Cardiac rehabilitation (CR) is a globally recognized standard of care that has the potential to provide significant health benefits, including increased cardiorespiratory fitness and quality of life as well as reduced adverse event risk.1,2 The evidence base supporting CR is substantial, spans several decades, and overwhelmingly supports its utilization for all qualified patients.3,4 However, important lines of inquiry remain and require attention, including (1) further clarity on the efficacy of traditional CR overall and in specific subgroups (eg, women, multimorbidity); (2) the impact of alternative delivery models; (3) factors associated with patients who participate in but do not respond to CR; and (4) behavioral and motivational factors that influence CR participation and long-term adoption of health-behavior change.
Cardiac rehabilitation centers providing patient care have the capability to meaningfully contribute to our scientific understanding of this important lifestyle intervention through both a rigorous and well-planned prospective collection of data available from standard practice (ie, clinical registries) and by providing a platform to perform prospective clinical trials in collaboration with researchers in the field.4–6 TotalCardiology® Rehabilitation (TCR) has provided outpatient CR services in Calgary, Alberta, Canada, since 1996. In 2005, TCR formed a research committee with the initial charge of refining and subsequently analyzing its large clinical registry and disseminating significant findings with clinical impact at scientific conferences and through peer-reviewed publications. In 2008, TCR formalized a collaboration with the Alberta Provincial Project for Outcomes Assessments in Coronary Heart Disease (APPROACH),7 which tracks >200 000 patients with cardiovascular (CV) disease, including all patients referred to TCR CR. This partnership allowed the TCR research committee to, among other things, integrate important health outcomes, such as all-cause mortality, into the database. In addition to the clinical registry initiative, TCR has provided a platform for prospective research projects in partnership with academic researchers from multiple institutions whose interests align with that of TCR CR; projects in behavioral modification and exploring patient-centered barriers to CR participation have been a particular focus to this point. To date, with limited extramural funding to support the TCR research enterprise, we have produced 26 peer-reviewed publications and 47 conference abstracts (see Supplemental Digital Content 1, available at: http://links.lww.com/JCRP/A141).
In 2019, TCR formally rebranded its research committee, becoming the TotalCardiology® Research Network (TCRN; see Supplemental Digital Content 2, available at: http://links.lww.com/JCRP/A142). A web address was also secured (www.tcrn.ca) and content development is underway. This intentional strategy was used to reflect an emerging, differentiated identity and further solidify the organization's commitment to high-quality clinical research moving forward. The TCRN comprises a core group of clinicians, administrators, and researchers who are charged with overseeing the research agenda for the organization. The TCRN mission is to support and participate in high-quality research to enhance CV disease prevention, treatment, and rehabilitation services. The vision is to become a world leader in CV research by (1) performing impactful research and disseminating findings at top-tier conferences and in high-impact journals and (2) training a second generation of scholars. The current members of the TCRN quickly began planning initiatives that would help realize the group's vision.
The inaugural TCRN Research Retreat was held on March 20, 2019. Three TCRN core members, all established academic researchers, proposed 4 junior scholars (1 PhD student, 1 masters student planning to enroll in a PhD program, and 2 early-career assistant professors) with exceptional promise and high interest in CR research. All individuals were unanimously approved and, working closely with their primary mentor(s), were given the following charge in preparation for the retreat: (1) Prepare 1 conference-ready abstract, describing the study during a 10-min presentation during the retreat; (2) Present career plans and receive support and feedback from TCRN members; and (3) Prepare and present a 10-min research proposal focused on another analysis using the TCR CR registry, other data sources, or a new prospective clinical investigation. The initial conference-ready abstracts were developed by the mentees, working with their primary mentor prior to the retreat. These abstracts were submitted to the full TCRN committee on or before March 7 for review. The Table lists the mentees, primary mentors, the title of the conference-ready abstract submitted to TCRN members prior to the retreat, and the potential target conference(s) for the abstracts. Mentees presented their abstracts at the retreat on March 20 and received both oral and written feedback from TCRN committee members. Proposed conferences for submission of these abstracts were supported by all committee members. Discussion regarding these 4 projects continued, centering on preparation of full manuscripts and the value of additional statistical analyses and framing of the message in the introduction and discussion. A goal of complete manuscript drafts being circulated to the TCRN committee within 3 mo was agreed upon by all mentors and mentees.
The research retreat continued with mentees each delivering a 10-min presentation on their career goals. Each talk was followed by a 15-min discussion. Mentees concluded their talks with specific questions for TCRN members (eg, What are mechanisms for funding if you are not on a traditional tenure track?). The TCRN senior members, with extensive academic, clinical, and/or administrative experience, provided perspective on the proposed career plans and key points for each mentee to consider (eg, selecting post-doc and faculty positions, building collaborative networks, increasing publication productivity). The final round of 10-min presentations by the mentees was focused on a new research proposal in collaboration with TCRN. Three of the 4 proposals entailed prospective studies within the TCR CR program. The proposals by Drs Laddu and Ozemek require new data collection with respect to assessing physical activity status and fall risk. Dr Laddu's proposal also requires research involving a unique interventional approach. Both proposals were positively received and facilitated discussions regarding initial steps to assess feasibility and collecting pilot data. The TCRN committee agreed to continue planning discussions following the retreat and develop a plan to collect initial pilot data in collaboration with Drs Laddu and Ozemek. The prospective study proposal by Ms Williamson has already been reviewed and approved by the TCRN committee and a grant has been submitted to the Cardiac Arrhythmia Network of Canada. The remaining proposal by Dr Liu entailed a follow-up analysis of the existing TCRN database, which has been approved by the TCRN Executive Board and analysis is underway. Participants' career goals and the titles of proposed research studies presented by the mentees are provided in Supplemental Digital Content 3, available at: http://links.lww.com/JCRP/A143.
Of note, discussions following mentee presentations facilitated dialogue related to how new data collection and findings from these proposed studies could potentially improve clinical practice. For example, Dr Laddu raised the issue of fall risk in patients with CV disease, which prompted discussion on how fall risk assessments can be performed in clinical practice; Dr Laddu subsequently provided fall risk questionnaires to the TCRN executive board for consideration. Ms Williamson's presentations prompted a discussion on how patient education approaches may be used as part of usual care to enhance patient knowledge and attitudes toward CR. These discussions embody one of TCRN's core philosophies—conducting research that informs practice.
The retreat concluded with closing remarks and a review of action items that included the following: (1) Mentors will provide final comments regarding abstracts prepared by mentees within 1 wk of the retreat. Mentees will work with primary mentors to select a conference and submit within the next 3 mo; (2) Mentees will work with their primary mentors to prepare a manuscript from the abstracts submitted for conference presentation. Complete first drafts of manuscripts are due to the TCRN Executive Board within 3 mo of the retreat; and (3) The TCRN Executive Board will formulate an initial plan for collecting the pilot data needed to assess the feasibility of future projects by Drs Laddu and Ozemek. The TCRN Executive Board then met to share initial impressions of the retreat and format for next year. The Board unanimously decided to preserve the same format for next year's retreat with a focus on behavioral, physical activity, and artificial intelligence research projects. A plan to perform a database update, adding new quality-of-life and physical activity measures, was agreed upon with a goal of having an updated database within 6 mo. Once the new database is available, the TCRN Executive Board will select mentors and mentees to invite to the second annual research retreat to tentatively be held in March 2020. The Executive Board also discussed core areas of focus for TCRN, concluding that behavioral factors and cardiorespiratory fitness represent current research priorities. The Executive Board discussed the potential to conduct randomized controlled trials focused on understanding the added value of novel behavior change interventions for self-management for chronic disease management in the TCR CR program, randomized to either standard CR alone or standard CR + behavioral intervention.
The authors of this commentary hope that this framework or elements of it as described herein through the integration of science, practice, and mentorship inspire other CR programs to consider similar initiatives. As depicted, the core tenets to a successful and productive clinical research program include (1) collaboration that is beneficial to all stakeholders (eg, clinicians, researchers, administrators, patients); (2) a research agenda that informs the program and does not impede clinical practice; and (3) a team science approach.
Cardiac rehabilitation programs offer a platform for a clinical research agenda that can be crafted to inform the program (ie, conducting research whose findings will enhance the delivery of CR), creating a win-win for all. Several recent American Association of Cardiovascular and Pulmonary Rehabilitation statements and reviews published in this journal are a clear indication that there are numerous areas of important CR-focused research requiring further inquiry.8–14 As such, CR programs interested in establishing a research arm, regardless of size or scope, are encouraged to seek out academic partnerships.
The approach and infrastructure will certainly look different depending on characteristics of a given CR program (eg, size, resources, staff interests/expertise). Smaller and/or independent CR programs may consider forming networks to share resources/workloads/expertise and increase the sample size of a clinical registry or prospective study. Professional organizations, such as the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiovascular Prevention and Rehabilitation, may serve as resources in developing networks. Moreover, multicenter analyses, if carefully planned to ensure homogeneity of data collection and research procedures, increase the impact and generalizability of research findings. In this context, larger CR programs, such as those within academic medical centers, should consider forming or participating in networks/consortiums. While CR programs of any size will have expertise and an in-depth understanding of the clinical (eg, patient care) and administrative (eg, financial, staffing) aspects of operation, identifying collaborators with appropriate expertise in clinical research is a centrally important component. Certain departments within a university or college, such as exercise physiology, medicine, nursing, nutrition, and psychology, are likely to have 1 or more research-focused faculty who would be interested in collaborating.
In conclusion, the First Annual TCRN Research Retreat was highly successful and positively received. We have been able to demonstrate that our approach can be done with limited extramural research funding and can be highly productive, as indicated by our history of conference presentations as well as peer-reviewed published manuscripts and abstracts. Collaborations with academic partners with expertise in CV research and top-down support from TCR management are key components. We also highly value a team-science approach, bringing clinicians, researchers, and administrators together to formulate the most clinically impactful research questions. It is our hope that this invited commentary inspires other groups to consider similar initiatives, at a scale that is feasible, further expanding the CR evidence base in a way that facilitates an evolution of clinical practice that optimally improves patient outcomes.
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