Cardiac Rehabilitation Quality Research Articles

Cardiac rehabilitation patient data management and quality improvement in Australia: A national survey

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council Synergy Grant Background Receipt of guideline-indicated comprehensive cardiac rehabilitation improves patient outcomes. Optimum service delivery and meeting quality standards necessitates accurate standardised data collection and reporting. The methods, processes and systems used for data capture and reporting in cardiac rehabilitation are under-documented, limiting identification of areas needing change and creation of a platform for quality improvement (QI) at national levels. Purpose To describe data capture, management, and reporting and the awareness and use of quality indicators in contemporary Australian CR programs. Methods CR programs (n=396) were identified through professional and national directories, jurisdictional networks, webinars, and direct provider contact. Program coordinators completed an online survey on individual service characteristics, data capture and management systems (paper, electronic, database, integrated platform) including awareness, use and usefulness of the published National Cardiac Rehabilitation Quality toolkit components. Results Respondents totalled 319 (80.5%), from all eight states and territories. Coverage of Metropolitan, rural and remote towns, and regional centres was 46.3%, 45.9% and 7.8%, respectively. Indicative annual patient enrolments were >200 (31.0%), 51-200 (46.4%) and ≤50 (22.6%). Most programs used ≥2 data management systems: paper and electronic 62.6% or multiple e-systems 19.1%, or one system, either paper 20.9% or electronic 16.3%. Use of multiple systems and combinations of systems did not differ by number of patients enrolled. QI systems were infrequently used: QI Platforms 17.2%, QI Databases 10.0%. Supplementary to patient care, data gained was used for reports for management (57.0%), QI (56.1%), funding support (43.2%), required jurisdictional reporting (41.1%) and research (30.7%). Higher volume programs were more likely to be using the data capture for multiple purposes. Independent covariates of services using data for QI were enrolments of >200 (OR 3.83 95% CI 1.76, 8.34) and the state/territory location, such that use of QI was less likely in the states of Victoria (OR 0.24 95% CI 0.08, 0.77), New South Wales (OR 0.25 95% CI 0.08, 0.76) and Western Australia (OR 0.16 95% CI 0.05, 0.57). Conclusions Management of cardiac rehabilitation patient data is highly variable across Australian programs and jurisdictions, often including multiple different systems, with limited use of the data for QI. A national user-friendly, low burden approach to CR data collection incorporated into daily work-flow that is capable of benchmarking and informs QI is essential.

Quality of Cardiac Rehabilitation in Rural South Australia After a Quality Improvement Program: Results of the Country Heart Attack Prevention (CHAP) Project

Quality of Cardiac Rehabilitation in Rural South Australia After a Quality Improvement Program: Results of the Country Heart Attack Prevention (CHAP) Project

Data Quality and the Feasibility of Assessing the Cardiac Rehabilitation Quality Indicators in Manitoba, Canada

Data Quality and the Feasibility of Assessing the Cardiac Rehabilitation Quality Indicators in Manitoba, Canada

Participation and Prognostic Impact of Cardiac Rehabilitation After Acute Coronary Syndrome: Big-Data Study of the Korean National Health Insurance Service.

To investigate the actual rate and quality of cardiac rehabilitation (CR) participation in South Korea and its short-term impact on clinical outcomes after acute coronary syndrome (ACS). Data, including confirmed ACS diagnosis, socio-demographics, comorbidities, clinical outcomes, and CR claim codes, were collected from the Korean National Health Insurance Service claims database and compared between the CR and non-CR groups. Overall, 102,544 patients were included in the study, of which only 5.8% attended CR. Regarding testing, 83.6% of CR patients performed the cardiopulmonary exercise test, but follow-up testing was infrequently performed; in addition, 53.1% of them participated in an electrocardiogram monitoring exercise, but over half participated in only one session. After 1:1 propensity score matching, post-ACS cardiovascular events were significantly lower in the CR group than in the non-CR group. The cumulative 3-year hazard ratio for all-cause death was 0.612 (95% confidence interval [CI], 0.495-0.756), recurrent ACS was 0.92 (95% CI, 0.853-0.993), CR readmission was 0.817 (95% CI, 0.768-0.868), and major adverse cardiovascular events (MACE) was 0.827 (95% CI, 0.781-0.874) in the CR group. CR was associated with a significant dose-response effect on MACE, with a reduction in incidence from 0.854 to 0.711. The actual rate of CR participation in South Korea remains low, and participation quality was not outstanding despite National Health Insurance coverage. Nevertheless, the impact of CR on cardiovascular outcomes after ACS was significantly superior. Efforts to increase CR participation should be increased by establishing new CR facilities and strategies to resolve associated barriers.

