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Abstract

Background Despite the clinical benefits of cardiac rehabilitation (CR) and its cost-effectiveness, it is not widely received. Arguably, capacity could be greatly increased if lower-cost models were implemented. The aims of this review were to describe: the costs associated with CR delivery, approaches to reduce these costs, and associated implications. Methods Upon finalizing the PICO statement, information scientists were enlisted to develop the search strategy of MEDLINE, Embase, CDSR, Google Scholar and Scopus. Citations identified were considered for inclusion by the first author. Extracted cost data were summarized in tabular format and qualitatively synthesized. Results There is wide variability in the cost of CR delivery around the world, and patients pay out-of-pocket for some or all of services in 55% of countries. Supervised CR costs in high-income countries ranged from PPP$294 (Purchasing Power Parity; 2016 United States Dollars) in the United Kingdom to PPP$12,409 in Italy, and in middle-income countries ranged from PPP$146 in Venezuela to PPP$1095 in Brazil. Costs relate to facilities, personnel, and session dose. Delivering CR using information and communication technology (mean cost PPP$753/patient/program), lowering the dose and using lower-cost personnel and equipment are important strategies to consider in containing costs, however few explicitly low-cost models are available in the literature. Conclusion More research is needed regarding the costs to deliver CR in community settings, the cost-effectiveness of CR in most countries, and the economic impact of return-to-work with CR participation. A low-cost model of CR should be standardized and tested for efficacy across multiple healthcare systems.

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... In only 14 (12.6%) of the 111 countries known to offer CR globally [31] are the costs to run a program per patient known, at a median of $884 USD (2016 PPP) in high-income countries (HICs) [32]. Where assessed, delivery costs were generally higher in private versus public healthcare systems. ...
... Moreover CR results in less healthcare utilization and more return-to-work, which further economically benefits society, adding further value to the low delivery cost. The only other available data on overall program costs [32] stem from the HICs of Canada ($884 2016USDPPP) [25] and Australia ($1312 2016USDPPP) [24]. In the former, while human resource and equipment costs were high, space figured more prominently, as it did in the Australian study (although they considered some unit costs not assessed herein such as "administration" and "technology" which should be considered in future research). ...
... In the former, while human resource and equipment costs were high, space figured more prominently, as it did in the Australian study (although they considered some unit costs not assessed herein such as "administration" and "technology" which should be considered in future research). The available literature on CR personnel costs specifically is reviewed elsewhere [32]. Given the multi-component nature of CR, and hence the multiple disciplines required to deliver it comprehensively, personnel costs are understandably quite high. ...
... The clinical benefits and cost-effectiveness of health services such as CR can be optimized where it is evidence-based, timely, patient-centered, equitable and otherwise of high-quality [8]. It is well-established that there is often a wide gap between clinical practice guideline recommendations and care, and this is also true for CVD secondary prevention [9], despite the relatively low cost of recommended therapies [10,11]. Registries serve as key means to understand and improve care [12]. ...
... Change in systolic blood pressure from pre-to post-program. 10 Change in mean quality of life score from pre-to postprogram. * Not compared to other sites, as number prescribed varies by program; only compared to own program first 6 months in ICRR versus after 6 months. ...
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Introduction: The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) is developing a registry (ICRR) specifically for low-resource settings, where the burden of cardiovascular diseases is greatest and the need for program development highest. Herein we describe the development process, including the variable selection process. Method: Following a literature search on registry best practices, a stepwise model for ICRR development was identified. Then, based on recommendations by Core Outcome Set STAndards for Development (COS-STAD), we underwent a process to identify variables. All available CR registries were contacted to request their data dictionaries, reviewed CR quality indicators and guideline recommendations, and searched for common data elements and core outcome sets; 35 unique variables (including patient-reported outcomes) were selected for potential inclusion. Twenty-one purposively-identified stakeholders and experts agreed to serve on a Delphi panel. Panelists rated the variables in an online survey, and suggested potential additional variables; A webcall was held to reach consensus on which to include/exclude. Next, panelists provided input to finalize each variable definition, and rated which associated indicators should be used for benchmarking in registry dashboards and a patient lay summary; a second consensus call was held. A 1-month public comment period ensued. Results: First, registry objectives and governance were approved by ICCPR, including data quality and access policies. The protocol was developed, for public posting. For variable selection, the overall mean rating was 6.1 ± 0.3/7; 12 were excluded, some of which were moved to a program survey, and others were revised. Two variables were added in an annual follow-up, resulting in 13 program and 16 patient-reported variables. Legal advice was sought to finalize ICRR agreements. Ethics approvals were obtained. Usability testing is now being initiated. Conclusion: It is hoped this will serve to harmonize CR assessment internationally and enable quality improvement in CR delivery in low-resource settings.
... CR programs in the state generally offer structured exercise only (not comprehensive programs delivering all core components), delivered primarily by physiotherapists and physicians, 2 or 3 times per week and median duration of 15 weeks (Q25-75 = 12-16) [22]. There is no cost for patients to enroll in public CR services; for privately-funded programs, the cost varies between the equivalent of $100-300 USD per month [28], depending on whether the program is delivered in a group or individually. ...
... We need more programs before we can promote and automate CR referral by physicians [35]. CR programs themselves should be comprehensive, but simplified [35], low-cost [28] models have been forwarded, which should exploit unsupervised delivery modalities (e.g., smartphones) [36]. Finally, evidence-based strategies that motivate the participation and adherence of patients such as counseling by clinicians should be applied [37]. ...
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Background: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its' worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting. Methods: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.
... Note: Due to missing data, percentages are computed where the denominator is the number of valid responses from responding programs. study, as well as others [9,28]. Affordable models of CR delivery should be implemented given the need in low and middle-income countries [27,29]. ...
... Information and communications technology should be exploited to increase the number of patients each program can treat, while maintaining program quality and safety [30]. It is essential for CR associations and other international societies to advocate for CR implementation and reimbursement; advocacy tools are available from the ICCPR [28]. This association also offers a certification program for healthcare professionals, which could address the reported barrier of lack of human resources to deliver CR [31]. ...
Article
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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<.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=.92, 95%CI=.91–.93) or public (OR=.83, 95%CI=.82–84) 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.
... Note: Due to missing data, percentages are computed where the denominator is the number of valid responses from responding programs. study, as well as others [9,28]. Affordable models of CR delivery should be implemented given the need in low and middle-income countries [27,29]. ...
... Information and communications technology should be exploited to increase the number of patients each program can treat, while maintaining program quality and safety [30]. It is essential for CR associations and other international societies to advocate for CR implementation and reimbursement; advocacy tools are available from the ICCPR [28]. This association also offers a certification program for healthcare professionals, which could address the reported barrier of lack of human resources to deliver CR [31]. ...
Article
Full-text available
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 b .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 = .92, 95%CI =.91–.93) or public (OR = .83, 95%CI = .82–84) 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
... CBCR referral is a health care quality performance metric [5,6], yet for three decades, only 10% to 20% of eligible women have attended CBCR, with up to a 56% dropout rate [7][8][9][10][11][12][13][14][15][16][17][18]. CBCR underutilization stems from numerous intrapersonal, interpersonal, logistical, programmatic, and health system barriers [19,20]. Inadequate health insurance and copayments of up to US $250 per session deter women from CBCR participation [21]. ...
... CBCR-eligible patients given the choice between HBCR and CBCR are up to four times more likely to participate in HBCR [40][41][42]. Compared with CBCR, HBCR overcomes logistical barriers to access, the need for expensive facilities, specialized exercise equipment, and high personnel costs and provides education, coaching, and monitoring by a health coach through, when available, wearable sensors and smartphones that are potentially operational 24 hours a day, 7 days a week [20,43]. Moreover, HBCR assesses daily PA, whereas CBCR only measures supervised exercise sessions [44]. ...
Article
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Background: Coronary heart disease (CHD) is the leading cause of death and disability among American women. The prevalence of CHD is expected to increase by more than 40% by 2035. In 2015, the estimated cost of caring for patients with CHD was US $182 billion in the United States; hospitalizations accounted for more than half of the costs. Compared with men, women with CHD or those who have undergone coronary revascularization have up to 30% more rehospitalizations within 30 days and up to 1 year. Center-based cardiac rehabilitation is the gold standard of care after an acute coronary event, but few women attend these valuable programs. Effective home-based interventions for improving cardiovascular health among women with CHD are vital for addressing this gap in care. Objective: The ubiquity of mobile phones has made mobile health (mHealth) behavioral interventions a viable option to improve healthy behaviors of both women and men with CHD. First, this study aimed to examine the usability of a prototypic mHealth intervention designed specifically for women with CHD (herein referred to as HerBeat). Second, we examined the influence of HerBeat on selected health behaviors (self-efficacy for diet, exercise, and managing chronic illness) and psychological (perceived stress and depressive symptoms) characteristics of the participants. Methods: Using a single-group, pretest, posttest design, 10 women participated in the 12-week usability study. Participants were provided a smartphone and a smartwatch on which the HerBeat app was installed. Using a Web portal dashboard, a health coach monitored participants' ecological momentary assessment data, their behavioral data, and their heart rate and step count. Participants then completed a 12-week follow-up assessment. Results: All 10 women (age: mean 64.4 years, SD 6.3 years) completed the study. The usability and acceptability of HerBeat were good, with a mean system usability score of 83.60 (SD 16.3). The participants demonstrated statistically significant improvements in waist circumference (P=.048), weight (P=.02), and BMI (P=.01). Furthermore, depressive symptoms, measured with the Patient Health Questionnaire-9, significantly improved from baseline (P=.04). Conclusions: The mHealth prototype was feasible and usable for women with CHD. Participants provided data that were useful for further development of HerBeat. The mHealth intervention is expected to help women with CHD self-manage their health behaviors . A randomized controlled trial is needed to further verify the findings.
... The clinical benefits and cost-effectiveness of health services such as CR can be optimized where it is evidence-based, timely, patient-centered, equitable and otherwise of high-quality [8]. It is well-established that there is often a wide gap between clinical practice guideline recommendations and care, and this is also true for CVD secondary prevention [9], despite the relatively low cost of recommended therapies [10,11]. Registries serve as key means to understand and improve care [12]. ...
