanlong1; Norman, Joseph F.1; Pozehl, Bunny J.2; Duncan, Kathleen A.2; Hertzog, Melody A.2
INSTITUTIONS: 1. Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha, NE, United States. 
2. College of Nursing, University of Nebraska Medical Center, Lincoln, NE, United States. 
ABSTRACT BODY: 
Introduction: 
Maintaining an adequate level of daily physical activity is important to the overall physical function and quality of life of individuals with chronic heart failure (CHF). Being able to accurately monitor and quantify the amount of physical activity an individual with CHF performs can be of assistance in developing appropriate interventions.

Purpose: 
To evaluate the validity of two accelerometers, the RT-3 and Actiwatch, to oxygen consumption during the performance of typical daily activities.

Design: 
A descriptive correlational design was used in this study.

Methods: 
Fifteen subjects (9 men/6 women) with CHF (mean LVEF= 31±8 %) consented to participate in this study. Subjects performed a total of 30 minutes of continuous physical activity, involving 4 light (reading newspaper, washing dishes, watching TV, dusting) and 2 moderate (climbing stairs, vacuuming) intensity activities, in a random sequence while donning the RT-3 and Actiwatch accelerometers and having oxygen consumption (VO2) measured with a portable metabolic gas analyzer. Data were analyzed using descriptive statistics, Wilcoxon Signed Ranks Tests and Spearman Correlation Coefficients. 

Results: 
No significant difference was noted between the RT-3 and VO2 based on mean caloric (Kcal) expenditure (p=0.67). However, comparing higher versus lower intensity activities the higher intensity activities showed a trend towards a significant difference in caloric expenditure between the RT-3 and VO2 while for the lower intensity activities there were no significant differences. In addition, a strong correlation (rs= 0.81, p< 0.02) was found between RT-3 activity counts and indirect calorimetry (Kcal) across all activities. Though no significant difference (p= 0.48) was noted in mean activity counts between the RT-3 and Actiwatch, there were differences (p< 0.05) noted in activities requiring more upper extremity movement (washing dishes and dusting). No significant relationship was noted between the Actiwatch activity counts and indirect calorimetry (p= 0.46). 

Conclusions:
Compared to the Actiwatch, the RT-3 accelerometer is a better and more valid device for measuring daily physical activity in individuals with CHF.
 

Thursday, September 4

213

1:30 PM – 2:30 PM

Beginning Investigator Scientific Abstract Award Presentations 

 

TITLE: Utilization of Cardiac Rehabilitation Among Veterans with Heart Failure
PRESENTER: Linda Park
AUTHORS: Park, Linda G.1; Schopfer, David W.1; Whooley, Mary A.1, 2; Takemoto, Steven1, 3
INSTITUTIONS: 1. Medicine, San Francisco VA Medical Center, San Francisco, CA, United States. 
2. Medicine, University of California, San Francisco, San Francisco, CA, United States. 
3. Anesthesia/Perioperative Care, University of California, San Francisco, San Francisco, CA, United States. 
ABSTRACT BODY: 
Introduction: 
Cardiac rehabilitation (CR) is linked to reduced mortality and morbidity including improvements in cardiorespiratory fitness, psychosocial state, and quality of life in patients with heart failure (HF). However, little is known about CR utilization among patients with HF in the Veterans Health Administration (VA) Healthcare System. 

Purpose: 
We sought to determine: a) the proportion of Veterans with HF who participated in CR during a 5-year period; and b) patient and hospital characteristics associated with participation. 

Design: 
A retrospective study was conducted using national data from the VA Healthcare System.

Methods: 
We used ICD-9 codes to identify all patients hospitalized for HF at VA facilities between 10/2006 and 9/2011. After excluding patients who died within 12 months of hospitalization, we identified participation in (VA or non-VA) CR programs using CPT codes from VA and Medicare claims data. Multivariate logistic regression was used to identify patient characteristics independently associated with CR participation. 

Results: 
During the five-year study period, 57,468 patients were hospitalized for HF at 121 VA medical centers. Of the 40,227 (70%) patients who lived for at least 12 months after hospitalization, 564 (1.4%) attended one or more sessions of outpatient CR. After multivariable adjustment, the patient characteristics most strongly associated with greater CR participation included younger age, White race, being married, and history of ischemic heart disease. Additional characteristics associated with participation included living closer to a VA facility, hyperlipidemia, higher income and lack of chronic obstructive pulmonary disease. Characteristics not associated with participation included gender and other comorbid conditions (hypertension, diabetes, chronic kidney disease, history of stroke, peripheral artery disease).

Conclusions: 
Between 2006 and 2011, 1.4% of Veterans hospitalized for HF participated in CR. Younger age, White race, being married, and history of ischemic heart disease were associated with greater participation in CR. Increasing utilization of CR programs may benefit patients with HF. 

