Intervention Adherence in REHAB‐HF: Predictors and Relationship With Physical Function, Quality of Life, and Clinical Events

Abstract

Background The REHAB‐HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) trial showed that a novel, early, transitional, tailored, progressive, multidomain physical rehabilitation intervention improved physical function and quality of life in older, frail patients hospitalized for acute decompensated heart failure. This analysis examined the relationship between intervention adherence and outcomes. Methods and Results Adherence was defined as percent of sessions attended and percent of sessions attended adjusted for missed sessions for medical reasons. Baseline characteristics were examined to identify predictors of session attendance. Associations of session attendance with change in physical function (Short Physical Performance Battery [primary outcome], 6‐minute walk distance, quality of life [Kansas City Cardiomyopathy Questionnaire], depression, and clinical events [landmarked postintervention]) were examined in multivariate analyses. Adherence was 67%±34%, and adherence adjusted for missed sessions for medical reasons was 78%±34%. Independent predictors of higher session attendance were the following: nonsmoking, absence of myocardial infarction history and depression, and higher baseline Short Physical Performance Battery. After adjustment for predictors, adherence was significantly associated with larger increases in Short Physical Performance Battery (parameter estimate: β=0.06[0.03–0.10], P =0.001), 6‐minute walk distance (β=1.8[0.2–3.5], P =0.032), and Kansas City Cardiomyopathy Questionnaire score (β=0.62[0.26–0.98], P =0.001), and reduction in depression (β=−0.08[−0.12 to 0.04], P <0.001). Additionally, higher adherence was significantly associated with reduced 6‐month all‐cause rehospitalization (rate ratio: 0.97 [0.95–0.99], P =0.020), combined all‐cause rehospitalization and death (0.97 [0.95–0.99], P =0.017), and all‐cause rehospitalization days (0.96 [0.94–0.99], P =0.004) postintervention. Conclusions In older, frail patients with acute decompensated heart failure, higher adherence was significantly associated with improved patient‐centered and clinical event outcomes. These data support the efficacy of the comprehensive adherence plan and the subsequent intervention‐related benefits observed in REHAB‐HF. Registration URL: https://clinicaltrials.gov/ ; Unique identifier: NCT02196038.

Frailty and Effects of a Multidomain Physical Rehabilitation Intervention Among Older Patients Hospitalized for Acute Heart Failure

“…The individualized exercise program during the maintenance phase included primarily walking and functional strength exercises that were safe to perform at home and required no special equipment. High rates of participant retention and adherence to the intervention sessions were maintained under the supervision of a dedicated committee …”

“…High rates of participant retention and adherence to the intervention sessions were maintained under the supervision of a dedicated committee. 11,15…”

New Paradigms to Address Long-Term Exercise Adherence, An Achilles Heel of Lifestyle Interventions

“…Heart failure (HF) is one of the conditions for which multicomponent cardiac rehabilitation and even exercise training alone improve both exercise capacity and clinical outcomes. 1,2 As a result, cardiac rehabilitation (including exercise training, medication education, dietary recommendations, and psychosocial support) and exercise training alone are codified in US and European guidelines for management of patients with HF regardless of ejection fraction, as class 1 to 2a recommendations. Of note, the efficacy of exercise intervention is significantly affected by adherence.…”

“…Of note, the efficacy of exercise intervention is significantly affected by adherence. 2 Short-term adherence rates of up to ~80% can be achieved in rigorous clinical trials of exercise interventions, 2 but longer-term sustainability remains either poor or untested globally. This is particularly true once individuals transition out of in-person supervised sessions to the home environment.…”

“…Several clinical factors are associated with adherence, but these account for very little of the variance in individual adherence. 2 This leaves an enormous gap in the knowledge base necessary to sustain exercise therapy in this high-risk population. Traditional efforts to improve adherence (as detailed in the following) have demonstrated important, albeit modest benefits.…”