Next Article in Journal
The Growing Role of Echocardiography in Pulmonary Arterial Hypertension Risk Stratification: The Missing Piece
Previous Article in Journal
Assessing Problematic Social Media Use in Adolescents by Parental Ratings: Development and Validation of the Social Media Disorder Scale for Parents (SMDS-P)
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 10
Issue 4
10.3390/jcm10040618
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study

by
Hiroyuki Ohbe
1,
Kensuke Nakamura
2,*,
Kazuaki Uda
1,
Hiroki Matsui
1 and
Hideo Yasunaga
1
1
Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
2
Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonantyo, Hitachi, Ibaraki 3170077, Japan
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2021, 10(4), 618; https://doi.org/10.3390/jcm10040618
Submission received: 30 December 2020 / Revised: 1 February 2021 / Accepted: 3 February 2021 / Published: 6 February 2021
(This article belongs to the Section Emergency Medicine)
Browse Figure
Review Reports Versions Notes

Abstract

:
It is unclear when to begin rehabilitation after coronary artery bypass grafting (CABG) in the intensive care unit (ICU). Using the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2018, we identified adult patients who underwent a CABG and who were admitted to the ICU for ≥3 consecutive days from the date of their CABG. Patients who started any rehabilitation program prescribed by physicians or therapists within 3 days of CABG were defined as the early rehabilitation group, and the remaining patients were defined as the usual care group. We identified 30,568 eligible patients, with 13,150 (43%) patients in the early rehabilitation group. An inverse probability of treatment weighting analyses showed that the Barthel Index score at discharge in the early rehabilitation group was significantly higher than that in the usual care group (difference: 3.2; 95% confidence interval: 1.5–4.8). The early rehabilitation group had significantly lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay vs. the usual care group. Our results suggested that early rehabilitation by physicians or therapists beginning within 3 days of CABG was safe, as suggested by the low mortality and improved physical function in patients who underwent CABG.

1. Introduction

Patients admitted to intensive care units (ICUs) can experience physical disabilities, cognitive impairments, or psychological difficulties, which are related to post-intensive care syndrome (PICS). PICS occurs within 24 h of ICU admission and progresses [1,2,3], and is induced by critical illness, treatments, ongoing health conditions, and a lack of movement during the ICU stay [4]. Patients with PICS have a very poor long-term health-related quality of life; therefore, maintaining activities of daily living (ADLs) during hospitalization is important [5]. Early rehabilitation, mobilization, or active exercise programs are increasingly being provided to maintain ADLs and independence for critically ill patients in ICUs [6].
Coronary artery bypass grafting (CABG) is used for multivessel diseases that are difficult to revascularize using a percutaneous coronary intervention. Following CABG, patients are more likely to have physical impairments and PICS because of their low cardiac function, the risk of ischemia, and the surgical invasiveness [7]. Therefore, cardiac rehabilitation has been widely performed with patients after a CABG. The timing of cardiac rehabilitation is divided into phase 1 (acute stage: within 7 days of onset), phase 2 (healing stage: from 1 week to 6 months after onset), and phase 3 (healed stage: >6 months after onset) [8]. Previous studies showed that cardiac rehabilitation demonstrated beneficial effects on physical function [9,10], cardiopulmonary function [11,12], cardiopulmonary symptoms [13], stenoses in coronary arteries [14], inflammatory response [15], and autonomic function [16]. However, after CABG, the beneficial effects of cardiac rehabilitation were demonstrated mainly in phases 2 and 3 [7]. Evidence supporting a beneficial effect of phase 1 cardiac rehabilitation after CABG is limited, and it is not well known when to start phase 1 rehabilitation after CABG. Previous small, randomized studies showed conflicting results of the effects of early rehabilitation within 3 days after CABG [17,18,19,20,21]. Rehabilitation too soon after CABG may increase the risk of coronary ischemia or inhibit wound healing [22]. Therefore, this study aimed to assess whether early rehabilitation beginning within 3 days of CABG improved physical function at discharge by using a large national inpatient database in Japan.