Experience of Cardiac Rehabilitation in Patients with Coronary Artery Disease: a Qualitative Study

Purpose: In order to improve the quality of cardiac rehabilitation, it is important to examine the experiences of the patients and how they feel about each part of the process. We used a qualitative research methodology to conduct an in-depth review of the experiences of patients who participated in cardiac rehabilitation.Methods: According to semi-structured guidelines, in-depth interviews were conducted with a total of five patients undergoing cardiac rehabilitation.Results: A total of 232 codes was derived; these codes were split into 4 categories and 10 subcategories. Although the patients were apprehensive about the diagnosis of heart disease, it also gave them a chance to reflect on their health behaviors of the past. In addition, they began to appreciate their families and support networks more as the disease progressed. The participants did not know about cardiac rehabilitation until the medical staff recommended it, but they participated in the program with the expectation that they could become healthier. The participants felt that they became more physically and mentally healthy while undergoing cardiac rehabilitation. Rehabilitation served as an opportunity to improve other health behaviors as well. However, they emphasized that it is necessary to continuously maintain improved health behavior, find an exercise method that is suitable for one’s physical ability and not monotonous, and prepare a plan to reduce the time and economic burden of cardiac rehabilitation.Conclusion: The participants' positive experiences confirmed in this study will be used as evidence for the expansion of cardiac rehabilitation programs.

Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators

BackgroundEvery year, over 65,000 Australians experience an acute coronary syndrome (ACS) and around one-third occur in people with prior coronary heart disease. Cardiac rehabilitation (CR) aims to prevent a repeat ACS by supporting patients’ return to an active and fulfilling lifestyle. CR programs are efficacious, but audits of clinical practice show variability of program delivery, which may compromise patient outcomes. Core components, quality indicators and accreditation of programs have been introduced internationally to increase program standardisation. With Australian quality indicators (QIs) for cardiac rehabilitation recently introduced, we aimed to conduct a survey in one state of Australia to assess the extent to which programs adhere to the measurement of QIs comparing country, metropolitan, telephone and face to face programs.MethodsA cross- sectional survey design with face validity testing was used to formulate questions to evaluate cardiac rehabilitation program and personnel characteristics and QI adherence. Between October 2020- December 2021, 23 cardiac rehabilitation programs across country and metropolitan areas were invited to participate. Quality improvement was defined as adherence to the Australian Quality Indicators, and we developed an objective score to calculate program performance categorised by quartiles. Significance of CR completion and time to enrolment between program type (telephone versus face to face) and location (country versus metropolitan were compared using Pearson’s Chi-square and Mann–Whitney U tests.ResultsAmong the 23 CR programs, 15 were country and 8 metropolitan-based and 22 were face to face and 1 telephone-based. Median wait time from discharge was 27.0 days, (interquartile range 19.3–46.0) across all programs and country completions of enrolled were 76.9% versus metropolitan 56.5%, p < 0.001 and telephone versus face to face 92.9% versus 59.6% p < 0.001. Pre-program QI adherence was higher than post program for depression, medication adherence, health-related quality of life and comprehensive re-assessment. Seventy four percent of programs were ranked at a medium level of performance (mean score: 11.4/16, SD ± 0.79).ConclusionsA survey of 23 cardiac rehabilitation programs, showed variability in adherence to measurement of the Australian Cardiovascular and Rehabilitation Association and Australian Heart Foundation Cardiac Rehabilitation Quality Indicators.Trial registrationAustralia New Zealand Clinical Trials Registry (ANZCTR), ACTRN12621000222842, registered 03/03/2021.

A nationwide survey on participation in cardiac rehabilitation among patients with coronary heart disease using health claims data in Japan

Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017–2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6–10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39–2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.

Cardiac Rehabilitation Quality Improvement: A NARRATIVE REVIEW.

