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Cardiac rehabilitation availability limited in low-, middle-income countries, but meets guidelines
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The availability of cardiac rehabilitation programs were lower in low- to middle-income countries compared with higher-income countries, according to findings published in Heart.
But despite its inaccessibility in many of the low- and middle-income countries, the cardiac rehabilitation services that were provided met guidelines.
Ella Pesah, BSc, a graduate student at York University in Toronto, and colleagues compared cardiac rehabilitation programs in low- to middle-income countries with programs in high-income countries based on availability and characteristics to programs. Funding sources in cardiac rehabilitation were also examined.
“No one had ever gone out and actively determined where cardiac rehab existed in the world,” Sherry L. Grace, PhD, CRFC, professor at York University and the University Health Network in Toronto, told Cardiology Today. “We knew there was grossly insufficient capacity, particularly in low- and middle-income countries where the burden of heart disease is rising fastest, but for the first time ever we are able to quantify what the exact need is in relation to burden of heart disease for every country of the world, and also what is delivered in relation to what evidence-based guidelines recommend.”
Accessibility of cardiac rehab
The researchers analyzed data from a cross-sectional online survey administered to all cardiac rehab programs around the world. Cardiac rehabilitation need was computed using incident heart disease estimates from the Global Burden of Disease study.
According to the researchers, cardiac rehabilitation was available in only 39.9% of the 138 low- and middle-income countries of the world. Overall, they received responses from programs in 85% of those countries with 53.5% of the programs in those countries filling out a survey.
There was only one cardiac rehabilitation spot for every 66 patients with ischemic heart disease in low- to middle-income countries each year compared with one per 3.4 patients in high-income countries, the researchers wrote. Cardiac rehabilitation was most often paid for by patients in low- and middle-income countries compared with government sources in high-income countries (65%) compared with government sources in high-income countries. This renders cardiac rehab even less accessible, Grace said.
Nature of cardiac rehab services
More than 85% of programs appropriately accepted guideline-indicated patients such as those who have had a MI or stent, the researchers wrote.
Many cardiac rehabilitation teams consisted of cardiologists (89%; with more physician contact in lower-income countries) as well as nurses, but there was a greater percentage of nurses on rehabilitation teams in high-income countries (79.6% for low- to middle-income countries vs. 91.7% in high-income countries, P = .001), the researchers wrote. Physiotherapists also were common providers on cardiac rehabilitation staff (78%). There was an average of 5.8 staff per program.
Cardiac rehabilitation programs in low- and middle-income countries offered slightly fewer of the 10 core components compared with programs in high-income countries (7.3 for low- and middle-income countries vs. 7.8 for high-income countries; P < .01; more return-to-work and tobacco cessation counseling as well as stress management needed) over an average of 33.7 sessions for each patient (more than in high-income countries; P < .001), the researchers wrote.
Publicly funded programs were more likely to have social workers and psychologists on staff and offer tobacco cessation and psychosocial counseling, the researchers wrote.
This is important because burden of mental distress was very high in patients with heart disease and was related to higher death rates, Grace said.
Grace told Cardiology Today that acute heart care providers will need to think more about how they can ensure that their patients have a cardiac rehab program to go to, based on recommendations in clinical practice guidelines.
“So many patients are dying unnecessarily without access to these lifesaving programs,” she said. “Cardiac rehab is also affordable and cost-effective, so we are wasting precious health care dollars when patients do not access cardiac rehab.” – by Earl Holland Jr.
Disclosures: Pesah and Grace report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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