Cardiac Rehab Research

Cardiac Rehab Research

Cardiac Rehab Research Abstracts 2006-2008

Cardiac Rehab Research Abstracts 2006-2008

Scales, R., Hartlein, E., Manuel, J. K., Kelly, R. L., Miller, J. H., Akalan, C., Lawler, A. J., Kozicki, A. K. (2008). Assessment of motivational interviewing proficiency in cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, Abstract S113, 28, 4: 275.

Scales, R., Hartlein, E., Manuel, J. K., Kelly, R. L., Miller, J. H., Akalan, C., Lawler, A. J., Kozicki, A. K. (2008). Assessment of motivational interviewing proficiency in cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, Abstract S113, 28, 4: 275.

Motivational interviewing (MI) is a method of communication that can significantly improve the health behaviors of cardiac rehabilitation (CR) patients. However, healthcare provider (HCP) skill levels may vary, and MI proficiency is not typically measured in CR patient consultations. This study was designed to assess MI proficiency during health education consultations in an outpatient CR program. Patients were given the Consultation and Relational Empathy (CARE) Measure immediately following a 30-minute CR consultation with a health educator who was trained in MI. The CARE Measure is a 10-item questionnaire that asks patients to anonymously assess the level of empathy that is expressed by a HCP during a consultation, which is considered to be a defining characteristic of MI. 411 questionnaires were completed and each item was scored on a 1-5 Likert scale (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). In addition, five patient consultations were randomly selected and the patients gave permission for their consultations to be confidentially audiotaped and analyzed by a MI coding expert. The Motivational Interviewing Treatment Integrity 3.0 (MITI 3.0) Coding Instrument was used to score the consultations on global ratings that used a 1-5 scale, and an objective behavioral count that determines MI proficiency. The overall mean score for the CARE Measure was 47.6 (SD=4.4) out of a possible maximum of 50. The overall mean global rating score for the MITI 3.0 was 4.2 (SD=0.5) out of a possible maximum of 5. The mean global rating score for MI spirit was 4.1 (SD=0.5) and the mean global rating score for empathy was 4, where all consultations were scored the same. On the behavioral count, reflections outweighed questions with a mean reflection-to question ratio of 1.4. The mean percentage for MI adherence was 100%. In this study, the health educator demonstrated MI consistent behavior. It appears that the CARE Measure and the MITI 3.0 are assessment tools that can be used in CR to provide feedback on MI proficiency. Further investigation is needed to determine the relationship between MI proficiency and patient outcomes in CR.


Akalan, C., Scales, R., Hartlein, E., Kelly, R. L., Lawler, A. J., Kozicki, A. K. (2008). Patient satisfaction in an early outpatient exercise-based cardiac rehabilitation program. Journal of Cardiopulmonary Rehabilitation and Prevention, Abstract S118, 28, 4: 276. 

Akalan, C., Scales, R., Hartlein, E., Kelly, R. L., Lawler, A. J., Kozicki, A. K. (2008). Patient satisfaction in an early outpatient exercise-based cardiac rehabilitation program. Journal of Cardiopulmonary Rehabilitation and Prevention, Abstract S118, 28, 4: 276. 

The assessment of patient satisfaction is a requirement for national program accreditation in cardiac rehabilitation (CR). However, questionnaires that assess patient satisfaction with the exercise component of a CR program are not readily available. This study pilot tested the application of a patient satisfaction questionnaire that was specifically designed for patients attending an exercisebased CR program. Seventy-six patients recovering from a recent cardiac event anonymously completed the patient satisfaction questionnaire twelve weeks after starting an early outpatient CR program. The 15-item questionnaire asked patients to rate their level of satisfaction with the services that were involved in the delivery of an exercise-based CR program. This included the process of scheduling appointments, registering the patient on arrival at the clinic, exercise testing, and exercise supervision. In addition, patients were asked to rate the overall care provided. The questionnaire was scored on a 1-5 Likert scale (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). The mean score for the questions that were associated with scheduling, registering, exercise testing, and exercise supervision were 4.2, 4.3, 4.6, and 4.6 respectively. The overall mean score for each item of the 15-item questionnaire was 4.7 out of a possible maximum of 5. In this preliminary investigation, it appears that it is feasible to use this initial version of the questionnaire with CR patients. Further investigation is needed to establish face and content validity of the instrument by conducting qualitative interviews with patients and experts in CR.


Scales, R. (2008). National program certification: The status of cardiac rehabilitation programs in the Rocky Mountain Region. Proceedings of a conference. Rocky Mountain Cardiopulmonary Rehabilitation Association Annual Meeting, Greeley, Colorado. 

Scales, R. (2008). National program certification: The status of cardiac rehabilitation programs in the Rocky Mountain Region. Proceedings of a conference. Rocky Mountain Cardiopulmonary Rehabilitation Association Annual Meeting, Greeley, Colorado. 

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommend that every cardiac rehabilitation (CR) program becomes nationally certified to ensure strict standards of patient care and quality programming. Future Medicare reimbursement for CR services may be tied to program standards that are considered imperative, such as those required in the AACVPR program certification process. This investigation was conducted to determine the number of CR programs that are AACVPR certified within the Rocky Mountain Region. The Rocky Mountain Cardiopulmonary Rehabilitation Association (RMCRA) is an affiliate organization of the AACVPR and represents Wyoming (WY), Colorado (CO) and New Mexico (NM). Delegated RMCRA representatives for all six districts within the Rocky Mountain Region provided a record of programs that offered early outpatient CR within their designated area. An updated record through December 2007 was then compiled for WY, CO and NM. There were a total of 18 AACVPR certified CR programs in the Rocky Mountain Region (WY=3; CO=14; NM=1). According to RMCRA records, 65 programs offer early outpatients CR in the Rocky Mountain Region (WY=16; CO=35; NM=14). This means that twenty-eight percent of all early outpatient CR programs within the Rocky Mountain Region are certified. It is recommended that the RMCRA continues to routinely update their record of CR programs and that initiatives be developed to assist CR programs in the certification process.


Kozicki, A. K., Lawler, A. J., Scales, R., Akalan, C., Kelly, R. L., Hartlein, E. (2008). National program certification: Meeting standards for outcome evaluation in a cardiac rehabilitation program. Proceedings of a conference. Rocky Mountain Cardiopulmonary Rehabilitation Association Annual Meeting, Greeley, Colorado. 

Kozicki, A. K., Lawler, A. J., Scales, R., Akalan, C., Kelly, R. L., Hartlein, E. (2008). National program certification: Meeting standards for outcome evaluation in a cardiac rehabilitation program. Proceedings of a conference. Rocky Mountain Cardiopulmonary Rehabilitation Association Annual Meeting, Greeley, Colorado. 

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) stipulate that early outpatient cardiac rehabilitation (CR) programs select quality outcome measures in the program certification process. In this investigation, the program effectiveness of an early outpatient CR program was evaluated based on three of the four outcome domains (clinical, health and service) that have been identified by AACVPR certification committee. Outcome measures were evaluated starting in December, 2006, and the first 30 patients to complete a 12-week assessment were reported in this study. The predicted metabolic equivalent (MET) exercise intensity achieved at a moderate rating of perceived exertion (RPE) during a sub-maximal 12-lead EKG graded exercise treadmill (GXT) test was reported in the clinical domain. Perceived emotional stress was assessed with the 10-Item Perceived Stress Scale (PSS-10) in the health domain, and a 15-item patient satisfaction questionnaire (PSQ-15) was developed specifically to assess the exercise portion of the CR program in the service domain. Dependent sample t-tests indicated a significant mean difference between the baseline and 12-week MET level and PSS-10 scores (p<0.05). The mean MET level increased from 3.8 (SD=1.7) to 4.8 (SD=2.1) and the mean PSS-10 scores decreased from 15.3 (SD=6.7) to 12.4 (SD=5.6). The overall mean score for each item of the PSQ-15 at 12-weeks was 4.8 (SD=0.5) out of a possible maximum of 5. The CR program in this investigation satisfactorily evaluated three of the four outcome domains that are required for AACVPR program certification. It is recommended that further analysis of existing program data be conducted in the behavioral outcome domain. The 13-Item Brief Dietary Screen for High Fat (BDSHF-13) is an outcome measure of dietary fat intake that meets national program certification standards.


Scales, R. (2007). The application of the Consulting and Relational Empathy (CARE) measure in a cardiac rehabilitation setting. Journal of Cardiopulmonary Rehabilitation and Prevention, Abstract 105, 27, 5: 388.

Scales, R. (2007). The application of the Consulting and Relational Empathy (CARE) measure in a cardiac rehabilitation setting. Journal of Cardiopulmonary Rehabilitation and Prevention, Abstract 105, 27, 5: 388.

The expression of empathy by a healthcare provider (HCP) is considered to be a key component in fostering a therapeutic relationship. This study investigated the feasibility of using the CARE Measure to assess relational empathy from a patient’s perspective during a health education consultation in a cardiac rehabilitation (CR) setting. The CARE Measure is a 10-item questionnaire that is designed to assess the extent to which a HCP expresses empathy from a patient’s perspective and it is based on a broad definition of empathy in the context of a therapeutic relationship during a consultation. The patient is asked to score the HCP for each item of the questionnaire on a 1-4 scale (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). 162 patients attending an outpatient CR program were given the CARE measure immediately following a 30-minute consultation with a health educator who was trained in motivational interviewing (MI). In a previous randomized controlled trial, we identified that compared with traditional CR, the addition of a MI-based intervention significantly enhanced multiple health-related behaviors in patients recovering from heart disease. Empathic listening is one essential and defining characteristic of MI. In this investigation, 57% of the patients completed the CARE Measure and the overall mean score was 47 out of a possible maximum of 50. It appears that is feasible to use the CARE Measure with patients attending CR and that this measure may provide feedback for the HCP, at least from a patient’s perspective, on the level of empathy being expressed during a consultation. It is recommended that future research includes an objective assessment of empathy and MI proficiency.


Maes, J. D., Scales, R., Baker, D., Malott, T., Ketchens, V., Ferguson, K. (2006). Modifications to an inpatient cardiac discharge order can expedite the referral process to cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation, Abstract 22, 26, 4: 266.

Maes, J. D., Scales, R., Baker, D., Malott, T., Ketchens, V., Ferguson, K. (2006). Modifications to an inpatient cardiac discharge order can expedite the referral process to cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation, Abstract 22, 26, 4: 266.

Cardiac rehabilitation (CR) is standard practice in Australia after a cardiac event and the referral process is considered automatic for eligible patients. Whereas, in the United States, the referral is at the physician’s discretion and less than 20% of patients participate. This study investigated the impact of streamlining the referral process to a hospital-based outpatient CR program by modifying the inpatient cardiac discharge order to include an automatic referral for eligible cardiac patients unless otherwise indicated by the discharge physician. Consequently, the onus was now on the physician to deny rather than refer the patient to CR. The CR staff received copies of every discharge order to expedite the referral process. A signed referral was then obtained from the patient’s assigned cardiologist in the outpatient clinic. A descriptive analysis compared the number of referrals over two 3-month periods (January-March) over consecutive years (2005 & 2006). All of the referred patients had either coronary artery disease (77%) or another related cardiac diagnosis. Results indicated there was a 15% increase in referrals to CR after the introduction of the modified discharge order. There were 107 referrals (62% male) in 2005 versus 126 referrals (57% male) in 2006. It appears that a more streamlined referral process may not only increase the number referrals, but also potentially expedite an invitation to outpatient CR and make it easier for physicians to refer.


Scales, R., Maes, J. D., Malott, T., Figueredo, V., Ketchens, V., Ferguson, K., Rollinson. (2006). Lovelace Cardiac Rehabilitation: A guideline to quality programming. Journal of Exercise Physiologyonline, Abstract 16, 9: 2.

Scales, R., Maes, J. D., Malott, T., Figueredo, V., Ketchens, V., Ferguson, K., Rollinson. (2006). Lovelace Cardiac Rehabilitation: A guideline to quality programming. Journal of Exercise Physiologyonline, Abstract 16, 9: 2.

After a meticulous review of over 900 scientific studies involving cardiac rehabilitation (CR) exercise therapy, education and counseling, a group of independent reviewers came to the conclusion that CR is effective, safe and very much underutilized in the United States. This resulted in the 1995 publication of the Federal Guideline for Cardiac Rehabilitation, which stipulated that CR is an essential component in a patient’s recovery after a cardiac event, and for those who are eligible, a referral should be automatic. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommend that every program becomes nationally accredited to ensure strict standards of patient care and quality programming. Future Medicare reimbursement for services will more likely be honored in accredited programs. The Lovelace Program is the first in New Mexico to receive accreditation from the AACVPR. The program was evaluated over a 12-month period in 19 different categories. Program policies and procedures were evaluated for patient safety and treatment protocols that meet national guidelines. Over 400 new patients were referred to the program and clinical outcomes were measured. All participants receive a comprehensive lifestyle and risk factor evaluation, standardized exercise assessment and personalized feedback with ongoing progress reports. Patients have the option to participate in physician-directed, supervised exercise therapy, or receive guidelines for home-based exercise, and through motivational interviewing, receive individualized education on the clinical aspects of heart health and risk factor modification. The plan is communicated to the primary care physician and cardiologist.


Trujillo, R., Scales, R., Maes, J. D., Malott, T. (2006). Motivational strategies to improve patient adherence in a rehabilitation setting. Proceedings of a conference. 7th Annual Southwest Conference on Disability, Albuquerque, New Mexico.

Trujillo, R., Scales, R., Maes, J. D., Malott, T. (2006). Motivational strategies to improve patient adherence in a rehabilitation setting. Proceedings of a conference. 7th Annual Southwest Conference on Disability, Albuquerque, New Mexico.

Failure to keep medical appointments may undermine a patient’s treatment plan. Consequently, this study investigated adherence to attending scheduled appointments in a cardiac rehabilitation setting, where motivational interviewing was an integral part of the program. A descriptive analysis of two 3-month periods over consecutive years (January-March, 2005-2006) identified that only 13% and 5% of patients failed to attend without prior notice from a total of 552 and 533 scheduled appointments over the respective years. Personalized reminder calls were added in 2006 and may have contributed to the improved adherence. It appears that the way in which rehabilitation professionals interact with patients may have a profound effect on adherence.


Scales, R., Maes, J. D. (2006). Cardiac rehabilitation and disease management: A guideline for quality programming. Proceedings of a conference. 7th Annual Southwest Conference on Disability, Albuquerque, New Mexico.

Scales, R., Maes, J. D. (2006). Cardiac rehabilitation and disease management: A guideline for quality programming. Proceedings of a conference. 7th Annual Southwest Conference on Disability, Albuquerque, New Mexico.

The governing body for cardiac rehabilitation (CR) recommends that every program becomes nationally accredited to ensure strict standards of patient care and quality programming. The accreditation process requires that programs be evaluated over a 12-month period in 20 different categories. Program policies and procedures are scrutinized for patient safety and treatment protocols that meet national guidelines. Future Medicare reimbursement for services will more likely be honored in accredited programs. The cardiac rehab program at the Lovelace Heart Center is the first in New Mexico to receive national accreditation and provides a guideline for others to follow.