Goal attainment in a randomized controlled trial of rehabilitation after myocardial infarction

PURPOSE: Goal setting is an established strategy in health behavior change programs although its usefulness remains uncertain. The authors investigate the validity of attainment of a patient-identified goal as an outcome measure in cardiac rehabilitation after myocardial infarction. METHODS: On entry into a randomized controlled trial of cardiac rehabilitation after an acute myocardial infarction, patients identified one activity that, if and when attained, would reflect their perception of a successful recovery. Patients reported whether they had attained their goal and the time of goal attainment. This was then related to trial outcomes that included generic and specific health-related quality of life and percent predicted exercise tolerance. RESULTS: Goals identified by 180 of the 201 (89.6%) patients, were attained by 51.5% at 8 weeks and by 86.5% at 12 months. At the end of the 8-week intervention, there was a substantial trend for fewer rehabilitation than usual care patients to have attained their identified goal (P < 0.06), although rehabilitation patients demonstrated greater improvement in specific health-related quality of life and exercise tolerance than usual care patients (P < 0.05). Among patients who identified a recreational physical activity goal (26.7%), significantly fewer (P < 0.007) rehabilitation than usual care patients had attained their goal at the end of the intervention with no differences in improvement in outcomes. CONCLUSIONS: Although improvement in outcomes was greater in rehabilitation patients than usual care patients at 8 weeks, goal attainment, particularly for the recreational physical activity goal, was greater among usual care patients. The validity of self-identified activity goal attainment as a measure of the efficacy of cardiac rehabilitation is unclear and might give misleading results.     

Effectiveness of rehabilitation with musculoskeletal diseases

Multidisciplinary treatment focusing on impairments, activities and participation are an important component within the therapeutic regimen in musculoskeletal conditions. In Germany, for more than 95% of the patients multidisciplinary treatment is provided as inpatient rehabilitation. According to the results of a study from the Netherlands, inpatient rehabilitation is superior to usual care in terms of decreasing disease activity and improving emotional well-being in rheumatoid arthritis. Another randomized, controlled study gives evidence that rehabilitation is more effective as compared to usual care in ankylosing spondylitis. In patients suffering from fibromyalgia, after inpatient rehabilitation, symptoms improve significantly and this is true even one year after discharge. The results of a quality management project financed by the German health insurance and including several thousand patients with musculoskeletal diseases show an improvement in physical and emotional dimensions of health status at discharge and after a six month follow-up. Recent studies comparing inpatient with outpatient rehabilitation in patients with musculoskeletal diseases provide information that both forms are equally effective. Taking into account the high number of inpatient rehabilitation procedures in Germany, more outcomes research is required urgently.     

Exercise-based cardiac rehabilitation for very old patients (> or =75 years): focus on physical function

Older patients have high rates of physical function impairment and disability following a cardiac event. Exercise training has been shown to favorably affect such limitations, as well as cardiovascular risk factors, symptoms, and mortality post coronary event in middle-aged patients. Aerobic capacity, body strength, quality of life, and physical function are improved with exercise-based cardiac rehabilitation (CR) in patients older than 65 years. However, there have been relatively few studies of the effects of exercise-based CR on physical function recovery in the very old patients (> or =75 years), despite the continuous growth of this segment of the population. After hospitalization for a cardiac event, postacute inpatient CR serves as a bridge between acute care and independent home living for the most disabled older patients. It plays an important role in the physical recovery process, particularly after cardiac surgery. Exercise-based outpatient (phase II) CR, starting early after hospital discharge, is safe in very old patients and studies demonstrate that these patients derive similar benefits from CR, compared with younger patients, regarding physical function improvement. Older patients, however, are less likely than younger cardiac patients to participate in outpatient CR programs. There is a need to find protocols that could increase the referral and participation rates of the frailer and older cardiac patient to exercise-based CR.     

Is the MacNew quality of life questionnaire a useful diagnostic and evaluation instrument for cardiac rehabilitation?

PURPOSE: The MacNew health-related quality of life questionnaire is internationally used as a standard for psychosocial assessment in many cardiac rehabilitation centres. This study investigates its discriminating capacity between diagnostic disease categories, sex and age at entry (T1) and at the end (T2) of cardiac rehabilitation as well as the responsiveness of the MacNew during this period. METHOD: Data were used from 6,749 cardiac rehabilitation patients at T1 and 1,654 at T2. RESULTS: Results show that the global MacNew as well as the three (physical, emotional, social) subscales have high internal consistencies, and differentiate well and in the expected direction at T1 between diagnostic groups (heart surgery, myocardial infarction with and without percutaneous coronary intervention, stable angina with and without percutaneous coronary intervention, implantable cardioverter defibrillator, and heart failure patients), sex and age. The MacNew also proves to be an adequate evaluation instrument for cardiac rehabilitation, as all scales are responsive enough to capture changes from T1 to T2. At T2, however, the MacNew seems to lose some of its discriminating power, partly because of ceiling effects. CONCLUSION: It is suggested to complement the use of the MacNew both at T1 and T2 with a brief anxiety and depression measure, which is valid and responsive for different groups of cardiac rehabilitation patients.     

Comparative outcome one year after formal cardiac rehabilitation: the effects of a randomized intervention to improve exercise adherence.

BACKGROUND: Methods to ensure sustained benefits of cardiac rehabilitation need to be explored. The aim was to assess the effect of a home-based intervention (INT) on exercise adherence and risk factors after cardiac rehabilitation. DESIGN: Prospective randomized study. METHODS: We evaluated patients who were followed for 1 year after either inpatient (ICR) or outpatient cardiac rehabilitation (OCR) by assessment of exercise capacity, physical activity, risk factors and quality of life, both at the completion of rehabilitation, and after 1 year. Patients were randomized to either be instructed how to use a diary of physical activities complemented by quarterly group meetings (INT) or to receive standard treatment (usual care). RESULTS: Two hundred and sixty-one patients gave consent to be reevaluated after 1 year. Of these patients 33 were lost to follow-up (two deaths); thus 228 patients had complete 1-year follow-up data (195 male and 33 female, 91% with coronary artery disease). At 1-year follow-up significantly more patients of the INT group than of the control group adhered to regular physical activity (73 vs. 40%, P<0.0001). Moreover, INT patients showed a better evolution of body mass index and lipid values. In a stepwise multiple regression analysis the following variables showed a significant impact on regular physical activity at follow-up: study INT [odds ratio (OR): 4.19, P<0.0001], previous cardiac surgery (OR: 2.50, P=0.008), BMI at baseline (OR: 0.89, P=0.018) and quality of life at baseline (OR: 1.58, P=0.041). CONCLUSION: Sustained benefits of cardiac rehabilitation can be documented 1 year after both inpatient and outpatient programmes. Self-monitoring of physical activity greatly increased long-term adherence to regular exercise, which in turn was associated with greater improvements of risk factors and quality of life.     

Effects of an outpatient physical exercise program on hematopoietic stem-cell transplantation recipients: a randomized clinical trial

Patients who undergo hematopoietic SCT (HSCT) often experience physical and psychological problems, even long after treatment has been completed. This study was performed to evaluate the effects of a 12-week outpatient physical exercise (PE) program, incorporating aerobic and strength exercises, as compared with a usual care control condition on patients' physical performance and psychosocial well-being. Patients who had completed HSCT up to 6 months earlier were randomly assigned to a supervised PE program (n=64) or a usual care control group (n=67). Primary outcomes were quantified physical performance and self-reported physical functioning. Secondary outcomes were body composition measurement, quantified walking activity and patient-reported outcomes (physical activity, fatigue and health-related quality of life). Assessments were at baseline, immediately after program completion and at 3-month follow-up. Significant intervention effects were observed at both posttreatment and follow-up on physical performance measures. No other outcomes yielded statistically significant group differences. PE should be considered in the management of HSCT recipients to improve physical performance after discharge from the hospital. Further research is needed to determine how the program can be enhanced so that improved physical performance also translates into improved physical and psychosocial functioning in daily life.     

