A Review of Cardiac Rehabilitation Delivery Around the World.

Herein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases. Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.non

Burden, screening, and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: a prospective study

Background Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality among women. Women with CVD experience a greater burden of psychosocial distress than men, and practice guidelines promote screening in cardiac patients, especially women. The objectives herein were to describe the burden of psychosocial distress, extent of screening, forms of treatment, and whether receipt of treatment was related to psychosocial distress symptom severity at follow-up, among women. Methods Within a multi-center trial of women randomized to cardiac rehabilitation models, consenting participants were asked to complete surveys upon consent and 6 months later. Clinical data were extracted from charts. This study presents a secondary analysis of the surveys, including investigator-generated items assessing screening and treatment, the Beck Depression Inventory-II, the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-2. Results Of the 128 (67.0%) participants with valid baseline and follow-up survey results, 48 (40.3%) self-reported that they recalled being screened, and of these, 10 (21.3%) recalled discussing the results with a health care professional. Fifty-six (43.8%) retained participants had elevated symptoms of psychosocial distress at baseline, of which 25 (44.6%) were receiving treatment. Regression analyses showed that treatment of psychosocial distress was not significantly associated with follow-up depressive symptoms, but was significantly associated with greater follow-up anxiety. Conclusions Findings reiterate the great burden of psychosocial distress among women with CVD. Less than half of patients with elevated symptoms were treated, and the treatment approaches appeared to insufficiently achieve symptom relief.This research was funded by the Heart and Stroke Foundation of Ontario (HSFO), Grant-in-Aid #NA 6682

Cardiac Rehabilitation Models around the Globe.

Alternative models of cardiac rehabilitation (CR) delivery, such as home or community-based programs, have been developed to overcome underutilization. However, their availability and characteristics have never been assessed globally. In this cross-sectional study, a piloted survey was administered online to CR programs globally. CR was available in 111/203 (54.7%) countries globally; data were collected in 93 (83.8% country response rate). 1082 surveys (32.1% program response rate) were initiated. Globally, 85 (76.6%) countries with CR offered supervised programs, and 51 (45.9%; or 25.1% of all countries) offered some alternative model. Thirty-eight (34.2%) countries with CR offered home-based programs, with 106 (63.9%) programs offering some form of electronic CR (eCR). Twenty-five (22.5%) countries with CR offered community-based programs. Where available, programs served a mean of 21.4% ± 22.8% of their patients in home-based programs. The median dose for home-based CR was 3 sessions (Q25-Q75 = 1.0⁻4.0) and for community-based programs was 20 (Q25⁻Q75 = 9.6⁻36.0). Seventy-eight (47.0%) respondents did not perceive they had sufficient capacity to meet demand in their home-based program, for reasons including funding and insufficient staff. Where alternative CR models are offered, capacity is insufficient half the time. Home-based CR dose is insufficient to achieve health benefits. Allocation to program model should be evidence-based

Qualitative study measuring the usability of the International Cardiac Rehabilitation Registry

OBJECTIVE: Cardiac rehabilitation (CR) is a comprehensive model of secondary preventive care. There is a wide variety in implementation characteristics globally, and hence quality control is paramount. Thus, the International Council of Cardiovascular Prevention and Rehabilitation was urged to develop a CR registry. The purpose of this study was to test the perceived usability of the International Cardiac Rehabilitation Registry (ICRR) to optimise it. DESIGN: This was a qualitative study, comprising virtual usability tests using a think-aloud method to elicit feedback on the ICRR, while end-users were entering patient data, followed by semistructured interviews. SETTING: Ultimately, 12 tests were conducted with CR staff (67% female) in low-resource settings from a variety of disciplines in all regions of the world but Europe before saturation was achieved. PRIMARY OUTCOME MEASURE: Participants completed the System Usability Scale. Interviews were transcribed verbatim except to preserve anonymity, and coded using NVIVO by two researchers independently. The Unified Theory of Acceptance and Use of Technology 2 informed analysis. RESULTS: The ICRR was established as easy to use, relevant, efficient, with easy learnability, operability, perceived usefulness, positive perceptions of output quality and high end-user satisfaction. System usability was 83.75, or 'excellent' and rated 'A'. Four major themes were deduced from the interviews: (1) ease of approvals, adoption and implementation; (2) benefits for programmes, (3) variables and their definitions, as well as (4) patient report and follow-up assessment. Based on participant observation and utterances, suggestions for changes to the ICRR were implemented, including to the programme survey, on-boarding processes, navigational instructions, inclusion of programme logos, direction on handling unavailable data and optimising data completeness, as well as policies for authorship and programme certification. CONCLUSIONS: With usability of the ICRR optimised, pilot testing shall ensue