Despite evidence of the effectiveness of cardiac rehabilitation (CR), there is wide variability in programs, which may impact their quality. The objectives of this review were to (1) evaluate the ways in which we measure CR quality internationally; (2) summarize what we know about CR quality and quality improvement; and (3) recommend potential ways to improve quality. For this narrative review, the literature was searched for CR quality indicators (QIs) available internationally and experts were also consulted. For the second objective, literature on CR quality was reviewed and data on available QIs were obtained from the Canadian Cardiac Rehabilitation Registry (CCRR). For the last objective, literature on health care quality improvement strategies that might apply in CR settings was reviewed. CR QIs have been developed by American, Canadian, European, Australian, and Japanese CR associations. CR quality has only been audited across the United Kingdom, the Netherlands, and Canada. Twenty-seven QIs are assessed in the CCRR. CR quality was high for the following indicators: promoting physical activity post-program, assessing blood pressure, and communicating with primary care. Areas of low quality included provision of stress management, smoking cessation, incorporating the recommended elements in discharge summaries, and assessment of blood glucose. Recommended approaches to improve quality include patient and provider education, reminder systems, organizational change, and advocacy for improved CR reimbursement. An audit and feedback strategy alone is not successful. Although not a lot is known about CR quality, gaps were identified. The quality improvement initiatives recommended herein require testing to ascertain whether quality can be improved.

How do I track Cardiac Rehabilitation in my patient with ischemic heart disease using Strava

Abstract Cardiac rehabilitation is a program which reduces morbidity and mortality in patients with ischemic heart disease. However only some European centers provide these programs for patients diagnosed with cardiac ischemia. Therefore home-based programs were developed for cardiac rehabilitation. Strava is a social network developed to track activities of running and cycling both in athletes and individuals searching for recreation and sport activities. In our work we present an approach based on Strava tracking to improve the quality of cardiac rehabilitation. Real-time monitoring of heart rate, steps per minute and speed during recreational or competitive activities can be used to increase physical capacity in individuals with ischemic heart disease. Key words: cardiac rehabilitation, Strava, ischemic heart disease, home-based,

To what extent is the variation in cardiac rehabilitation quality associated with patient characteristics?

BackgroundHuge variability in quality of service delivery of cardiac rehabilitation (CR) in the UK. This study aimed to ascertain whether the variation in quality of CR delivery is associated with participants’ characteristics.MethodsIndividual patient data from 1 April 2013 to 31 March 2014 were collected electronically from the UK’s National Audit of Cardiac Rehabilitation database. Quality of CR delivery is categorised as low, middle, and high based on six service-level criteria. The study included a range of patient variables: patient demographics, cardiovascular risk factors, comorbidities, physical and psychosocial health measures, and index of multiple deprivation.ResultsThe chance that a CR patient with more comorbidities attended a high-quality programme was 2.13 and 1.85 times higher than the chance that the same patient attended a low- or middle-quality programme, respectively. Patients who participated in high-quality CR programmes tended to be at high risk (e.g. increased waist size and high blood pressure); high BMI, low physical activity levels and high Hospital Anxiety and Depression Scale scores; and were more likely to be smokers, and be in more socially deprived groups than patients in low-quality programmes.ConclusionsThese findings show that the quality of CR delivery can be improved and meet national standards by serving a more multi-morbid population which is important for patients, health providers and commissioners of healthcare. In order for low-quality programmes to meet clinical standards, CR services need to be more inclusive in respect of patients’ characteristics identified in the study. Evaluation and dissemination of information about the populations served by CR programmes may help low-quality programmes to be more inclusive.

Creating National Benchmarks for Cardiac Rehabilitation Quality – New South Wales, Australian Capital Territory and Tasmania Snapshot

Background: Cardiac rehabilitation (CR) is recommended to promote recovery and secondary prevention following cardiac events, yet the quality of delivery in Australia has not yet been adequately assessed. Purpose: To conduct a snapshot of CR as a basis for creating a minimal set of national benchmarks for quality. Methods: CR sites volunteers were selected to represent metropolitan, rural and regional areas across New South Wales (NSW) (n = 36), Tasmania (n = 2) and Australian Capital Territory (ACT) (n = 1) and provided data on 11 quality indicators (based on pilot) for delivery and outcomes. Results: Sites delivered centre-based (97%), home-based (44%), education only (44%), telehealth/phone coaching (17.9%) and group (2.5%) programs. Participants (n = 2436) mean age was 66.3 ± 12.5 years, 68.5% were male and 17.1% were culturally and linguistically diverse. Most common diagnoses were ACS (45.8%), cardiac surgery (23.4%) and elective PCI (10%). CR Delivery. Median waiting time was 15days (IQR 9–25), 59% completed, 75% were referred to GP/specialist and 37% to CR follow-up. Participants had entry and discharge assessment for adiposity (62%, 45%), exercise capacity (59%, 42%), guideline medications (97%, 61%) and entry only for depression (89%) and smoking (97%). Of those screened positive for depression and smoking referral discussion occurred for 77% and 78%. CR Outcomes. Improvements occurred in waist circumference of 1.16cms (95%CI −1.44, −0.89) and exercise of 69.17meters in 6MWT (95% CI, 64.77, 73.61) and 3.06 in metabolic equivalents (95% CI 2.82, 3.36). Conclusions: This cross-state CR quality snapshot provides a basis for developing benchmarks for CR delivery and outcomes in Australia.