... Change in systolic blood pressure from pre-to post-program. 10 Change in mean quality of life score from pre-to postprogram. * Not compared to other sites, as number prescribed varies by program; only compared to own program first 6 months in ICRR versus after 6 months. ...
... Em coronariopatas estáveis, a RCV é uma estratégia que, em termos de custo-efetividade, supera, com larga margem, procedimentos amplamente utilizados no país, tais como a intervenção coronariana percutânea (ICP). 46,47 Além disso, sua utilização em maior escala proporcionaria redução nos gastos com saúde, em decorrência da diminuição de novos eventos cardiovasculares, reinternações hospitalares e tratamentos intervencionistas. 48,49 Assim, sua disseminação deveria ser considerada uma estratégia de saúde pública prioritária. ...
... This study further supports the use of exercise-based secondary prevention programs in a broad range of patients with CVD [47]. Traditional interventions in patients with CVD consist primarily of supervised exercise sessions delivered in a hospital [51]. However, notable evidence indicates that these models are often neither financially viable nor sustainable [52,53]. ...
Article
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Background To assess the association between walking speed (WS) and its improvement on hospitalization rates and costs in outpatients with cardiovascular disease. Methods Six hundred forty-nine patients participating in an exercise-based secondary prevention program were studied. Patients were divided at baseline into two groups characterized by low and high WS based on the average WS maintained during a moderate 1-km treadmill-walking test. WS and other covariates were grouped into three domains (demographic factors, medical history and risk factors), and used to estimate a propensity score, in order to create homogeneous groups of patients. All-cause hospitalization was assessed 3 years after baseline as a function of WS. Hospitalization and related costs were also assessed during the fourth-to-sixth years after enrollment. To test whether the hospitalization costs were related to changes in WS after 36 months, a multistrata permutation test was performed by combining within strata partial tests. Results The results support the hypothesis that hospitalization costs are significantly reduced in accordance with an improvement in WS. This effect is most evident among older patients, overweight or obese, smokers, and those without a history of coronary artery bypass surgery. Conclusions The present study supports growing evidence of an inverse association between WS, risk of hospitalization and consequent health-care costs. The joint use of propensity score and multistrata permutation approaches represent a flexible and robust testing method which avoids the possible effects of several confounding factors typical of these studies.
... Although the health benefits of CR thus are obvious, there is still a wide cost variability of these programs in a worldwide perspective. The estimated Purchasing Power Parity (PPP), expressed in 2016 USD, varies from USD294 to USD12,409 in high-income countries, and from USD146 to USD1,095 in middle-income countries [4]. However, CR programs save healthcare resources by reducing unplanned re-hospitalization and some, such as home-based cardiac rehabilitation (HBCR), could potentially decrease the burden on cardiac departments considerably [5,6]. ...
Introduction: . Determining cost-utility differences between home-based cardiac rehabilitation (HBCR) on the one hand, and usual post-discharge care (UC) on the other, can improve resource-allocation in healthcare settings. Areas covered: . In June 2019, PubMed, Web of Science, Scopus and Cochrane library were searched for randomized controlled HBCR trials. Standardized mean differences (SMDs) of cost and quality-adjusted life years (QALYs) between HBCRs and UCs were calculated using random effect models. Heterogeneity was assessed by inconsistency index (I2) and publication bias by funnel plot and Egger's regression test. Thirteen articles, representing 2,992 participants, were deemed representative for final analysis. In the meta-analyses, a significant difference with respect to QALYs favored HBCR, while no significant cost difference was observed between HBCR and UC. However, subgroup-analyses of trials with different follow-up durations revealed somewhat different results, and HBCR was found to be significantly better with regard to both cost and QALYs for patients with heart failure. Cost-utility analysis categorizing interventions as 'dominant', 'effective', 'doubtful' and 'dominated', found HBCRs dominant. Expert opinion: . Although HBCR tended to be superior compared to UC in this review, larger and more robust trials addressing specific patients groups are needed for definitive results.
... In Australia, most CR programs are publicly funded [22]. A considerable proportion of the cost of CR is associated with the number of staff involved in the delivery of CR [40]. If programs only accept people with TIA and mild stroke, who have minimal deficits, it is unlikely that additional staff will be needed. ...
Article
Background: Cardiac rehabilitation (CR) may be an effective secondary prevention program for people with stroke or transient ischaemic attack (TIA). The aims of this study were to determine whether people with stroke or TIA were attending CR in Australia and if there were any barriers to attendance. Methods: An invitation to participate in an online survey was distributed between January and April 2018, via email, to 411 phase 2 CR coordinators located across Australia. These coordinators were identified through a publicly available directory. The survey contained questions on the demographics of CR programs and attendance of people with stroke or TIA. A Likert scale was used to investigate perceived barriers to CR for people with stroke or TIA. Descriptive statistics were completed for all survey responses except those from open text questions, which were analysed via an inductive qualitative approach. Results: In total, 149 CR coordinators responded who managed a total of 154 programs. The programs were primarily located in regional (40%) or metropolitan (31%) areas. Nearly 50% of programs were based in a public hospital-based gym/outpatient centre. Over 90% (n = 97/104) of coordinators reported that people with a primary diagnosis of stroke or TIA accounted for less than 2% of their patient population. Despite this, 52% of coordinators thought CR was an appropriate form of secondary prevention for people with stroke or TIA. The largest perceived barriers to attendance were safety (79%, n = 80/101), limited staff to patient ratio (76%, n = 77/101), integration difficulties (68%. n = 69/101) and a lack of referrals (66%, n = 67/101). Conclusion: Few people with a primary diagnosis of stroke or TIA attend CR in Australia, despite over half of CR coordinators believing that CR is appropriate for this group. Cardiac rehabilitation may be particularly suitable for people with mild-stroke or TIA. However, further research is required.
... As such, cardiac rehabilitation carries a strong potential to contribute positively to the occupational outcome. Some scarce evidence documents that patients who participate in cardiac rehabilitation are more likely to RTW than noncardiac rehabilitation participants [30]. In addition, recall of work-related information has been shown to be better among patients admitted to a rehabilitation facility (65%) compared to those who did not receive rehabilitation (p < .05) ...
Article
Cardiovascular disease is one of the main causes of morbidity and sick leave in Belgium, imposing a great socio-economic burden on the contemporary healthcare system and society. Cardiac rehabilitation is an evidence-based treatment strategy that not only improves the cardiac patients’ health state but also holds promise so as to facilitate vocational reintegration in the society. This position paper was developed and endorsed by the Belgian Working Group of Cardiovascular Prevention and Rehabilitation. It provides an overview of the currently available Belgian data with regard to the role of cardiac rehabilitation in return to work after an initial cardiac event. It identifies the relevant barriers and facilitators of vocational integration of cardiac patients and summarises the contemporary Belgian legal and medical framework in this regard. Cardiac rehabilitation remains a primordial component of the post-acute event management of the cardiac patient, facilitating vocational reintegrating and thereby decreasing the pressure on social security. Despite the availability of a relevant legislative framework, there is a need for well-defined algorithms to assess readiness for return to work that can be used in daily clinical practice.
... 30 Comparatively, the cost of CR delivery in high income countries ranges from US$294 in the UK to $US12,409 in Italy. 31 Beyond associated healthcare costs, reduced time in hospital is likely to be an important incentive for patients to attend CR and for their families to encourage such participation. From a societal perspective there would be less disability and loss of productivity. ...
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Background:: Ageing populations and increasing survival following acute coronary syndrome has resulted in large numbers of people living with cardiovascular disease and at high risk of hospitalizations. Rising hospital admissions have a significant financial cost to the healthcare system. Aim:: The purpose of this study was to determine whether cardiac rehabilitation is protective against long-term hospital readmission (frequency and length) following acute coronary syndrome. Methods:: Data from 416 Australian patients with acute coronary syndrome enrolled in the Anxiety Depression and heart rate Variability in cardiac patients: Evaluating the impact of Negative emotions on functioning after Twenty four months (ADVENT) prospective cohort study between January 2013-June 2014 was analyzed secondarily. Participants self-reported cardiac rehabilitation attendance over the 12 months post-discharge. All-cause readmission data were extracted from hospital records 24 months post-index event. The association between cardiac rehabilitation and all-cause readmission, frequency of readmissions, and length of stay was assessed using three methods (a) regression analysis, (b) propensity score matching, and (c) inverse probability treatment weighting. Results:: Overall, 416 patients consented (53% of eligible patients), of which 414 (99.5%) survived the first 30 days post-discharge and were included in the analysis. Medical records were located for 409 participants after 24 months (98% follow-up rate). In total, 267 (65%) reported attending cardiac rehabilitation; there were 392 readmissions by 239 patients. Cardiac rehabilitation attendance was not associated with all-cause hospital readmission; however, it was associated with lower frequency of hospital admissions (odds ratio 0.53, 95% confidence interval: 0.31-0.91 p-value:0.022) and length of stay (coefficient -1.21 days, 95% confidence interval: -2.46-0.26; marginally significant p-value: 0.055) in adjusted models. Conclusion:: This study substantiates the long-term benefits of cardiac rehabilitation on readmissions, including length of stay, which would result in lower costs to the healthcare system.
... These differences were explained principally by differences related to facilities, personnel involved, and session dose. 50 In the present economic evaluation, we did not include drug therapy in the cost determination because this is part of usual care. If drug therapy were to be included, the CR cost in the standard model could increase to almost $1500, making it comparable to programs in other countries. ...
Article
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Purpose: To assess the cost-effectiveness of 3 models of exercise-based cardiac rehabilitation (CR) compared with standard care in survivors of acute coronary syndrome (ACS) within the public health system in Chile. Methods: A Markov model was designed using 5 health states: ACS survivor, second ACS, complications, general mortality, and cardiovascular mortality. The transition probabilities between health states for standard care and corresponding relative risk for CR were calculated from a systematic review. Health benefits were measured with the EuroQol 5-dimensional 3-level (EQ-5D-3L) survey. Costs for each health state were quantified using the national cost verification study. The CR cost was estimated with a microcosting methodology. The time horizon was a lifetime and the discount rate was 3% per year for costs and benefits. Deterministic and probabilistic analyses were performed. Structural uncertainty was managed by designing 3 scenarios: CR as currently delivered in a specific Chilean public health center, CR as recommended by South American guidelines, and CR as proposed for low-resource settings. Results: Cardiac rehabilitation versus standard care showed an incremental cost-effectiveness ratio for the standard model of $722, for the South American model of $1247, and for the low-resource model of $666. The tornado diagram showed higher uncertainty in relative risk for the complications state and for the second ACS state. Conclusion: Considering a cost-effectiveness threshold of 1 unit of gross domestic product per capita (∼$19 000), CR is highly cost-effective for the public health system in Chile.
... Nevertheless, it is no wonder that patients of low socioeconomic status are underrepresented in CR programs and that utilization rates overall are suboptimal. [27][28][29][30][31] Strategies to mitigate these costs to patients include a national Pharmacare program, tele-health care, 32 and home-based CR. 33 Providing care to patients in their home contexts remotely may reduce costs to the health care system (although this is not the case for home-based CR, which is equivalent in cost to delivering traditional supervised CR), 34,35 and would discernibly reduce costs to patients as well. 34 Reviews demonstrate equivalent outcome improvement with home-and telehealth-based vs traditional supervised CR. [35][36][37][38] At present, there is not broad availability of care through these means. ...
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Background The objectives of this study were to describe: (1) healthcare utilization and associated patient time and out-of-pocket costs (OOP) over 2 years following a cardiac diagnosis, (2) the sociodemographic and clinical drivers of these costs, and (3) patient costs related to cardiac rehabilitation (CR) participation. Methods Secondary analysis was conducted on an observational, prospective CR program evaluation cohort in Ontario which has a publicly-funded healthcare system. A convenience sample of patients from one of 3 CR programs was approached at their first visit, and consenting participants completed a survey. Participants were emailed surveys again 6 months, 1 and 2 years later; these assessed their cardiac care and medications, and the time and OOP costs associated with care visits. Patient time was valued based on average wages in Ontario. Results Of 411 consenting patients, 240 (58.3%) completed CR, and 192 (46.7%) were retained at 2 years. Patients most often had visits to their general practitioner, electrocardiograms, and treatment for angina. The total cost to patients over 2 years was $73.70±275.84 for time and $377.01±321.72 for OOP costs ($525.93±467.08 overall). With adjustment, there were significantly higher OOP costs for females (p<.001), and less educated (p<.001) patients. Participants spent considerable money relatively OOP on CR visits alone ($384.78±269.67), with time costs at $379.07±1035.49 ($939.43±1333.29 overall; 1.6% share of 1 year’s income). Conclusions In conclusion, time and OOP costs are modest for cardiac patients, except for CR. Alternative delivery models are needed, in particular for low-income patients.
Article
Background: Home-based cardiac rehabilitations (CRs) with digital technologies have been researched and implemented to replace, augment, and complement traditional center-based CR in recent years with considerable success. One problem that technology-enhanced home-based CR can potentially address is the gap between cardiac interventions and formal CR programs. In the Netherlands and some other countries (eg, Australia), patients after cardiac interventions stay at home for 3-4 weeks without much support from their physicians, and often engage in very little physical activity (PA). A home-based exercise program enabled by digital technologies may help patients to better prepare for the later center-based CR programs, potentially increasing the uptake rate of those programs. Objective: In a randomized controlled trial (RCT), we will evaluate the effectiveness of a home-based walking exercise program enhanced by self-tracking and mobile-based coaching (treatment condition), comparing it with a version of the same program without these technologies (control condition). The added value of the digital technologies is justified if patients in the treatment group walk more steps on average (primary outcome) and show better physical fitness in a bicycle ergometer test and higher self-efficacy toward PA (secondary outcomes). Methods: Based on a power analysis, we will recruit 100 cardiac patients and assign them evenly to the 2 parallel groups. Eligible patients are those who are scheduled in the postanesthesia care unit, know the Dutch language, have basic literacy of using smartphones, and are without medical conditions that may increase risks associated with PA. In a face-to-face meeting with a nurse practitioner, all patients are prescribed a 3-week exercise program at home (2 walking exercises per day with increasing duration), based on national and international guidelines and tailored to their physical conditions after cardiac intervention. Their physical activities (daily steps) will be measured by the Axivity AX3 accelerometer worn at hip position. Patients in the treatment group will also be supported by a Neo Health One self-tracking device and a mobile platform called Heart Angel, through which they are monitored and coached by their nurses. After the study, all patients will perform a bicycle ergometer test and return the devices within 1 week. In addition, 5 questionnaires will be sent to the patients by emails to assess their self-efficacy toward PA and other psychological states for exploratory analyses (at discharge, at the end of each monitoring week, and 1 week after the study). To minimize bias, the randomization procedure will be performed after introducing the exercise program, so the nurse practitioners are blind to the experimental conditions until that point. Results: The study protocol has been approved by the Medical Research Ethics Committees United on February 26, 2018 (NL 62142.100.17/R17.51). By the end of 2018, we completed a small pilot study with 8 patients and the results based on interviews and app usage data suggest that a larger clinical trial with the targeted population is feasible. We expect to complete the RCT by the end of 2021, and statistical analyses will follow. Conclusions: Results of the RCT will help us to test the hypothesized benefits of self-tracking and mobile-based coaching for cardiac patients in home-based exercise programs during the discharge-rehabilitation gap. If the results are positive, cost-effectiveness analysis will be performed based on the insights of the study to inform the translation of the technology-enhanced program to clinical practice. We also note limitations of the trial in the discussion. Trial registration: Registered at Netherlands Trial Register NL8040; https://www.trialregister.nl/trial/8040. International registered report identifier (irrid): PRR1-10.2196/16737.
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Introduction: Cardiac rehabilitation (CR) programmes are well established, and their effectiveness and cost-effectiveness are proven. In spite of this, CR remains underused, especially in lower-resource settings such as Latin America. There is an urgent need to create more accessible CR delivery models to reach all patients in need. This trial aims to evaluate if the prevention of recurrent cardiovascular events is not inferior in a hybrid CR programme compared with a standard programme. Method and analysis: A non-inferiority, pragmatic, multicentre, parallel (1:1), prospective, randomised and open with blinded endpoint assessment clinical trial will be conducted. 308 patients with coronary artery disease will be recruited consecutively. Participants will be randomised to hybrid or standard rehabilitation programme. The hybrid CR programme includes 10 supervised exercise sessions and individualised lifestyle counselling by a physiotherapist, with a transition after 4-6 weeks to unsupervised delivery via text messages and phone calls. The standard CR consists of 18-22 supervised exercise sessions, as well as group education sessions about lifestyle. Intervention in both groups is between 8 and 12 weeks. The primary outcome is a composite of cardiovascular mortality and hospitalisations due to cardiovascular causes. Secondary outcomes are health-related quality of life, exercise capacity, muscle strength, heart-healthy behaviour, return-to-work, cardiovascular risk factor, adherence, and exercise-related adverse events. The outcomes will be measured at the end of intervention, at 6 months and at 12 months follow-up from recruitment. The primary outcome will be tracked through the end of the trial. Per-protocol and intention-to-treat analysis will be undertaken.Cox regression model will be used to compare primary outcome among study groups. Ethics and dissemination: Ethics committees at the sponsor institution and each centre where participants will be recruited approved the study protocol and the Informed Consent. Research findings will be published in peer-reviewed journals; additionally, results will be disseminated among region stakeholders. Trial registration number: NCT03881150; Pre-results. Date and version: 01 October 2019.
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Exercise-based cardiac rehabilitation (CR) plays a vital role in improving function and preventing mortality of cardiovascular disease (CVD) patients. Outpatient (Phase II and III) CR is almost nonexistent in India because of several reasons such as time, cost, distance, education level, scarcity of resources and so forth. Cardiologists or cardiac surgeons can directly advise patients and their family members to do an optimal dose of exercise in low-resource settings, that is, rural, low-income, or low-educated patients. Talk test is a no-cost, subjective tool for exercise prescription which is gaining popularity in CR because of its simplicity. This brief descriptive review covers history, administration, physiological mechanisms, reliability and validity, and safety among cardiac patients along with limitations of the ‘talk test’. This review also theoretically discusses how the talk test could be used in primary and secondary prevention of CVD. Finally, it advocates Indian CR team to use this simple validated tool as a self-monitoring tool of exercise intensity.
Article
Background Cardiac rehabilitation (CR) is a recommended model of care for cardiovascular diseases; however, is not widely available and is underutilized, especially in low- and middle-income countries. Objectives To identify the CR programs available in one Brazilian state (Minas Gerais; MG) and describe their characteristics by funding type. Methods In this multi-center descriptive study, CR programs were identified in four MG regions and 41 CR coordinators were sent a survey to report the characteristics of their programs, including CR components described in guidelines and barriers to patients’ participation. Descriptive and comparative analysis between public and private programs were carried out. Results Forty-one CR programs were identified, only 21.9% public. Nineteen completed the survey. The majority of CR programs offered initial assessment and physical training. Components of comprehensive CR programs that were rarely offered included treatment of tobacco dependence, psychological support and lipid control. Physical therapists were present in all CR programs. The six-minute walk test was used in most programs to assess functional capacity. Programs were located intra-hospital only in public hospitals. Phase 2 (initial outpatient) and phase 4 (maintenance) were offered significantly more in private programs when compared to public ones. The main barrier for CR participation was the lack of referral. Conclusions The availability of CR programs in MG state is low, especially public programs. Most programs do not offer all core components of CR.
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Background The objectives of this study were to describe: (1) healthcare utilization and associated patient time and out-of-pocket costs (OOP) over 2 years following a cardiac diagnosis, (2) the sociodemographic and clinical drivers of these costs, and (3) patient costs related to cardiac rehabilitation (CR) participation. Methods Secondary analysis was conducted on an observational, prospective CR program evaluation cohort in Ontario which has a publicly-funded healthcare system. A convenience sample of patients from one of 3 CR programs was approached at their first visit, and consenting participants completed a survey. Participants were emailed surveys again 6 months, 1 and 2 years later; these assessed their cardiac care and medications, and the time and OOP costs associated with care visits. Patient time was valued based on average wages in Ontario. Results Of 411 consenting patients, 240 (58.3%) completed CR, and 192 (46.7%) were retained at 2 years. Patients most often had visits to their general practitioner, electrocardiograms, and treatment for angina. The total cost to patients over 2 years was $73.70±275.84 for time and $377.01±321.72 for OOP costs ($525.93±467.08 overall). With adjustment, there were significantly higher OOP costs for females (p<.001), and less educated (p<.001) patients. Participants spent considerable money relatively OOP on CR visits alone ($384.78±269.67), with time costs at $379.07±1035.49 ($939.43±1333.29 overall; 1.6% share of 1 year’s income). Conclusions In conclusion, time and OOP costs are modest for cardiac patients, except for CR. Alternative delivery models are needed, in particular for low-income patients.
