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

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

Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis.

OBJECTIVES: To compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care. DESIGN: Systematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources. SETTING: Acute care geriatric and nongeriatric hospital units. PARTICIPANTS: Acutely ill or injured adults (N = 6,839) with an average age of 81. INTERVENTIONS: Acute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment. MEASUREMENTS: Falls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions. RESULTS: Acute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29-0.88), less delirium (RR = 0.73, 95% CI = 0.61-0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78-0.97), shorter length of hospital stay (weighted mean difference (WMD) = -0.61, 95% CI = -1.16 to -0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68-0.99), lower costs (WMD = -$245.80, 95% CI = -$446.23 to -$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01-1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions. CONCLUSION: Acute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults' illness or injury, improves patient- and system-level outcomes.