Development and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Program Certification for Low-Resource Settings.

Background: Cardiac rehabilitation (CR) is a proven model of secondary prevention, but new sites, providing quality care, are needed in low-resource settings. This study (1) described the development of International Council of Cardiovascular Prevention and Rehabilitation's (ICCPR) Program Certification and (2a) tested its implementation, considering (b) appropriateness of quality standards for these settings. Methods: The Steering Committee finalized 13 standards, requiring 70% be met. They are assessed initially through International CR Registry (ICRR) program survey and patient data; if Certification appears possible, a two-hour virtual site assessment is arranged to corroborate. Standard operating procedures for Assessor training were developed. A multi-method pilot study was then undertaken with a quantitative (description of quality indicators) and qualitative (focus groups on MS Teams) component. ICRR sites with post-program data by April 2022 were invited to participate. Two team members independently analyzed focus group transcripts, using a deductive-thematic approach with NVIVO. Results: Five CR programs from the Eastern Mediterranean, South-East Asian and American regions participated. Upon application, with some data cleaning, initially four programs were eligible to proceed to virtual site assessment. Ultimately, all five programs were certified, each meeting a minimum of 12/13 standards (peak MET increase and program completion rate were not met by some centres). Four themes resulted from the two focus groups of 13 site data stewards: motivation and benefits (eg, international recognition, additional program resources), logistics (eg, communication, cost, site visit process), the standards and their assessment (eg, balance of rigor and feasibility), and suggestions for improvement (eg, website). Conclusion: ICCPR's Program Certification has been demonstrated to be feasible, rigorous, and acceptable. Standards are attainable in low-resource settings. Certified programs reap benefits including additional resources. This first international Certification is suitable for low-resource settings, to complement that from the American and European CR Societies.

Changes in the burden and underlying causes of heart failure in the Eastern Mediterranean Region, 1990-2019: An analysis of the Global Burden of Disease Study 2019.

Background: The burden of heart failure (HF) is high globally, but information on its burden in the Eastern Mediterranean Region (EMR) is limited. This study provides a systematic analysis of the burden and underlying causes of HF in the EMR, including at the country level, between 1990 and 2019. Methods: We used the 2019 Global Burden of Disease (GBD) data for estimates of prevalence, years lived with disability (YLDs), and underlying causes of HF in the EMR. Age-standardised prevalence, YLDs, and underlying causes of HF were compared by 5-year age groups (considering 15 years old and more), sex (male and female), and countries. Findings: In contrast with the decreasing trend of HF burden globally, EMR showed an increasing trend. Globally, the HF age-standardised prevalence and YLDs decreased by 7.06% (95% UI: -7.22%, -6.9%) and 6.82% (95% UI: -6.98%, -6.66%) respectively, from 1990 to 2019. The HF age-standardised prevalence and YLDs in the EMR in 2019 were 706.43 (95% UI: 558.22-887.87) and 63.46 (95% UI: 39.82-92.59) per 100,000 persons, representing an increase of 8.07% (95% UI: 7.9%, 8.24%) and 8.79% (95% UI: 8.61%, 8.97%) from 1990, respectively. Amongst EMR countries, the age-standardised prevalence and YLDs were highest in Kuwait, while Pakistan consistently had the lowest HF burden. The dramatic increase of the age-standardised prevalence and YLDs were seen in Oman (28.79%; 95% UI: 28.51%, 29.07% and 29.56%; 95% UI: 29.28%, 29.84%), while Bahrain witnessed a reduction over the period shown (-9.66%; 95% UI: -9.84%, -9.48% and-9.14%; 95% UI: -9.32%, -8.96%). There were significant country-specific differences in trends of HF burden from 1990 to 2019. Males had relatively higher rates than females in all age groups. Among all causes of HF in 2019, ischemic heart disease accounted for the highest age-standardised prevalence and YLDs, followed by hypertensive heart disease. Interpretation: The burden of HF in the EMR was higher than the global, with increasing age-standardised prevalence and YLDs in countries of the region. A more comprehensive approach is needed to prevent underlying causes and improve medical care to control the burden of HF in the region. Funding: None.

