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This review encompasses several practical components of supervised exercise therapy (SET) for patients with claudication including referral, exercise training, and billing issues. Real-life SET session examples are also provided. SET was approved for reimbursement by the Centers for MedicareMedicaid Services (CMS) in 2017, and there is continual growth of programs offering SET and in participation. The purpose of this review is to provide useful information for the clinical exercise professionals working with these patients.The 2016 ACC/AHA Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease (PAD) provided a class I (highest level) recommendation for the use of SET in those with symptomatic PAD. Since there has been much growth in the literature about the utility of SET, the literature was reviewed (PubMed) to provide information for this article. Topics reviewed include the benefits of exercise training, exercise prescription, billing, referral and participation, and best practices.SET should be offered to all patients with symptomatic PAD who are not at risk of acute limb ischemia. For optimal results, SET should be implemented several times per week and in a progressive process to increase exercise intensity as tolerated. For best results, programs should recommend patients supplement SET with home exercise. Considerations for utilizing reimbursed sessions should also be discussed because patients have a maximum of 72 sessions/lifetime. Referral practices need refinement, and participation rates remain extremely low and may be influenced by demographics. Research on best practices and home or hybrid training must continue to address issues related to common enrollment and participation barriers.Supervised exercise training (SET) for symptomatic peripheral artery disease is a class IA recommendation and reimbursable by most insurances. Improvements in walking performance can be dramatic. However, referral and participation in SET remain very low and thus SET is vastly underutilized.

Objective This study examined whether the efficacy of a standard‐of‐care pediatric obesity treatment was affected by the COVID‐19 pandemic. Methods Analyses leveraged data from an ongoing pediatric obesity treatment trial involving 230 lower‐income, urban children aged 6 to 12 years. Mixed‐effects regression models compared children who participated in a 12‐month weight‐management intervention before versus during the COVID‐19 pandemic on change from baseline in BMI z score (ΔzBMI) at 3, 6, 9, and 12 months. Results The observed pattern of ΔzBMI was significantly different before versus during the pandemic (χ2 = 22.73, p < 0.0001). Children treated before the pandemic maintained an average weight loss of −0.06 ΔzBMI at 12 months, whereas children treated during the pandemic steadily gained weight over time, averaging a net gain of 0.11 ΔzBMI at 12 months (χ2 = 34.99, p < 0.0001). Treatment session completion did not differ before versus during the pandemic (60.4% vs. 55.7%, respectively; p = 0.30) or account for differences in ΔzBMI. Conclusions Similar reductions in intervention efficacy may be anticipated in other pediatric obesity treatment trials conducted during the COVID‐19 pandemic. Many families that have struggled with managing their child’s weight during this period may need encouragement to continue engaging in structured weight management as society renormalizes.

Purpose This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR. Review methods To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations. Summary A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.

Objective To evaluate the effectiveness of a traditional didactic session (TDS) as compared to a self-paced, interactive, multimedia module (SPM) on the application of evidence-based medicine (EBM) skills among medical students during their inpatient pediatric rotation. Methods We conducted a randomized controlled trial from June, 2017 to June, 2018 at a quaternary care children's hospital. Students were randomized to TDS or SPM during each 2-week block. All students completed a critical appraisal tool (CAT) of evidence related to a clinical question in a standardized appraisal form and self-reflected about the EBM process. The primary outcome was the numeric score of the CAT derived by using the validated Fresno tool. Secondary outcomes of knowledge, attitudes, confidence, and self-reported behaviors related to EBM were measured using validated surveys. Statistical analysis was performed using Student's t test for CAT scores and mixed-model procedure (PROC MIXED), with subject as random effect and time as repeated measure for the secondary outcomes. Results One hundred twenty-seven clerkship students were included. Overall, there was no significant difference in mean CAT scores for TDS (n = 59) versus SPM (n = 66) groups (90.3 vs 92.0, P = .65). There were no significant differences between SPM and TDS groups for knowledge (P = .66), attitudes (P = .97), confidence (P = .55), and accessing evidence (P = .27). Both groups showed significant gains in knowledge, attitudes, confidence, and accessing evidence from baseline to postcourse. Improvements in knowledge and confidence were sustained at 3-months. Conclusion A SPM learning module is as effective as a TDS module for application of EBM concepts and knowledge to patient care.

This study examined predictors of physical performance, a key aspect of quality of life, in children with excess weight.Participants were 269 children aged 6-12 years with a body mass index above the 85th percentile. Children completed a standardized physical performance task capturing lower extremity strength, balance, and gait speed. Height, weight, and waist circumference were objectively measured, and daily moderate-vigorous physical activity (min/day) and sedentary time (% of day) were assessed with a 7-day accelerometer protocol.Physical performance task completion averaged 15.0 (SD = 2.5) seconds. Children with higher body mass index z-scores and waist circumferences had significantly longer task completion times. The task took 1.8 additional seconds per 1.0 body mass index z-score (p .001), and 1.2 additional seconds for every 20 cm higher waist circumference (p .001). Daily moderate-vigorous physical activity and sedentary time were unrelated to physical performance, and did not moderate its associations with the adiposity measures.Among children with excess weight, physical performance declines with increasing levels of total and central adiposity. Daily activity levels do not moderate this association. Interventions that directly target weight reduction would likely yield the greatest improvement in physical performance in children with overweight or obesity.

BACKGROUND: Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management. METHODS: We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI. RESULTS: A total of 211 children were included; the median age was 1.0 month (interquartile range 0–2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals. CONCLUSIONS: No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.

BACKGROUND:Studies have revealed an association between hospitalization of breastfed infants and weaning posthospitalization. It is unknown what steps inpatient providers at children’s hospitals are currently taking to support breastfeeding mothers of hospitalized infants, their comfort providing breastfeeding counseling, and what training they receive.METHODS:We conducted a multicenter survey study of pediatric providers who care for infants hospitalized at 3 urban, tertiary-care children’s hospitals over a 12-month period. A convenience sample of nurses, residents, and attending physicians agreed to participate. Participants completed a 24-question questionnaire addressing provider practices, comfort with breastfeeding counseling, and previous breastfeeding education. Data were summarized as medians (interquartile ranges) and frequencies (percentages). Kruskal-Wallis and χ2 tests were used to compare between provider types.RESULTS:A total of 361 out of 1097 (33%) eligible providers completed the survey: 133 (21%) nurses, 166 (45%) residents, and 62 (63%) attending physicians. Provider practices varied by provider type. We observed a general trend that providers do not routinely review breastfeeding techniques, directly observe feeds, or use standardized breastfeeding assessment tools. Residents and attending physicians were more likely than nurses to feel comfortable with breastfeeding counseling (P = .02). Residents were more likely than nurses and attending physicians to have received breastfeeding education in the last 3 years (P < .001).CONCLUSIONS:Practices, comfort, and previous education varied by provider type. There was a general pattern that providers do not routinely perform certain practices. Further studies are needed to determine if inpatient provider practices affect weaning posthospitalization and if inpatient quality improvement initiatives will help mothers continue breastfeeding posthospitalization.

Gregg C. Fonarow, MD, FACC, FAHA, Chair Geoffrey D. Barnes, MD, MSc, FACC[‡][1] Biykem Bozkurt, MD, PhD, FACC[‡][1] Sandeep Das, MD, MPH[‡][1] Michelle Gurvitz, MD, FACC[§][2] Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA[‡][1] Hani Jneid, MD, FACC, FAHA[‡][1] Patricia Keegan, DNP

In May 2017 the Centers for Medicare and Medicaid Services (CMS) published a final decision memo for supervised exercise therapy for symptomatic peripheral artery disease. This was because there was sufficient evidence demonstrating the benefit of exercise training for improving pain-free and peak walking time. This training can take place in a clinic setting or within a cardiac rehabilitation program. There were specific instructions for what must take place during supervised exercise training during each session day a patient was present. The goal of this review is to provide background information about the research that led to this decision from CMS. It will also review specifics of a supervised exercise training session and conclude with specifics about the CMS decision memo language as it relates to implementing a supervised exercise training session.

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts’ focus on achieving more than 70% performance in the “ABCS” of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record–based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

The American College of Cardiology (ACC)/American Heart Association (AHA) performance measurement sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement. Writing committees are instructed to consider the methodology of performance measure development1 and to ensure that the measures developed are aligned with ACC/AHA clinical guidelines. The writing committees also are charged with constructing measures that maximally capture important aspects of care quality, including …

One-third of children in the United States are overweight or obese. Comorbidities continue into adulthood if a healthy weight is not established. While expert guidelines for management of this condition are recognized, provider adherence to guidelines is lacking. The purpose of this quality improvement project was to evaluate the effectiveness of the chronic care model (CCM) on improving primary care provider identification, prevention, and management of childhood overweight and obesity. A pre- and postintervention chart audit was completed to evaluate documentation of 20 assessment measures included in expert guidelines. A chi-square analysis was conducted to assess differences. Statistically significant improvements were found in documentation of parental obesity, family medical history, sleep assessment, endocrine assessment, and weight classification as a diagnosis. Use of the CCM had a positive impact on provider adherence to expert guidelines. Furthermore, not all aspects of the CCM must be used to see statistically significant improvements.