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Background: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention of ischemic heart disease. It is critically important in low- and middle-income countries (LMIC), where the burden of ischemic heart disease is substantial and growing. However, the availability and utilization of CR in LMIC is not systematically known. Objectives: This study sought to characterize the availability, use, and barriers to the use of CR. Methods: Electronic databases (Cochrane Library, EMBASE, PubMed, Web of Science) were searched from January 1, 1980 to May 31, 2013 for articles on CR in LMIC. Citations on availability, use, and/or barriers to CR were screened for inclusion by title, abstract, and full text. Data were summarized by region or country to determine the characteristics of CR in LMIC and gaps in the peer-reviewed biomedical publications. Results: Our search yielded a total of 5,805 citations, of which 34 satisfied full inclusion and exclusion criteria. The total number of CR programs available ranged from 1 in Algeria and Paraguay to 51 in Serbia. Referral rates for CR ranged from 5.0% in Mexico to 90.3% in Lithuania. Attendance rates ranged from 31.7% in Bulgaria to 95.6% in Lithuania, and CR attendance was correlated with higher educational background. The most commonly cited barrier to CR in LMIC was lack of physician referral. Conclusions: Our results illustrate that the published reports reflects heterogeneity of CR availability and use in LMIC. Overall, CR is insufficiently available and underutilized. Further characterization of CR in LMIC, especially in Asia and Africa, is necessary to develop targeted strategies to improve availability and utilization. Patient, physician, and systems factors must be addressed to overcome barriers to participation in CR in LMIC.
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Background National guidance for England recommends that cardiovascular disease (CVD) should be managed as a family of diseases in the community. Here, we describe the results of such an approach. Methods Patients with established CVD or who were at high multifactorial risk (HRI) underwent a 12-week community-based nurse-led prevention programme (MyAction) that included lifestyle and risk factor management, prescription of medication and weekly exercise and education sessions. Results Over a 6-year period, 3232 patients attended an initial assessment; 63% were male, and 48% belonged to black and minority ethnic groups. 56% attended an end-of-programme assessment, and 33% attended a one year assessment. By the end of the programme, there was a significant reduction in smoking prevalence but only in HRI (−3.7%, p<0.001). Mediterranean diet score increased in both CVD (+1.2, p<0.001) and HRI (+1.5; p<0.001), as did fitness levels (CVD +0.8 estimated Mets maximum, p<0.001, HRI +0.9 estimated Mets maximum, p<0.001) and the proportions achieving their physical activity targets (CVD +40%, p<0.001, HRI +37%, p<0.001). There were significant increases in proportions achieving their blood pressure (CVD +15.4%, p<0.001, HRI +25%, p<0.001 and low-density lipoprotein cholesterol targets (CVD +6%, p=0.004, HRI +23%, p<0.001). Statins and antihypertensive medications significantly increased in HRI. Significant improvements in depression scores and quality-of-life measures were also seen. The majority of improvements were maintained at 1 year. Conclusion These results demonstrate that an integrated vascular prevention programme is feasible in practice and reduces cardiovascular risk in patients with established CVD and in those at high multifactorial risk.
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Background Cardiac rehabilitation has beneficial effects on morbidity and mortality in patients with coronary artery disease, but is vastly underutilised and short-term improvements are often not sustained. Telerehabilitation has the potential to overcome these barriers, but its superiority has not been convincingly demonstrated yet. This may be due to insufficient focus on behavioural change and development of patients’ self-management skills. Moreover, potentially beneficial communication methods, such as internet and video consultation, are rarely used. We hypothesise that, when compared to centre-based cardiac rehabilitation, cardiac telerehabilitation using evidence-based behavioural change strategies, modern communication methods and on-demand coaching will result in improved self-management skills and sustainable behavioural change, which translates to higher physical activity levels in a cost-effective way. Methods This randomised controlled trial compares cardiac telerehabilitation with centre-based cardiac rehabilitation in patients with coronary artery disease. We randomise 300 patients entering cardiac rehabilitation to centre-based cardiac rehabilitation (control group) or cardiac telerehabilitation (intervention group). The core component of the intervention is a patient-centred web application, which enables patients to adjust rehabilitation goals, inspect training and physical activity data, share data with other caregivers and to use video consultation. After six supervised training sessions, the intervention group continues exercise training at home, wearing an accelerometer and heart rate monitor. In addition, physical activity levels are assessed by the accelerometer for four days per week. Patients upload training and physical activity data weekly and receive feedback through video consultation once a week. After completion of the rehabilitation programme, on-demand coaching is performed when training adherence or physical activity levels decline with 50% or more. The primary outcome measure is physical activity level, assessed at baseline, three months and twelve months, and is calculated from accelerometer and heart rate data. Secondary outcome measures include physical fitness, quality of life, anxiety and depression, patient empowerment, patient satisfaction and cost-effectiveness. DiscussionThis study is one of the first studies evaluating effects and costs of a cardiac telerehabilitation intervention comprising a combination of modern technology and evidence-based behavioural change strategies including relapse prevention. We hypothesise that this intervention has superior effects on exercise behaviour without exceeding the costs of a traditional centre-based intervention. Trial registrationNetherlands Trial Register NTR5156. Registered 22 April 2015.
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Background: Non-fatal outcomes of disease and injury increasingly detract from the ability of the world's population to live in full health, a trend largely attributable to an epidemiological transition in many countries from causes affecting children, to non-communicable diseases (NCDs) more common in adults. For the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015), we estimated the incidence, prevalence, and years lived with disability for diseases and injuries at the global, regional, and national scale over the period of 1990 to 2015. Methods: We estimated incidence and prevalence by age, sex, cause, year, and geography with a wide range of updated and standardised analytical procedures. Improvements from GBD 2013 included the addition of new data sources, updates to literature reviews for 85 causes, and the identification and inclusion of additional studies published up to November, 2015, to expand the database used for estimation of non-fatal outcomes to 60 900 unique data sources. Prevalence and incidence by cause and sequelae were determined with DisMod-MR 2.1, an improved version of the DisMod-MR Bayesian meta-regression tool first developed for GBD 2010 and GBD 2013. For some causes, we used alternative modelling strategies where the complexity of the disease was not suited to DisMod-MR 2.1 or where incidence and prevalence needed to be determined from other data. For GBD 2015 we created a summary indicator that combines measures of income per capita, educational attainment, and fertility (the Socio-demographic Index [SDI]) and used it to compare observed patterns of health loss to the expected pattern for countries or locations with similar SDI scores. Findings: We generated 9·3 billion estimates from the various combinations of prevalence, incidence, and YLDs for causes, sequelae, and impairments by age, sex, geography, and year. In 2015, two causes had acute incidences in excess of 1 billion: upper respiratory infections (17·2 billion, 95% uncertainty interval [UI] 15·4–19·2 billion) and diarrhoeal diseases (2·39 billion, 2·30–2·50 billion). Eight causes of chronic disease and injury each affected more than 10% of the world's population in 2015: permanent caries, tension-type headache, iron-deficiency anaemia, age-related and other hearing loss, migraine, genital herpes, refraction and accommodation disorders, and ascariasis. The impairment that affected the greatest number of people in 2015 was anaemia, with 2·36 billion (2·35–2·37 billion) individuals affected. The second and third leading impairments by number of individuals affected were hearing loss and vision loss, respectively. Between 2005 and 2015, there was little change in the leading causes of years lived with disability (YLDs) on a global basis. NCDs accounted for 18 of the leading 20 causes of age-standardised YLDs on a global scale. Where rates were decreasing, the rate of decrease for YLDs was slower than that of years of life lost (YLLs) for nearly every cause included in our analysis. For low SDI geographies, Group 1 causes typically accounted for 20–30% of total disability, largely attributable to nutritional deficiencies, malaria, neglected tropical diseases, HIV/AIDS, and tuberculosis. Lower back and neck pain was the leading global cause of disability in 2015 in most countries. The leading cause was sense organ disorders in 22 countries in Asia and Africa and one in central Latin America; diabetes in four countries in Oceania; HIV/AIDS in three southern sub-Saharan African countries; collective violence and legal intervention in two north African and Middle Eastern countries; iron-deficiency anaemia in Somalia and Venezuela; depression in Uganda; onchoceriasis in Liberia; and other neglected tropical diseases in the Democratic Republic of the Congo. Interpretation: Ageing of the world's population is increasing the number of people living with sequelae of diseases and injuries. Shifts in the epidemiological profile driven by socioeconomic change also contribute to the continued increase in years lived with disability (YLDs) as well as the rate of increase in YLDs. Despite limitations imposed by gaps in data availability and the variable quality of the data available, the standardised and comprehensive approach of the GBD study provides opportunities to examine broad trends, compare those trends between countries or subnational geographies, benchmark against locations at similar stages of development, and gauge the strength or weakness of the estimates available.