 

TITLE: Development and Psychometric Validation of the 2nd Version of the Coronary Artery Disease Education Questionnaire(CADE-Q II)
PRESENTER: Gabriela Ghisi
AUTHORS: Ghisi, Gabriela1, 2; Grace, Sherry L.1, 3; Thomas, Scott2; Evans, Michael F.4; Oh, Paul1
INSTITUTIONS: 1. Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, ON, Canada. 
2. Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada. 
3. School of Kinesiology and Health Science, York University, Toronto, ON, Canada. 
4. Health Design Lab, St Michael’s Hospital, Toronto, ON, Canada. 
ABSTRACT BODY: 
Introduction: 
The Coronary Artery Disease Education Questionnaire (CADE-Q) was developed and psychometrically-validated in Brazil and Canada to assess patients’ knowledge about CAD. Although both versions demonstrated good validity, the CADE-Q presented lack of assessment of all core components of cardiac rehabilitation (CR).

Purpose: 
To develop and psychometrically validate the CADE-Q II.

Design: 
Observational study.

Methods: 
Development of CADE-Q II involved extracting items based on an information needs assessment tool (INCR) and focus group with CR experts (n=15) that resulted in a 31-item tool. Overall, three items from the CADE-Q were retained. The questionnaire underwent pilot testing in 30 patients and psychometrically-testing in 307. The internal consistency was assessed using Cronbach's alpha, the dimensional structure through an exploratory factor analysis, and the criterion validity with regard to educational level.

Results:
Cronbach's alpha was 0.93. Criterion validity was supported by significant differences in mean scores by educational level (p=0.03). Factor analysis revealed 4 factors, which were all internally-consistent and well-defined by the items. The mean total score was 53.62±29.4. Knowledge about exercise and medical condition was significantly higher.

Conclusions: 
The CADE-Q II was demonstrated to have good reliability and validity.

 

CONTROL ID: 1968350
TITLE: The Effect of Statin Use on Cardiac Rehabilitation Exercise Training
PRESENTER: Jason Rengo
AUTHORS: Rengo, Jason1; Savage, Patrick D.1; Toth, Michael J.2; Ades, Philip1, 2
INSTITUTIONS: 1. Division of Cardiology, Cardiac Rehabilitation and Prevention, Fletcher Allen Health Care, Burlington, VT, United States. 
2. Department of Medicine, University of Vermont, Burlington, VT, United States. 
ABSTRACT BODY: 
Introduction: 
A recent publication in JACC by Mikus et al. reported that simvastatin attenuated aerobic training in statin-naïve, overweight subjects at risk for metabolic syndrome following a 12-week exercise program similar to that used in cardiac rehabilitation. This is concerning to Cardiac Rehabilitation (CR) populations given the prevalence of statin treatment amongst patients and that baseline aerobic capacity and improvements following CR are correlated with reductions in all-cause and cardiovascular mortality.

Purpose: 
As a diminished training response may limit some of the long-term beneficial effects of CR, we sought to determine whether statin use attenuates the exercise training response, measured directly by VO2peak (mLO2*kg-1*min-1), in CR patients with coronary heart disease (CHD).

Design: 
The study was a single center, retrospective analysis of patients completing CR between January 1996 to July 2013.

Methods: 
The magnitude of the exercise training response was assessed in 1,201 CHD patients who performed entry and exit ETT’s with expired gas analysis. The cohort was divided into two groups according to statin status upon entry to CR with 968 (81%) individuals taking a statin medication throughout the study period (Statin Group) and 233 (19%) individuals remaining statin-naïve (Non-Statin Group). All patients performed a standard CR exercise program consisting of 3 sessions per week for 36 sessions. ANOVA and chi2 tests were used to compare differences between groups at baseline and following treatment. Paired t-tests were used to compare differences within groups. Statistical significance was set at the level of p<0.05.

Results: 
VO2peak increased significantly following exercise training in both the statin and non-statin groups when expressed relative to body mass 3.2±3.7vs3.1±3.7 (mLO2*kg-1*min-1)(p=0.73) or in absolute terms (LO2*min-1)(p=0.84). For patients with a surgical diagnosis (CABG), 392 (76%) were taking statins vs. 122 not taking statins. The increase in VO2peak between these subgroups was similar (4.0±3.9vs3.8±3.6 mLO2*kg-1*min-1, p=0.74). Within the statin group, males had a higher baseline VO2peak (20.6±6.6vs15.6±4.4 mLO2*kg-1*min-1, p<0.0001) and greater increase with training 19.4±21.8% compared to females 13.1±20.8% (p<0.0001), although differences were consistent across statin status (p=NS). Additionally, changes in handgrip strength and self-reported physical function scores were similar (p=NS).

Conclusions: 
Our analysis demonstrates no effect of statins on the exercise-induced improvement in VO2peak following CR. This remained consistent across surgical status and sex indicating that chronic statin use does not attenuate aerobic training effects in CR patients with CHD and expected survival benefits should indeed persist.