2. Materials and Methods

This was an observational study using an administrative database, where the study conformed to the REporting of studies Conducted using Observational Routinely-collected Data (RECORD) statement reporting guidelines [23]. This study was conducted in accordance with the amended Declaration of Helsinki and was approved by the Institutional Review Board of the University of Tokyo (approval number: 3501-(3); 25 December 2017). Because the data were anonymous, the Institutional Review Board waived the requirement for informed consent. No information about individual patients, hospitals, or treating physicians was available.
We used the Japanese Diagnosis Procedure Combination inpatient database, which contains administrative claims data and discharge abstracts from more than 1200 acute care hospitals and covers approximately 90% of all tertiary emergency hospitals in Japan [24]. The database includes age, sex, smoking history, body weight, body height, level of consciousness at admission, diagnoses (main diagnosis, comorbidities present at admission, and complications arising after admission) that were recorded according to the International Classification of Diseases Tenth Revision codes, treatments recorded according to Japanese medical procedure codes, discharge status, and activities of daily living scores that could be converted to Barthel Index scores at both admission and discharge [24]. To optimize the accuracy of the recorded diagnoses, attending physicians are required to report the objective evidence for diagnoses for treatment reimbursement. In a previous validation study that evaluated the records of diagnoses and procedures in the database, the specificity of the diagnoses exceeded 96%, while the sensitivity of the diagnoses ranged from 50 to 80%; the specificity and sensitivity of procedures both exceeded 90% [25].
Using the Japanese Diagnosis Procedure Combination inpatient database from 1 July 2010 to 31 March 2018, we identified patients who underwent CABG and who were admitted to the ICU for more than 3 consecutive days from the date of CABG. We excluded patients aged <18 years and those who received cardiopulmonary resuscitation within 3 days of their CABG.

3. Group Assignment

Patients beginning any rehabilitation program prescribed by physicians, physical therapists, or occupational therapists within 3 days of their CABG were defined as the early rehabilitation group. The remaining patients were defined as the usual care group. In the usual care group, nurses provided rehabilitation as needed, without a formal rehabilitation program. In Japan, rehabilitation by physicians, physical therapists, or occupational therapists is reimbursed by the universal healthcare insurance system, and one rehabilitation unit is considered to be 20 min [26].

4. Outcomes and Covariates

The primary outcome was patients’ physical function at discharge, as measured via the Barthel Index score using continuous scales [27]. Patients who died during hospitalization were assigned scores of 0 for the Barthel Index [6]. The secondary outcomes were in-hospital mortality, length of ICU stay, length of hospital stay, and total hospitalization costs.
The covariates were age, sex, smoking history, body mass index at admission, Barthel Index score at admission, Japan Coma Scale score at admission [28], calendar year, ambulance use, emergency admission, length of stay until surgery, annual hospital volume, teaching hospital, Charlson Comorbidity Index score [29], comorbidities, surgical characteristics, and treatments within 2 days of the CABG.

5. Multiple Imputation

Some patients had missing data for body mass index, smoking history, Barthel Index at admission, or Barthel Index at discharge. Therefore, we performed multiple imputation to address missing values that were assumed to be missing at random [30]. We created 20 imputed datasets constituting all the covariates and outcomes using multiple imputation via chained equations for the missing data. We used the “mi impute chained” command in STATA/MP 16.0 software (StataCorp, College Station, TX, USA) [31]. We combined the imputation estimates and standard errors according to Rubin’s rule [32].

6. Statistical Analysis

We used the inverse probability of treatment weighting (IPTW) to compare outcomes of the early rehabilitation group with those of the usual care group [33,34]. We applied a multivariable logistic regression model to predict the propensity scores for patients undergoing rehabilitation within 3 days of their CABG using all variables listed in Table 1 as predictor variables. We used the stabilized average treatment effect weight, which allowed us to maintain the total sample size of the original data and provided a more accurate interval estimate of the variance of the main effect and controls for type I error compared with the non-stabilized IPTW [35].
We calculated the absolute standardized differences of each covariate in the unweighted and weighted cohorts to confirm the balance of the distribution of the covariates between the early rehabilitation and usual care groups. When the absolute standardized differences between the two groups were less than 10%, we considered the imbalance in the distribution of the covariates to be negligible [36].
We used a weighted generalized linear model to compare the outcomes, with cluster-robust standard errors and individual treating hospitals as clusters. We calculated the differences and their 95% confidence intervals for outcomes using the identity link function.
We performed two sensitivity analyses to confirm the robustness of our results. First, we performed a complete case analysis that excluded patients with any variable with missing values. Second, we performed propensity-score-adjusted analyses in which we employed a multivariable regression model using primary or secondary outcomes as the dependent variable with early rehabilitation within 3 days of CABG and the estimated propensity scores in the main analyses as the independent variables.
Continuous variables were presented as a mean and standard deviation (SD), while categorical variables were presented as a number and percentage. We considered all reported p-values as two-sided and p < 0.05 as statistically significant. All analyses were performed using STATA/MP 16.0 software (StataCorp).

