Publications by authors named "Gordon R Reeves"

26 Publications

  • Page 1 of 1

Economic Outcomes of Rehabilitation Therapy in Older Patients With Acute Heart Failure in the REHAB-HF Trial: A Secondary Analysis of a Randomized Clinical Trial.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.

Importance: In the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a novel 12-week rehabilitation intervention demonstrated significant improvements in validated measures of physical function, quality of life, and depression, but no significant reductions in rehospitalizations or mortality compared with a control condition during the 6-month follow up. The economic implications of these results are important given the increasing pressures for cost containment in health care.

Objective: To report the economic outcomes of the REHAB-HF trial and estimate the potential cost-effectiveness of the intervention.

Design, Setting, Participants: The multicenter REHAB-HF trial randomized 349 patients 60 years or older who were hospitalized for acute decompensated heart failure to rehabilitation intervention or a control group; patients were enrolled from September 17, 2014, through September 19, 2019. For this preplanned secondary analysis of the economic outcomes, data on medical resource use and quality of life (via the 5-level EuroQol 5-Dimension scores converted to health utilities) were collected. Medical resource use and medication costs were estimated using 2019 US Medicare payments and the Federal Supply Schedule, respectively. Cost-effectiveness was estimated using the validated Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, which uses an individual-patient simulation model informed by the prospectively collected trial data. Data were analyzed from March 24, 2019, to December 1, 2020.

Interventions: Rehabilitation intervention or control.

Main Outcomes And Measures: Costs, quality-adjusted life-years (QALYs), and the lifetime estimated cost per QALY gained (incremental cost-effectiveness ratio).

Results: Among the 349 patients included in the analysis (183 women [52.4%]; mean [SD] age, 72.7 [8.1] years; 176 non-White [50.4%] and 173 White [49.6%]), mean (SD) cumulative costs per patient were $26 421 ($38 955) in the intervention group (excluding intervention costs) and $27 650 ($30 712) in the control group (difference, -$1229; 95% CI, -$8159 to $6394; P = .80). The mean (SD) cost of the intervention was $4204 ($2059). Quality of life gains were significantly greater in the intervention vs control group during 6 months (mean utility difference, 0.074; P = .001) and sustained beyond the 12-week intervention. Incremental cost-effectiveness ratios were estimated at $58 409 and $35 600 per QALY gained for the full cohort and in patients with preserved ejection fraction, respectively.

Conclusions And Relevance: These analyses suggest that longer-term benefits of this novel rehabilitation intervention, particularly in the subgroup of patients with preserved ejection fraction, may yield good value to the health care system. However, long-term cost-effectiveness is currently uncertain and dependent on the assumption that benefits are sustained beyond study follow-up, which needs to be corroborated in future trials in this patient population.
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http://dx.doi.org/10.1001/jamacardio.2021.4836DOI Listing
November 2021

Rehabilitation Intervention in Older Patients With Acute Heart Failure With Preserved Versus Reduced Ejection Fraction.

JACC Heart Fail 2021 10 7;9(10):747-757. Epub 2021 Jul 7.

Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Sections on Geriatrics, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA. Electronic address:

Objectives: This study assessed for treatment interactions by ejection fraction (EF) subgroup (≥45% [heart failure with preserved ejection fraction (HFpEF); vs <45% [heart failure with reduced ejection fraction (HFrEF)]).

Background: The REHAB-HF trial showed that an early multidomain rehabilitation intervention improved physical function, frailty, quality-of-life, and depression in older patients hospitalized with acute decompensated heart failure (ADHF).

Methods: Three-month outcomes were: Short Physical Performance Battery (SPPB), 6-min walk distance (6MWD), and Kansas City Cardiomyopathy Questionnaire (KCCQ). Six-month end points included all-cause rehospitalization and death and a global rank of death, all-cause rehospitalization, and SPPB. Prespecified significance level for interaction was P ≤ 0.1.

Results: Among 349 total participants, 185 (53%) had HFpEF and 164 (47%) had HFrEF. Compared with HFrEF, HFpEF participants were more often women (61% vs 43%) and had significantly worse baseline physical function, frailty, quality of life, and depression. Although interaction P values for 3-month outcomes were not significant, effect sizes were larger for HFpEF vs HFrEF: SPPB +1.9 (95% CI: 1.1-2.6) vs +1.1 (95% CI: 0.3-1.9); 6MWD +40 meters (95% CI: 9 meters-72 meters) vs +27 (95% CI: -6 meters to 59 meters); KCCQ +9 (2-16) vs +6 (-2 to 14). All-cause rehospitalization rate was nominally lower with intervention in HFpEF but not HFrEF [effect size 0.83 (95% CI: 0.64-1.09) vs 0.99 (95% CI: 0.74-1.33); interaction P = 0.40]. There were significantly greater treatment benefits in HFpEF vs HFrEF for all-cause death [interaction P = 0.08; intervention rate ratio 0.63 (95% CI: 0.25-1.61) vs 2.21 (95% CI: 0.78-6.25)], and the global rank end point (interaction P = 0.098) with benefit seen in HFpEF [probability index 0.59 (95% CI: 0.50-0.68)] but not HFrEF.