 

TITLE: Pre-Exercise Stretching Adaptations on a Cardiac Rehab (CR) Population
PRESENTER: Emily Knorr
AUTHORS: Knorr, Emily1
INSTITUTIONS: 1. Cardiac Rehabilitation, UC Davis Medical Center, Sacramento, CA, United States. 
ABSTRACT BODY: 
Introduction: 
Static stretching prior to exercise has been utilized in warm-ups throughout cardiac rehabilitation (CR) clinics. However, it is unknown if pre-exercise stretching influences the patients' endurance and flexibility. 

Purpose: 
The purpose of this study was to analyze the influence of pre-exercise static stretching upon the functionality and cardiovascular endurance of the CR population.

Design: 
The cross-over, within-subjects design had the subjects complete a four-week study, weeks one and three were 3-d-wk of no stretching (baseline) and weeks two and four were 3-d-wk of placebo (PLO) or experimental (EXP) stretching while attending the CR program.

Methods: 
Twelve subjects (females = 3) were CR patients who participated in low-intensity exercise for 3-d-wk in the maintenance (MNT) phase of the CR program. Week 1 (baseline)-no pre-exercise stretching performed; collection of dependent (dep) variables only, i.e. peak heart rate (HR), Rate of Perceived Exertion (RPE), HR one-minute post-exercise and 6-minute walking test (Meters). Week 2-two groups of 6 subjects randomized into EXP and PLO; EXP performed ten 30-second stretch-holds, repeated once and PLO performed ten stretch-holds ≤ 5 seconds, repeated once; dep. variables collected. End of Week 2-6-minute walk test collected. Week 3-No stretching. Week 4-Cross-Over of EXP to PLO and vice-versa; dep. variables & 6-minute walk test collected. Statistical analyses of one-way ANOVAs, followed by tukey post-hoc test were used to determine the influence of pre-exercise stretching on the subjects' peak HR, RPE, HR one-minute post-exercise and 6-minute walking tests. 

Results: 
EXP vs the baseline had a significant increase within the six-minute walk tests (405.66 ± 19.22m vs 461.54 ± 26.87m p = 0.005). No difference between PLO and baseline and between EXP and PLO treatment (tx)s within the (3) 6-minute walk tests. For peak HRs and RPE, no significant difference between the three txs (p = 0.3) over 3-d-wk of txs (p = 0.2). The EXP tx had significantly lower HRs from Mon to Fri (88.3 ± 3.4bpm vs 83.3 ± 4.1bpm, p = 0.003).

Conclusions: 
Pre-exercise static stretching (EXP) improved the distance (meters) in 6-minute walking tests over duration of one week thus improving patients' functionality. Pre-exercise static stretching also improved HR one-minute post-exercise. Pre-exercise static stretching had no influence upon peak HRs and RPE. The results from the current study have warranted the continuation of research on pre-exercise static stretching within CR programs. CR programs should consider group stretching led by a trained staff member, in order to ensure full benefits of pre-exercise static stretching.

 

 

Friday, September 5

306

8:00 AM – 9:30 AM

Scientific Oral Abstract Presentations

 

 
TITLE: Increases in Cardiac Rehabilitation Utilization Following Implementation of a Physician Education and Financial Incentive Program
PRESENTER: Michelle La Londe
AUTHORS: La Londe, Michelle1; Shaffer, Lynn1; Albers, Anne2; Lam, Gregory2; Mudrick, Daniel W.2; Hickerson, Jesse2; Cantrell, Julie S.2; Snow, Richard J.3; Caulin-Glaser, Teresa2
INSTITUTIONS: 1. McConnell Heart Health Center, OhioHealth Corporation, Columbus, OH, United States. 
2. Heart & Vascular Services, OhioHealth Corporation, Columbus, OH, United States. 
3. Clinical Effectiveness, OhioHealth Corporation, Columbus, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Despite the recognized benefits of cardiac rehabilitation (CR), utilization remains low. Several studies indicate that physician endorsement of CR with recommendation to their patients increases participation in CR.

Purpose: 
This investigation evaluated whether a multi-faceted intervention consisting of peer to peer physician education and salary bonus tied to quality targets could increase CR utilization.

Design: 
Retrospective cohort analysis

Methods: 
From April-June 2013, ongoing peer to peer education was conducted with health system employed physicians reviewing the evidence of CR benefits. Additionally, a salary bonus incentive was included as part of a quality initiative if ≥ 25% CR utilization rate was achieved as part of a balanced scorecard. Quality data included patients with qualifying diagnoses cared for by the health system employed physicians.

To determine CR utilization, information was collected from administrative databases of three large central Ohio hospitals in the OhioHealth system on all cases of percutaneous cardiac intervention (PCI) or surgical cardiac intervention during 7/1/2012 to 12/31/2012 and 7/1/2013 to 12/31/2013 performed on patients of the employed physician group who resided in zip codes reflecting the main service area for the 3 hospitals. Billing information was reviewed to ascertain whether the patients involved in the identified procedures subsequently participated in CR at any of the 3 hospitals. Cases were excluded from analysis based on discharge disposition (i.e.: expired, discharge to hospice, discharge to a long term care facility). For staged procedures, utilization was based on the later procedure. 

Patients from the 2012 and 2013 time periods were compared both overall and according to their participation status. A comparison of 2012 to 2013 CR utilization was also performed. Means were compared using t-tests and count data was compared using chi-square analysis. SAS software (version 9.2) was used to perform statistical analysis.

Results: 
Included were 680 and 637 patients from 2012 and 2013, respectively. For both periods, mean age was 63 and females constituted just over 30%. About three-quarters underwent PCI. No significant differences were found in demographic or procedural characteristics between patients (both CR participants and non-participants) from 2012 and 2013 (p>0.2 for all comparisons).

CR utilization for 2012 and 2013 showed a statistically significant increase from 22.8% to 27.8% respectively (p=0.042).

Conclusions:
Preliminary data indicates that peer to peer physician education about CR combined with quality targets linked to physician bonuses provides a method for increasing CR utilization

 
 

TITLE: The Impact of Cardiac Rehabilitation Program Expansion on Key Program Outcomes
PRESENTER: Jesse Hickerson
AUTHORS: Hickerson, Jesse1; La Londe, Michelle1; Shaffer, Lynn1; Lam, Gregory2; Mudrick, Daniel W.2; Albers, Anne2; Cantrell, Julie S.2; Snow, Richard J.3; Caulin-Glaser, Teresa2
INSTITUTIONS: 1. McConnell Heart Health Center, OhioHealth Corporation, Columbus, OH, United States. 
2. Heart & Vascular Services, OhioHealth Corporation, Columbus, OH, United States. 
3. Clinical Effectiveness, OhioHealth Corporation, Columbus, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Many cardiac rehabilitation (CR) programs are expanding by establishing satellite programs in surrounding communities.

Purpose: 
The purpose of this investigation was to examine the impact of program expansion on LDL and BP goal achievement and on MET level change.

Design: 
This investigation was a retrospective cohort design

Methods: 
-Achievement of LDL and BP goal and MET level change were compared for 669 patients from the pre expansion time period (4/1/2008 to 3/30/2010) to 644 patients from the post expansion time period (1/1/2011 to 5/28/2013). Patients in this analysis had demographic and program outcomes available for analysis. LDL goal was defined as LDL < 100 mg/dl. BP goal was defined as systolic BP < 140 and diastolic BP < 90 mm Hg. MET level change was calculated as the difference between exit and entry MET levels.

Descriptive analysis using chi-square for frequency data and students t-test for continuous data was performed to identify pre expansion and post expansion patient differences. Important differences were used as candidate variables for statistical modeling to determine if time period was a significant factor after adjustment for differences. Logistic regression was used for LDL and BP goal achievement and linear regression was used for MET level change. SAS software (version 9.2) was used to perform statistical analysis. 

Results: 
An unadjusted comparison showed that 86.3% of pre expansion patients achieved LDL goal compared to 86.2% of post expansion patients (p=1.0). After adjustment for race, entry LDL and obesity prevalence, the post expansion group was 30% less likely to achieve LDL goal (p=0.05).

An unadjusted comparison showed that 95.8% of pre expansion patients achieved BP goal compared to 91.9% of post expansion patients (p=0.004). After adjustment for hypertension prevalence and CR sessions attended, post expansion patients were 52% less likely to achieve BP goal (p = 0.004).

An unadjusted comparison showed a pre expansion MET increase of 1.73±1.46 METs compared to a post expansion increase of 1.56±1.49 METs (p=0.04). After adjustment for gender, diagnosis and diabetes prevalence, MET level change was not significantly different between groups (p=0.52). The adjusted MET level increase for pre expansion and post expansion patients was 1.53 and 1.48 METs, respectively.

Conclusions: 
Both pre expansion and post expansion patients showed significant improvements in LDL, BP and MET level; however, there were differences in LDL and BP goal achievement. Unadjusted comparisons did not always reflect the true difference between groups. While expansion may help programs reach more patients, differences in the new patient population combined with other factors may present challenges to maintaining or improving program outcomes.

 

TITLE: Factors Affecting Veteran Participation in Cardiac Rehabilitation
PRESENTER: David Schopfer
AUTHORS: Schopfer, David W.1; Priano, Susan 2; Allsup, Kelly 3; Forman, Daniel E.3, 4; Whooley, Mary A.2, 5
INSTITUTIONS: 1. San Francisco VA Medical Center, San Francisco, CA, United States. 
2. University of California San Francisco, San Francisco, CA, United States. 
3. New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston , MA, United States. 
4. Medicine, Harvard Medical School, Boston, MA, United States. 
5. Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States. 
ABSTRACT BODY: 
Introduction: 
Cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease (IHD) but are vastly underutilized in the United States, including the Veterans Health Administration (VHA) healthcare system. Numerous barriers affecting utilization have been identified in other healthcare systems, but the specific factors affecting Veterans are unknown.

Purpose: 
We sought to identify barriers and facilitators associated with utilization of CR programs in VHA.