Endorsed by the American College of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac Rehabilitation, the European Association for Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. This document was approved by the American College of Cardiology Foundation Executive Committee in April 2010, by the American Heart Association Science Advisory and Coordinating Committee in April 2010, and by the AACVPR Document Oversight Committee and Board of Directors in June 2010. The American College of Cardiology Foundation requests that this document be cited as follows: Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol 2010;56:1159–1167. This article is copublished in Circulation and the Journal of Cadiopulmonary Rehabilitation and Prevention. Copyright ©2010 by the American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology Foundation, and American Heart Association, Inc. Published by Elsevier Inc. CPT™ contained in the online data supplement is ©2009 American Medical Association.

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability. Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of …

Medicine is experiencing an unprecedented focus on quantifying and improving health care quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multi-faceted strategy to facilitate the process of improving clinical care. The initial phase of this

Background. In the United States, overweight/obesity among youth has reached epidemic proportions. The purpose of this project was to (1) examine primary care provider adherence to American Academy of Pediatrics guidelines; (2) compare adherence based on patients’ weight classification, age, race, and gender; and (3) identify areas for improvement in health care delivery. Methods. A retrospective chart audit and feedback quality improvement project was conducted with a stratified random sample of 175 charts of 6- to 19-year-olds seen for well-child visits. Frequencies of provider adherence were reported. χ2Analyses of weight classification, age, race, or gender influence on adherence was calculated. Results. After discussion with the primary care providers, 5 areas were identified as priorities for change (diagnosis based on BMI, parental history of obesity, sleep assessment, endocrine assessment, and attendance of patients at the follow-up visit). Conclusion. Cost-efficient, feasible strategies to improve provider adherence to recommendations for identification, prevention and management of childhood overweight and obesity were identified.

Vasovagal syncope is a condition better known as neurocardiogenic or neurally mediated syncope. Dysautonomic syncope is the irregular neuroautonomic response during the body's attempt to maintain homeostasis. Both types of syncope are associated with orthostatic hypotension and are nonlethal. The underlying pathophysiology manifests the vast symptoms suffered by the individual. Research continues to develop new markers to improve diagnostic testing and therapies for treatment. Advanced practice nurses now have a new tool with Head-Up Tilt Training Programs to offer the patients who suffer from frequent and refractory neurocardiogenic and dysautonomic syncope.

BACKGROUND: Assessment of the reliability of performance measure (PM) abstraction is an important step in PM validation. Reliability has not been previously assessed for abstracting PMs for the referral of patients to cardiac rehabilitation (CR) and secondary prevention (SP) programs. To help validate these PMs, we carried out a multicenter assessment of their reliability. METHODS: Hospitals and clinical practices from around the United States were invited to participate in the Cardiac Rehabilitation Referral Reliability (CR3) Project. Twenty-nine hospitals and 23 outpatient centers expressed interest in participating. Seven hospitals and 6 outpatient centers met participation criteria and submitted completed data. Site coordinators identified 35 patients whose charts were reviewed by 2 site abstractors twice, 1 week apart. Percent agreement and the Cohen [kappa] statistic were used to describe intra- and interabstractor reliability for patient eligibility for CR/SP, patient exceptions for CR/SP referral, and documented referral to CR/SP. RESULTS: Results were obtained from within-site data, as well as from pooled data of all inpatient and all outpatient sites. We found that intra-abstractor reliability reflected excellent repeatability (>=90% agreement; [kappa] >= 0.75) for ratings of CR/SP eligibility, exceptions, and referral, both from pooled and site-specific analyses of inpatient and outpatient data. Similarly, the interabstractor agreement from pooled analysis ranged from good to excellent for the 3 items, although with slightly lower measures of reliability. CONCLUSIONS: Abstraction of PMs for CR/SP referral has high reliability, supporting the use of these PMs in quality improvement initiatives aimed at increasing CR/SP delivery to patients with cardiovascular disease.