Cardiovascular Rehabilitation Delivery and Outcomes in Switzerland in More Than a Hundred Thousand Patients Over the Last Decade.

Abstract

The modern definition of cardiac rehabilitation (CR) is a medically supervised, exercise-based, comprehensive, and multidisciplinary intervention aiming to improve recovery after an acute cardiovascular event, intervention, or surgery and to improve exercise capacity, cardiovascular risk profile, quality of life (QoL), and prognosis.1 The “Swiss Working Group for Cardiovascular Prevention, Rehabilitation and Sports Cardiology” (SCPRS) currently consists of 67 registered outpatient and 15 inpatient CR programs. To receive official accreditation, all CR programs have to meet quality standards, which are checked by an audit at the launch of each program, after major structural changes or after a change of program director. The purpose of this study is to report for the first-time data on CR activities and quality measures of all Swiss CR centers from 2010 to 2019. METHODS Data were from 2010 to 2019 of the SCPRS national database on quality standards, which have to be provided on a yearly basis by all accredited Swiss CR centers. These include the number of patients enrolled and their characteristics, as well as different patient outcome measures. Data were collected from an online platform consisting of 35 items including sex, age, days from hospital discharge to beginning of the program, smoking status, medical indication for CR, program duration, major complications during the program (death or resuscitation), smoking habits, functional tests (6-min walk test, cycle-ergometer or treadmill exercise test), QoL questionnaires, and assessment of depression and anxiety questionnaires. Annual data were from all individual patient data from each center. Since data were collected only for quality control purposes, no ethical or formal approval by local institutional review boards or written patient consent was required. Results are presented as mean ± SD for continuous variables and n (%) of patients for categorical variables. We used the paired Student t test to compare changes of outcome variables between admission and discharge of the program. Differences were considered significant at a P value of < .05 level. Data analysis and basic statistics were performed using Xcel and R (R Foundation) statistical software. RESULTS From 2010 to 2019, a total number of 133 060 patients (68 690 inpatients and 64 370 outpatients) participated in a CR program. The number of CR participants increased progressively over this time span with a peak of 14 909 patients in 2018 (Figure). Mean age of the participants was 60.0 ± 1.0 yr and 68 ± 1.1 yr in outpatient and inpatient programs, with a proportion of women of 21% and 32%, respectively. The most frequent CR indication in outpatient programs was acute coronary syndrome (51%) while in inpatient programs patients after coronary bypass and/or valve surgery prevailed (60%).Figure.: Number of CR participants in Switzerland in outpatient and inpatient program from 2010 to 2019. Abbreviation: CR, cardiac rehabilitation. This figure is available in color online (www.jcrpjournal.com).The 6-min walk est distance at admission was 292 ± 13 m for inpatient and 418 ± 29 m for outpatient programs. At the end of the program, respective values were 403 ± 9 m (improvement of 38 ± 3.6%, P < .001) for inpatient and 519 ± 33 m (improvement of 24 ± 3.8%, P < .001) for outpatient programs. Mean maximal power output by cycle-ergometer at admission was 79.7 ± 4.5 W for inpatient and 125.1 ± 4.9 W for outpatient programs. At the end of the program, respective values were 103.4 ± 4.5 W (improvement of 30 ± 4.2%, P < .001) and 151.7 ± 6.3 W (improvement of 21 ± 2.2%, P < .001). The QoL data from the MacNew Heart questionnaire from 10 393 inpatients (3218 women, 7175 men) showed a significantly increased score at discharge. The emotional status increased from 5.27 ± 1.12 to 5.93 ± 1 (P < .001), the physical function from 4.43 ± 1.7 to 5.8 ± 1.22 (P < .001), and the social function from 5.21 ± 1.24 to 6.15 ± 1.01 (P < .001). Data from the Hospital Discharge and Depression Scale in >2000 inpatients demonstrated significant improvement at discharge. The score for depression improved from 5.78 ± 3.80 to 4.66 ± 3.71 (P < .001) and for anxiety from 6.73 ± 4.92 to 5.79 ± 5.30 (P < .001). The mean relative reduction of smokers during CR was 32% for inpatient programs and 46% for outpatient programs. DISCUSSION This is the first report of CR activities in Switzerland, including 133 060 patients, both in inpatient and outpatient programs over a time span of 10 yr. Data were available not only on CR delivery but also partially on patient quality outcomes, which is not the case in recent surveys or national reports.2 Significant improvements were observed in different outcome variables, such as functional capacity, QoL and scores of anxiety and depression. Acute coronary syndrome was the main reason for CR referral, representing 35% of all CR indications in the last decade. Our data also confirm that a minority of women, overall a quarter of all patients, participate in CR, which had also been demonstrated in several studies.3,4 Functional capacity was assessed mostly by 6-min walk test in inpatient programs, and by cycle-ergometer in outpatient programs, with an improvement at CR discharge of 38% and 21%, respectively, in line with the recently published European standards of quality indicators.5 Regarding QoL, both the MacNew Heart and the Hospital Discharge and Depression Scale questionnaire showed an improvement at discharge, respectively, of 20% and 16%. Participation in a CR program also seemed to be highly efficient to help quit smoking, both in outpatient and inpatient programs. This confirms the fact that offering smoking cessation counseling in combination with an exercise training program appears to be the most effective way for smoking cessation.6 Several limitations, however, must be considered. First, and most importantly, these were data from a register and the data set therefore is incomplete. Second, most data represent means or medians of each center and not individual patient data. Third, patient-reported data analyses were impaired by missing data and the use of different QoL questionnaires, highlighting a lack of uniformity between CR centers. This first report on CR activities in a large cohort of patients in Switzerland demonstrates a steady increase in CR participation over the last decade, especially in the outpatient setting. It shows improvements of functional capacity, health-related QoL, and smoking cessation rates, which all meet the European standard of quality indicators. For the future, the access to individual CR patient data would be desirable to improve not only robustness and reliability but also benchmarking of different CR programs.