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Objective To update the Cochrane review comparing the effects of home-based and supervised centre-based cardiac rehabilitation (CR) on mortality and morbidity, quality of life, and modifiable cardiac risk factors in patients with heart disease. Methods Systematic review and meta-analysis. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and CINAHL were searched up to October 2014, without language restriction. Randomised trials comparing home-based and centre-based CR programmes in adults with myocardial infarction, angina, heart failure or who had undergone coronary revascularisation were included. Results 17 studies with 2172 patients were included. No difference was seen between home-based and centre-based CR in terms of: mortality (relative risk (RR) 0.79, 95% CI 0.43 to 1.47); cardiac events; exercise capacity (mean difference (MD) −0.10, −0.29 to 0.08); total cholesterol (MD 0.07 mmol/L, −0.24 to 0.11); low-density lipoprotein cholesterol (MD −0.06 mmol/L, −0.27 to 0.15); triglycerides (MD −0.16 mmol/L, −0.38 to 0.07); systolic blood pressure (MD 0.2 mm Hg, −3.4 to 3.8); smoking (RR 0.98, 0.79 to 1.21); health-related quality of life and healthcare costs. Lower high-density lipoprotein cholesterol (MD −0.07 mmol/L, −0.11 to −0.03, p=0.001) and lower diastolic blood pressure (MD −1.9 mm Hg, −0.8 to −3.0, p=0.009) were observed in centre-based participants. Home-based CR was associated with slightly higher adherence (RR 1.04, 95% CI 1.01 to 1.07). Conclusions Home-based and centre-based CR provide similar benefits in terms of clinical and health-related quality of life outcomes at equivalent cost for those with heart failure and following myocardial infarction and revascularisation.
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Background Cardiovascular diseases (CVD) are the leading cause of death globally. Cardiac rehabilitation (CR) is an evidence-based intervention recommended for patients with CVD, to prevent recurrent events and to improve quality of life. However, despite the proven benefits, only a small percentage of those would benefit from CR actually receive it worldwide.This paper by the International Council of Cardiovascular Prevention and Rehabilitation forwards the groundwork for successful CR advocacy to achieve broader reimbursement, and hence implementation. Methods First, the results of the International Council’s survey on national CR reimbursement policies by government and insurance companies are summarized. Second, a multi-faceted approach to CR advocacy is forwarded. Finally, as per the advocacy recommendations, the economic impact of CVD and the corresponding benefits of CR and its cost-effectiveness are summarized. This provides the case for CR reimbursement advocacy. ResultsThirty-one responses were received, from 25 different countries: 18 (58.1 %) were from high-income countries, 10 (32.4 %) from upper middle-income, and 3 (9.9 %) from lower middle-income countries. When asked who reimburses at least some portion of CR services in their country, 19 (61.3 %) reported the government, 17 (54.8 %) reported patients pay out-of-pocket, 16 (51.6 %) reported insurance companies, 12 (38.7 %) reported that it is shared between the patient and another source, and 7 (22.6 %) reported another source. Conclusions Many patients pay out-of-pocket for CR. CR reimbursement around the world is inconsistent and insufficient. Advocacy campaigns forwarding the CR cause, supported by the relevant literature, enlisting sources of support in a unified manner with an organized plan, are needed, and must be pursued persistently.
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Objective: The aim of this paper is to compare the state of Cardiac Rehabilitation Programs (CRP) in 2009 with 2015. We shall focus on assistance, training of health-providers, research and the implementation barriers. Methods: All authors of RENAPREC-2009, and other cardiac rehabilitation leaders in Mexico were requested to participate. These centers were distributed in two groups: RENAPREC-2009 centers that participated in 2015 and the new CRP units. Results: In 2009 there were 14 centers, two of them disappeared and another two did not respond. CRP-units increased 71% (n=24), and their geographic distribution shows a centripetal pattern. The coverage of CRP-units was 0.02 centers per 100,000 inhabitants. Only 4.4% of eligible patients were referred to CRP, with a rate of 10.4 patients/100,000 inhabitants in 2015. The ratio of Clinical Cardiologists to Cardiac Rehabilitation Specialists is 94:1, and the ratio of Intervention Specialists to cardiac rehabilitation experts is 16:1. Cardiac rehabilitation activities and costs varied widely. Patient's dropout rate in phase II was 12%. Several barriers were identified: financial crisis (83%), lack of skilled personnel (67%), deficient equipment (46%), inadequate areas (42%) and a reduced number of operating centers (38%). Conclusions: CRPs in Mexico are still in the process of maturing. Mexican CRP-centers have several strengths like the quality of the education of the professionals and multidisciplinary programs. However, the lack of reference of patients and the heterogeneity of procedures are still their main weaknesses.
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Objective Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries. Methods A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not. Results Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings. Conclusions Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.
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Although recommended in guidelines for the management of coronary heart disease (CHD), concerns have been raised about the applicability of evidence from existing meta-analyses of exercise-based cardiac rehabilitation (CR). The goal of this study is to update the Cochrane systematic review and meta-analysis of exercise-based CR for CHD. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Science Citation Index Expanded were searched to July 2014. Retrieved papers, systematic reviews, and trial registries were hand-searched. We included randomized controlled trials with at least 6 months of follow-up, comparing CR to no-exercise controls following myocardial infarction or revascularization, or with a diagnosis of angina pectoris or CHD defined by angiography. Two authors screened titles for inclusion, extracted data, and assessed risk of bias. Studies were pooled using random effects meta-analysis, and stratified analyses were undertaken to examine potential treatment effect modifiers. A total of 63 studies with 14,486 participants with median follow-up of 12 months were included. Overall, CR led to a reduction in cardiovascular mortality (relative risk: 0.74; 95% confidence interval: 0.64 to 0.86) and the risk of hospital admissions (relative risk: 0.82; 95% confidence interval: 0.70 to 0.96). There was no significant effect on total mortality, myocardial infarction, or revascularization. The majority of studies (14 of 20) showed higher levels of health-related quality of life in 1 or more domains following exercise-based CR compared with control subjects. This study confirms that exercise-based CR reduces cardiovascular mortality and provides important data showing reductions in hospital admissions and improvements in quality of life. These benefits appear to be consistent across patients and intervention types and were independent of study quality, setting, and publication date.
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Background: Despite the high burden of cardiovascular diseases in Arab countries, little is known about cardiac rehabilitation (CR) delivery. This study assessed availability, and CR program characteristics in the Arab World, compared to Canada. Methods: A questionnaire incorporating items from 4 national / regional published CR program surveys was created for this cross-sectional study. The survey was emailed to all Arab CR program contacts that were identified through published studies, conference abstracts, a snowball sampling strategy, and other key informants from the 22 Arab countries. An online survey link was also emailed to all contacts in the Canadian Association of Cardiovascular Prevention and Rehabilitation directory. Descriptive statistics were used to describe all closed-ended items in the survey. All open-ended responses were coded using an interpretive-descriptive approach. Results: Eight programs were identified in Arab countries, of which 5 (62.5 %) participated; 128 programs were identified in Canada, of which 39 (30.5 %) participated. There was consistency in core components delivered in Arab countries and Canada; however, Arab programs more often delivered women-only classes. Lack of human resources was perceived as the greatest barrier to CR provision in all settings, with space also a barrier in Arab settings, and financial resources in Canada. The median number of patients served per program was 300 for Canada vs. 200 for Arab countries. Conclusion: Availability of CR programs in Arab countries is incredibly limited, despite the fact that most responses stemmed from high-income countries. Where available, CR programs in Arab countries appear to be delivered in a manner consistent with Canada.
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Cardiovascular disease (CVD) is the most-prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low-income and middle-income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost-effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient's functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under-used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high-income and 23% of LMICs (8.3% for low-income and 28.2% for middle-income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.
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Background: Home-based exercise training in cardiac rehabilitation (CR) has the potential to improve CR uptake, decrease costs and increase self-management skills. The FIT@Home study evaluates home-based CR with telemonitoring guidance using coaching interventions including strategies for behavioural changes with the aim to maintain adherence to a healthy lifestyle and to improve long-term effects. In this interim analysis we provide short-term results on exercise capacity, quality of life and training adherence of the first 50 patients included in the FIT@Home study. Design: The study design was a randomised controlled trial. Methods: Low to moderate risk CR patients were randomised to a 12-week home-based training (HT) programme or a 12-week centre-based training (CT) programme. In both groups, training was performed at 70-85% of maximal heart rate (HRmax) for 45-60 min, 2-3 times per week. The HT group received three supervised training sessions, before commencing training with a heart rate monitor in their home environment. These patients received individual coaching by telephone weekly, based on training data uploaded on the Internet. The CT programme was performed under the direct supervision of a physical therapist. Exercise capacity and health-related quality of life were assessed at baseline and at 12 weeks. Results: CT (n = 25) and HT (n = 25) both showed a significant improvement in peak oxygen uptake (peak VO2) (10% and 14% respectively) and quality of life after 12 weeks of training, without significant between-group differences. The average training intensity of the HT group was 73.3 ± 3.5% of HRmax. Training adherence was similar between groups. Conclusion: This analysis shows that HT with telemonitoring guidance has similar short-term effects on exercise capacity and quality of life as CT in CR patients.
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The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.
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Background: Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). Methods: Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. Findings: Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350 000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. Conclusions: Rates of YLDs per 100 000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. Funding: Bill & Melinda Gates Foundation.
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Cardiac rehabilitation (CR), a multidisciplinary program consisting of exercise, risk factor modification and psychosocial intervention, forms an integral part of managing patients after myocardial infarction (MI), revascularization surgery and percutaneous coronary interventions, as well as patients with heart failure (HF). This systematic review seeks to examine the cost-effectiveness of CR for patients with MI or HF and inform policy makers in Singapore on published cost-effectiveness studies on CR. Electronic databases (EMBASE, MEDLINE, NHS EED, PEDro, CINAHL) were searched from inception to May 2010 for published economic studies. Additional references were identified through searching bibliographies of included studies. Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Quality assessment of economic evaluations was undertaken using Drummond's checklist. A total of 22 articles were selected for review. However five articles were further excluded because they were cost-minimization analyses, whilst one included patients with stroke. Of the final 16 articles, one article addressed both centre-based cardiac rehabilitation versus no rehabilitation, as well as home-based cardiac rehabilitation versus no rehabilitation. Therefore, nine studies compared cost-effectiveness between centre-based supervised CR and no CR; three studies examined that between centre- and home based CR; one between inpatient and outpatient CR; and four between home-based CR and no CR. These studies were characterized by differences in the study perspectives, economic study designs and time frames, as well as variability in clinical data and assumptions made on costs. Overall, the studies suggested that: (1) supervised centre-based CR was highly cost-effective and the dominant strategy when compared to no CR; (2) home-based CR was no different from centre-based CR; (3) no difference existed between inpatient and outpatient CR; and (4) home-based programs were generally cost-saving compared to no CR. Overall, all the studies supported the implementation of CR for MI and HF. However, comparison across studies highlighted wide variability of CR program design and delivery. Policy makers need to exercise caution when generalizing these findings to the Singapore context.
