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Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation.

ABSTRACT: Background:Cardiac rehabilitation (CR) is recommended in clinical practice guidelines for comprehensive secondary prevention. While India has a high burden of cardiovascular diseases (CVD), availability and nature of services delivered there is unknown. In this study, we undertook secondary analysis of the Indian data from the global CR audit and survey, conducted by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR). Methods:In this cross-sectional study, an online survey was administered to CR programs, identified in India by CR champions and through snowball sampling. CR density was computed using Global Burden of Disease study ischemic heart disease (IHD) incidence estimates. Results:Twenty-three centres were identified, of which 18 (78.3%) responded, from 3 southern states. There was only one spot for every 360 IHD patients/year, with 3,304,474 more CR spaces needed each year. Most programs accepted guideline-indicated patients, and most of these patients paid out-of-pocket for services. Programs were delivered by a multidisciplinary team, including physicians, physiotherapists, among others. Programs were very comprehensive. Apart from exercise training, which was offered across all centers, some centers also offered yoga therapy. Top barriers to delivery were lack of patient referral and financial resources. Conclusions:Of all countries in ICCPR's global audit, the greatest need for CR exists in India, particularly in the North. Programs must be financially supported by government, and healthcare providers trained to deliver it to increase capacity. Where CR did exist, it was generally delivered in accordance with guideline recommendations. Tobacco cessation interventions should be universally offered.

SUBMITTER: Babu AS

PROVIDER: S-EPMC7218762 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation.

Babu Abraham Samuel AS Turk-Adawi Karam K Supervia Marta M Jimenez Francisco Lopez FL Contractor Aashish A Grace Sherry L SL

Global heart 20200403 1

<h4>Background</h4>Cardiac rehabilitation (CR) is recommended in clinical practice guidelines for comprehensive secondary prevention. While India has a high burden of cardiovascular diseases (CVD), availability and nature of services delivered there is unknown. In this study, we undertook secondary analysis of the Indian data from the global CR audit and survey, conducted by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR).<h4>Methods</h4>In this cross-sectional ...[more]

PMID: 32489801

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Project description:Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular (CV) disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea. This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of thirty-three authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified. CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers CV mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Project description:BackgroundHome Based Cardiac Rehabilitation (HBCR) has been considered a reasonable alternative to Center-based Cardiac Rehabilitation (CBCR) in patients with established cardiovascular disease, especially in the midst of COVID-19 pandemic. However, the long-term cardiovascular outcomes of patients referred to HBCR remains unknown.ObjectivesTo compare outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR).MethodsWe performed a retrospective study of 269 patients referred to HBCR at Providence Veterans Affairs Medical Center (PVAMC). From November 2017 to March 2020, 427 patients were eligible and referred for Cardiac Rehabilitation (CR) at PVAMC. Of total patients, 158 patients were referred to CBCR and 269 patients to HBCR based on patient and/or clinician preference. The analysis of outcomes was focused on HBCR patients. We compared outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR) from 3 to 12 months of the referral date. HBCR consisted of face-to-face entry exam with exercise prescription, weekly phone calls for education and exercise monitoring, with adjustments where applicable, for 12-weeks and an exit exam. Primary outcome was composite of all-cause mortality and hospitalizations. Secondary outcomes were all-cause hospitalization, all-cause mortality and cardiovascular hospitalizations, separately. We used cox proportional methods to calculate hazard ratios (HR) and 95% CI. We adjusted for imbalanced characteristics at baseline: smoking, left ventricular ejection fraction and CABG status.ResultsA total of 269 patients (mean age: 72, 98% Male) were referred to HBCR, however, only 157 (58%) patients attended HBCR. The primary outcome occurred in 30 patients (19.1%) in the HBCR group and 30 patients (30%) in the Non-HBCR group (adjusted HR=0.56, CI 0.33-0.95, P=.03). All-cause mortality occurred in 6.4% of patients in the HBCR group and 13% patients in the Non-HBCR group 3 to 12 months after HBCR referral (adjusted HR=0.43, CI 0.18-1.0, P= .05). There was no difference in cardiovascular hospitalizations (HBCR: 5.7% vs Non-HBCR: 10%, adjusted HR 0.57, CI 0.22-1.4, P= .23) or all cause hospitalizations at 3 to 12 months between the groups (HBCR: 12.7% vs Non-HBCR: 21%, adjusted HR 0.53, CI 0.28-1.01, P= .05).ConclusionCompletion of HBCR among referred patients was associated with a lower risk of the combined all-cause mortality and all-cause hospitalizations up to 12 months. Based on the outcomes, HBCR is a reasonable option that can improve access to CR for patients who are not candidates of or cannot attend CBCR. Randomized-controlled studies are needed to confirm these findings.

Project description:ProblemIntegrated care for patients who survive a myocardial infarction is lacking. Many patients are not offered cardiac rehabilitation, and secondary prevention is not optimal.Design12 month audit of 106 patients who survived an acute myocardial infarction.Background and settingCarrick Primary Care Trust in Cornwall (population 98 500) and one district general hospital.Key measures for improvementProportion of patients who complete a cardiac rehabilitation programme after a myocardial infarction. Proportion of patients with optimal secondary prevention, as measured by smoking status, body mass index, cholesterol <5.0 mmol/l, and blood pressure <140/85 mm Hg.Strategies for changeWe set up a novel, integrated, and seamless system for cardiac rehabilitation. We employed a cardiac liaison nurse to identify and assess in hospital all patients with suspected acute myocardial infarction. The nurse offered patients the choice of home based rehabilitation with the Heart Manual or hospital based rehabilitation. The nurse gave discharge details to the patient's general practice; these were to be included on a practice based register of coronary heart disease.Effects of changeAll 106 eligible patients were offered cardiac rehabilitation and were included in a practice based register of coronary heart disease to facilitate long term follow up in primary care. 47 (44%) patients chose home based rehabilitation with the Heart Manual, and 41 (87%) of these completed the programme; 35 (33%) patients chose hospital based rehabilitation, and 17 (49%) of these completed the programme. The numbers of patients achieving secondary prevention targets improved significantly: those with serum cholesterol <5.0 mmol/l at discharge increased from 28% at baseline to 75% at 12 months. Optimal care (at least 80-90% uptake of an intervention) was seen with antiplatelet and statin treatments and with smoking cessation. Significantly more patients were prescribed statins at follow up than at baseline (77/106 v 80/91, P=0.005).Lessons learntNational service framework targets for cardiac rehabilitation and secondary prevention can be achieved in patients who survive a myocardial infarction by integrating rehabilitation services (home and hospital) with secondary prevention clinics in primary care. Nurse led clinics in primary care facilitate long term structured care and optimal secondary prevention.

Dataset Information

Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation.

Publications

Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation.

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