Design: 
We performed a qualitative study of 51 VHA patients, providers, and CR program managers representing 29 different VA facilities.

Methods: 
We conducted semi-structured interviews with key informants to explore their attitudes and knowledge towards CR. Interviewees included 30 clinical managers of CR programs in VHA, 11 providers (physicians, nurses, and exercise physiologists), and 10 patients who recently attended a CR program. Standard probes, such as verification, were used to clarify responses. Clinical program managers at each VHA facility were selected using purposive sampling. Providers were also identified using purposive sampling and contacted initially by email. Providers were asked to identify patients who had recently participated in a CR program and were willing to participate in an interview. Two interviewers conducted all interviews. Transcriptions of the semi-structured interviews were analyzed using the thematic framework of grounded theory to analyze and identify themes which were then used to code the interview data. Although we initially used framework analysis to determine key themes and concepts a priori, we also allowed for the inductive identification of emergent themes. The coding framework was finalized after all interviews were completed and consisted of the major factors identified influencing referral to and participation in CR programs. Analyses were conducted using the qualitative data analysis package ATLAS.ti.

Results: 
Analysis resulted in identification of 6 themes as barriers and 5 as facilitators. The most common barriers to participation in CR were patient travel issues (73%), lack of an available VA program (33%), and provider perceptions that patients lack desire (31%). The most common facilitators were involvement of a dedicated provider or “clinical champion” (55%), provider knowledge of or experience with CR (53%), and patient interest (33%).

Conclusions: 
A number of modifiable factors limit utilization of CR in VHA. Patients need improved support, education, and access to CR program. Providers’ attitudes and knowledge also contribute to low CR referral.

 

TITLE: Impact of Cardiac Rehabilitation on Outcomes for Heart Valve and Coronary Artery Bypass Surgery Patients
PRESENTER: Patrick Savage
AUTHORS: Savage, Patrick D.1; Rengo, Jason1; Menzies, Keon1; Ades, Philip1
INSTITUTIONS: 1. cardiology, fletcher allen health care, S. Burlington, VT, United States. 
ABSTRACT BODY: 
Introduction: 
Medicare expanded cardiac rehabilitation (CR) coverage in 2006 to include patients undergoing heart valve (V) surgery. There has been little study of outcomes for V patients participating in CR.

Purpose: 
Assess the efficacy of CR exercise training on outcomes for V and coronary artery bypass graft (CBG) surgery patients participating in CR. 

Design: 
Prospective, observational.

Methods: 
The cohort (N=522) included consecutive V (N=123) or CBG (N=399) (all with full sternotomy) patients entering CR between 2006 and 2012. Outcome measures included weight, handgrip strength measured by dynamometer, peakVO2 directly measured with expired gas analysis, left ventricular ejection fraction (EF), self-reported physical function (Medical Outcome Survey SF-36) and Yesavage Geriatric Depression scores. Changes in outcome measures were assessed for individuals that completed CR (N=323). All results are presented V vs CBG, respectively. Statistical methods included paired and unpaired t-tests and Chi-square analysis. A p-value<0.05 determined significance and results are presented as mean+SD.

Results: 
Valve-related disorders within the V group consisted of aortic (N=85), mitral (N=30) and both aortic and mitral (N=8) while the mean number of anastomoses in the CBG group was 3.2+1.1. At baseline, V patients were older (66.2+12.3 vs 63.6+9.5), had a lower body mass index (BMI) (27.6+5.0 vs 29.4+5.5) and handgrip strength (31.2+11.9 vs 35.3+10.1) (all,p<0.05). Females constituted a greater percentage within the V group (36.6 vs 16.7%) and V patients were more likely to have convalesced post-operatively in sub-acute rehabilitation (22.8 vs 7.8%) (both,p<0.05). The groups were similar, in the number of days between surgery and entry to CR (52.6+41.0 vs 47.4+34.5), self-reported physical function (57.4+21.6 vs 56.7+23.2)and depression scores (3.3+3.0 vs 3.1+2.7), EF (58.0+10.0 vs 54.3+11.5%), and peakVO2 (17.2+5.3 vs 17.8+4.6 mLO2*kg-1*minute-1) (all,p=NS). The number of CR sessions attended (28.9+8.5 vs 27.2+8.9) and the percentage of patients to complete CR was similar between groups (68.3 vs 64.7%) (both, p=NS). Significant improvements were observed for both V and CBG patients regarding peakVO2 (+ 3.8+6.9 vs 3.8+9.9 mLO2*kg-1*minute-1), handgrip strength (+ 3.1+3.6 vs 2.6+4.8kg), and physical function (+ 21.8+23.7 vs 27.8+22.4) and depression scores (- 0.7+2.6 vs 1.2+2.3) (differences between groups, p=NS). Neither group experienced changes in weight and BMI (data not shown).

Conclusions:
Participation in CR results in significant improvements for V patients in peakVO2, strength, and physical function and depression scores. Our results demonstrate that V patients achieve improvements in outcomes that are similar in magnitude to those observed for CBG patients. 

 

TITLE: Pulmonary Rehabilitation improves Short Physical Performance Battery performance
PRESENTER: Charlotte Teneback
AUTHORS: Teneback, Charlotte1, 2; Hunton, Deborah A.2; Stevens, Diane2; Savage, Patrick D.2
INSTITUTIONS: 1. University of Vermont, Burlington, VT, United States. 
2. Fletcher Allen Health Care, Burlington, VT, United States. 
ABSTRACT BODY: 
Introduction: 
The Short Physical Performance Battery (SPPB) quantifies lower extremity function by measuring balance, walking speed, and ability to rise from seated position. SPPB scores correlate with disability in a general geriatric population, and are lower in COPD patients than age matched controls. 

Purpose: 
We hypothesized that Pulmonary Rehabilitation (PR) leads to improved lower extremity function as measured by the SPPB.

Design: 
Prospective, non-randomized

Methods: 
16 participants (m=6) underwent SPPB testing prior to and at completion of PR. Total and SPPB sub-scores were recorded, as well as age, lung function (FEV1), and 6-minute walk distance. Paired t-tests were used to compare pre- and post-scores and Pearsons correlations to test baseline relationships. 

Results: 
SPPB scores improved significantly at completion of PR (p<0.05), with a mean improvement of 2.25+3.21 points (out of 12 total). For sub-scores, there were significant improvements in chair stand and balance (both <0.05), but not in gait speed. There was a significant correlation between baseline total SPPB score and 6-minute walk distance (r=0.655, p<0.01) and SPPB score and age (r=-0.52, p<0.05), but no relationship with FEV1.

Conclusions: 
PR results in significant improvements in physical function as assessed by SPPB. 

 

TITLE: The Impact of Disability on Cardiac Rehabilitation Attendance: A Population-based Study of Medicare Beneficiaries who used Post-acute Care Services after Hospitalization for Myocardial Infarction
PRESENTER: Melissa Zullo
AUTHORS: Zullo, Melissa D.1; Dolansky, Mary A.2; Josephson, Richard A.3
INSTITUTIONS: 1. College of Public Health, Kent State University, Kent , OH, United States. 
2. Nursing, Case Western Reserve University, Cleveland, OH, United States. 
3. Cardiology , University Hospitals Case Medical Center, Cleveland, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Disability is prevalent after myocardial infarction (MI) and may act as a barrier to cardiac rehabilitation (CR). Post-acute care (PAC) is transitional service that may facilitate CR use. 

Purpose: 
This research examined the impact of disability after MI on CR use in older adults discharged to home health care (HHC), skilled nursing facilities (SNF), and inpatient rehabilitation facilities (IRF). 

Design: 
This retrospective study used clinical and administrative Medicare data from the Chronic Conditions Warehouse of Beneficiaries (n=63,127) discharged to PAC after MI in 2008. 

Methods: 
Multivariable logistic regression examined factors associated with CR use. 

Results: 
PAC discharge destination included 47% discharged to SNF, 45% sent home with HHC, and 8% discharged to IRF. There was a high burden of disability as 92% and 95% of those who used SNF or IRF compared to 34% of those who used HHC needed assistance or were dependent. Only 9% of older adults with MI who received PAC attended CR. This low proportion of CR attendance ranged from 5% of older adults who used SNF to 13% who used HHC. Adjusted analysis demonstrated that compared to those who received HHC, those discharged to SNF or IRF were 25% and 57% more likely to attend CR. Disability was the strongest predictor of not attending CR as older adults with any disability were 64% to 85% less likely to attend CR compared to those without disability. Sixty-three percent were rehospitalized within one-year.

Conclusions: 
Of all known barriers to CR use, disability had the strongest impact on not attending CR. Despite greater burden of disability at admission to SNF and IRF, Beneficiaries who used these services had higher likelihood of CR attendance compared to those who used HHC; however, use was low overall. The current CR model needs to be updated to transition older adults through the full continuum of CR care to prevent the gap that is occurring between PAC and outpatient CR. 

 

Friday, September 5

 

326

4:00 PM – 5:00 PM

Scientific Oral Abstract Presentations

PRESENTER: Susan Dunn
AUTHORS: Dunn, Susan L.1; Dunn, Maureen L.2; Rieth, Nicole P.1, 3; Clark, Jacob A.4; Tintle, Nathan L.4
INSTITUTIONS: 1. Nursing, Hope College, Holland, MI, United States. 
2. Kinesiology, Hope College, Holland , MI, United States. 
3. Spectrum Health, Grand Rapids, MI, United States. 
4. Mathematics and Statistics, Dordt College, Sioux Center, IA, United States. 
ABSTRACT BODY: 
Introduction: 
Hopelessness is prevalent and can persist in patients with a coronary heart disease (CHD), adversely affecting morbidity and mortality. No prior research has examined whether regular exercise can decrease hopelessness in patients with CHD.