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Little is known about the relative cost-effectiveness of different secondary prevention cardiac rehabilitation (CR) program designs or how cost-effectiveness is influenced by patient clinical and demographic characteristics. The purpose of the study was (i) to evaluate the incremental cost-effectiveness of a standard 3-month CR program (SCR) versus a program distributed over 12 months (distributed CR, DCR); and (ii) to determine the effect of patient demographic characteristics (cardiac risk, cardiac diagnosis, sex) on incremental cost-effectiveness. A two group cost-effectiveness analysis was conducted alongside a randomized controlled trial. Patients with coronary artery disease (mean age=58 years, SD+/-10) were randomized to either SCR (n=196) or DCR (n=196) and followed for 24 months. Program delivery costs, cardiac healthcare use, morbidity, mortality, and quality-adjusted life years were assessed. Cost-effectiveness was evaluated with incremental cost-utility analysis. In the pooled analysis, we found the probability of SCR being more cost-effective than DCR was 63-67%. The subanalysis found SCR to be the more cost-effective intervention for patients at high risk, patients with previous coronary artery bypass graft and for male patients. The DCR program was more cost-effective for patients with lower risk of disease progression and for female patients. Differences were noted in the cost-effectiveness of CR models based on cardiac risk level, reason for referral, and demographic characteristics. Our results suggest improved cost-effectiveness may be gained by triaging patients to different CR intervention models, however, further investigation is required.
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As many as 70% of smokers with acute myocardial infarction (AMI) continue to smoke after hospital discharge despite high rates of inpatient smoking cessation counseling. Supportive contact after discharge improves quit rates but is rarely used. Using data from a meta-analysis of randomized trials of smoking cessation interventions and other published sources, we developed a Monte Carlo model to project health and economic outcomes for a hypothetical US cohort of 327,600 smokers hospitalized with AMI. We compared routine care, consisting of advice to quit smoking, with counseling with supportive follow-up, consisting of routine care and follow-up telephone calls from a nurse after discharge. Primary outcomes were number of smokers, AMIs, and deaths averted; health care and productivity costs; cost per quitter; and cost per quality-adjusted life-year. Implementation of smoking cessation counseling with follow-up contact for the 2010 cohort of hospitalized smokers would create 50,230 new quitters, cost $27.3 million in nurse wages and materials, and prevent 1380 nonfatal AMIs and 7860 deaths. During a 10-year period, it would save $22.1 million in reduced hospitalizations but increase health care costs by $166.4 million, primarily through increased longevity. Productivity costs from premature death would fall by $1.99 billion and nonmedical expenditures would increase by $928 million, for a net positive value to society of $894 million. The program would cost $540 per quitter considering only intervention costs. Cost-effectiveness would be $5050 per quality-adjusted life-year. Results were sensitive to the utility and incidence of nonfatal AMI and the potential effect of pharmacotherapies. Smoking cessation counseling with supportive contact after discharge is potentially cost-effective and may reduce the incidence of smoking and its associated adverse health events and social costs.
Article
Objectives: To examine the relationship between cardiac rehabilitation participation and health service expenditures in Ontario, Canada. Patients and methods: A total of 6284 patients referred to cardiac rehabilitation between April 1, 2003, and December 31, 2010, were linked to 6284 matched cardiac rehabilitation eligible nonreferred controls and followed over a 3-year period across multiple linked administrative databases to identify health service utilization expenditures and mortality. All patients had previous cardiac hospitalizations within the preceding year. Four cardiac rehabilitation eligible groups of patients were balanced using propensity score weights: (1) no referral; (2) no participation; (3) low participation levels (ie, attending <67% of prescheduled classes); and (4) high participation levels (ie, attending ?67% prescheduled classes). Each group of patients was balanced in age, sex, geography, socioeconomic status, previous hospitalizations, ambulatory care conditions, cardiovascular risk factors, comorbidities, and previous health care expenditures. Generalized linear models were used to examine differences in health service expenditures (from all sources including hospitalizations, physician visits, diagnostic tests, and drugs for those older than 65 years) per "eligible day alive" over the 3-year period. Results: Compared with the nonreferred population, health service expenditures followed a dose-response relationship and were lowest in patients who had the highest cardiac rehabilitation programmatic participation levels (P<.001). Cost differences across groups separated early, remained divergent, and applied to all components of health care expenditures (P<.001). Sensitivity analyses confirmed that the findings were not secondary to reverse causality. Conclusion: Participation in cardiac rehabilitation is associated with lower long-term health service utilization expenditures within a publicly funded health care system.
Article
Background While cardiac rehabilitation in patients with ischaemic heart disease and heart failure is considered cost-effective, this evidence may not be transferable to heart valve surgery patients. The aim of this study was to investigate the cost-effectiveness of cardiac rehabilitation following heart valve surgery. Design We conducted a cost-utility analysis based on a randomised controlled trial of 147 patients who had undergone heart valve surgery and were followed for 6 months. Methods Patients were randomised to cardiac rehabilitation consisting of 12 weeks of physical exercise training and monthly psycho-educational consultations or to usual care. Costs were measured from a societal perspective and quality-adjusted life years were based on the EuroQol five-dimensional questionnaire (EQ-5D). Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and effect differences were presented in a cost-effectiveness plane and were transformed into net benefit and presented in cost-effectiveness acceptability curves. Results No statistically significant differences were found in total societal costs (-1609 Euros; 95% CI: -6162 to 2942 Euros) or in quality-adjusted life years (-0.000; 95% CI -0.021 to 0.020) between groups. However, approximately 70% of the cost and effect differences were located below the x-axis in the cost-effectiveness plane, and the cost-effectiveness acceptability curves showed that the probability for cost- effectiveness of cardiac rehabilitation compared to usual care is at minimum 75%, driven by a tendency towards costs savings. Conclusions Cardiac rehabilitation after heart valve surgery may not have improved health-related quality of life in this study, but is likely to be cost-effective for society, outweighing the extra costs of cardiac rehabilitation.
Article
Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.
Article
Health care decision-making requires evidence of the cost-effectiveness of medical therapies. We evaluated the cost-effectiveness of exercise-based cardiac rehabilitation (ECR) implemented according to guidelines. All the patients (n = 204) had experienced a recent acute coronary syndrome and were randomized to a 1-year ECR (n = 109) or usual care (UC) group (n = 95). The patients’ health-related quality of life was followed using the 15D instrument and health care costs were collected from electronic health registries. The cost-effectiveness of ECR was estimated based on intervention and health care costs and quality-adjusted life years (QALYs) gained. The total average cost per patient was lower in ECR than in UC. The incremental cost was divided by the baseline-adjusted incremental QALYs (0.045), yielding an incremental cost-effectiveness ratio of −€24511/QALYs. A combined endpoint of mortality, recurrent coronary event, or hospitalization for a heart failure occurred for five patients in ECR and 16 patients in UC (HR 3.9, 95% CI 1.4–10.6, P = 0.004, relative risk reduction 73%, number needed to treat eight). ECR is a dominant treatment option and decreases the occurrence of adverse cardiac events. These results are useful for decision-making when planning optimal utilization of resources in Finnish health care.
Article
Cardiac rehabilitation (CR) is a proven model of secondary prevention. Indicated cardiac conditions for CR are well established, and participation of these patients results in significantly lower mortality and morbidity when compared with usual care. There are approximately 170 CR programs in Canada, which varies widely by province. There is a grossly insufficient capacity to treat all patients with cardiac indications in Canada and beyond. The density of CR services is about half that in the United States, at 1 program per 208,823 inhabitants or 1 program per 7779 patients with cardiac disease. Despite the Canadian Cardiovascular Society's target of 85% referral for CR for cardiac inpatients with the appropriate indications, significantly fewer patients are referred for CR. Moreover, certain patient groups—such as women, ethnocultural minorities, and those of low socioeconomic status—are less likely to access CR, despite greater need because of poorer outcomes. CR appears to be reaching a healthier population that is perhaps more adherent to secondary prevention recommendations and hence in less need of the limited CR spots available. The reasons for CR underuse are well established and include factors at patient, referring provider, CR program, and health system levels. A Cochrane review has established some effective interventions to increase CR use, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must reallocate our CR resources to patients with the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely available, lower-cost, and effective alternative model of CR.
Article
Background: Cardiac rehabilitation is an important component in the continuum of care for individuals with cardiovascular disease, providing a multidisciplinary education and exercise programme to improve morbidity and mortality risk. Internationally, cardiac rehabilitation programmes are implemented through various models. This review compared cardiac rehabilitation guidelines in order to identify any differences and/or consensus in exercise testing, prescription and monitoring. Methods: Guidelines, position statements and policy documents for cardiac rehabilitation, available internationally in the English language, were identified through a search of electronic databases and government and cardiology society websites. Information about programme delivery, exercise testing, prescription and monitoring were extracted and compared. Results: Leading cardiac rehabilitation societies in North America and Europe recommend that patients progress from moderate- to vigorous-intensity aerobic endurance exercise over the course of the programme, with resistance training included as an important adjunct, for maintaining independence and quality of life. North American and European guidelines also recommend electrocardiograph-monitored exercise stress tests. Guidelines for South America and individual European nations typically include similar recommendations; however, those in the United Kingdom, Australia and New Zealand specify lower-intensity exercise and less technical assessment of functional capacity. Conclusion: Higher-intensity aerobic training programmes, supplemented by resistance training, have been recommended and deemed safe for cardiac rehabilitation patients by many authorities. Based on research evidence, this may also provide superior outcomes for patients and should therefore be considered when developing an international consensus for exercise prescription in cardiac rehabilitation.