7. Results

After applying the inclusion and exclusion criteria, 30,568 patients were included in this study (Figure 1). Of these, 13,150 (43%) patients were assigned to the early rehabilitation group (rehabilitation beginning within 3 days of CABG). The frequency of rehabilitation within 7 days of CABG was 7.3 units (SD: 5.1 units) in the early rehabilitation group and 1.3 units (SD: 2.1 units) in the usual care group.
The patients’ characteristics and the numbers of patients with missing values for each variable are presented in Tables S1 and S2 show the results of comparing the distributions of the variables between patients with complete and incomplete data. Multiple imputation created 20 imputed datasets, where the patients’ characteristics for one of the imputed datasets are shown in Table 1. After the IPTW, the patients’ characteristics were well-balanced between the two groups. The propensity score distribution between the two groups was adequately balanced after the IPTW (Figures S1 and S2).
Table 2 shows the outcomes in the unweighted and weighted cohorts. After the IPTW, the Barthel Index scores at discharge in the early rehabilitation group were significantly higher than those in the usual care group (difference: 3.2; 95% confidence interval: 1.5–4.8). The early rehabilitation group had lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay vs. the usual care group. The results of the sensitivity analyses for the complete case analysis and propensity score adjustment (Table 3 and Table S3, respectively) were similar to those of the main analysis.

8. Discussion

The present study using nationwide real-world data showed that early rehabilitation beginning within 3 days of CABG prescribed by physicians or therapists was significantly associated with improved ADLs at discharge after the CABG. Furthermore, early rehabilitation was significantly associated with lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay.
Similar to previous studies, our results suggested that early cardiac rehabilitation within 3 days of CABG effectively maintained ADLs in patients after their CABG [17,18,19]. Previous studies also revealed that early rehabilitation was more effective in patients undergoing CABG than for those with other cardiovascular diseases because patients undergoing CABG had several narrowed or blocked coronary vessels, underwent marked surgical stress, were exposed to longer immobilization periods, and required longer recovery periods [19,37]. Although our study did not evaluate the intensity of the rehabilitation, one study showed that even small amounts of exercise improved physical function in patients who underwent CABG [17]. Generally, earlier cardiac rehabilitation programs are more effective in the ICU after CABG surgery.
Our results indicated that cardiac rehabilitation in the early stage in phase 1 after a CABG was safe. Similarly, recent studies showed that early ICU rehabilitation was considered safe without increasing the complications of coronary ischemia or heart failure when the rehabilitation was administered with appropriate timing and discontinuation criteria [38,39,40]. Previous studies also showed that the hemodynamic responses triggered by very early cardiac rehabilitation were similar and safe, regardless of whether the patients had low or high cardiac function after their CABG [41,42]. Therefore, early rehabilitation after CABG can be administered safely, even in patients with low cardiac function, as well as in other patients in the ICU.
Early cardiac rehabilitation was associated with a lower length of ICU stay, hospital stay, and total hospitalization costs in our study. Guidelines for cardiac diseases recommend starting cardiac rehabilitation during phase 1; however, very early rehabilitation in phase 1, such as beginning on day 2 or 3 after CABG, is not recommended because of limited evidence [22]. The real-world data in our study suggested that early rehabilitation within 3 days of CABG was clinically effective and economical. Further studies evaluating the efficacy and safety of early rehabilitation and when to begin are warranted.
There are several limitations to the present study. First, because we used a real-world Japanese database, the decision whether to start rehabilitation was made by individual clinicians according to their own criteria. The decision to start rehabilitation itself may be an indicator of severity, and the reasons for making this decision were not standardized, which led to confounding by indication. We attempted to control for this confounding by indication using propensity score analyses. However, we were unable to control for possible unmeasured variables, such as vital signs or cardiac function. Second, because the database contained information collected only during hospitalization, we were unable to analyze long-term outcomes after discharge. We were also unable to assess the detailed effects and safety of factors that may have contributed to improved mortality, such as cardiopulmonary function, cardiopulmonary symptoms, stenoses in coronary arteries, the inflammatory response, or autonomic function. Third, we could not evaluate the exercise intensity of the rehabilitation.

9. Conclusions

This study using a national inpatient database suggested that early rehabilitation beginning within 3 days of CABG was safe, as evidenced by the low mortality and improved physical function at discharge in patients who underwent CABG.

