Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement

Background: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its’ benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations. Methods: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment. Results: The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95±0.69 (mean ± standard deviation), 5.33±1.12 and 5.64±1.08, respectively. Conclusions: Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs

Availability and delivery of cardiac rehabilitation in South-East Asia: How does it compare globally?

Background: The aims of this study were to establish cardiac rehabilitation (CR) availability and density, as well as the nature of programs in South-East Asian Region (SEAR) countries, and to compare this with other regions globally. Methods: In 2016/2017, the International Council of Cardiovascular Prevention and Rehabilitation engaged cardiac associations to facilitate program identification globally. An online survey was administered to identify programs using REDCap, assessing capacity and characteristics. CR density was computed using Global Burden of Disease study annual ischemic heart disease (IHD) incidence estimates. The program audit was updated in 2020. Results: CR was available in 6/11 (54.5%) SEAR countries. Data were collected in 5 countries (83.3% country response); 32/69 (68.1% response rate from 2016/2017) programs completed the survey. These data were compared to 1082 (32.1%) programs in 93/111 (83.3%) countries with CR. Across SEAR countries, there was only one CR spot per 283 IHD patients (vs. 12 globally), with an unmet regional need of 4,258,968 spots annually. Most programs were in tertiary care centers (n = 25, 78.1%; vs. 46.1% globally, P < 0.001). Most were funded privately (n = 17, 56.7%; vs. 17.9%, P < 0.001), and 22 (73.3%) patients were paying out of pocket (vs. 36.2% globally; P < 0.001). The mean number of staff on the multidisciplinary teams was 5.5 ± 3.0 (vs. 5.9 ± 2.8 globally P = 0.268), offering 8.6 ± 1.7/11 core components (consistent with other countries) over 16.8 ± 12.6 h (vs. 36.2 ± 53.3 globally, P = 0.01). Conclusion: Funded CR capacity must be augmented in SEAR. Where available, services were consistent with guidelines, and other regions of the globe, despite programs being shorter than other regions

Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation

Background: Women are less likely than men to use cardiac rehabilitation (CR); thus, women-focused (W-F) CR was developed. Implementation of W-F CR globally was investigated, as well as barriers and enablers to its delivery. Methods: In this cross-sectional study, a survey was administered to CR programs via Research Electronic Data Capture (REDCap) from May to July, 2023. Potential respondents were identified via the International Council of Cardiovascular Prevention and Rehabilitation’s network. Results: A total of 223 responses were received from 52 of 111 countries (46.8% country response rate) in the world that have any CR, across all 6 World Health Organization regions. Thirty-three programs (14.8%) from 30 countries reported offering any W-F programming. Programs commonly did offer elements preferred by women and recommended, namely, the following: patient choice of session time (n = 151; 70.6%); invitations for informal care providers and/or partners to attend sessions (n = 121; 57.1%); CR staff that have expertise in women and heart diseases (n = 112; 53.3%); separate changerooms for women (n = 38; 52.8%); and discussion of CR referral with patients (n = 112; 52.1%). Main barriers to delivery of W-F exercise were physical resources (n = 33; 14.8%), space (n = 30; 13.5%), and staff time (n = 26; 11.7%) and expertise (n = 33; 10.3%). Main barriers to delivery of W-F education were human resources (n = 114; 51.1%), educational resources (n = 26; 11.7%), and expertise in the content (n = 74; 33.2%). Enablers of W-F education delivery were availability of materials, in multiple modalities, as well as educated staff and financial resources. Conclusions: Despite the benefits, W-F CR is not commonly offered globally. Considering the barriers and enablers identified, the International Council of Cardiovascular Prevention and Rehabilitation is developing resources to expand delivery. Résumé: Contexte: Les femmes étant moins susceptibles que les hommes d’avoir recours à la réadaptation cardiaque (RC), il convient d’élaborer des programmes de RC qui sont mieux adaptés à leurs besoins. Le recours à de tels programmes dans le monde a fait l’objet d’une étude, laquelle portait également sur les obstacles à leur prestation et les facteurs qui les favorisent. Méthodologie: Dans cette étude transversale, un sondage a été mené auprès de programmes de RC via la REDCap (Research Electronic Data Capture) de mai à juillet 2023. Les participants potentiels au sondage ont été sélectionnés par le réseau de l’International Council of Cardiovascular Prevention and Rehabilitation. Résultats: Au total, 223 réponses ont été reçues de 52 pays sur 111 qui ont un programme de RC (taux de réponse des pays de 46,8 %), dans les 6 régions de l’Organisation mondiale de la Santé. Selon les résultats, trente-trois programmes (14,8 %) de 30 pays offrent des services axés sur les femmes. Les programmes offraient habituellement des éléments privilégiés par les femmes et recommandaient notamment des séances au moment choisi par les patientes (n = 151; 70,6 %); la possibilité de se faire accompagner par un aidant naturel et/ou un(e) partenaire (n = 121; 57,1 %); du personnel de RC possédant une expertise auprès des femmes et en matière de maladies cardiaques (n = 112; 53,3 %); des vestiaires réservés aux femmes (n = 38; 52,8 %); et une discussion avec les patientes sur leur orientation vers des spécialistes en RC (n = 112; 52,1 %). Les principaux obstacles à la prestation de services pour les femmes étaient les ressources physiques (n = 33; 14,8 %), l’espace (n = 30; 13,5 %) ainsi que la disponibilité du personnel (n = 26; 11,7 %) et son expertise (n = 33; 10,3 %). Les principaux obstacles à l’éducation destinée aux femmes étaient les ressources humaines (n = 114; 51,1 %), les ressources éducatives (n = 26; 11,7 %) et l’expertise liée au contenu (n = 74; 33,2 %). Les facteurs qui favorisent l’éducation destinée aux femmes étaient la disponibilité du matériel, sous plusieurs formes, de même que le personnel formé et les ressources financières. Conclusions: En dépit des bienfaits, la RC axée sur les femmes n’est pas couramment offerte dans le monde. En tenant compte des obstacles et des facteurs favorisant la prestation des services cités, l’International Council of Cardiovascular Prevention and Rehabilitation s’affaire à concevoir des ressources pour élargir la portée des programmes destinés aux femmes

Nature of cardiac rehabilitation around the globe

Abstract Background: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. Methods: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. Findings: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p &lt; 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ± 1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p &lt; 0.01). All regions met ≥ 16/20 quality indicators, but quality was &lt; 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). Interpretation: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes

Cardiac rehabilitation availability and density around the globe

Abstract Background: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. Methods: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. Findings: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p &lt; 0.001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = 0.92, 95%CI = 0.91–0.93) or public (OR = 0.83, 95%CI = 0.82–0.84) funding compared to hybrid sources. Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25–Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. Interpretation: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation