On-site programmatic attendance to cardiac rehabilitation and the healthy-adherer effect

David A Alter; Brandon Zagorski; Susan Marzolini; Mary Forhan; Paul I Oh

doi:10.1177/2047487314544084

On-site programmatic attendance to cardiac rehabilitation and the healthy-adherer effect

Eur J Prev Cardiol. 2015 Oct;22(10):1232-46. doi: 10.1177/2047487314544084. Epub 2014 Jul 30.

Authors

David A Alter¹, Brandon Zagorski², Susan Marzolini³, Mary Forhan⁴, Paul I Oh⁵

Affiliations

¹ Institute for Clinical Evaluative Sciences, Toronto, Canada University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada Department of Medicine, University of Toronto, Canada Department of Health Policy, Management and Evaluation, University of Toronto, Canada david.alter@ices.on.ca.
² Department of Health Policy, Management and Evaluation, University of Toronto, Canada.
³ University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada.
⁴ University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada Faculty of Rehabilitation Medicine, University of Alberta, Canada.
⁵ University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada Department of Medicine, University of Toronto, Canada.

PMID: 25079239
DOI: 10.1177/2047487314544084

Abstract

Background: On-site attendance to prescheduled cardiac rehabilitation visits has been shown to be associated with improved outcomes following cardiac rehabilitation. The extent to which on-site programmatic attendance represents a healthy-adherer effect remains unknown.

Methods: This retrospective cohort study consisted of 17,000 consecutively referred patients to a cardiac rehabilitation program in Ontario, Canada. On-site attendance at prescheduled visits was our primary exposure variable. The primary outcome was all-cause death or hospitalization at two years following the expected program completion date, irrespective of drop-out. Secondary outcomes included adherence to statins, health-seeking preventative health visits, and changes in clinical risk-profiles. Cox proportional hazards adjusted for baseline sociodemographic, clinical and comorbid characteristics.

Results: Among the 12,440 patients who attended at least one prescheduled on-site visit, on-site attendance was inversely correlated with baseline smoking rates and body mass index at program entry. After adjustment for baseline factors, the risk of death or hospitalization progressively fell with incremental increases in on-site attendance (adjusted hazard ratio for each 10% increase in on-site attendance: 0.96; 95% confidence interval: 0.93-0.99, p = 0.007). Such associations were driven predominantly by differences in non-cardiovascular hospitalizations. Incremental increases in on-site attendance were associated with improvements in cardiopulmonary fitness and body mass index (both p < 0.001), better attendance of preventative care physician visits (p < 0.001) and higher medication adherence to statins (p = 0.007).

Conclusions: Associations between on-site attendance at cardiac rehabilitation and outcomes may represent a healthy-adherer effect. Future research must evaluate the clinical utility of on-site attendance as a behavioral health-adherence metric for cardiac rehabilitation monitoring and surveillance.

Keywords: Cardiac rehabilitation; adherence; attendance; outcomes; self-management.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Aged
Appointments and Schedules*
Chi-Square Distribution
Comorbidity
Female
Health Status
Heart Diseases / diagnosis
Heart Diseases / mortality
Heart Diseases / rehabilitation*
Hospitalization
Humans
Hydroxymethylglutaryl-CoA Reductase Inhibitors / therapeutic use
Least-Squares Analysis
Logistic Models
Male
Middle Aged
Multivariate Analysis
Ontario
Outpatient Clinics, Hospital*
Patient Compliance*
Patient Dropouts
Preventive Health Services
Program Evaluation
Proportional Hazards Models
Retrospective Studies
Risk Assessment
Risk Factors
Self Care
Time Factors
Treatment Outcome

Substances

Hydroxymethylglutaryl-CoA Reductase Inhibitors