The Association Between Waiting Time and Starting, Completion and Outcomes in Post-Surgical Cardiac Rehabilitation Patients Following Sternotomy

Abstract

Aim: Prolonged waiting times for post-surgical cardiac rehabilitation (CR) patients following median sternotomy may influence their chances of starting, completing, and potentially determine the extent by which patients benefit. This thesis aims to determine the level of association between waiting time and CR utilisation and outcomes for patients following sternotomy.

Methods: A literature review was conducted in 2019 and updated in 2022 using Ovid MEDLINE, Ovid Embase and CENTRAL to identify and critically appraise eligible papers published since 2000. Overall 26 eligible papers were included and critically appraised using PEDro score and JBI tools. In reviewing the papers, key variables were identified that were included in the NACR and subsequent analysis, in addition to providing an evidential comparison for the thesis’ findings. The data collected by the National Audit of Cardiac Rehabilitation (NACR) for the period between January 2013 to December 2019 were used for in the following observational studies: • Starting CR and waiting time using a logistic regression model, employing complete case analysis, to assess the association between CR starting and waiting time, patient factors and cardiac-event factors. • CR completion and waiting time using a logistic regression model while employing multiple imputations to assess the association between CR completion and waiting time, patient factors, cardiac-event factors, pre-CR assessment factors and CR delivery factors. • CR outcomes and waiting time were used for regression analysis (9 logistics and 2 linear) as a complete case analysis to assess the association between CR outcomes of cardiovascular risk factors, psychological health and physical fitness and waiting time, patients’ factors, cardiac events factors, and CR delivery factors.

Results: There were 93,869 patients post-surgery with a mean age of 67 (SD = 11) years 25% of the population were female. In accordance with clinical guidance the likelihood of post-surgical patients starting CR increased with waiting more than 6 weeks from the treatment compared to starting early and waiting up to 6 weeks by OR: 2.55 (95% CI: 2.41, 2.70). In contrast for patients who waited more than 6 weeks to start CR, their probability of completing CR decreased by OR: 0.94 (95% CI: 0.89, 0.99). Waiting longer was negatively associated with physical activity status, depression, and physical fitness measures.

Conclusion: This thesis is the first to conduct observational studies of routine practice clinical data in post-sternotomy patients’ investigating waiting times and their association with CR starting, completion and outcomes. The thesis provides clinically relevant insight into waiting time and related factors that influence patients‘ chances of CR utilisation and the extent of benefit following rehabilitation. A key recommendation is that CR programmes and their patients are likely to benefit from tailoring their services according to patient factors identified as influential in this work.