Conclusions: Among older patients hospitalized with ADHF, compared with HFrEF those with HFpEF had significantly worse impairments at baseline and may derive greater benefit from the intervention. (A Trial of Rehabilitation Therapy in Older Acute Heart Failure Patients [REHAB-HF]; NCT02196038).
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http://dx.doi.org/10.1016/j.jchf.2021.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8487922PMC
October 2021

Physical Rehabilitation for Older Patients Hospitalized for Heart Failure.

N Engl J Med 2021 07 16;385(3):203-216. Epub 2021 May 16.

From the Department of Internal Medicine, Sections of Cardiovascular Medicine (D.W.K., M.B.N., B.U.) and Gerontology and Geriatric Medicine (D.W.K., M.A.E.), and the Departments of Neurology (P.D.) and Biostatistics and Data Science (H.C., M.A.E.), Wake Forest School of Medicine, Winston-Salem, the Department of Orthopedic Surgery, Doctor of Physical Therapy Division (A.M.P.), the Department of Medicine, Division of Cardiology (R.J.M.), and the Department of Population Health Sciences (S.D.R.), Duke University School of Medicine, Durham, and Novant Health Heart and Vascular Institute, Charlotte (G.R.R.) - all in North Carolina; the Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University (D.J.W.), and the Department of Physical Therapy, Jefferson College of Rehabilitation Sciences at Thomas Jefferson University (L.A.H.) - both in Philadelphia; and Inova Heart and Vascular Institute, Fairfax, VA (C.M.O.).

Background: Older patients who are hospitalized for acute decompensated heart failure have high rates of physical frailty, poor quality of life, delayed recovery, and frequent rehospitalizations. Interventions to address physical frailty in this population are not well established.

Methods: We conducted a multicenter, randomized, controlled trial to evaluate a transitional, tailored, progressive rehabilitation intervention that included four physical-function domains (strength, balance, mobility, and endurance). The intervention was initiated during, or early after, hospitalization for heart failure and was continued after discharge for 36 outpatient sessions. The primary outcome was the score on the Short Physical Performance Battery (total scores range from 0 to 12, with lower scores indicating more severe physical dysfunction) at 3 months. The secondary outcome was the 6-month rate of rehospitalization for any cause.

Results: A total of 349 patients underwent randomization; 175 were assigned to the rehabilitation intervention and 174 to usual care (control). At baseline, patients in each group had markedly impaired physical function, and 97% were frail or prefrail; the mean number of coexisting conditions was five in each group. Patient retention in the intervention group was 82%, and adherence to the intervention sessions was 67%. After adjustment for baseline Short Physical Performance Battery score and other baseline characteristics, the least-squares mean (±SE) score on the Short Physical Performance Battery at 3 months was 8.3±0.2 in the intervention group and 6.9±0.2 in the control group (mean between-group difference, 1.5; 95% confidence interval [CI], 0.9 to 2.0; P<0.001). At 6 months, the rates of rehospitalization for any cause were 1.18 in the intervention group and 1.28 in the control group (rate ratio, 0.93; 95% CI, 0.66 to 1.19). There were 21 deaths (15 from cardiovascular causes) in the intervention group and 16 deaths (8 from cardiovascular causes) in the control group. The rates of death from any cause were 0.13 and 0.10, respectively (rate ratio, 1.17; 95% CI, 0.61 to 2.27).

Conclusions: In a diverse population of older patients who were hospitalized for acute decompensated heart failure, an early, transitional, tailored, progressive rehabilitation intervention that included multiple physical-function domains resulted in greater improvement in physical function than usual care. (Funded by the National Institutes of Health and others; REHAB-HF ClinicalTrials.gov number, NCT02196038.).
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http://dx.doi.org/10.1056/NEJMoa2026141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8353658PMC
July 2021

The other striated muscle: The role of sarcopenia in older persons with heart failure.

J Am Geriatr Soc 2021 07 17;69(7):1811-1814. Epub 2021 Apr 17.

Sections on Cardiovascular Medicine and Geriatrics/Gerontology, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.

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http://dx.doi.org/10.1111/jgs.17160DOI Listing
July 2021

Contrast-Enhanced Ultrasound of Muscle Perfusion May Indicate Patient Response to Left Ventricular Assist Device Therapy.

J Ultrasound Med 2021 Dec 5;40(12):2675-2683. Epub 2021 Mar 5.

Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Purpose: Left ventricular assist device (LVAD) support is associated with peripheral vascular abnormalities beyond those associated with heart failure (HF). These abnormalities are associated with persistent functional impairments that adversely impact quality of life (QoL). Methods for measuring peripheral vascular function in this population are needed.

Methods: This pilot study investigated the use of contrast-enhanced ultrasound (CEUS) using standardized protocols to estimate changes in peripheral (quadriceps) muscle perfusion among patients with HF (INTERMACS profile 3) undergoing LVAD implantation (n = 7). Patients were then stratified by those who did ("responders", n = 4) and did not ("nonresponders", n = 3) report QoL improvement with LVAD support.

Results: Serial measurements obtained preoperatively and 3 months following LVAD implantation showed no significant change (P > .23) in muscle perfusion by all CEUS-based measures at rest or with an exercise stimulus for the overall population. Responders exhibited improved muscle perfusion at rest (P = .043) and decreased time to peak contrast enhancement (P = .010) at 3 months compared with baseline, suggesting improved delivery of blood to the extremities post-LVAD. Nonresponders showed unchanged resting muscle perfusion (P > .99), time to peak contrast enhancement (P = .59), and response to exercise stimulus (P > .99) following LVAD therapy.