Ambulante Rehabilitation nach Herzinfarkt und bei Herzinsuffizienz

Reducing cardiac mortality and improving quality of life are the main objectives of cardiac rehabilitation. In recent years, outpatient rehabilitation within easy patient reach has achieved the same status as inpatient rehabilitation. Outpatient rehabilitation permits close involvement of the patient's family and social environment, thus easing reintegration into everyday life. However, the health care system is not yet utilizing outpatient rehabilitation to its full potential. This contribution illustrates the principles of rehabilitation following myocardial infarction or for heart failure in an outpatient setting, as well as its potential and future development.     

Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome

RATIONALE: Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS). OBJECTIVES: To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge. METHODS: We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge. MEASUREMENTS: Clinical and functional outcomes, health care use, and direct medical costs. RESULTS: Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from emotional role and mental health, all other domains remained below that of the normal population. From ICU admission to 2 yr after ICU discharge, the largest portion of health care costs for a survivor of ARDS was the initial hospital stay, with ICU costs accounting for 76% of these costs. After the initial hospital stay, health care costs were related to hospital readmissions and inpatient rehabilitation. CONCLUSIONS: Survivors of ARDS continued to have functional impairment and compromised health-related quality of life 2 yr after discharge from the ICU. Health care use and costs after the initial hospitalization were driven by hospital readmissions and inpatient rehabilitation.     

Improvement in physiological outcomes and health-related quality of life following cardiac rehabilitation in patients with acute myocardial infarction.

BACKGROUND: The present study examined the impact of an 8-week cardiac rehabilitation (CR) program on physiological outcomes and health-related quality of life (HRQOL) of patients with acute myocardial infarction (AMI). METHODS AND RESULTS: A total of 124 consecutive AMI patients were divided into a supervised outpatient CR group (n=82) and a non-CR group as a control (n=42). Peak oxygen uptake, handgrip strength, and knee extension muscular strength were used as physiological outcome measures. HRQOL outcomes were assessed by the Medical Outcome Study Short Form 36 (SF-36). CR group patients performed both aerobic exercise and moderate resistance training from 1 month (T1) to 3 months (T2) after AMI onset. Age, sex, body mass index, medications, and ejection fraction were similar in both groups. Significantly greater increases in overall physiological outcomes from T1 to T2 were measured in the CR group compared with those of the non-CR group. There were also significantly greater improvements in 4 of the 8 SF-36 health status subscales (physical functioning, role-physical, general health, and vitality) in the CR group compared with the non-CR group. CONCLUSIONS: Eight weeks of exercise training have specific effects on improvement in HRQOL and physiological outcomes in Japanese patients.     

Effect of Different Endurance Training Protocols During Cardiac Rehabilitation on Quality of Life

BackgroundThis study aimed to assess the effect of different types of endurance training during outpatient cardiac rehabilitation on patients’ health-related quality of life (HRQL).MethodsThe MacNew Heart Disease HRQL questionnaire and the Hospital Anxiety and Depression Scale were used to assess changes in HRQL in 66 patients before and after 6 weeks of cardiac rehabilitation. Patients were randomized to 1 of 3 types of supervised endurance training: continuous endurance training, high-intensity interval training, and pyramid training. Two-way analysis of variance for repeated measure and chi-square test were used to analyze changes before and after rehabilitation.ResultsAttendance rate during the 6 weeks of exercise training was 99.2%. Physical work capacity increased from 136.1 to 165.5 watts (+22.9%; P < .001), and there were no statistical differences between training protocols. Fully completed questionnaires at both time points were available in 46 patients (73.9%; 61.3±11.6 years, 34 males, 12 females). Regardless of the type of supervised endurance training, there was significant improvement during rehabilitation in each of the categories of the MacNew questionnaire (ie, emotion, physical, social, global; all P < .05) and the Hospital Anxiety and Depression Scale (anxiety: P = .05; depression: P = .032), without significant differences between protocols.ConclusionsAll 3 types of endurance training led to significant and well comparable increases in physical work capacity, which was associated with an increase in HRQL independent of the type of training. Our findings support further individualization of training regimes, which could possibly lead to better compliance during life-long home-based exercise training.     

Effects of home-based rehabilitation on health-related quality of life and psychological status in Chinese patients recovering from acute myocardial infarction

Objective

This study evaluated the effects of a home-based rehabilitation program for Chinese patients with myocardial infarction in terms of health-related quality of life and psychological status.

Methods

This was a randomized, controlled trial with data collected at 2 university-affiliated public general hospitals in Xian (Shaanxi Province, People's Republic of China). One hundred and sixty patients with a myocardial infarction were randomly assigned to either the interventional group (a home-based cardiac rehabilitation program using a self-help manual) or the control group (usual care). Health-related quality of life (generic, Chinese Short Form 36-Item Health Survey; disease-specific, Chinese Myocardial Infarction Dimensional Assessment Scale) and psychological status (the Chinese Hospital Anxiety and Depression Scale) were measured at baseline, program completion (6 weeks), and 3 and 6 months after hospital discharge.

Results

Significant differences were evident in the main outcomes when the home-based group was compared with the usual care group at 6 weeks, 3 months, and 6 months. The home-based group had significantly higher scores on 4 of the 8 domains of the Chinese Short Form 36-Item Health Survey and on 3 of the 7 dimensions of the Chinese Myocardial Infarction Dimensional Assessment Scale, with significantly lower scores on the anxiety, but not the depression, subscale of the Chinese Hospital Anxiety and Depression Scale.

Conclusions

A simple, home-based cardiac rehabilitation program for patients with acute myocardial infarction, using a self-help manual, improves health-related quality of life and reduces anxiety. It appears feasible and acceptable, and does not produce inferior outcomes compared with usualcare in China.     

Health-Related Quality of Life in Children and Adolescents with Asthma: Results from the ESTAR Study

Our aim was to assess the psychosocial well-being of asthmatic children and adolescents, the influencing factors, and to determine the effect of inpatient rehabilitation on their quality of life; 226 asthmatic children and adolescents participated in the inpatient rehabilitation (IG). The comparison group (CG) included 92 asthmatic children and adolescents receiving standard medical treatments. Patients were aged between 8 and 16 years and were predominantly male. The health-related quality of life was measured with the German version of the “Paediatric Asthma Quality of Life Questionnaire.” Interviews were carried out for IG 2 weeks before the commencement of their inpatient stay and 1 year after their stay ended. The same time schedule was carried out for CG. All patients reported a mild to moderate impairment of their quality of life. Girls described a slightly lower quality of life than boys. With increasing asthma severity, quality of life decreased. Inpatients described a lower quality of life than CG at enrollment. Inpatient rehabilitation resulted in a greater improvement of quality of life over time for IG than for CG. Gender and severity status had no effect on this time course. The only modestly affected quality of life may reflect the good adaptation to the disease and medical treatment. Children and adolescents in the IG recorded improvements in their quality of life. Differences in quality of life based on gender and disease severity were not shown to influence the improvements. In summary, inpatient rehabilitation results in an improvement of health-related quality of life. Further research concerning the psychosocial situation of children and adolescents in this setting is needed.     

Health-related quality of life in children and adolescents with asthma: results from the ESTAR Study.

Our aim was to assess the psychosocial well-being of asthmatic children and adolescents, the influencing factors, and to determine the effect of inpatient rehabilitation on their quality of life; 226 asthmatic children and adolescents participated in the inpatient rehabilitation (IG). The comparison group (CG) included 92 asthmatic children and adolescents receiving standard medical treatments. Patients were aged between 8 and 16 years and were predominantly male. The health-related quality of life was measured with the German version of the "Paediatric Asthma Quality of Life Questionnaire." Interviews were carried out for IG 2 weeks before the commencement of their inpatient stay and 1 year after their stay ended. The same time schedule was carried out for CG. All patients reported a mild to moderate impairment of their quality of life. Girls described a slightly lower quality of life than boys. With increasing asthma severity, quality of life decreased. Inpatients described a lower quality of life than CG at enrollment. Inpatient rehabilitation resulted in a greater improvement of quality of life over time for IG than for CG. Gender and severity status had no effect on this time course. The only modestly affected quality of life may reflect the good adaptation to the disease and medical treatment. Children and adolescents in the IG recorded improvements in their quality of life. Differences in quality of life based on gender and disease severity were not shown to influence the improvements. In summary, inpatient rehabilitation results in an improvement of health-related quality of life. Further research concerning the psychosocial situation of children and adolescents in this setting is needed.     

Comparison of intensive outpatient cardiac rehabilitation to standard outpatient care in veterans: effects on quality of life

BACKGROUND: Examination of the effect of cardiac rehabilitation (CR) on quality of life has been relatively limited. The current study examined existing clinical data, which had been obtained during the course of program evaluation. Changes in quality of life for patients who participated in an intensive rehabilitation program and those who had received standard outpatient care only were compared. METHODS: Quality-of-life changes in cardiac patients (n = 87) from two treatment groups were compared. Patients had either participated in an 8-week intensive CR program (n = 45) consisting of monitored exercise 3 days weekly and inter-disciplinary education sessions, or routine outpatient clinic services (n = 42). RESULTS: Patients in the intensive CR program demonstrated significant (P < 0.05-< 0.001) improvement in all areas of quality of life assessed. In contrast, patients that received routine outpatient care did not demonstrate any areas of improvement, while Vitality was significantly (P < 0.05) poorer at posttest. CONCLUSIONS: Our results suggest that provision of more intensive outpatient CR can improve quality of life more than standard outpatient care.     

Effectiveness and cost-effectiveness of adding a cognitive behavioral treatment to the rehabilitation of chronic low back pain

OBJECTIVE: To investigate return to work and cost-effectiveness of the addition of cognitive-behavioral treatment to standard therapy compared to standard 3-week inpatient rehabilitation for patients with chronic low back pain. METHODS: A prospective economic evaluation alongside a randomized controlled trial was performed. Outcomes included days off work due to spinal complaints, health-related quality of life, and direct and indirect disease-related costs. RESULTS: A total of 409 patients with chronic low back pain, who were admitted to a 3-week inpatient rehabilitation, were randomly assigned to usual care or usual care plus cognitive behavioral treatment. Average incremental costs for psychological treatment during rehabilitation were Euros 127 (95% CI 125.6, 130.9; p < 0.001). Six months after rehabilitation, patients in the intervention group were absent from work an average of 5.4 (95% CI -1.4, 12.1; p = 0.12) days less than patients receiving usual treatment. Between groups, there were no significant differences in quality-adjusted life-years gained or in direct medical or nonmedical costs. The cognitive behavioral treatment showed lower indirect costs: Euros 751 (95% CI -145, 1641; p = 0.097). CONCLUSION: Adding a cognitive behavioral component to standard therapy may reduce work days lost and thus decrease indirect costs. From a societal perspective, the cost of the psychological treatment was compensated by lower indirect costs.     

