Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi School of Management, Milan, Italy.
Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi School of Management, Milan, Italy.
Clin Ther. 2022 Apr;44(4):491-507. doi: 10.1016/j.clinthera.2022.02.002. Epub 2022 Mar 3.
Cardiac rehabilitation (CR) is a class I recommendation after valvular surgery. Few data exist on the level of access to CR after surgical aortic valve replacement (SAVR), and the factors affecting the probability of timely access to CR after SAVR have never been empirically investigated. This study aims at estimating the proportion of SAVR patients who initiated timely CR and understanding to what extent timely access to CR for SAVR patients is influenced by specific characteristics of patients and hospitals.
We conducted a real-world, retrospective, population-based study by identifying from the Italian National Hospital Discharge Records all the discharged alive SAVR patients who accessed timely CR from 2009-2016. Two different cutoffs for timely access were considered, i.e. one and 21 days after discharge. A unique dataset was constructed by merging several data sources. Multiple logistic regressions were performed to identify the factors influencing the probability to access to timely CR.
107,545 patients underwent SAVR in Italy from 2009-2016 and were discharged alive. Overall, 71,593 SAVR patients (66.6%) accessed timely CR, with an increasing trend over time. Additional 6,149 patients (5.7%) started CR from 2-21 days after discharge, slightly decreasing over time. The probability of timely CR (one-day cutoff) was significantly higher in older (OR=1.025, p<0.001) female patients (OR = 1.003, p<0.05) and patients with cardiovascular and cerebrovascular comorbidities. Presence of rehabilitation wards and number of rehabilitation beds in the index hospital significantly increased the probability of timely access to CR (OR = 1.105, p<0.001 and OR = 1.006, p<0.001 respectively). Patients hospitalized in private teaching hospitals had the highest predicted probability of timely CR after SAVR. A substantial variation in access to CR was found across Italian regions. Similar results were obtained with the alternative 21-days cutoff.
Approximately one-third of SAVR patients did not benefit from CR in Italy, mainly due to shortness of rehabilitation facilities, with relevant disparities across the country. The cessation of CR services during the COVID-19 pandemic provides the opportunity to re-think and innovate CR, shifting from center-based to home-based models. Digital health technologies can supplement traditional health services and grant safe, effective, and equitable access to care, especially for countries with insufficient rehabilitation bed capacity. As CR is associated with better outcomes, we recommend decision-makers to use our results to plan adequate healthcare services, also investing in digital health, to ensure patients' access to cost-effective care.
心脏康复（CR）是瓣膜手术后的 I 级推荐。关于主动脉瓣置换术后（SAVR）患者获得 CR 的程度的数据很少，并且从未对影响 SAVR 患者及时获得 CR 的概率的因素进行过实证研究。本研究旨在估计接受 SAVR 的患者中有多少比例开始了及时的 CR，并了解患者和医院的特定特征在多大程度上影响 SAVR 患者及时获得 CR。
我们通过从意大利国家住院记录中确定所有在 2009-2016 年期间接受过及时 CR 的存活出院的 SAVR 患者，进行了一项真实、回顾性、基于人群的研究。考虑了两个不同的及时获得 CR 的截止时间，即出院后 1 天和 21 天。通过合并多个数据源构建了一个独特的数据集。使用多项逻辑回归来确定影响及时获得 CR 的概率的因素。
2009-2016 年期间，意大利共有 107545 例 SAVR 患者，存活出院。总体而言，71593 例 SAVR 患者（66.6%）接受了及时的 CR，且呈时间趋势上升。另有 6149 例（5.7%）患者从出院后 2-21 天开始接受 CR，呈略下降趋势。及时接受 CR（一天截止时间）的概率在年龄较大（OR=1.025，p<0.001）的女性患者（OR=1.003，p<0.05）和患有心血管和脑血管合并症的患者中明显更高。索引医院的康复病房和康复床位数量的存在显著增加了及时获得 CR 的概率（OR=1.105，p<0.001 和 OR=1.006，p<0.001）。在私立教学医院住院的患者接受 SAVR 后及时获得 CR 的预测概率最高。在意大利各地区之间发现了接受 CR 的程度存在显著差异。使用替代的 21 天截止时间也得到了类似的结果。
大约三分之一的 SAVR 患者在意大利没有从 CR 中受益，主要是由于康复设施不足，全国范围内存在相关差异。在 COVID-19 大流行期间停止 CR 服务为重新思考和创新 CR 提供了机会，从以中心为基础的模式转向以家庭为基础的模式。数字健康技术可以补充传统的健康服务，并确保安全、有效和公平地获得护理，特别是对于康复床位容量不足的国家。由于 CR 与更好的结果相关，我们建议决策者使用我们的结果来规划足够的医疗保健服务，还可以投资数字健康，以确保患者获得具有成本效益的护理。