Conclusion: Our findings suggest that CEUS evaluation is a promising noninvasive, quantitative modality for real-time assessment of peripheral vasculature and muscle perfusion as an indication of treatment response in LVAD recipients and that this modality may capture perfusion measures important to QoL following LVAD implantation.
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http://dx.doi.org/10.1002/jum.15658DOI Listing
December 2021

Cognition, Physical Function, and Quality of Life in Older Patients With Acute Decompensated Heart Failure.

J Card Fail 2021 03 18;27(3):286-294. Epub 2020 Sep 18.

Department of Neurology and Sticht Center on Aging Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

Background: Older adults with acute decompensated heart failure have persistently poor clinical outcomes. Cognitive impairment (CI) may be a contributing factor. However, the prevalence of CI and the relationship of cognition with other patient-centered factors such a physical function and quality of life (QOL) that also may contribute to poor outcomes are incompletely understood.

Methods And Results: Older (≥60 years) hospitalized patients with acute decompensated heart failure were assessed for cognition (Montreal Cognitive Assessment [MoCA]), physical function (Short Physical Performance Battery [SPPB], 6-minute walk distance [6MWD]), and QOL (Kansas City Cardiomyopathy Questionnaire, Short Form-12). Among patients (N = 198, 72.1 ± 7.6 years), 78% screened positive for CI (MoCA of <26) despite rare medical record documentation (2%). Participants also had severely diminished physical function (SPPB 6.0 ± 2.5 units, 6MWD 186 ± 100 m) and QOL (scores of <50). MoCA positively related to SPPB (ß = 0.47, P < .001), 6MWD ß = 0.01, P = .006) and inversely related to Kansas City Cardiomyopathy Questionnaire Overall Score (ß = -0.05, P < .002) and Short Form-12 Physical Component Score (ß = -0.09, P = .006). MoCA was a small but significant predictor of the results on the SPPB, 6MWD, and Kansas City Cardiomyopathy Questionnaire.

Conclusions: Among older hospitalized patients with acute decompensated heart failure, CI is highly prevalent, is underrecognized clinically, and is associated with severe physical dysfunction and poor QOL. Formal screening may reduce adverse events by identifying patients who may require more tailored care.
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http://dx.doi.org/10.1016/j.cardfail.2020.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914148PMC
March 2021

Frailty Among Older Decompensated Heart Failure Patients: Prevalence, Association With Patient-Centered Outcomes, and Efficient Detection Methods.

JACC Heart Fail 2019 12;7(12):1079-1088

Heart and Vascular Institute, Novant Health, Charlotte, North Carolina. Electronic address:

Objectives: This study sought to assess the prevalence of frailty, its associations with physical function, quality of life (QoL), cognition, and depression and to investigate more efficient methods of detection in older patients hospitalized with acute decompensated heart failure (ADHF).

Background: In contrast to the outpatient population with chronic HF, much less is known regarding frailty in older, hospitalized patients with ADHF.

Methods: Older hospitalized patients (N = 202) with ADHF underwent assessment of frailty (using Fried criteria), short physical performance battery (SPPB), 6-min walk test (6-MWT) distance, quality of life (QoL using the Kansas City Cardiomyopathy Questionnaire), cognition (using the Montreal Cognition Assessment), and depression (using the Geriatric Depression Screen [GDS]). The associations of frailty with these patient-centered outcomes were assessed by using adjusted linear regression models. Novel strategies to identify frailty were examined.

Results: A total of 50% of older, hospitalized patients with ADHF were frail, 48% were pre-frail, and 2% were non-frail. Female sex, burden of comorbidity, and prior HF hospitalization were significantly associated with higher likelihood of frailty. Frailty (vs. pre-frail status) was associated with a significantly worse SPPB score (5 ± 2.2 vs. 7 ± 2.4, respectively), 6-MWT distance (143 ± 79 m vs. 221 ± 99 m, respectively), QoL (35 ± 19 vs. 46 ± 21, respectively), and more depression (GDS score: 5.5 ± 3.5 vs. 4.2 ± 3.3, respectively) but similar cognition. These associations were unchanged after adjustment for age, sex, race, total comorbidities, and body mass index. Slow gait speed plus low physical activity signaled frailty status as well (C-statistic = 0.85).

Conclusions: Ninety-eight percent of older, hospitalized patients with ADHF are frail or pre-frail. Frailty (vs. pre-frail status) is associated with worse physical function, QoL, comorbidity, and depression. The simple 4-m walk test combined with self-reported physical activity may quickly and efficiently identify frailty in older patients with ADHF.
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http://dx.doi.org/10.1016/j.jchf.2019.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8067953PMC
December 2019

Cardiac Rehabilitation in Older Adults with Heart Failure: Fitting a Square Peg in a Round Hole.

Clin Geriatr Med 2019 11 3;35(4):517-526. Epub 2019 Jul 3.

Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, PA 19107, USA; Advanced Heart Failure for the Greater Charlotte Market, Novant Health Heart and Vascular Institute, 1718 E 4th Street, Suite 501, Charlotte, NC 28204, USA. Electronic address:

Cardiac rehabilitation (CR) is a structured exercise and lifestyle program that improves mortality and quality of life in patients with heart failure (HF) with reduced ejection fraction. However, significant gaps remain in optimizing CR for older adults with HF. This review summarizes the state of the science and specific knowledge gaps regarding older adults with HF. The authors discuss the importance of geriatric complexities in the design and implementation of CR, summarize promising future research in this area, and provide a clinical framework for current CR clinicians to follow when considering the specific needs of older adults with HF.
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http://dx.doi.org/10.1016/j.cger.2019.07.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760316PMC
November 2019

Getting Paid to Participate: Financial Incentives to Improve Adherence to Cardiac Rehabilitation.

JACC Heart Fail 2019 07 8;7(7):547-549. Epub 2019 May 8.

Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.jchf.2019.03.004DOI Listing
July 2019

Physical Function, Frailty, Cognition, Depression, and Quality of Life in Hospitalized Adults ≥60 Years With Acute Decompensated Heart Failure With Preserved Versus Reduced Ejection Fraction.

Circ Heart Fail 2018 11;11(11):e005254

Department of Medicine, Thomas Jefferson University, Philadelphia, PA (D.J.W., G.R.R.).

Background: Older hospitalized acute decompensated heart failure (HF) patients have persistently poor outcomes and delayed recovery regardless of ejection fraction (EF). We hypothesized that impairments in physical function, frailty, cognition, mood, and quality of life (QoL) potentially contributing to poor clinical outcomes would be similarly severe in acute decompensated HF patients ≥60 years of age with preserved versus reduced EF (HFpEF and HFrEF).

Methods And Results: In 202 consecutive older (≥60 years) hospitalized acute decompensated HF patients in a multicenter trial, we prospectively performed at baseline: short physical performance battery, 6-minute walk distance, frailty assessment, Geriatric Depression Scale, Montreal Cognitive Assessment, and QoL assessments. Older acute decompensated HFpEF (EF ≥45%, n=96) and HFrEF (EF <45%, n=106) patients had similar impairments in all physical function measures (short physical performance battery [5.9±0.3 versus 6.2±0.2]; 6-minute walk distance [184±10 versus 186±9 m]; and gait speed [0.60±0.02 versus 0.61±0.02 m/s]) and rates of frailty (55% versus 52%; P=0.70) and cognitive impairment (77% versus 81%; P=0.56) when adjusted for differences in sex, body mass index, and comorbidities. However, depression and QoL were consistently worse in HFpEF versus HFrEF. Depression was usually unrecognized clinically with 38% having Geriatric Depression Scale ≥5 and no documented history of depression.

Conclusions: Patients ≥60 years hospitalized with acute decompensated HF patients have broad, marked impairments in physical function and high rates of frailty and impaired cognition: these impairments are similar in HFpEF versus HFrEF. Further, depression was common and QoL was reduced, and both were worse in HFpEF than HFrEF. Depression was usually unrecognized clinically. These findings suggest opportunities for novel interventions to improve these important patient-centered outcomes.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02196038.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.118.005254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380360PMC
November 2018

Left Ventricular Assist Device Decommissioning Compared with Explantation for Ventricular Recovery: A Systematic Review.

ASAIO J 2020 01;66(1):17-22

From the Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

Left ventricular assist device (LVAD) withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. The aim of this systematic review was to examine the patient outcomes of device withdrawal via minimally invasive pump decommissioning as compared with reoperation for pump explantation. An electronic search was performed to identify all studies in the English literature assessing LVAD withdrawal. All identified articles were systematically assessed for inclusion and exclusion criteria. Overall, 44 studies (85 patients) were included in the analysis, of whom 20% underwent decommissioning and 80% underwent explantation. The most commonly used LVAD types included the HeartMate II (decommissioning 23.5% vs. explantation 60.3%; p = 0.01) and HeartWare HVAD (decommissioning 76.5% vs. explantation 17.6%; p < 0.001). At median follow-up of 389 days, there were no significant differences in the incidence of cerebrovascular accidents (p = 0.88), infection (p = 0.75), and survival (p = 0.20). However, there was a trend toward a higher recurrence of heart failure in patients who underwent decommissioning as compared with explantation (decommissioning 15.4% vs. explantation 8.2%, cumulative hazard; p = 0.06). Decommissioning appears to be a feasible alternative to LVAD explantation in terms of overall patient outcomes.
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http://dx.doi.org/10.1097/MAT.0000000000000926DOI Listing
January 2020

Percutaneous coronary intervention versus coronary artery bypass grafting in heart transplant recipients with coronary allograft vasculopathy: a systematic review and meta-analysis of 1,520 patients.

Ann Cardiothorac Surg 2018 Jan;7(1):19-30

Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Background: Transplant coronary artery vasculopathy (TCAV) is the major cause of late allograft failure and death in heart transplant recipients. The aim of this systematic review was to examine the outcomes of percutaneous coronary interventions (PCIs) as compared to coronary artery bypass grafting (CABG) surgery in the management of TCAV. Our secondary objective was to compare the use and outcomes of drug eluting stents (DES) as compared to bare metal stents (BMS) in this patient population.

Methods: Electronic search was performed to identify all studies in the English literature examining PCI as compared to CABG for TCAV in heart transplant recipients. All identified articles were systematically assessed for inclusion and exclusion criteria.

Results: Of the 4,989 studies identified, 29 studies were included. Among 1,520 patients who developed TCAV, 1,470 patients underwent PCI and 50 patients underwent CABG. There were no significant differences in baseline demographics and comorbidities among the PCI and CABG cohorts. Compared to the PCI cohort, patients who underwent CABG had a higher early mortality (CABG 36.4% . PCI 4.3%, P<0.001) and overall mortality (CABG 42.3% . PCI 21.4%, P=0.049). When comparing DES versus BMS cohorts, there were no significant differences in the rate of in-stent stenosis (DES 14.5% . BMS 24.4%, P=0.476), overall mortality (DES 17.4% . BMS 30.8%, P=0.302) or cardiac related mortality (DES 7.7% . BMS 21.8%, P=0.415).

Conclusions: CABG and PCI are both feasible modalities for revascularization in patients with TCAV where PCI is associated with lower mortality. There were no differences in outcomes among patients who underwent PCI with DES as compared to BMS. Potential bias may exist due to heterogeneity in available data. Further studies are needed to delineate evidence-based guidelines to tailor the appropriate therapy, CABG or PCI, to the appropriate patient.
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http://dx.doi.org/10.21037/acs.2018.01.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827131PMC
January 2018

Strategies for supporting intervention fidelity in the rehabilitation therapy in older acute heart failure patients (REHAB-HF) trial.

Contemp Clin Trials 2018 01 25;64:118-127. Epub 2017 Oct 25.

Wake Forest University School of Medicine, Winston-Salem, NC, USA. Electronic address:

Introduction: Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in older adults. Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial is a multi-site clinical trial to determine if physical rehabilitation intervention in older patients with ADHF improves physical function and reduces rehospitalizations. The REHAB-HF intervention aims to improve functional performance utilizing reproducible and progressive exercises that are individually tailored to the patient's physiological and physical capabilities. Fidelity of the intervention is essential to the trial's integrity and success. Maintaining fidelity is challenged by the complex, multi-domain design of the intervention implemented across multiple sites and delivered to an older, heterogeneous participant pool with severe underlying disease and multi-morbidity.

Methods/design: Given the dynamic nature of the REHAB-HF intervention, rigorous fidelity strategies were formulated. In this paper we summarize the specific strategies that REHAB-HF is using to meet the National Institutes of Health (NIH) Behavior Change Consortium Treatment Fidelity Workgroup recommendations in 5 key areas: 1) ensuring the intervention dose is consistent across participants, 2) standardizing interventionist training, 3) monitoring intervention delivery, 4) evaluating participants' understanding of information provided, and 5) ensuring that participants use the skills taught in the intervention.

Discussion: Effective intervention fidelity strategies are essential to the reliability and validity of physical function intervention trials. The REHAB-HF trial has developed comprehensive, specific strategies to ensure intervention fidelity despite a challenging study population and a complex intervention to meet NIH recommendations. This experience provides a strong working model for future physical function intervention trials.
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http://dx.doi.org/10.1016/j.cct.2017.10.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5742023PMC
January 2018

Can a Left Ventricular Assist Device in Individuals with Advanced Systolic Heart Failure Improve or Reverse Frailty?

J Am Geriatr Soc 2017 Nov 21;65(11):2383-2390. Epub 2017 Sep 21.

Thomas Jefferson University, Philadelphia, Pennsylvania.

Background/objectives: Frailty, characterized by low physiological reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure, making a distinction between them difficult. We sought to determine whether implantation of a left ventricular assist device (LVAD) would decrease frailty.

Design: Prospective, cohort study.

Setting: Five academic medical centers.

Participants: Frail individuals (N = 29; mean age 70.6 ± 5.5, 72.4% male).

Measurements: Frailty, defined as having 3 or more of the Fried frailty criteria, was assessed before LVAD implantation and 1, 3, and 6 months after implantation. Other domains assessed included quality of life, using the Kansas City Cardiomyopathy Questionnaire; mood, using the Patient Health Questionnaire; and cognitive function, using the Trail-Making Test Part B.

Results: After 6 months, three subjects had died, and one had undergone a heart transplant; of 19 subjects with serial frailty measures, the average number of frailty criteria decreased from 3.9 ± 0.9 at baseline to 2.8 ± 1.4 at 6 months (P = .003). Improvements were observed after 3 to 6 months of LVAD support, although 10 (52.6%) participants still had 3 or more Fried criteria, and all subjects had at least one at 6 months. Changes in frailty were associated with improvement in QOL but not with changes in mood or cognition. Higher estimated glomerular filtration rate at baseline was independently associated with a decrease in frailty.

Conclusion: Frailty decreased in approximately half of older adults with advanced heart failure after 6 months of LVAD support. Strategies to enhance frailty reversal in this population are worthy of additional study.
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http://dx.doi.org/10.1111/jgs.15124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5681378PMC
November 2017

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Circulation 2017 Apr 23;135(16):e894-e918. Epub 2017 Mar 23.

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.
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http://dx.doi.org/10.1161/CIR.0000000000000483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252210PMC
April 2017

A Novel Rehabilitation Intervention for Older Patients With Acute Decompensated Heart Failure: The REHAB-HF Pilot Study.