Supplementary Materials

The following are available online at https://www.mdpi.com/2077-0383/10/4/618/s1, Figure S1: Distribution of the propensity scores in the early rehabilitation and usual care groups in the unweighted cohort, Figure S1: Distribution of the propensity scores in the early rehabilitation and usual care groups in the weighted cohort by inverse probability of treatment weighting analyses, Table S1: Patients’ characteristics and the numbers (percentages) of missing values for each patient variable, Table S2: Comparing the distributions of the variables between patients with complete and incomplete data, Table S3: Results of the propensity score adjustment analysis.

Author Contributions

Conceptualization, H.O. and K.N.; methodology, H.O., K.U., and H.M.; software, H.O., K.U., and H.M.; formal analysis, H.O., K.U., and H.M.; resources, H.Y.; data curation, K.U. and H.M.; writing—preparing the original draft of the manuscript, H.O., K.N., and H.Y.; writing—reviewing and editing the manuscript, H.O., K.N., and H.Y.; visualization, H.O.; supervision, H.Y.; project administration, H.O. and K.N.; funding acquisition, H.Y. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by grants from the Ministry of Health, Labour and Welfare, Japan, grant numbers 19AA2007 and H30-Policy-Designated-004, and the Ministry of Education, Culture, Sports, Science and Technology, Japan, grant number 17H04141.

Institutional Review Board Statement

This study was performed in accordance with the amended Declaration of Helsinki, and the Institutional Review Board of The University of Tokyo approved this study (approval number: 3501-(3); 25 December 2017).

Informed Consent Statement

The review board waived the requirement for informed consent because of the anonymous nature of the data. No information describing individual patients, hospitals, or treating physicians was obtained.