Evaluation of Qatar’s first cardiac rehabilitation program: A brief report

Background: There are few studies on the impact of cardiac rehabilitation (CR) in the Eastern Mediterranean Region (EMR), where the burden of risk factors and context is somewhat different from Western countries where much of the evidence is derived. Objective: To evaluate patient engagement in, and outcomes associated with, participation in Qatar’s first and only CR program, from inception. Methods: This was a retrospective, observational study of patients referred to Heart Hospital’s CR program from January 2013-September, 2018. The program offered 3 sessions/week over 6–12 weeks, depending on patient risk. An initial assessment was performed, and outcomes (i.e., functional capacity, risk factors, and psychosocial well-being (quality of life [SF-36] and depressive symptoms) were re-assessed post-program in those who did not drop-out. Session attendance was recorded. Results: 682 patients enrolled; they attended 77.6% of prescribed sessions; 554 (81.2%) completed the program and post-assessment. Improvements in functional capacity were statistically and clinically meaningful (METs 9.3 ± 3.3 pre and 11.1 ± 3.7 post; p < 0.001). There were significant improvements in body mass index (28.7 ± 5.2 kg/m2 pre and 28.2 ± 5.4 post; p < 0.001), waist circumference (102.8 ± 13.0 cm pre and 101.8 ± 13.2 post; p < 0.001), low-density lipoprotein (LDL 1.9 ± 0.9 mmol/L pre and 1.6 ± 0.8 post; p = < 0.001), total cholesterol (3.6 ± 1.1 mmol/L pre and 3.3 ± 0.8 post; p < 0.001), systolic blood pressure (SBP 128.5 ± 17.7 mmHg pre and 123.7 ± 14.8 post; p < 0.001), hemoglobin A1c (6.8 ± 1.6% pre and 6.5 ± 1.3 post; p < 0.001) and depressive symptoms (Cardiac Depression Scale score 78.3 ± 23.9 pre and 66.3 ± 21.3 post; p < 0.001). Improvements on 7 of the 8 quality of life domains were also observed (all p < .05; e.g., physical functioning 68.2 ± 24.0 pre and 74.9 ± 24.4 post). Conclusion: The new Qatari CR program is very engaging to patients, and resulted in clinically significant risk factors (LDL, SBP, and cholesterol) as well as functional capacity and health-related quality of life improvements, which likely translate to reduced morbidity and mortality.This research was funded by Qatar University

Funding sources and costs to deliver cardiac rehabilitation around the globe: Drivers and barriers

Background: Cardiac rehabilitation (CR) reach is minimal globally, primarily due to financial factors. This study characterized CR funding sources, cost to patients to participate, cost to programs to serve patients, and the drivers of these costs. Methods: In this cross-sectional study, an online survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Costs in each country were reported using purchasing power parity (PPP). Results were compared by World Bank country income classification using generalized linear mixed models. Results: 111/203 (54.68%) countries in the world offer CR, of which data were collected in 93 (83.78% country response rate; N = 1082 surveys, 32.0% program response rate). CR was most-often publicly funded (more in high-income countries [HICs]; p < .001), but in 60.20% of countries patients paid some or all of the cost. Funding source impacted capacity (p = .004), number of patients per exercise session (p < .001), personnel (p = .037), and functional capacity testing (p = .039). The median cost to serve 1 patient was $945.91PPP globally. In low and middle-income countries (LMICs), exercise equipment and stress testing were perceived as the most expensive delivery elements, with front-line personnel costs perceived as costlier in HICs (p = .003). Modifiable factors associated with higher costs included CR team composition (p = .001), stress testing (p = .002) and telemetry monitoring in HICs (p = .01), and not offering alternative models in LMICs (p = .02). Conclusions: Too many patients are paying out-of-pocket for CR, and more public funding is needed. Lower-cost delivery approaches are imperative, and include walk tests, task-shifting, and intensity monitoring via perceived exertion

Рец. на кн.: Книга памяти профессора Е. П. Прохорова: Научные статьи. Воспоминания / отв. ред. И. Е. Прохорова. - Москва: Издательство Московского университета, 2013. - 320 с.