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials

PURPOSE: To review the effectiveness of exercise-based cardiac rehabilitation in patients with coronary heart disease. METHODS: A systematic review and meta-analysis of randomized controlled trials was undertaken. Databases such as MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2003. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise training alone or in combination with psychological or educational interventions. RESULTS: We included 48 trials with a total of 8940 patients. Compared with usual care, cardiac rehabilitation was associated with reduced all-cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) and cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96); greater reductions in total cholesterol level (weighted mean difference, -0.37 mmol/L [-14.3 mg/dL]; 95% CI: -0.63 to -0.11 mmol/L [-24.3 to -4.2 mg/dL]), triglyceride level (weighted mean difference, -0.23 mmol/L [-20.4 mg/dL]; 95% CI: -0.39 to -0.07 mmol/L [-34.5 to -6.2 mg/dL]), and systolic blood pressure (weighted mean difference, -3.2 mm Hg; 95% CI: -5.4 to -0.9 mm Hg); and lower rates of self-reported smoking (OR = 0.64; 95% CI: 0.50 to 0.83). There were no significant differences in the rates of nonfatal myocardial infarction and revascularization, and changes in high- and low-density lipoprotein cholesterol levels and diastolic pressure. Health-related quality of life improved to similar levels with cardiac rehabilitation and usual care. The effect of cardiac rehabilitation on total mortality was independent of coronary heart disease diagnosis, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date. CONCLUSION: This review confirms the benefits of exercise-based cardiac rehabilitation within the context of today's cardiovascular service provision.     

Therapies for Advanced Heart Failure Patients Ineligible for Heart Transplantation: Beyond Pharmacotherapy

Globally, there are ∼ 26 million people living with heart failure (HF), 50% of them with reduced ejection fraction, costing countries billions of dollars each year. Improvements in treatment of cardiovascular diseases, including advanced HF, have allowed an unprecedented number of patients to survive into old age. Despite these advances, patients with HF deteriorate and often require advanced therapies. As the proportion of elderly patients in the population increases, there will be an increasing number of patients to be evaluated for advanced therapies and an increasing number that do not qualify for, won’t be considered for, or decline orthotopic heart transplantation. The purpose of this article is to review the benefits of palliative care (PC), exercise-based cardiac rehabilitation (ExCR), device therapy (cardiac resynchronization therapy and mitral clip), and mechanical circulatory support (MCS) in advanced HF patients who are transplant ineligible. PC interventions should be introduced early in the course of a patient’s diagnosis to manage symptoms, address goals of care, and improve patient-centered outcomes. Further improvement in health-related quality of life as well as functional capacity can be achieved safely in patients with advanced HF through patient participation in ExCR. Device therapy and MCS can reduce HF hospitalizations and improve survival. In fact, early survival with MCS approaches that of heart transplantation. Despite their being transplant ineligible, there are a variety of treatment options available to patients to improve their quality of life, decrease hospitalizations, and potentially improve mortality.     

Long-term effects of outpatient rehabilitation of COPD: A randomized trial

OBJECTIVE: To examine the short- and long-term effects of an outpatient pulmonary rehabilitation program for COPD patients on dyspnea, exercise, health-related quality of life, and hospitalization rate. SETTING: Secondary-care respiratory clinic in Barcelona. METHODS: We conducted a randomized controlled trial with blinding of outcome assessment and follow-up at 3, 6, 9, 12, 18, and 24 months. Sixty patients with moderate to severe COPD (age 65 +/- 7 years; FEV(1) 35 +/- 14%) were recruited. Thirty patients randomized to rehabilitation received 3 months of outpatient breathing retraining and chest physiotherapy, 3 months of daily supervised exercise, and 6 months of weekly supervised breathing exercises. Thirty patients randomized to the control group received standard care. RESULTS: We found significant differences between groups in perception of dyspnea (p < 0.0001), in 6-min walking test distance (p < 0.0001), and in day-to-day dyspnea, fatigue, and emotional function measured by the Chronic Respiratory Questionnaire (p < 0. 01). The improvements were evident at the third month and continued with somewhat diminished magnitude in the second year of follow-up. The PR group experienced a significant (p < 0.0001) reduction in exacerbations, but not the number of hospitalizations. The number of patients needed to treat to achieve significant benefit in health-related quality of life for a 2-year period was approximately three. CONCLUSION: Outpatient rehabilitation programs can achieve worthwhile benefits that persist for a period of 2 years.     

Does early pulmonary rehabilitation reduce acute health‐care utilization in COPD patients admitted with an exacerbation? A randomized controlled study

Background and objective: In COPD, hospital admissions and readmissions account for the majority of health‐care costs. The aim of this prospective randomized controlled study was to determine if early pulmonary rehabilitation, commenced as an inpatient and continued after discharge, reduced acute health‐care utilization. Methods: Consecutive COPD patients (n = 397), admitted with an exacerbation, were screened: 228 satisfied the eligibility criteria, of whom 97 consented to randomization to rehabilitation or usual care. Both intention‐to‐treat and per‐protocol analyses are reported with adherence being defined a priori as participation in at least 75% of rehabilitation sessions. Results: The participants were elderly with severe impairment of pulmonary function, poor health‐related quality of life and high COPD‐related morbidity. The rehabilitation group demonstrated a 23% (95% CI: 11–36%) risk of readmission at 3 months, with attendees having a 16% (95% CI: 0–32%) risk compared with 32% (95% CI: 19–45%) for usual care. These differences were not significant. There were a total of 79 COPD‐related readmission days (1.7 per patient, 95% CI: 0.6–2.7, P = 0.19) in the rehabilitation group, compared with 25 (1.3 per patient, 95% CI: 0–3.1, P = 0.17) for the attendees and 209 (4.2 per patient, 95% CI: 1.7–6.7) for usual care. The BMI, airflow obstruction, dyspnoea and exercise capacity index showed a non‐significant trend to greater improvement among attendees compared with those receiving usual care (5.5 (2.3) and 5.6 (2.7) at baseline, improving to 3.7 (1.9) and 4.5 (2.5), respectively, at 3 months). No adverse effects were identified. Conclusions: Early inpatient–outpatient rehabilitation for COPD patients admitted with an exacerbation was feasible and safe, and was associated with a non‐significant trend towards reduced acute health‐care utilization.     

Post-discharge home-based support for older cardiac patients: a randomised controlled trial

BACKGROUND: Hospital and exercise-based cardiac rehabilitation programmes do not suit many older patients and home-based rehabilitation may be more effective. OBJECTIVE: To evaluate a home-based intervention for patients aged 65 years or over discharged home from hospital after emergency admission for suspected myocardial infarction. DESIGN: A single-blind randomised controlled trial comparing home-based intervention by a nurse with usual care. SUBJECTS: Patients aged 65 years or over discharged home after hospitalisation with suspected myocardial infarction (n= 324). INTERVENTION: Home-based intervention (n = 163) consisted of home visits at 1-2 and 6-8 weeks after hospital discharge by a nurse who encouraged compliance with and knowledge of their treatment regimen, offered support and guidance about resuming daily activities, and involved other community services as appropriate. MEASUREMENTS: Up to 100 days after admission, data were collected on deaths, hospital readmissions and use of outpatient services. Survivors were sent a postal questionnaire to assess activities of daily living and quality of life. RESULTS: At 100 day follow-up there was no difference in deaths, activities of daily living or overall quality of life, but those in the intervention group scored significantly better on the confidence and self-esteem subsections. The intervention group had fewer hospital readmissions (35 versus 51, relative risk 0.68, 95% CI 0.47-0.98, P < 0.05) and fewer days of hospitalisation after initial discharge (mean difference -1.7, 95% CI -2.09 to -1.31, P < 0.05). A total of 42/43 individuals in the intervention group had resumed driving at follow-up, compared with 32/43 in the usual care group (observed difference between proportions 23%, 95% CI 9-37%, P < 0.05). CONCLUSION: Amongst older patients discharged home after hospitalisation for suspected myocardial infarction, home-based nurse intervention may improve confidence and self-esteem, and reduce early hospital readmissions.