Article
Background: Cardiac rehabilitation is one of the most widely recommended strategies to reduce the burden of cardiovascular disease. The multicomponent nature of cardiac rehabilitation programs requires a multidisciplinary team of healthcare professionals including nurses who are equipped with extensive knowledge and skills. However, there is a lack of a comprehensive, explicit career pathway that contains academic and clinical development to prepare nurses to become cardiac rehabilitation specialists. Objective: The aim of this study is to identify the 3 essential components for cardiac rehabilitation professionals: (1) educational preparation, (2) role/responsibility, and (3) competency to inform the framework of career development for cardiac rehabilitation nurses. Methods: Through scoping review, 4 stages from the methodological framework of scoping review by Arksey and O'Malley (Int J Soc Methodol. 2005;8:19-32) were used. Results: Some attempts have been made in developing frameworks of career development for cardiac rehabilitation professionals with these 3 components through guidelines/standards and core curriculum development worldwide, among which the United States is the only country with a well-established system including guidelines for cardiac rehabilitation/secondary prevention programs, a position statement in terms of competencies, and certification examination for cardiac rehabilitation professionals. Nevertheless, further development and integration of these efforts, specifically for cardiac rehabilitation nurses, are required. Conclusions: It is vital to raise the awareness of the significant contribution that appropriately educated and trained nurses make in reducing the global burden of cardiovascular disease through cardiac rehabilitation. Therefore, action on establishing a system of comprehensive, clearly defined career development pathway for cardiac rehabilitation nurses worldwide is of immediate priority.
Article
Objective Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD). Methods CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre- based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence. Results 11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low- density lipoprotein cholesterol. Telehealth and centre- based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors. Conclusions Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.
Article
Background: Cardiac rehabilitation can reduce mortality of patients with cardiovascular disease, but a frequently low participation rate in rehabilitation programs has been found globally. The objective of the Teledialog study was to assess the cost-utility (CU) of a cardiac telerehabilitation (CTR) program. The aim of the intervention was to increase the patients' participation in the CTR program. At discharge, an individualized 3-month rehabilitation plan was formulated for each patient. At home, the patients measured their own blood pressure, pulse, weight, and steps taken for 3 months. Materials and methods: The analysis was carried out together with a randomized controlled trial with 151 patients during 2012-2014. Costs of the intervention were estimated with a health sector perspective following international guidelines for CU. Quality of life was assessed using the 36-Item Short Form Health Survey. Results: The rehabilitation activities were approximately the same in the two groups, but the number of contacts with the physiotherapist was higher among the intervention group. The mean total cost per patient was €1,700 higher in the intervention group. The quality-adjusted life-years (QALYs) gain was higher in the intervention group, but the difference was not statistically significant. The incremental CU ratio was more than €400,000 per QALY gained. Conclusions: Even though the rehabilitation activities increased, the program does not appear to be cost-effective. The intervention itself was not costly (less than €500), and increasing the number of patients may show reduced costs of the devices and make the CTR more cost-effective. Telerehabilitation can increase participation, but the intervention, in its current form, does not appear to be cost-effective.
Article
Heart failure (HF) accounts for 5% of all emergency hospital admissions in the UK. To ensure cost-effectiveness, the potential for any intervention to reduce admissions must be balanced against its required investment. This economic analysis compared costeffectiveness of home- versus hospitalbased exercise training as delivered within a randomised-controlled trial (RCT) for HF. The additional costs of delivering eight weeks of home- versus hospital-based training for 46 people with HF, within an established cardiac rehabilitation service, were balanced against emergency hospital admission costs incurred by home-training (n=15), hospital-training (n=15) and control (n=16) groups over five years. The total cost of home-training was £3,244.47 (£196.53 per patient) - much of which was a fixed cost attributed to producing the hometraining package. Hospital-training cost £3,656.06 (£221.58 per patient). Over five years, total admission costs for controls (of £157,305.23) were considerably higher than for both home- (£115,735.43) and hospital- (£108,117.51) training groups. In conclusion, both training programmes incurred similar costs, which were offset by a reduction in emergency admission costs, compared with controls. Although hospital-training offered greater potential for reducing admission costs, with larger patient numbers, the cost of home-training per patient would decrease, increasing its likelihood of being the more costeffective option.
Article
Importance Cardiovascular disease prevention, including lifestyle modification, is important but underutilized. Mobile health strategies could address this gap but lack evidence of therapeutic benefit.Objective To examine the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text message on cardiovascular risk factors.Design and Setting The Tobacco, Exercise and Diet Messages (TEXT ME) trial was a parallel-group, single-blind, randomized clinical trial that recruited 710 patients (mean age, 58 [SD, 9.2] years; 82% men; 53% current smokers) with proven coronary heart disease (prior myocardial infarction or proven angiographically) between September 2011 and November 2013 from a large tertiary hospital in Sydney, Australia.Interventions Patients in the intervention group (n = 352) received 4 text messages per week for 6 months in addition to usual care. Text messages provided advice, motivational reminders, and support to change lifestyle behaviors. Patients in the control group (n=358) received usual care. Messages for each participant were selected from a bank of messages according to baseline characteristics (eg, smoking) and delivered via an automated computerized message management system. The program was not interactive.Main Outcomes and Measures The primary end point was low-density lipoprotein cholesterol (LDL-C) level at 6 months. Secondary end points included systolic blood pressure, body mass index (BMI), physical activity, and smoking status.Results At 6 months, levels of LDL-C were significantly lower in intervention participants (mean difference, −5 mg/dL [95% CI, −9 to 0]; P = .04). There were concurrent reductions in systolic blood pressure (−7.6 mm Hg [95% CI, −9.8 to −5.4]; P < .001) and BMI (−1.3 [95% CI, −1.6 to −0.9]; P < .001), significant increases in physical activity (+293 metabolic equivalent task min/wk [95% CI, 102 to 485]; P = .003), and a significant reduction in smoking (26% vs 44%; relative risk, 0.61 [95% CI, 0.48 to 0.76]; P < .001). The majority reported the text-message program to be useful (91%), easy to understand (97%), and appropriate in frequency (86%).Conclusions and Relevance Among patients with coronary heart disease, the use of a lifestyle-focused text messaging service compared with usual care resulted in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors. The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined.Trial Registration anzctr.org.au Identifier: ACTRN12611000161921
Article
Background Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review originally published in 2009. Objectives To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease. Search methods To update searches from the previous Cochrane review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41),PsycINFO (Ovid, 1806 to October week 2 2014), and CINAHL (EBSCO, to October 2014). We checked reference lists of included trials and recent systematic reviews. No language restrictions were applied. Selection criteria Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction (MI), angina, heart failure or who had undergone revascularisation. Data collection and analysis Two authors independently assessed the eligibility of the identified trials and data were extracted by a single author and checked by a second. Authors were contacted where possible to obtain missing information. Main results Seventeen trials included a total of 2172 participants undergoing cardiac rehabilitation following an acute MI or revascularisation, or with heart failure. This update included an additional five trials on 345 patients with hear t failure. Authors of a number of included trials failed to give sufficient detail to assess their potential risk of bias, and details of generation and concealment of random allocation sequence were particularly poorly reported. In the main, no difference was seen between home- and centre-based cardiac rehabilitation in outcomes up to 12 months of follow up: mortality (relative risk (RR) = 0.79, 95% confidence interval (CI) 0.43 to 1.47, P = 0.46, fixed-effect), cardiac events (data not poolable), exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.29 to 0.08,P = 0.29, random-effects), modifiable risk factors (total cholesterol: mean difference (MD) = 0.07 mmol/L, 95% CI -0.24 to 0.11, P= 0.47, random-effects; low density lipoprotein cholesterol: MD = -0.06 mmol/ L, 95% CI -0.27 to 0.15, P = 0.55, random-effects;systolic blood pressure: mean difference (MD) = 0.19 mmHg, 95% CI -3.37 to 3.75, P = 0.92, random-effects; proportion of smokers at follow up (RR = 0.98, 95% CI 0.79 to 1.21, P = 0.83, fixed-effect), or health-related quality of life (not poolable). Small outcome differences in favour of centre-based participants were seen in high density lipoprotein cholesterol (MD = -0.07 mmol/ L, 95% CI -0.11 to -0.03, P = 0.001, fixed-effect), and triglycerides (MD = -0.18 mmol/L, 95% CI -0.34 to -0.02, P = 0.03, fixed-effect, diastolic blood pressure (MD = -1.86 mmHg; 95% CI -0.76 to -2.95, P = 0.0009, fixed-effect). In contrast, in home-based participants, there was evidence of a marginally higher levels of programme completion (RR = 1.04, 95% CI 1.01 to 1.07, P = 0.009, fixed-effect) and adherence to the programme (not poolable). No consistent difference was seen in healthcare costs between the two forms of cardiac rehabilitation. Authors’ conclusions This updated review supports the conclusions of the previous version of this review that home- and centre-based forms of cardiac rehabilitation se em to be equally effective for improving the clinical and health-related quality of life outcomes in low risk patients after MI or revascularisation, or with heart failure. This finding, together with the absence of evidence of important differences inhealthcare costs between the two approaches, supports the continued expansion of evidence-based, home-based cardiac rehabilitationprogrammes. The choice of par ticipating in a more traditional and supervised centre-based programme or a home-based pr ogrammeshould reflect the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in these short-term trials can be confirmed in the longer term. A number of studies failed to givesufficient detail to assess their risk of bias.
Article
Notwithstanding the cardiovascular disease epidemic, current budgetary constraints do not allow for budget expansion of conventional cardiac rehabilitation programmes. Consequently, there is an increasing need for cost-effectiveness studies of alternative strategies such as telerehabilitation. The present study evaluated the cost-effectiveness of a comprehensive cardiac telerehabilitation programme. This multi-centre randomized controlled trial comprised 140 cardiac rehabilitation patients, randomized (1:1) to a 24-week telerehabilitation programme in addition to conventional cardiac rehabilitation (intervention group) or to conventional cardiac rehabilitation alone (control group). The incremental cost-effectiveness ratio was calculated based on intervention and health care costs (incremental cost), and the differential incremental quality adjusted life years (QALYs) gained. The total average cost per patient was significantly lower in the intervention group (€2156 ± €126) than in the control group (€2720 ± €276) (p = 0.01) with an overall incremental cost of €-564.40. Dividing this incremental cost by the baseline adjusted differential incremental QALYs (0.026 QALYs) yielded an incremental cost-effectiveness ratio of €-21,707/QALY. The number of days lost due to cardiovascular rehospitalizations in the intervention group (0.33 ± 0.15) was significantly lower than in the control group (0.79 ± 0.20) (p = 0.037). This paper shows the addition of cardiac telerehabilitation to conventional centre-based cardiac rehabilitation to be more effective and efficient than centre-based cardiac rehabilitation alone. These results are useful for policy makers charged with deciding how limited health care resources should best be allocated in the era of exploding need. © The European Society of Cardiology 2015.