The Eastern Mediterranean region (EMR) comprises 22 countries or territories spanning from Morocco in the west to Pakistan in the east, and contains a population of almost 600 million people. Like many other developing regions, the burden of disease in the EMR has shifted in the past 30 years from primarily communicable diseases to noncommunicable diseases such as cardiovascular disease (CVD). Cardiovascular mortality in the EMR, mostly attributable to ischaemic heart disease, is expected to increase more dramatically in the next decade than in any other region except Africa. The most prominent CVD risk factors in this region include tobacco consumption, physical inactivity, depression, obesity, hypertension, and diabetes mellitus. Many individuals living in the EMR are unaware of their risk factor status, and even if treated, these risk factors are often poorly controlled. Furthermore, infrequent use of emergency medical services, delays in access to care, and lack of access to cardiac catheterization affects the timely diagnosis of CVD. Treatment of CVD is also suboptimal in this region, consisting primarily of thrombolysis, with insufficient provision of timely revascularization. In this Review, we summarize what is known about CVD burden, risk factors, and treatment strategies for individuals living in the EMR. This information will hopefully aid decision-makers when devising strategies on how to improve CVD prevention and management in this region.S.L.G. is supported in her work by the Toronto General & Toronto Western Hospital Foundation and the Peter Munk Cardiac Centre, University Health Network

The impact of ICCPR's Global Audit of Cardiac Rehabilitation: where are we now and where do we need to go?

Despite the global epidemic of cardiovascular disease and the well-established mitigating benefits of cardiovascular rehabilitation (CR), availability is known to be grossly insufficient, and little was known about the nature of services delivered in resource-poor settings where it is needed most. Indeed, this had not been quantified before the International Council of Cardiovascular Prevention and Rehabilitation's (ICCPR) 2017 Global Audit, published in volume 13 of eClinicalMedicine.1,2 This commentary will: (1) summarize the key findings of the Global Audit, (2) actions taken to address identified issues, (3) what is known about current CR availability and the nature of delivered services globally, and finally (4) consider open questions and future directions to achieve change. There were two main parts to the Audit. First, ICCPR's many members Associations (i.e., 43) and friends (https://globalcardiacrehab.com/Members) confirmed any program availability in every country globally (including number of programs in the country, where applicable). Second, they facilitated administration of an online survey to identified CR programs. This assessed program capacity and quality of services.There was no funding for this commentary. We have not been paid to write this article by a pharmaceutical company or other agency.Scopu

Developing a Complex Understanding of Physical Activity in Cardiometabolic Disease from Low-to-Middle-Income Countries—A Qualitative Systematic Review with Meta-Synthesis

Physical activity behaviour is complex, particularly in low-resource settings, while existing behavioural models of physical activity behaviour are often linear and deterministic. The objective of this review was to (i) synthesise the wide scope of factors that affect physical activity and thereby (ii) underpin the complexity of physical activity in low-resource settings through a qualitative meta-synthesis of studies conducted among patients with cardiometabolic disease living in low-to-middle income countries (LMIC). A total of 41 studies were included from 1200 unique citations (up to 15 March 2021). Using a hybrid form of content analysis, unique factors (n = 208) that inform physical activity were identified, and, through qualitative meta-synthesis, these codes were aggregated into categories (n = 61) and synthesised findings (n = 26). An additional five findings were added through deliberation within the review team. Collectively, the 31 synthesised findings highlight the complexity of physical activity behaviour, and the connectedness between person, social context, healthcare system, and built and natural environment. Existing behavioural and ecological models are inadequate in fully understanding physical activity participation in patients with cardiometabolic disease living in LMIC. Future research, building on complexity science and systems thinking, is needed to identify key mechanisms of action applicable to the local context

Developing a Complex Understanding of Physical Activity in Cardiometabolic Disease from Low-to-Middle-Income Countries—A Qualitative Systematic Review with Meta-Synthesis

From MDPI via Jisc Publications RouterHistory: accepted 2021-11-06, pub-electronic 2021-11-15Publication status: PublishedPhysical activity behaviour is complex, particularly in low-resource settings, while existing behavioural models of physical activity behaviour are often linear and deterministic. The objective of this review was to (i) synthesise the wide scope of factors that affect physical activity and thereby (ii) underpin the complexity of physical activity in low-resource settings through a qualitative meta-synthesis of studies conducted among patients with cardiometabolic disease living in low-to-middle income countries (LMIC). A total of 41 studies were included from 1200 unique citations (up to 15 March 2021). Using a hybrid form of content analysis, unique factors (n = 208) that inform physical activity were identified, and, through qualitative meta-synthesis, these codes were aggregated into categories (n = 61) and synthesised findings (n = 26). An additional five findings were added through deliberation within the review team. Collectively, the 31 synthesised findings highlight the complexity of physical activity behaviour, and the connectedness between person, social context, healthcare system, and built and natural environment. Existing behavioural and ecological models are inadequate in fully understanding physical activity participation in patients with cardiometabolic disease living in LMIC. Future research, building on complexity science and systems thinking, is needed to identify key mechanisms of action applicable to the local context