JACC Heart Fail 2017 05 8;5(5):359-366. Epub 2017 Mar 8.

Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina. Electronic address:

Objectives: This study sought to assess a novel physical rehabilitation intervention in older patients hospitalized for acute decompensated heart failure (ADHF).

Background: After ADHF, older patients, who are frequently frail with multiple comorbidities, have prolonged and incomplete recovery of physical function and remain at high risk for poor outcomes.

Methods: The REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) pilot study was a 3-site, randomized, attention-controlled pilot study of a tailored, progressive, multidomain physical rehabilitation intervention beginning in the hospital and continuing for 12 weeks post-discharge in patients ≥60 years hospitalized with ADHF. The primary purpose was to assess the feasibility and reasonableness of the hypothesis that the novel rehabilitation intervention would improve physical function (Short Physical Performance Battery [SPPB]) over 3 months and reduce all-cause rehospitalizations over 6 months.

Results: The study enrolled 27 patients with ADHF (ages 60 to 98 years; 59% women; 56% African American; 41% with preserved ejection fraction [≥45%]). At baseline, participants had marked impairments in physical function, multiple comorbidities, and frailty. Study retention (89%) and intervention adherence (93%) were excellent. At 3 months, an intervention effect size was measured for the SPPB score of +1.1 U (7.4 ± 0.5 U vs. 6.3 ± 0.5 U), and at 6 months an effect size was observed for an all-cause rehospitalization rate of -0.48 (1.16 ± 0.35 vs. 1.64 ± 0.39). The change in SPPB score was strongly related to all-cause rehospitalizations, explaining 91% of change.

Conclusions: These findings support the feasibility and rationale for a recently launched, National Institutes of Health-funded trial to test the safety and efficacy of this novel multidomain physical rehabilitation intervention to improve physical function and reduce rehospitalizations in older, frail patients with ADHF with multiple comorbidities. (Rehabilitation and Exercise Training After Hospitalization [REHAB-HF]; NCT01508650; A Trial of Rehabilitation Therapy in Older Acute Heart Failure Patients [REHAB-HF]; NCT02196038).
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http://dx.doi.org/10.1016/j.jchf.2016.12.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5409854PMC
May 2017

Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial: Design and rationale.

Am Heart J 2017 Mar 28;185:130-139. Epub 2016 Dec 28.

Wake Forest School of Medicine, Winston-Salem, NC.

Background: Acute decompensated heart failure (ADHF) is a leading cause of hospitalization in older persons in the United States. Reduced physical function and frailty are major determinants of adverse outcomes in older patients with hospitalized ADHF. However, these are not addressed by current heart failure (HF) management strategies and there has been little study of exercise training in older, frail HF patients with recent ADHF.

Hypothesis: Targeting physical frailty with a multi-domain structured physical rehabilitation intervention will improve physical function and reduce adverse outcomes among older patients experiencing a HF hospitalization.

Study Design: REHAB-HF is a multi-center clinical trial in which 360 patients ≥60 years hospitalized with ADHF will be randomized either to a novel 12-week multi-domain physical rehabilitation intervention or to attention control. The goal of the intervention is to improve balance, mobility, strength and endurance utilizing reproducible, targeted exercises administered by a multi-disciplinary team with specific milestones for progression. The primary study aim is to assess the efficacy of the REHAB-HF intervention on physical function measured by total Short Physical Performance Battery score. The secondary outcome is 6-month all-cause rehospitalization. Additional outcome measures include quality of life and costs.

Conclusions: REHAB-HF is the first randomized trial of a physical function intervention in older patients with hospitalized ADHF designed to determine if addressing deficits in balance, mobility, strength and endurance improves physical function and reduces rehospitalizations. It will address key evidence gaps concerning the role of physical rehabilitation in the care of older patients, those with ADHF, frailty, and multiple comorbidities.
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http://dx.doi.org/10.1016/j.ahj.2016.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5341700PMC
March 2017

Comparison of Frequency of Frailty and Severely Impaired Physical Function in Patients ≥60 Years Hospitalized With Acute Decompensated Heart Failure Versus Chronic Stable Heart Failure With Reduced and Preserved Left Ventricular Ejection Fraction.

Am J Cardiol 2016 Jun 6;117(12):1953-8. Epub 2016 Apr 6.

Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina. Electronic address:

Older patients with acute decompensated heart failure (ADHF) have persistently poor outcomes including frequent rehospitalization despite guidelines-based therapy. We hypothesized that such patients have multiple, severe impairments in physical function, cognition, and mood that are not addressed by current care pathways. We prospectively examined frailty, physical function, cognition, mood, and quality of life in 27 consecutive older patients with ADHF at 3 medical centers and compared these with 197 participants in 3 age-matched cohorts: stable heart failure (HF) with preserved ejection fraction (n = 80), stable HF with reduced ejection fraction (n = 56), and healthy older adults (n = 61). Based on Fried criteria, frailty was present in 56% of patients with ADHF versus 0 for the age-matched chronic HF and health cohorts. Patients with ADHF had markedly reduced Short Physical Performance Battery score (5.3 ± 2.8) and 6-minute walk distance (178 ± 102 m) (p <0.001 vs other cohorts), with severe deficits in all domains of physical function: balance, mobility, strength, and endurance. In the patients with ADHF, cognitive impairment (78%) and depression (30%) were common, and quality of life was poor. In conclusion, older patients with ADHF are frequently frail with severe and widespread impairments in physical function, cognition, mood, and quality of life that may contribute to their persistently poor outcomes, are frequently unrecognized, are not addressed in current ADHF care paradigms, and are potentially modifiable with targeted interventions.
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http://dx.doi.org/10.1016/j.amjcard.2016.03.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943325PMC
June 2016

Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2016 Sep-Oct;36(5):309-19

Medicine (Drs Reeves and Gupta), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Geriatric Cardiology Section of the Divisions of Cardiology and Geriatrics (Dr Forman), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Geriatric Research, Education, and Clinical Center (Dr Forman), VA Pittsburgh Healthcare System University of Pittsburgh, and Department of Medicine (Dr Forman), University of Pittsburgh, Pittsburgh, Pennsylvania.

Symptom-limited (maximal) exercise testing before cardiac rehabilitation (CR) was once an unambiguous standard of care. In particular, it served as an important screen for residual ischemia and instability before initiating a progressive exercise training regimen. However, improved revascularization and therapy for coronary heart disease has led many clinicians to downplay this application of exercise testing, especially because such testing is also a potential encumbrance to CR enrollment (delaying ease and efficiency of enrollment after procedures and hospitalizations) and patient burden (eg, added costs, logistic hassle, and anxiety). Nonetheless, exercise testing has enduring value for CR, especially because it reveals dynamic physiological responses as well as ischemia, arrhythmias, and symptoms pertinent to exercise prescription and training and to overall stability and prognosis. Moreover, as indications for CR have expanded, the value of exercise testing and functional assessment is more relevant than ever in the growing population of eligible patients, including those with heart failure, valvular heart disease, and posttransplantation, especially as current patients also tend to be more clinically complex, with advanced ages, multimorbidity, frailty, and obesity. This review focuses on the appropriate use of exercise testing in the CR setting. Graded exercise tests, cardiopulmonary exercise tests, submaximal walking tests, and other functional assessments (strength, frailty) for CR are discussed.
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http://dx.doi.org/10.1097/HCR.0000000000000176DOI Listing
December 2017

Gait Speed: Stepping Towards Improved Assessment of Heart Failure Patients.

JACC Heart Fail 2016 Apr;4(4):299-300

Geriatric Cardiology Section in the Divisions of Cardiology and Geriatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jchf.2016.02.002DOI Listing
April 2016

Isosorbide Mononitrate in Heart Failure with Preserved Ejection Fraction.

N Engl J Med 2015 Dec 8;373(24):2314-24. Epub 2015 Nov 8.

From the Mayo Clinic, Rochester, MN (M.M.R., B.A.B., H.H.C.); Duke Clinical Research Institute (K.J.A., S.E.M., E.J.V.) and Duke University Medical Center (G.M.F.) - both in Durham, NC; Mayo Clinic, Scottsdale, AZ (J.A.L., G.A.K.); University of Vermont Medical Center, Burlington (M.M.L.); Washington University School of Medicine, St. Louis (S.M.J.); Northwestern University, Chicago (S.J.S.); Massachusetts General Hospital (M.J.S.) and Harvard Medical School (E.B.) - both in Boston; Emory University, Atlanta (R.T.C.); Thomas Jefferson University, Philadelphia (G.R.R.); Johns Hopkins University School of Medicine, Baltimore (R.J.T.), and the National Heart, Lung, and Blood Institute, Bethesda (M.R.S.) - both in Maryland; and the Cleveland Clinic Foundation, Cleveland (W.H.W.T.).

Background: Nitrates are commonly prescribed to enhance activity tolerance in patients with heart failure and a preserved ejection fraction. We compared the effect of isosorbide mononitrate or placebo on daily activity in such patients.

Methods: In this multicenter, double-blind, crossover study, 110 patients with heart failure and a preserved ejection fraction were randomly assigned to a 6-week dose-escalation regimen of isosorbide mononitrate (from 30 mg to 60 mg to 120 mg once daily) or placebo, with subsequent crossover to the other group for 6 weeks. The primary end point was the daily activity level, quantified as the average daily accelerometer units during the 120-mg phase, as assessed by patient-worn accelerometers. Secondary end points included hours of activity per day during the 120-mg phase, daily accelerometer units during all three dose regimens, quality-of-life scores, 6-minute walk distance, and levels of N-terminal pro-brain natriuretic peptide (NT-proBNP).

Results: In the group receiving the 120-mg dose of isosorbide mononitrate, as compared with the placebo group, there was a nonsignificant trend toward lower daily activity (-381 accelerometer units; 95% confidence interval [CI], -780 to 17; P=0.06) and a significant decrease in hours of activity per day (-0.30 hours; 95% CI, -0.55 to -0.05; P=0.02). During all dose regimens, activity in the isosorbide mononitrate group was lower than that in the placebo group (-439 accelerometer units; 95% CI, -792 to -86; P=0.02). Activity levels decreased progressively and significantly with increased doses of isosorbide mononitrate (but not placebo). There were no significant between-group differences in the 6-minute walk distance, quality-of-life scores, or NT-proBNP levels.

Conclusions: Patients with heart failure and a preserved ejection fraction who received isosorbide mononitrate were less active and did not have better quality of life or submaximal exercise capacity than did patients who received placebo. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02053493.).
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http://dx.doi.org/10.1056/NEJMoa1510774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712067PMC
December 2015

Exercise training as therapy for heart failure: current status and future directions.

Circ Heart Fail 2015 Jan;8(1):209-20

From the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C.); Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (B.A.B.); Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada (M.J.H.); Division of Cardiology, Duke University School of Medicine, Durham, NC (W.E.K.); Institute for Exercise and Environmental Medicine, University of Texas Southwestern Medical Center, Dallas (B.D.L.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Department of Kinesiology (D.C.P.) and Department of Anatomy and Physiology (D.C.P.), Kansas State University, Manhattan; Division of Cardiology, Jefferson Medical College, Philadelphia, PA (G.R.R., D.J.W.); and Sections on Cardiology and Geriatrics, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.).

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.113.001420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802377PMC
January 2015

Cardiac rehabilitation in left ventricular assist device recipients: can it bolster the benefits of restored flow?

JACC Heart Fail 2014 Dec 22;2(6):660-2. Epub 2014 Oct 22.

Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.jchf.2014.08.001DOI Listing
December 2014

Left ventricular dysfunction mimicking Takotsubo cardiomyopathy following cardiac surgery.

J Heart Valve Dis 2011 Jul;20(4):471-3

Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Left ventricular dysfunction with apical ballooning consistent with Takotsubo cardiomyopathy was encountered in a 68-year-old woman at 5 h after an uneventful mitral valve replacement and tricuspid valve repair. Preoperatively, the patient had emotional stress as well as worsening congestive heart failure, which might have contributed to this rare postoperative complication. Following diagnosis by transthoracic echocardiography (TTE), and characteristic findings of apical ballooning and a preserved basal contraction of the left ventricle, intra-aortic balloon pumping (IABP) was initiated to minimize the use of inotropic drugs. The patient was successfully weaned from both the IABP and pharmacological support. Follow up with serial TTE showed a gradual recovery of the left ventricle to normal systolic function. The mechanism of onset and pathophysiology of Takotsubo cardiomyopathy remain unclear, especially in postoperative cardiac surgery patients. Since excessive catecholamine stimulation has been proposed as a possible mechanism of Takotsubo cardiomyopathy, early mechanical circulatory assistance after cardiac surgery is advised to minimize catecholamine use in this rare complication.
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July 2011

Recent advances in cardiac rehabilitation.

Curr Opin Cardiol 2010 Nov;25(6):589-96

Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Purpose Of Review: Cardiac rehabilitation has been established as an effective treatment for patients with ischemic heart disease for many years. Despite this, utilization remains low. The purpose of this article is to review the latest research on the benefit, utilization, and implementation of cardiac rehabilitation.

Recent Findings: Recent research is supportive of the beneficial effects of cardiac rehabilitation in patients with heart failure as well as in older patients. Unfortunately, cardiac rehabilitation continues to be considerably underutilized with poor referral and enrollment rates. Implementing quality performance measures, automated referral systems, and the option of home-based cardiac rehabilitation for some patients may all help to increase participation. In addition, innovative exercise training regimens may help to enhance the beneficial effects of cardiac rehabilitation.

Summary: Cardiac rehabilitation appears beneficial in an increasing array of cardiovascular diseases. Ongoing efforts to improve its use are essential for optimal disease management.
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http://dx.doi.org/10.1097/HCO.0b013e32833f0208DOI Listing
November 2010

Dissociation between hospital performance of the smoking cessation counseling quality metric and cessation outcomes after myocardial infarction.

Arch Intern Med 2008 Oct;168(19):2111-7

Department of Internal Medicine, Duke Clinical Research Institute, Durham, NC 27705, USA.

Background: Recognizing the importance of smoking cessation after acute myocardial infarction (AMI), the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations currently uses documentation of smoking cessation counseling (SCC) as a metric of hospitals' quality of AMI care. Yet, the association between hospitals' performance of this quality measure and subsequent tobacco cessation rates has not been established.

Methods: We analyzed 889 consecutive smokers treated for AMI at 19 hospitals in PREMIER (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) between January 1, 2003, and June 28, 2004. Patients were followed up for 1 year after hospitalization. Multivariate regression modeling was performed to determine the association between hospital-level documented SCC rates and tobacco cessation rates after discharge.

Results: On a hospital level, the median medical record-documented SCC rate was 72.0% (interquartile range, 59.6%-90.1%). At 1 year, the median smoking cessation rate was 55.6% (interquartile range, 37.5%-61.9%). Although patients with documented SCC were more likely to recall receiving SCC at 1 month (86.1% vs 70.8%, P < .001), their rate of quitting at 1 year was lower than that of patients without documented SCC (50.1% vs 60.7%, P = .02; relative risk, 0.76; 95% confidence interval, 0.61-0.94). At the hospital level, there was no correlation between SCC documentation and successful quitting at 6 months (r = -0.19, P = .11) or 1 year (r = -0.13, P = .45).

Conclusions: The performance metric for SCC, as it is currently structured, does not correlate with actual smoking cessation at 6 months or 1 year. Revision of this performance measure should be considered to more effectively reflect the goal of promoting smoking cessation.
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http://dx.doi.org/10.1001/archinte.168.19.2111DOI Listing
October 2008
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