Article
By 2030, more than 80% of cardiovascular disease-related deaths and disability-adjusted life years will occur in the 139 low- and middle-income (LMIC) countries. Cardiac rehabilitation (CR) has been demonstrated to be effective and cost-effective mainly based on data from high-income countries. The purpose of this paper was to review the literature for cost and cost-effectiveness data on CR in LMICs. MEDLINE (Ovid) and EMBASE (Ovid) electronic databases were searched for CR 'cost' and 'cost-effectiveness' data in LMICs. Five CR publications with cost and cost-effectiveness data from middle-income countries were identified with none from low-income countries. Studies from Brazil demonstrated mean monthly savings of US$190 for CR, with a US$48 increase in a control group with mean costs of US$503 for a 3-month CR program. Mean costs to the public health care system of US$360 and US$540 when paid out-of-pocket were reported for a 3-month CR program in seven Latin American middle-income countries. Cardiac rehabilitation is reported to be cost-effective in both Brazil and Colombia. Cardiac rehabilitation for patients with heart failure in Brazil and Colombia was estimated to be cost-effective. However, given the limited health care budgets in many LMICs, affordable CR models will need to be developed for LMICs, particularly for low-income countries. © The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
Article
To assess the cost utility of a center-based outpatient cardiac rehabilitation program compared with no program within patient subgroups on the basis of age, sex, and clinical presentation (acute coronary syndrome [ACS] or non-ACS). We performed a cost-utility analysis from a health system payer perspective to compare cardiac rehabilitation with no cardiac rehabilitation for patients who had a cardiac catheterization. The Markov model was stratified by clinical presentation, age, and sex. Clinical, quality-of-life, and cost data were provided by the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology. The incremental cost per quality-adjusted life-year (QALY) gained for cardiac rehabilitation varies by subgroup, from $18,101 per QALY gained to $104,518 per QALY gained. There is uncertainty in the estimates due to uncertainty in the clinical effectiveness of cardiac rehabilitation. Overall, the probabilistic sensitivity analysis found that 75% of the time participation in cardiac rehabilitation is more expensive but more effective than not participating in cardiac rehabilitation. The cost-effectiveness of cardiac rehabilitation varies depending on patient characteristics. The current analysis indicates that cardiac rehabilitation is most cost effective for those with an ACS and those who are at higher risk for subsequent cardiac events. The findings of the current study provide insight into who may benefit most from cardiac rehabilitation, with important implications for patient referral patterns. Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
Article
Cardiovascular disease is a leading cause of morbidity worldwide. Cardiac rehabilitation (CR) is a comprehensive secondary prevention approach, with established benefits in reducing morbidity in high-income countries (HICs). The objectives of this review were to summarise what is known about the benefits of CR, including consideration of cost-effectiveness, in addition to rates of CR participation and adherence in high-, as well as low- and middle-income countries (LMICs). A literature search of Medline, Excerpta Medica Database (EMBASE), and Google Scholar was conducted for published articles from database inception to October 2013. The search was first directed to identify meta-analyses and reviews reporting on the benefits of CR. Then, the search was focussed to identify articles reporting CR participation and dropout rates. Full-text versions of relevant abstracts were summarised qualitatively. Based on meta-analysis, CR significantly reduced all-cause mortality by 13%-26%, cardiac mortality by 20%-36%, myocardial re-infarction by 25%-47%, and risk factors. CR is cost-effective in HICs. In LMICs, CR is demonstrated to reduce risk factors, with no studies on mortality or cost-effectiveness. Based on available data, CR participation rates are <50% in the majority of countries, with documented dropout rates up to 56% and 82% in high- and middle-income countries, respectively. CR is a beneficial intervention for heart patients in high and LMICs, but is underutilised with low participation and adherence rates worldwide. While more research is needed in LMICs, strategies shown to increase participation and program adherence should be implemented. Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
Article
Cardiac rehabilitation (CR) is an evidence-based recommendation for patients with coronary artery disease (CAD). However, CR is dramatically underutilized. Telehealth interventions have the potential to overcome barriers and may be an innovative model of delivering CR. This review aimed to determine the effectiveness of telehealth intervention delivered CR compared with center-based supervised CR. Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library and the Chinese BioMedical Literature Database (CBM), were searched to April 2014, without language restriction. Existing randomized controlled trials, reviews, relevant conference lists and gray literature were checked. Randomized controlled trials that compared telehealth intervention delivered CR with traditional center-based supervised CR in adults with CAD were included. Two reviewers selected studies and extracted data independently. Main clinical outcomes including clinical events, modifiable risk factors or other endpoints were measured. Fifteen articles reporting nine trials were reviewed, most of which recruited patients with myocardial infarction or revascularization. No statistically significant difference was found between telehealth interventions delivered and center-based supervised CR in exercise capacity (standardized mean difference (SMD) -0.01; 95% confidence interval (CI) -0.12-0.10), weight (SMD -0.13; 95% CI -0.30-0.05), systolic and diastolic blood pressure (mean difference (MD) -1.27; 95% CI -3.67-1.13 and MD 1.00; 95% CI -0.42-2.43, respectively), lipid profile, smoking (risk ratio (RR) 1.03; 95% CI 0.78-1.38), mortality (RR 1.15; 95% CI 0.61-2.19), quality of life and psychosocial state. Telehealth intervention delivered cardiac rehabilitation does not have significantly inferior outcomes compared to center-based supervised program in low to moderate risk CAD patients. Telehealth intervention offers an alternative deliver model of CR for individuals less able to access center-based cardiac rehabilitation. Choices should reflect preferences, anticipation, risk profile, funding, and accessibility to health service. © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Article
We conducted a cost benefit analysis of a home telehealth-based cardiac rehabilitation programme compared to the standard hospital-based programme. A total of 120 participants were enrolled in a trial, with 60 randomised to the telehealth group and 60 randomised to usual care. Participants in the telehealth group received a mobile phone, Wellness Diary and a Wellness web portal, with daily text messaging. Participants in the usual care group received the standard 6-week hospital-based outpatient cardiac rehabilitation programme, including gym sessions. The cost of delivery by telehealth was slightly lower than for patients attending a rehabilitation service in person. From the provider's perspective, the telehealth intervention could be delivered for $1633 per patient, compared to $1845 for the usual care group. From the participant's perspective, patient travel costs for home rehabilitation were substantially less than for hospital attendance ($80 vs $400). Cardiac rehabilitation by telehealth offers obvious advantages and the option should be available to all patients who are eligible for cardiac rehabilitation.
Article
Objective Cardiac rehabilitation (CR) is pivotal in preventing recurring events of myocardial infarction (MI). This study aims to investigate the effect of a smartphone-based home service delivery (Care Assessment Platform) of CR (CAP-CR) on CR use and health outcomes compared with a traditional, centre-based programme (TCR) in post-MI patients. Methods In this unblinded randomised controlled trial, post-MI patients were randomised to TCR (n=60; 55.7±10.4 years) and CAP-CR (n=60; 55.5±9.6 years) for a 6-week CR and 6-month self-maintenance period. CAP-CR, delivered in participants’ homes, included health and exercise monitoring, motivational and educational material delivery, and weekly mentoring consultations. CAP-CR uptake, adherence and completion rates were compared with TCR using intention-to-treat analyses. Changes in clinical outcomes (modifiable lifestyle factors, biomedical risk factors and health-related quality of life) across baseline, 6 weeks and 6 months were compared within, and between, groups using linear mixed model regression. Results CAP-CR had significantly higher uptake (80% vs 62%), adherence (94% vs 68%) and completion (80% vs 47%) rates than TCR (p<0.05). Both groups showed significant improvements in 6-minute walk test from baseline to 6 weeks (TCR: 537±86–584±99 m; CAP-CR: 510±77–570±80 m), which was maintained at 6 months. CAP-CR showed slight weight reduction (89±20–88±21 kg) and also demonstrated significant improvements in emotional state (K10: median (IQR) 14.6 (13.4–16.0) to 12.6 (11.5–13.8)), and quality of life (EQ5D-Index: median (IQR) 0.84 (0.8–0.9) to 0.92 (0.9–1.0)) at 6 weeks. Conclusions This smartphone-based home care CR programme improved post-MI CR uptake, adherence and completion. The home-based CR programme was as effective in improving physiological and psychological health outcomes as traditional CR. CAP-CR is a viable option towards optimising use of CR services. Trial registration number ANZCTR12609000251224.
Article
In Japan, metabolic risk factors have been increasing due to the westernization and urbanization of lifestyle. This justifiably raises a concern that the incidence of coronary heart disease (CHD) in Japan will increase over time, and indeed, recent epidemiological studies in Japan suggest the incidence of acute myocardial infarction (AMI) is increasing. Cardiac rehabilitation (CR) in Japan has been traditionally performed in the inpatient setting. To obtain reimbursement, a CR facility must fulfill certain criteria including being a medical institution with a cardiology/cardiac surgery section which has at least a cardiologist/cardiac surgeon and an experienced CR physician as full-time employees. These criteria create challenges to the availability of outpatient CR after hospital discharge. A recent analysis found outpatient CR participation rate was estimated to be between 3.8 and 7.6% in Japan. This review describes recent trends in the incidence of AMI and the current status of the use of CR in Japan.
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In the implementation and delivery of the seven core components, underpinned by seven service standards, the BACPR has emphasised that CR must be integral to any modern cardiology service. CR has a strong evidence base for being clinically effective, cost-effective and cost-saving, together with patient-centred aims which support longerterm health, self-management and wellbeing. These outcomes are especially true when rehabilitation is commenced early following acute treatment, discharge and/or diagnosis, which lead to increased uptake, adherence and prevention of unnecessary hospital readmissions. These SCC can only be met if training is undertaken to create skilled and competent specialist practitioners for each of the core components. An overall aim of the BACPR is to be a resource for providing appropriate guidance and training on the knowledge, skills and competences required.
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Current approaches to the secondary prevention of myocardial infarction include the use of both well-established and newer agents. Our Drug review considers their mode of action and properties and the evidence base for their efficacy, followed by sources of further information and the Datafile. Copyright © 2008 Wiley Interface Ltd