Qualitative study measuring the usability of the International Cardiac Rehabilitation Registry.

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

Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement.

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.

Cardiac rehabilitation delivery model for low-resource settings.

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.

Secondary Prevention Recommendation Attainment with Cardiac Rehabilitation: Is There a Gender Disparity?

BACKGROUND: Achievement of secondary prevention guideline recommendations (i.e., goals) with cardiac rehabilitation (CR) is not well-documented, especially for women. This study examined achievement of the American Heart Association/American College of Cardiology (AHA/ACC) goals before and after CR by gender. METHODS: Of 12,976 patients enrolled in the Wisconsin CR Outcomes Registry, 8,929 (68.8%) completed CR and were included in the sample. Attainment of 15 AHA/ACC goals before and after CR was examined by extracting corresponding data points in the registry as entered by CR program staff. Gender differences in achievement of these goals after CR were examined via generalized estimating equations technique. RESULTS: Attainment of AHA/ACC goals before CR ranged from 15.3% of patients (physical activity) to 98.1% (aspirin), and by 17.6% (physical activity) to 98.4% (diastolic blood pressure) by CR completion. Significant improvements were achieved for 8 goals (53.3%), ranging from 0.7% for body mass index (BMI) to 50.8% for physical activity. Women were significantly less likely than men to achieve the following goals by CR completion: triglycerides (adjusted odds ratio [AOR], 0.54; 95% confidence interval [CI], 0.45-0.66), physical activity (AOR, 0.66; 95% CI, 0.59-0.74), and hemoglobin A1C (AOR, 0.50; 95% CI, 0.32-0.78). Women were significantly more likely than men to achieve the high-density lipoprotein goal (AOR, 1.39; 95% CI, 1.05-1.86). There were no gender differences in goal achievement for blood pressure, total cholesterol, low-density lipoprotein, BMI, smoking cessation, or medication use. More than 94% of patients were taking three of four recommended secondary prevention medications both before and after the program. CONCLUSIONS: Men and women generally improved similarly in terms of AHA/ACC goal achievement. Quality improvement strategies need to focus on physical activity and blood glucose control in women.

Cardiac rehabilitation in Canada and Arab countries: comparing availability and program characteristics.

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.

Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries.

BACKGROUND: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Cardiac rehabilitation enrollment among referred patients: patient and organizational factors.

PURPOSE: Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. METHODS: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. RESULTS: Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. CONCLUSIONS: Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.

Cardiac rehabilitation patient and organizational factors: what keeps patients in programs?

BACKGROUND: Despite documented benefits of cardiac rehabilitation, adherence to programs is suboptimal with an average dropout rate of between 24% and 50%. The goal of this study was to identify organizational and patient factors associated with cardiac rehabilitation adherence. METHODS AND RESULTS: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry Project (N = 38) were surveyed and records of 4412 enrolled patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. The results show that organizational factors associated with significantly increased adherence were relaxation training and diet classes (group and individual formats) and group-based psychological counseling, medication counseling, and lifestyle modification, the medical director's presence in the cardiac rehabilitation activity area for ≥ 15 min/week, assessment of patient satisfaction, adequate space, and adequate equipment. Patient factors associated with significantly increased adherence were aged ≥ 65 years, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) high-risk category, having received coronary artery bypass grafting, and diabetes disease. Non-white race was negatively associated with adherence. There was no significant gender difference in adherence. None of the baseline patient clinical profiles were associated with adherence including body mass index, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and blood pressure. CONCLUSIONS: Factors associated with adherence to cardiac rehabilitation included both organizational and patient factors. Modifiable organizational factors may help directors of cardiac rehabilitation programs improve patient adherence to this beneficial program.