Comparison of the Expression and Granting of Requests for Euthanasia in Belgium in 2007 vs 2013
Authors: Sigrid Dierickx, Luc Deliens, Joachim Cohen, Kenneth Chambaere
Journal: JAMA Internal Medicine (2015)

sessions over 12-18 weeks) have better survival than those who leave the program prematurely. 3alady et al 4 have outlined several strategies to increase completion of cardiac rehabilitation programs, including policy initiatives to support alternative delivery models that center on the patient.Such patient-centered approaches include selective use of home-based exercise programs coupled with smartphone applications to track heart rate, blood pressure, glucose, lipids, body weight, and daily activity levels, along with Internet or mobile phone and/or text-based coaching and motivational strategies.Social media adds another layer of communication to optimize patient adherence and may provide a platform for friendly competition among participants who keep track of their weekly step counts outside of the program.In contrast to intensive rehabilitation programs at centers supervised by physicians, nurses, exercise physiologists, and case managers can oversee many aspects of personalized rehabilitation programs, thus lowering costs.Although discussed, it is unlikely in our view that cardiac rehabilitation can be offered to patients with a qualifying diagnosis free of charge, as some have recommended for the provision of essential medications following AMI.Current reimbursement policies do not account for the potential downstream cost savings associated with reduced readmissions.Current reimbursement policies are also generally inadequate to cover expenses associated with the infrastructural requirements of a center-based program and require direct hospital or health system support.Whether new payment mechanisms in the era of Accountable Care Organizations will alter this dynamic remains to be seen.Several early lines of evidence point to the success of home-based and digital and/or e-health strategies.For example, a Cochrane review of 12 randomized clinical trials comprising 1938 patients found no difference in short-or intermediate-term outcomes (including death, recurrent AMI, QOL, and cost) between center-and home-based cardiac rehabilitation. 5A meta-analysis of 9 trials that compared telehealth and center-based cardiac rehabilitation showed no significant differences between groups in body weight, blood pressure, smoking, lipid profiles, QOL, or mortality. 6 Blasco et al 7 reported improved risk factor, blood pressure, hemoglobin A 1c , and body mass index outcomes for patients randomized to lifestyle counseling plus mobile phone-enabled messaging compared with patients who received lifestyle counseling alone.Varnfield et al 8 randomized patients after AMI to traditional cardiac rehabilitation or a smartphone-based home delivery program including exercise monitoring, motivational and educational material delivery, and weekly monitoring consultations.The smartphone-based program had significantly higher rates of participation and completion, and was associated with significant improvements in patient emotional status and QOL.Several ongoing trials are evaluating the effectiveness of web-or smartphone-based interactive tools and comprehensive cardiac telerehabilitation. 9 Cardiac rehabilitation is a tremendously important component of the care of patients after AMI and/or coronary revascularization.The path forward to improve utilization in-volves novel approaches that center on the patient.We have seen only glimpses of what can be accomplished with digital and e-health strategies.Wide-scale change will require patients, clinicians, insurers, and health systems to adopt and catch up with what is already digitally achievable.