Quality Performance Measures in Cardiac Rehabilitation - Results of a Delphi Survey of Members of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR)

The present investigation aimed an explorative acquisition of potential performance measures for quantifying the quality of cardiac rehabilitation (CR) for patients under 65 years of age. A 4-level web based Delphi survey of physicians, psychologists, and sports or physiotherapists in CR was conducted from April to July in 2016. The experts assessed several parameters of physical performance, social medicine, subjective health and cardiovascular risk factors regarding their suitability as performance measures of CR. Of the 44 predetermined as well as by the participants proposed parameters, 21 parameters (48%) were selected as potential performance measures. Half of these were psychosocial factors. Merely, smoking habits, blood pressure, LDL-cholesterol and maximum capacity on exercise-ECG achieved a consensus (agreement>75% of the respondents). The experts' choice of performance measures was little consistent. Therefore, a clinical investigation and scientific evaluation of the predefined parameters is essential.

Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry

AimResults from EuroCaReD study should serve as a benchmark to improve guideline adherence and treatment quality of cardiac rehabilitation (CR) in Europe. Methods and resultsData from 2.054 CR patients in 12 European countries were derived from 69 centres. 76% were male. Indication for CR differed between countries being predominantly ACS in Switzerland (79%), Portugal (62%) and Germany (61%), elective PCI in Greece (37%), Austria (36%) and Spain (32%), and CABG in Croatia and Russia (36%). A minority of patients presented with chronic heart failure (4%). At CR start, most patients already were under medication according to current guidelines for the treatment of CV risk factors. A wide range of CR programme designs was found (duration 3 to 24weeks; total number of sessions 30 to 196). Patient programme adherence after admission was high (85%). With reservations that eCRF follow-up data exchange remained incomplete, patient CV risk profiles experienced only small improvements. CR success as defined by an increase of exercise capacity >25W was significantly higher in young patients and those who were employed. Results differed by countries. After CR only 9% of patients were admitted to a structured post-CR programme. ConclusionsClinical characteristics of CR patients, indications and programmes in Europe are different. Guideline adherence is poor. Thus, patient selection and CR programme designs should become more evidence-based. Routine eCRF documentation of CR results throughout European countries was not sufficient in its first application because of incomplete data exchange. Therefore better adherence of CR centres to minimal routine clinical standards is requested.

Feasibility of Assessing 2 Cardiac Rehabilitation Quality Indicators.

The Canadian Cardiovascular Society initiated a pan-Canadian process for development of quality indicators (QIs) for cardiac rehabilitation (CR). Before implementation, the QIs underwent pilot testing to ensure they were acceptable and feasible for field implementation. The objectives of this test were to assess (1) the technical feasibility of measuring the QIs; (2) the workload required to measure the QIs; and (3) acceptability of measuring the QIs and issues with their implementation. The 2 indicators chosen for field testing were QI-1 (% of eligible inpatients referred) and 2b (median wait time from CR referral receipt to enrollment). The approach consisted of 3 steps: (1) data extraction to test technical feasibility; (2) completing a workload diary; and (3) providing input through a semistructured interview regarding acceptability and implementation issues. Three academic CR sites were selected to undertake the field test. QI-1 ranged from 51.0% to 68.4%, and QI-2b was reported as 27 days (median) by one site, and 22 days (mean) by another. It was not considered feasible for CR programs to assess all potentially CR-eligible inpatients for CR referral exclusions. Compilation required 4.2 hours for QI-1 and 1.8 hours for QI-2b. QI assessment was acceptable to the programs, but changes in practice would be needed at each site to implement the QIs. CR programs may require enhancement of information-tracking processes to enable QI measurement. It was recommended that the QIs be implemented, but should undergo minor revisions to enhance feasibility.

Reporting and replicating trials of exercise-based cardiac rehabilitation: do we know what the researchers actually did?

Complete reporting of all components of complex interventions is essential for translation of research evidence into clinical practice. Previous work has highlighted deficiencies in the reporting of nonpharmacological interventions; however, the reporting quality of exercise-based interventions for coronary heart disease has not been examined. A systematic search strategy was used to identify randomized controlled trials of exercise-based cardiac rehabilitation published until December 2013. Fifty-seven trials were included, reporting on 74 interventions. Intervention description completeness was assessed using the Template for Intervention Description and Replication checklist. Missing intervention details were then sought from additional published material and also by emailing corresponding authors. Only 6 interventions (8%) sufficiently described all required items within the main publication; this increased to 11 (15%) after searching for additional published material and 32 (43%) after contacting trial authors. Although location/setting and duration were consistently well reported in publications, complete descriptions of the exercise schedule, as well as details about its tailoring and progression, were missing for over half of interventions (complete for 42% and 36% of interventions, respectively). Although some authors (25/61) were able to provide missing intervention details when contacted, others could not be located (20) or did not respond (16). Inadequate reporting of cardiac rehabilitation interventions is a substantial problem, with essential information frequently missing, and for almost half of all interventions, unobtainable after publication. A conscientious effort to address this problem could facilitate an improvement in the quality of cardiac rehabilitation delivered in clinical practice.

The Quality of Cardiac Rehabilitation in Canada: A Report of the Canadian Cardiac Rehab Registry

Cardiac rehabilitation (CR) significantly reduces morbidity and mortality compared with usual care. CR quality indicators (QIs) have recently been established in Canada. This article presents an assessment of real-world CR program achievement of process and outcome QIs in Canada, using the Canadian Cardiac Rehab Registry (CCRR). The CR QIs were developed through the Canadian Cardiovascular Society's Best Practice Methodology. After reconciling the QI with CCRR definitions, it was identified that 14 (46.7%) of the 30 QIs could be assessed through the CCRR. There were 5447 patient records from 11 CR programs in the CCRR. Wait times exceeded the 30-day QI target, at a median of 84 days from referral to enrollment. Assessment of QIs of blood pressure (90%) and adiposity (85%) were high, however assessment of QIs for lipids (41%), blood glucose among patients with diabetes (23%), and depression overall (13%) were low. A majority of the participants (68%) achieved the half metabolic equivalent increase in the exercise capacity QI from CR program entry to exit. Of smokers, only 61% were offered smoking cessation therapy. Thirty percent of participants were offered stress management. The CR program completion QI was met in 90% of patients. Areas for care and quality improvement have been identified for the CR community in Canada. Efforts to engage more CR programs assess a greater number of QIs, and to feed back the findings to participating programs quarterly are currently under way.

Can level of education, accreditation and use of databases in cardiac rehabilitation be improved? Results from the European Cardiac Rehabilitation Inventory Survey

Professional skills, education and accreditation, along with clinical outcome assessment, are considered important factors to achieve comprehensive delivery and quality of cardiac rehabilitation (CR). This study assessed professional educational programmes, accreditation and use of databases in CR across the European countries. Questions on professional education, accreditation and clinical databases from the European Cardiac Rehabilitation Inventory Survey, which is a postal questionnaire survey, conducted from November 2007 to January 2009 among national CR-related organizations in Europe; 28 countries responded (72%) to this survey. Among the participating countries, 32% had guidelines on professional CR skills, 61% had formal educational programmes and 29% had accreditation systems for professional CR skills. One hundred and seventy-four ad-hoc educational and scientific activities were registered during 2005-2007. Forty-three percent of the countries had established CR programme accreditation systems, primarily aimed at phase 2. One in three (35%) countries had established clinical CR databases with a further 25% planning to do so. More than half of the European countries had developed formal CR educational programmes. Furthermore, many ad-hoc CR-related meetings and conference activities take place across Europe. Although only a quarter of countries had developed accreditation systems aimed at professionals, programme accreditation was somewhat more widespread with over a third having programme accreditation systems. Clinical databases were underdeveloped. A greater focus on education, accreditation and database implementation is needed to promote CR availability and the quality of CR services for the benefit of cardiac patients across Europe.

Findings on gender differences in the quality of care in cardiac rehabilitation: are women discriminated against?

Questions and results concerning the quality of cardiac rehabilitation are discussed, and the outcomes of a study on 104 female and 206 male patients suffering from first coronary events are reported. No gender differences were found as far as rehabilitation utilization or rehabilitation programs are concerned. Rehabilitation programs and medicinal therapy were the same in women and men. Satisfaction with the in-hospital rehabilitation was slightly higher in women, but there were no gender differences in the preferences for cardiac rehabilitation features. Gender in Germany seems not a relevant variable in cardiac rehabilitation. Further questions for research on gender differences are discussed.