Data Availability Statement

The datasets analyzed during the current study are not publicly available owing to contracts with the hospitals providing data to the database.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Puthucheary, Z.A.; Rawal, J.; McPhail, M.; Connolly, B.; Ratnayake, G.; Chan, P.; Hopkinson, N.S.; Padhke, R.; Dew, T.; Sidhu, P.S.; et al. Acute Skeletal Muscle Wasting in Critical Illness. JAMA 2013, 310, 1591–1600. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  2. Hermans, G.; van den Berghe, G. Clinical review: Intensive care unit acquired weakness. Crit. Care. 2015, 19, 274. [Google Scholar] [CrossRef] [Green Version]
  3. Stevens, R.D.; Dowdy, D.W.; Michaels, R.K.; Mendez-Tellez, P.A.; Pronovost, P.J.; Needham, D.M. Neuromuscular dysfunction acquired in critical illness: A systematic review. Intensiv. Care Med. 2007, 33, 1876–1891. [Google Scholar] [CrossRef]
  4. Gosselink, R.; Bott, J.; Johnson, M.R.; Dean, E.; Nava, S.; Norrenberg, M.; Schönhofer, B.; Stiller, K.; Van De Leur, H.; Vincent, J.L. Physiotherapy for adult patients with critical illness: Recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensiv. Care Med. 2008, 34, 1188–1199. [Google Scholar] [CrossRef] [PubMed]
  5. Heyland, D.K.; Hopman, W.; Coo, H.; Tranmer, J.; McColl, M.A. Long-term health-related quality of life in survivors of sepsis. Short Form 36: A valid and reliable measure of health-related quality of life. Crit. Care Med. 2000, 28, 3599–3605. [Google Scholar] [CrossRef] [PubMed]
  6. Schweickert, W.D.; Pohlman, M.C.; Pohlman, A.S.; Nigos, C.; Pawlik, A.J.; Esbrook, C.L.; Spears, L.; Miller, M.; Franczyk, M.; Deprizio, D.; et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009, 373, 1874–1882. [Google Scholar] [CrossRef]
  7. Haykowsky, M.J.; Scott, J.; Esch, B.; Schopflocher, D.; Myers, J.; Paterson, I.; Warburton, D.E.R.; Jones, L.W.; Clark, A.M. A Meta-analysis of the effects of Exercise Training on Left Ventricular Remodeling Following Myocardial Infarction: Start early and go longer for greatest exercise benefits on remodeling. Trials 2011, 12, 92. [Google Scholar] [CrossRef] [Green Version]
  8. Heran, B.S.; Chen, J.M.; Ebrahim, S.; Moxham, T.; Oldridge, N.; Rees, K.; Thompson, D.R.; Taylor, R. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst. Rev. 2011, 2016, CD001800. [Google Scholar] [CrossRef]
  9. Demopoulos, L.; Yeh, M.; Gentilucci, M.; Testa, M.; Bijou, R.; Katz, S.D.; Mancini, N.; Jones, M.; LeJemtel, T.H. Nonselective β-Adrenergic Blockade With Carvedilol Does Not Hinder the Benefits of Exercise Training in Patients With Congestive Heart Failure. Circulation 1997, 95, 1764–1767. [Google Scholar] [CrossRef]
  10. McKelvie, R.S.; Teo, K.K.; McCartney, N.; Humen, D.; Montague, T.; Yusuf, S. Effects of exercise training in patients with congestive heart failure: A critical review. J. Am. Coll. Cardiol. 1995, 25, 789–796. [Google Scholar] [CrossRef] [Green Version]
  11. Belardinelli, R.; Georgiou, D.; Cianci, G.; Berman, N.; Ginzton, L.; Purcaro, A. Exercise training improves left ventricular diastolic filling in patients with dilated cardiomyopathy: Clinical and prognostic implications. Circulation 1995, 91, 2775–2784. [Google Scholar] [CrossRef] [PubMed]
  12. Coats, A.J.; Adamopoulos, S.; Radaelli, A.; McCance, A.; E Meyer, T.; Bernardi, L.; Solda, P.L.; Davey, P.; Ormerod, O.; Forfar, C. Controlled trial of physical training in chronic heart failure. Exercise performance, hemodynamics, ventilation, and autonomic function. Circulation 1992, 85, 2119–2131. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  13. McMahon, S.R.; Ades, P.A.; Thompson, P.D. The role of cardiac rehabilitation in patients with heart disease. Trends Cardiovasc Med. 2017, 27, 420–425. [Google Scholar] [CrossRef] [PubMed]
  14. Servey, J.T.; Stephens, M. Cardiac Rehabilitation: Improving Function and Reducing Risk. Am. Fam. Physician 2016, 94, 37–43. [Google Scholar]
  15. Kasapis, C.; Thompson, P.D. The effects of physical activity on serum C-reactive protein and inflammatory markers: A systematic review. J. Am. Coll. Cardiol. 2005, 45, 1563–1569. [Google Scholar] [CrossRef] [Green Version]
  16. Badrov, M.B.; Wood, K.N.; Lalande, S.; Sawicki, C.P.; Borrell, L.J.; Barron, C.C.; Vording, J.L.; Fleischhauer, A.; Suskin, N.; McGowan, C.L.; et al. Effects of 6 Months of Exercise-Based Cardiac Rehabilitation on Autonomic Function and Neuro-Cardiovascular Stress Reactivity in Coronary Artery Disease Patients. J. Am. Hear. Assoc. 2019, 8, e012257. [Google Scholar] [CrossRef] [PubMed]
  17. Tariq, M.I.; Khan, A.A.; Khalid, Z.; Farheen, H.; Siddiqi, F.A.; Amjad, I. Effect of Early ≤ 3 Mets (Metabolic Equivalent of Tasks) of Physical Activity on Patient’s Outcome after Cardiac Surgery. J. Coll. Physicians Surg. Pak. 2017, 27, 490–494. [Google Scholar]
  18. Zanini, M.; Nery, R.M.; de Lima, J.B.; Buhler, R.P.; da Silveira, A.D.; Stein, R. Effects of different rehabilitation protocols in inpatient cardiac rehabilitation after coronary artery bypass graft surgery: A randomized clinical trial. J. Cardiopulm. Rehabil. Prev. 2019, 39, E19–E25. [Google Scholar] [CrossRef]
  19. Szmigielska, K.; Szmigielska-Kapłon, A.; Jegier, A. The Influence of Comprehensive Cardiac Rehabilitation on Heart Rate Variability Indices after CABG is More Effective than after PCI. J. Cardiovasc. Transl. Res. 2018, 11, 50–57. [Google Scholar] [CrossRef]
  20. Ximenes, N.N.P.S.; Borges, D.L.; Lima, R.O.; E Silva, M.G.B.; Da Silva, L.N.; Costa, M.D.A.G.; Baldez, T.E.P.; Nina, V.J.D.S. Effects of Resistance Exercise Applied Early After Coronary Artery Bypass Grafting: A Randomized Controlled Trial. Braz. J. Cardiovasc. Surg. 2015, 30, 620–625. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  21. Højskov, I.E.; Moons, P.; Egerod, I.; Olsen, P.S.; Thygesen, L.C.; Hansen, N.V.; La Cour, S.; Bech, K.H.; Borregaard, B.; Gluud, C.; et al. Early physical and psycho-educational rehabilitation in patients with coronary artery bypass grafting: A randomized controlled trial. J. Rehabilitation Med. 2019, 51, 136–143. [Google Scholar] [CrossRef] [Green Version]
  22. Yancy, C.W.; Jessup, M.; Bozkurt, B.; Butler, J.; Casey, D.E.; Colvin, M.M.; Drazner, M.H.; Filippatos, G.S.; Fonarow, G.C.; Givertz, M.M.; et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Failure Society of Amer. Circulation 2017, 136, e137–e161. [Google Scholar] [CrossRef]
  23. Benchimol, E.I.; Smeeth, L.; Guttmann, A.; Harron, K.; Moher, D.; Petersen, I.; Sørensen, H.T.; Von Elm, E.; Langan, S.M.; RECORD Working Committee. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. PLoS Med. 2015, 12, e1001885. [Google Scholar] [CrossRef]
  24. Yasunaga, H. Real World Data in Japan: Chapter II The Diagnosis Procedure Combination Database. Ann. Clin. Epidemiology 2019, 1, 76–79. [Google Scholar] [CrossRef]
  25. Yamana, H.; Moriwaki, M.; Horiguchi, H.; Kodan, M.; Fushimi, K.; Yasunaga, H. Validity of diagnoses, procedures, and laboratory data in Japanese administrative data. J. Epidemiol. 2017, 27, 476–482. [Google Scholar] [CrossRef] [PubMed]
  26. Yagi, M.; Yasunaga, H.; Matsui, H.; Morita, K.; Fushimi, K.; Fujimoto, M.; Koyama, T.; Fujitani, J. Impact of rehabilitation on outcomes in patients with ischemic stroke: A nationwide retrospective cohort study in Japan. Stroke 2017, 48, 740–746. [Google Scholar] [CrossRef] [PubMed]
  27. Mahoney, F.I.; Barthel, D.W. Functional evaluattion: The Barthel Index. Md. State Med. J. 1965, 14, 61–65. [Google Scholar] [PubMed]
  28. Shigematsu, K.; Nakano, H.; Watanabe, Y. The eye response test alone is sufficient to predict stroke outcome—Reintroduction of Japan Coma Scale: A cohort study. BMJ Open 2013, 3, e002736. [Google Scholar] [CrossRef] [Green Version]
  29. Quan, H.; Li, B.; Couris, C.M.; Fushimi, K.; Graham, P.; Hider, P.; Januel, J.-M.; Sundararajan, V. Updating and Validating the Charlson Comorbidity Index and Score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries. Am. J. Epidemiol. 2011, 173, 676–682. [Google Scholar] [CrossRef] [Green Version]
  30. Rubin, D.B.; Schenker, N. Multiple imputation in health-are databases: An overview and some applications. Stat. Med. 1991, 10, 585–598. [Google Scholar] [CrossRef]
