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Improving the Quality of Care Following an Acute Cardiac Event
duration of CR from 12 to 18 weeks (with a maximum of 36 sessions providers about issues such as depression or uncontrolled risk factors,
covered). It recognizes that sessions without telemetry monitoring may and use of exercise equipment more appropriate for women and
be appropriate for some patients, which allows programs to be more elderly patients.
7,8,24,25
flexible and to for programming to be  individualized. Despite this,
underutilization remains a problem. In addition to provider, system, and environmental barriers common to
all patients, women have additional unique barriers to enrollment in CR.
Nurse-led co-ordination of care before and after hospital discharge Women have the same misconceptions about CR as providers, often
may be a strategy to increase enrollment in CR for older patients. Case considering CR to only include exercise in a gym environment, which is
management systems for high-risk patients, follow-up telephone an unfamiliar culture for many middle-aged and elderly women. Some
contact by the CR program, and involvement of CR staff in inpatient are embarrassed by exercising in a group setting or have co-morbidities,
rounds and rehabilitation care have been described as potential such as obesity, arthritis, osteoporosis, or urinary stress incontinence,
strategies to increase enrollment.
17,18
Carroll et al. used a collaborative that require special attention during exercise. They also have conflicting
peer advisor/advanced practice nurse intervention in 247 unpartnered attitudes about attending CR, often concerned that this may take them
older adults following myocardial infarction or coronary artery bypass away from their responsibilities at home.
17
graft to improve enrollment in CR.
19
Treatment consisted of a home
visit within 72 hours after discharge and follow-up telephone calls Recently, investigators have been studying innovative CR program
from an advanced practice nurse and a peer advisor. Compared with models specifically designed for women. Davidson et al. described a
usual care, significantly more patients were participating in CR Heart Awareness for Women Program, consisting of a six-week program
after  three months in this treatment group and there was a trend in which groups of five to 10 women met weekly for two hours in the CR
toward fewer re-hospitalizations. department for a facilitated session designed to promote education and
awareness, social support, and strategies for behavior change.
26
A nurse
Inpatient Rehabilitation for Elderly Patients facilitator promoted mutual support and sharing of commonality of
Some elderly patients are not appropriate for referral to an experience, views, and emotions. Participants also attended CR exercise
outpatient  CR program immediately after discharge from acute care, sessions. At the end of the program, participants (n=48) completed
especially those over 75 years of age who have had open-heart surgery. questionnaires to evaluate psychosocial outcomes. Although results
They have significant medical deconditioning and are often unable to were not statistically significant for changes in depression, stress, or
dress, shower, walk around the house, or cook meals. These patients can anxiety scores from pre-intervention to post-intervention, they were
benefit from transfer to an inpatient rehabilitation facility (IRF). Typically, able to identify four themes from qualitative data:
they participate in three or more hours of physical and occupational
therapy per day, working on independence in activities of daily living, • lack of understanding/awareness of symptoms prior to participation
independent ambulation, understanding medications and self- in CR;
management principles, and increasing physiological ability and • feelings of isolation following the event;
psychological confidence for return to home, often alone. Medical issues • not prioritizing their own health, putting the needs of other family
are also monitored and addressed, including fluid status, wound care, members ahead of their own; and
arrhythmias, diabetes, blood pressure, and pulmonary status.
14
• appreciating the benefits of supportive education/awareness.
Facilities providing this care track outcomes for quality improvement. Other investigators have described innovative program models such as
Data from eRehab, one of the large IRF data registries, show that in women’s-only exercise sessions and peer support activities. A recent
2008 the average length of stay for these patients (n=4,786) was article by Parkosewich is an excellent summary of barriers and
10.7 days. Percentage gain in functional independence measure was opportunities for women in CR.
17
28% at discharge and an additional 18% at  three months. Seventy-
nine percent  were discharged home and 82% were still living at Underutilization of Cardiac Rehabilitation by
home at  three months, with 4.5% three-month mortality.
20
Unless Minority Patients
patients have significant barriers to enrollment, such as dementia, Despite receiving similar mortality benefit from participation in CR,
all patients should be referred to an outpatient CR program close to minority patients are less likely to participate.
1,5,27
Non-white women are
their home at discharge. less likely to be referred to CR and are more likely to report financial
barriers.
27
Barriers to access for minority patients with socioeconomic
Barriers to Cardiac Rehabilitation Utilization in Women challenges include unavailability of CR programs in cities and rural
Women are 50% less likely to participate in CR compared with men
21
areas, few minority professionals in CR, inconsistent reimbursement by
despite equal benefit
1
and endorsement in clinical practice guidelines.
22
Medicaid programs, transportation issues, and programs that are
Again, some of this underutilization may be related to referral bias,
23
perceived as culturally insensitive. Inner-city hospitals often struggle
since CR programs were originally designed to return young men to financially and concentrate resources on high-volume or higher-profit
work. Over the past three decades, however, CR has progressed to a activities rather than on innovative CR programming. Increasing
comprehensive program for all patients.  CR includes  individualized participation in CR by minority patients and training minority CR
treatment plans that address secondary prevention issues and professionals should be priority areas for research and quality
promote lifelong exercise, communication with other healthcare improvement in the future.
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