Purpose: 
The purpose of this study was to determine the effect of home and hospital-based cardiac rehabilitation exercise on state (a temporary response) and trait (a habitual outlook) hopelessness in patients with CHD.

Design: 
This was a prospective, observational, longitudinal single-center study of patients (N=324) with CHD. 

Methods: 
Patients hospitalized with CHD completed the State-Trait Hopelessness Scale (STHS) and a cardiac rehabilitation exercise questionnaire at baseline (during hospitalization) and at 3, 8 and 12 months. General linear models were used to determine the relationship between hopelessness scores and participation in hospital-based and home exercise programs during the follow-up period.

Results: 
Among subjects, 33% participated in/completed a hospital-based exercise program, while 53% to 58% reported exercising at home at 3 and 12 months respectively. Among patients with moderate to severe hopelessness at baseline, regular (3 days a week or more) home or hospital-based exercise was significantly correlated with lower state and trait hopelessness, as compared to patients who did minimal or no exercise. The impact of exercise (home or hospital) was 1.5 to 2 times greater for state hopelessness as compared to trait hopelessness (state= 0.15 [home] vs. trait= 0.11 [home], state= 0.09 [hospital] vs. trait= 0.04 [hospital]). Among patients with little/no baseline hopelessness, there was minimal change (< 0.1 point) in hopelessness scores over the 12 months. To examine potential differences in home versus hospital-based programs, multivariate analysis was conducted. Home exercise was associated with a greater improvement (1.5 to 3 times) in STHS scores compared to hospital-based exercise (effect sizes: state= 0.15 [home] vs. 0.09 [hospital], trait= 0.11 [home] vs. 0.04 [hospital]). In subjects completing both types of exercise, there was no synergistic effect of dual participation on STHS scores (interaction p-values all >0.40).


Conclusions: 
This is the first study to examine hopelessness in CHD patients and determine the effects of exercise. Regular exercise decreased moderate to severe hopelessness in patients. Although improvement in hopelessness was found with both home and hospital-based exercise programs, home exercise had a stronger impact. Exercise also exhibited a greater impact on state as compared to trait hopelessness. Healthcare professionals should encourage patients with CHD to participate in exercise programs, with potential beneficial effects on morbidity and mortality.

 

PRESENTER: Joel Hughes
AUTHORS: Hughes, Joel1; Gathright, Emily1; Dolansky, Mary A.2; Josephson, Richard A.3; Zullo, Melissa D.1
INSTITUTIONS: 1. Kent State University, Kent, OH, United States. 
2. Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, United States. 
3. Harrington Heart & Vascular Institute, University Hospitals Health System, Cleveland, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Despite the well-established benefits of cardiac rehabilitation (CR), many patients do not attend. Depression is often considered a barrier to CR enrollment and completion. Depression has been reported to predict drop out from CR; however, we previously reported in a limited sample assessed during inpatient hospitalization for a cardiac event that depression did not predict failure to enroll in CR. The relationship between depression and CR participation has not been studied in a national population. 

Purpose: 
The purpose of the current study was to evaluate depression and participation in CR post-MI in a large sample of Medicare beneficiaries.

Design: 
This was a cross-sectional study of a large Medicare dataset. 

Methods: 
Data were from Medicare Beneficiaries (≥65 years) with an MI in 2008 (n=155,186). Depression diagnosis was obtained from the ICD-9 codes in the MEDPAR, Outpatient, and Carrier Files. Multivariable logistic regression examined the association between depression diagnosis during the index MI year and CR attendance.

Results: 
Overall, 15% of Beneficiaries attended CR. Beneficiaries who attended CR were 38% female, 95% white and 3% black, with a mean age of 75 (standard deviation=6.2).Twenty-seven percent had a diagnosis of depression in the index year of their MI and of these 29% attended CR. In adjusted analysis, Beneficiaries with depression were 4.3 (99% confidence interval: 4.1, 4.6) times more likely to attend CR compared to those without depression when controlling for other factors in the model. Fifty-six percent of CR patients with depression completed 25-36 sessions of CR compared to 27% without depression (p<0.001) in unadjusted analysis.

Conclusions: 
Presence of depression in Medicare Beneficiaries was a strongly associated with attending CR and attending more sessions of CR compared to those without depression. Depression was not a barrier to CR participation after an MI. These counter-intuitive findings merit an explanation. A chart diagnosis of depression may indicate that depression treatment was facilitating adherence to healthcare recommendations, including CR referral. It is also possible that CR staff may have provided greater encouragement to see a doctor for depression during CR. Recent, increased appreciation of the importance of addressing depression among post-MI patients may have played a role. Although overall utilization of CR was low, it is encouraging that so many Medicare beneficiaries with a chart diagnosis of depression attended CR. 

 

PRESENTER: Kent Dudycha
AUTHORS: Pack, Quinn R.1, 2; Dudycha, Kent J.1; Roschen, Kyle P.1; Thomas, Randal J.1; Squires, Ray1
INSTITUTIONS: 1. Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States. 
2. Cardiology, Baystate Medical Center, Springfield, MA, United States. 
ABSTRACT BODY: 
Introduction: 
Very early enrollment into cardiac rehabilitation (CR) increases participation rates in CR. However, many CR programs systematically delay enrollment of surgical patients for 4 weeks or more citing safety concerns and inability to exercise.

Purpose: 
To measure the safety of very early enrollment of surgical patients into CR.

Design: 
Retrospective cohort

Methods: 
We performed a detailed safety review of all events occurring within 6 months of hospital discharge for residents of Olmsted County, MN with either coronary artery bypass graft surgery (CABG) or heart valve surgery (HVS) who entered Mayo Clinic’s CR program between May 2009 and August 2012 with follow-up through February 2013. We defined a major clinical event to be death, myocardial infarction (MI), repeat revascularization, stroke, hospital readmission, placement of pacer device, repeat surgery, or sudden cardiac death; minor clinical events to be wound infection, sternal instability, or blood transfusion; and CR-related events to be the early stopping of CR exercise, fall, pre-syncope, unplanned medication administration, EKG, blood draw in CR, or admission to the emergency department following a CR exercise session. Survival analysis was performed using time-to-first safety event and log-rank statistical testing. 

Results: 
We analyzed 112, 69, and 59 patients with CABG, HVS, and MI, respectively. Median time from hospital discharge to CR enrollment [interquartile range] was 10.5 [8 to 15], 12 [8.5 to 21], and 9[7 to 14] days, respectively. There were 85(35%) major, 22(9.2%) minor, and 44(18.3%) CR-related safety events. The major event rate for patients with CABG, HVS, and MI was 23%, 33%, and 28% respectively, demonstrating no difference by diagnosis (log-rank p = 0.24). When compared to their late counterparts, early surgical enrollees had fewer major events (CABG, 16% vs. 30%, log-rank p = 0.037; HVS, 24% vs. 45%, log-rank p = 0.046.) When limited to events occurring only after CR enrollment, there was no difference between early vs. late enrollees for all diagnoses and events (46% vs. 48%, log rank p = 0.66.) Additionally, most CR-related events did not cause harm but rather were opportunities for intervention. 

Conclusions: 
Very early enrollment into CR (within 2 weeks) for patients with open heart surgery appears safe and may be beneficial. Given the other known benefits of early enrollment, it appears that commencing outpatient CR within 2 weeks should be the standard of care, regardless of qualifying diagnosis.

 

PRESENTER: Kristie Harris
AUTHORS: Harris, Kristie M.1; Anderson, Derek1; Landers, Jacob1; Emery, Charles F.1
INSTITUTIONS: 1. Psychology, The Ohio State University , Columbus, OH, United States. 
ABSTRACT BODY: 
Introduction: 
Among patients diagnosed with cardiovascular disease, participation in an outpatient cardiac rehabilitation (CR) program is associated with improvements in physical health. Psychological factors, including dispositional optimism and coping styles, have been shown to influence physical health following completion of CR. Greater optimism has been associated with increased physical health, while maladaptive styles of coping have been predictive of poorer physical functioning. 

Purpose: 
Prior studies have utilized physical health subscales from quality of life measures to examine the relationship among psychological factors and health. Studies have not yet examined objective measures of functional status in relation to optimism and coping. This study evaluated the influence of optimism and coping as moderators of change in physical health, as measured by functional status. 

Design: 
Observational study of patients diagnosed with cardiovascular disease referred to a standard 36-session CR program. Patients were assessed prior to CR and following completion of CR. 

Methods: 
A convenience sample of 31 patients (9 females; mean age = 58.5, SD = 12.4) in outpatient CR programs was recruited for participation. Patients completed self-report measures of optimism (Life Orientation Test (LOT)) and coping styles (Brief COPE) at the pre-CR assessment. A multi-method approach was taken to measure functional status, with patients completing cardiopulmonary exercise testing (VO2 peak), the Duke Activity Status Index (DASI), and the 60 foot walk test (60ftWT) – a novel assessment. Data were analyzed with hierarchical multiple regression, predicting post-CR functional status from the LOT total score and subscales of the Brief COPE, and the interaction of these scores with pre-CR functional status. 

Results:
Correlational analyses indicated that baseline VO2 peak was correlated with baseline score on the DASI (r=0.32, p<0.05) and with duration of the 60ftWT (r =-0.50, p<.001). Regression analyses indicated that optimism moderated change in VO2 peak from pre- to post-CR (β=0.22, p<.05), and self-blame coping moderated change on the DASI (β=0.16, p<.05). Also, self-blame was associated with shorter duration of the 60ftWT (β=-0.18, p=0.053). 

Conclusions: 
This study is the first to examine optimism and coping styles as moderators of functional status change in CR patients. The findings suggest that higher levels of optimism and greater use of self-blame coping at entry to CR are associated with greater gains in functional capacity. There may be activating aspects of self-blame that help facilitate improvement in functional capacity. It will be important to identify components of optimism and self-blame that facilitate greater gains in functional capacity among patients in CR. 

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