  31. Aloisio, K.M.; Micali, N.; Swanson, S.A.; Field, A.; Horton, N.J. Analysis of Partially Observed Clustered Data using Generalized Estimating Equations and Multiple Imputation. Stata J. Promot. Commun. Stat. Stata 2014, 14, 863–883. [Google Scholar] [CrossRef] [Green Version]
  32. Rubin, D.B. Multiple Imputation for Nonresponse in Surveys; John Wiley & Sons: Hoboken, NJ, USA, 2004. [Google Scholar]
  33. Griswold, M.E.; Localio, A.R.; Mulrow, C. Propensity Score Adjustment With Multilevel Data: Setting Your Sites on Decreasing Selection Bias. Ann. Intern. Med. 2010, 152, 393–395. [Google Scholar] [CrossRef] [PubMed]
  34. Rosenbaum, P.R.; Rubin, D.B. Constructing a control group using multivariate matched sampling methods that incorporate the propensity score. Am Stat. 1985, 39, 33. [Google Scholar]
  35. Cole, S.R.; Hernán, M.A. Constructing inverse probability weights for marginal structural models. Am. J. Epidemiol. 2008, 168, 656–664. [Google Scholar] [CrossRef]
  36. Austin, P.C. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat. Med. 2009, 28, 3083–3107. [Google Scholar] [CrossRef] [Green Version]
  37. Jelinek, H.J.; Huang, Z.Q.; Khandoker, A.H.; Chang, D.; Kiat, H. Cardiac rehabilitation outcomes following a 6-week program of PCI and CABG Patients. Front. Physiol. 2013, 4, 302. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  38. Nydahl, P.; Sricharoenchai, T.; Chandra, S.; Kundt, F.S.; Huang, M.; Fischill, M.; Needham, D.M. Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann. Am. Thorac. Soc. 2017, 14, 766–777. [Google Scholar] [CrossRef]
  39. E Højskov, I.; Moons, P.; Hansen, N.V.; Greve, H.; Olsen, D.B.; La Cour, S.; Glud, C.; Winkel, P.; Lindschou, J.; Egerod, I.; et al. Early physical training and psycho-educational intervention for patients undergoing coronary artery bypass grafting. The SheppHeart randomized 2 × 2 factorial clinical pilot trial. Eur. J. Cardiovasc. Nurs. 2016, 15, 425–437. [Google Scholar] [CrossRef] [PubMed]
  40. Hodgson, C.L.; Stiller, K.; Needham, D.M.; Tipping, C.J.; Harrold, M.; Baldwin, C.E.; Bradley, S.J.; Berney, S.; Caruana, L.R.; Elliott, D.; et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit. Care 2014, 18, 1–9. [Google Scholar] [CrossRef] [Green Version]
  41. Kirkeby-Garstad, I.; Sellevold, O.F.M.; Stenseth, R.; Skogvoll, E. Mixed venous oxygen desaturation during early mobilization after coronary artery bypass surgery. Acta Anaesthesiol. Scand. 2005, 49, 827–834. [Google Scholar] [CrossRef]
  42. Kirkeby-Garstad, I.; Stenseth, R.; Sellevold, O.F.M. Post-operative myocardial dysfunction does not affect the physiological response to early mobilization after coronary artery bypass grafting. Acta Anaesthesiol. Scand. 2005, 49, 1241–1247. [Google Scholar] [CrossRef] [PubMed]
Jcm 10 00618 g001 550
Figure 1. Patient inclusion/exclusion flowchart.
Figure 1. Patient inclusion/exclusion flowchart.
Jcm 10 00618 g001
Table
Table 1. Patients’ characteristics in the unweighted and weighted cohorts.
Table 1. Patients’ characteristics in the unweighted and weighted cohorts.
CharacteristicsUnweighted CohortWeighted Cohort
Usual Care
(n = 17,418)		Early Rehabilitation
(n = 13,150)		ASDUsual Care
(n = 17,547)		Early Rehabilitation
(n = 13,021)		ASD
Age, years, mean (SD)71 (10)71 (10)471 (10)71 (10)0
Male, %7374373730
Current/past smoker, %4751849490
Body mass index, kg/m2, mean (SD)24 (4)24 (4)424 (4)24 (4)0
Barthel Index score at admission, mean (SD)80 (35)88 (28)2383 (32)83 (32)2
Japan Coma Scale score at admission, %
  Alert95981296972
  Dizziness326221
  Somnolence106101
  Coma109111
Calendar year, %
  2010–20112183716152
  2012–201330212126251
  2014–201526311128291
  2016–201723403730312
Ambulance use, %19121716161
Emergency admission, %32231928281
Length of stay until surgery, %
  0 days1673012123
  1–7 days44562349501
  ≥8 days3937439391
Annual hospital volume, per year, mean (SD)23 (19)23 (18)323 (18)22 (17)1
Teaching hospital, %74671570701
Charlson comorbidity index score, mean (SD)1.8 (1.3)1.8 (1.3)31.8 (1.3)1.8 (1.3)1
Comorbidities, %
