A Toronto Rehab-led study suggests one size ‘does not’ fit all when it comes to cardiac rehab. Study leads Dr. David Alter, Senior Scientist, and Avi Biswas, PhD candidate, to recommend tailoring cardiac rehab services to the behaviours and profiles of the patient populations served to have a stronger impact on the number of lives saved. (Video: UHN)

Toronto Rehab researchers have discovered a new approach for determining which patient populations benefit most from cardiac rehabilitation.

In a Canadian study published recently in the Journal of Clinical Epidemiology, researchers discovered that frail, older adults with multiple illnesses and higher baseline risk factors including hypertension and diabetes benefit most from cardiac rehab – while women, living alone, being socio-economically disadvantaged, socially deprived, and those with greater levels of body mass index, report lower levels of success with the program.

The study, led by Dr. David Alter, Senior Scientist, Toronto Rehabilitation Institute-University Health Network (UHN), and Institute for Clinical Evaluative Sciences, revealed that an individual's baseline risk at the time they enter cardiac rehab – for example, age, sex, socioeconomic status and clinical risk factors  – had the strongest impact on the success of the program.

The study also examined the behavioural tendencies of the population, including their risk of dropping out of the program – which had a smaller, but still significant impact on the effectiveness of cardiac rehab.

Cardiac rehab helps people with heart disease improve their cardiac health and fitness. It also helps them reduce their chance of future cardiac incidents by making lasting lifestyle and behaviour changes.

"Before now, no study has demonstrated the impact of juxtaposing risk of program dropout versus risk of dying and finding out 'who' benefits most from cardiac rehab – and which patient populations require more support to access these services," says Dr. Alter.

"Across Canada, we operate on this 'one size fits all approach' to cardiac rehab – but this study suggests that we may have it wrong. We need to tailor cardiac rehab services to the behaviours and profiles of the patient populations we serve to have a stronger impact on the number of lives saved."

This study looked at the baseline profiles and program attendance of approximately 16,000 cardiac rehab patients at Toronto Rehab's Cardiac Prevention and Rehabilitation Program at Rumsey Centre from 1995-2011. Patients were admitted to the program a minimum of four to eight weeks after a cardiovascular event or surgical intervention, and expected to attend a weekly exercise session, one-on-one counseling, education and peer-to-peer support once per week for six months.

"We are now in a better position to inform policy makers on the most effective ways to allocate resources and funding to cardiac rehab programs – we need to ensure that our programs work for the most number of people to have the largest impact," says Avi Biswas, lead author and PhD candidate, Toronto Rehabilitation Institute-UHN.

In the elderly, frailer population, fitness levels tend to be very poor at the beginning and their ability to function independently in society is significantly impaired. Given this group is more likely to be re-hospitalized or succumb to their disease, even the smallest lifestyle changes and modifications to physical function can have huge survival benefits.

Conversely, other populations, including women, those who are socioeconomically disadvantaged and socially isolated, struggle behaviourally to attend the program for a host of reasons, which may include work commitments, transportation affordability, competing demands in the community or dependence on others to take them.

"While it's reassuring to know that cardiac rehab is so effective in improving the lives of the elderly population, this study has also shown a gap in care and illuminated an unmet delivery need," says Dr. Alter. "We need to find creative strategies to engage these less engaged populations."

The research team is looking into new and innovative ways of re-thinking the way cardiac rehab is delivered in an effort to reach a larger number of patients in the population; for example, the use of financial and rewards-based incentive programs through partnerships to keep people motivated and focused on rehab, exploring music strategies to improve exercise adherence, and looking beyond hospital walls to deliver programming into the community and at home. ​

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