  Chronic lung diseases344340
  Cerebrovascular diseases911610101
  Peripheral vascular diseases1012511110
  Diabetes mellitus4246944441
  Hypertension49561552521
  Chronic kidney diseases2018619190
Surgical characteristics
  Off-pump CABG, %3235834341
  Diseased vessels ≥2, %7979279790
  Concomitant valve replacement, %2827228280
  Total anesthetic time, minutes, mean (SD)526 (300)489 (285)13511 (253)510 (434)0
Treatments within 2 days of CABG, %
  Invasive blood pressure monitoring8989189901
  Central venous pressure monitoring5658557570
  Pulmonary artery pressure monitoring69621566660
  Supplemental oxygen27341630301
  Mechanical ventilation83791282820
  Renal replacement therapy21161519181
  Mechanical circulatory support27143321203
  Dopamine76711174740
  Dobutamine68611365650
  Noradrenaline88851187870
  Adrenaline17131215142
  Vasopressin442440
  Beta blockers6064861610
  Diuretics6972670700
  Propofol8989089890
  Midazolam7572773730
  Dexmedetomidine5353053541
  Antipsychotics1413114140
  Stress ulcer prophylaxis9999199990
  Enteral nutrition442440
  Parenteral nutrition113110
  Insulin7778177770
  Red blood cells85781782811
  Fresh frozen plasma76671972721
  Platelets52402447471
  Total fluids, L/day, mean (SD)6.8 (2.8)6.3 (2.3)226.6 (2.7)6.5 (2.5)2
ASD, absolute standardized difference; CABG, coronary artery bypass grafting; SD, standard deviation.
Table
Table 2. Outcomes in the unweighted and weighted cohorts using inverse probability of treatment weighting analyses.
Table 2. Outcomes in the unweighted and weighted cohorts using inverse probability of treatment weighting analyses.
OutcomesUnweighted CohortWeighted Cohort
Usual Care
(n = 17,418)		Early
Rehabilitation
(n = 13,150)		Usual Care
(n = 17,547)		Early Rehabilitation
(n = 13,021)		Differences
(95% CI)		p-Value
Primary outcome
  Barthel Index score at discharge, mean (SD)81.6 (34)88.8 (27)83.8 (32)86.8 (29)3.2 (1.5–4.8)<0.001
Secondary outcomes
  In-hospital mortality, %8.13.86.74.9−1.8 (−2.6 to −1.0)<0.001
Length of ICU stay, days, mean (SD)8.2 (10)7.0 (8)7.9 (9)7.4 (8)−0.5 (−0.8 to −0.3)<0.001
Length of hospital stay, days, mean (SD)43.8 (44)37.0 (29)42.3 (43)38.6 (31)−3.7 (−5.2 to −2.2)<0.001
Total hospitalization cost, ×105 yen, mean (SD)56.9 (34)48.1 (23)54.1 (31)50.5 (24)−3.6 (−5.1 to −2.1)<0.001
CI, confidence interval; ICU, intensive care unit.
Table
Table 3. Results of the complete case analyses.
Table 3. Results of the complete case analyses.
OutcomesUnweighted CohortWeighted Cohort
Usual Care
(n = 12,908)		Early Rehabilitation
(n = 10,442)		Usual Care
(n = 17,547)		Early Rehabilitation
(n = 13,021)		Differences
(95% CI)		p-Value
Primary outcome
  Barthel Index score at discharge, mean (SD)82.9 (33)89.7 (25.8)84.8 (31)87.9 (28)3.1 (1.2–5.0)0.001
Secondary outcomes
  In-hospital mortality, %7.63.66.34.6−1.7 (−2.6 to −0.8)<0.001
  Length of ICU stay, days, mean (SD)8.0 (9)6.9 (8)7.7 (8)7.2 (9)−0.5 (−0.8 to −0.2)0.003
Length of hospital stay, days, mean (SD)42.9 (44)36.3 (29)41.3 (43)38.1 (31)−3.2 (−4.8 to −1.6)<0.001
Total hospitalization cost, ×105 yen, mean (SD)55.4 (32)47.3 (22)52.7 (30)49.6 (24)−3.1 (−4.6 to −1.6)<0.001
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Ohbe, H.; Nakamura, K.; Uda, K.; Matsui, H.; Yasunaga, H. Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study. J. Clin. Med. 2021, 10, 618. https://doi.org/10.3390/jcm10040618

AMA Style

Ohbe H, Nakamura K, Uda K, Matsui H, Yasunaga H. Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study. Journal of Clinical Medicine. 2021; 10(4):618. https://doi.org/10.3390/jcm10040618

Chicago/Turabian Style

Ohbe, Hiroyuki, Kensuke Nakamura, Kazuaki Uda, Hiroki Matsui, and Hideo Yasunaga. 2021. "Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study" Journal of Clinical Medicine 10, no. 4: 618. https://doi.org/10.3390/jcm10040618

APA Style

Ohbe, H., Nakamura, K., Uda, K., Matsui, H., & Yasunaga, H. (2021). Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study. Journal of Clinical Medicine, 10(4), 618. https://doi.org/10.3390/jcm10040618

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop