The Global Cardiac Rehabilitation Survey: Program resources and impact in Australia Robyn Gallagher Marta Supervia Karam Turk-Adawi Dion Candelaria Laila Ladak Lis Neubeck Sherry Grace

Efficacy of cardiac rehabilitation Review Population Intervention Outcome Anderson et al., 2016 Cochrane Library Coronary heart disease Exercise-training alone or in combination Comparison usual care 12 months 26% reduction in Cardiovascular Mortality 18% reduction in Hospital Admissions Cost-effective Van Halewjin et al., 2017 Int J Cardio Coronary heart disease ≥ 50% Cardiac rehabilitation and secondary prevention (face-to-face) Published after 2009 58% reduction in Cardiovascular Mortality 30% reduction in MI CR is recommended for secondary prevention because if well-established efficacy. CR not only reduces cardiovascular mortality and hospital admissions, it is known improve functional capacity and quality of life in patients recovering from cardiovascular disease.

Efficacy of cardiac rehabilitation Review Population Intervention Outcome Anderson et al., 2016 Cochrane Library Coronary heart disease Exercise-training alone or in combination Comparison usual care 12 months 26% reduction in Cardiovascular Mortality 18% reduction in Hospital Admissions Cost-effective Van Halewjin et al., 2017 Int J Cardio Coronary heart disease ≥ 50% Cardiac rehabilitation and secondary prevention (face-to-face) Published after 2009 58% reduction in Cardiovascular Mortality 30% reduction in MI Powell et al., 2018 BMJ Open Published 2000-2017 No difference in Cardiovascular Mortality or MI 5% reduction in Hospital Admissions However, recent evidence questions the benefit of CR and as CR providers we need to ask why? One potential explanation is the substantial variation in delivery and quality of CR programs. Abell, Zecchin, Gallagher HLC 2018

there are well-established guidelines for the components needed to make CR effective. Most high income countries use these guidelines to determine content and delivery and also to benchmark the quality of services.

Furthermore most high income countries engage in audits and registries to ensure that the quality of CR program content and delivery is of an appropriate standard in practice.. Australia is one the rare exceptions. There is a lack of Australian data to evaluate quality or underpin improvement.

The Global Survey of Cardiac Rehabilitation Observational cross-sectional study of Phase II cardiac rehabilitation programs internationally Global team led by Sherry Grace, York University Canada, ICCPR 93/112 (83%) countries internationally ACRA Australian champions: distributed anonymous survey link to members 2016-2017 ACRA has a key role to lead quality initiatives nationally and we jumped at the chance to participate in the Global Survey of Cardiac Rehabilitation led by Sherry Grace, the Chair of ICCPR Supervia, Turk-Adawi, Grace 2017

Research aim To describe availability of resources and any resource barriers to CR service delivery in Australia

Methods Sample Survey topics Phase II CR programs eligible: initial assessment structured exercise ≥ one other strategy to control cardiovascular risk factors Program content (assessment, delivery and topics) Staff supervision of content ATSI support & participation Annual volume and capacity Barriers to serving patients Staffing Overall resources

Participating programs % Region   Urban (large cities/towns) Suburban (city outskirts) Rural 32 19 30 38.1 22.6 35.7 Location Community hospital Major hospital Rehabilitation facility Not hospital-based 24 10 28.6 11.9 On-site cardiac services Cardiology service PCI CABG Transplant 33 14 1 39.3 16.7 1.2 Administration Community health Cardiology Rehab/internal medicine Allied health General practice 22 23 8 2 26.2 27.3 9.5 2.4 Participating programs Response rate 85/314 (27%) PROBLEMS WITH SAMPLE some LHD responders

Resource barriers to improving patient participation Program coordinators rated a likert scale on issues and these are a major issue (5point scale)

Costs of program delivery Given that financial and budget costs were most often rated a major issue we then looked at costs of program delivery. The most costly aspects of program delivery were personnel, exercise equipment and risk assessment supplies. Although it was surprising that some aspects were free, including personnel. Perhaps a first indication that a small proportion of program staff do not know funding arrangements.

Personnel 89.3% multidisciplinary teams 65.5% ≥ 5 different disciplines Given that personnel were rated the major cost. We then looked at staffing. All programs were multidisciplinary Program staff were primarily shared with other services, with nurses being the predominant discipline with dedicated CR roles.

Program space The next most common barrier was space to conduct the program. Few programs had dedicated space, when they did it was staff office, individual assessment/counselling room, group education. Some programs operated without any of those spaces.

Patients served Current patients/year Potential patients 58/85 (68%) could provide the number Median 215 (range 6-1516) 60/85 (71%) could provide the number Median 200 (range 24-1000) We then asked annual patient capacity as this provides the foundation for calculating resource needs and costs in any business case. 68% or two thirds could provide this information. Of those who did there was a huge variation with a median of 215, range 6 – 1516; but to determine if the program was at capacity the number of patients that could be served in a year was also asked. A quick comparison shows that there is little difference between current and potential, meaning that programs were already at capacity. This means understanding of resources and costs is crucial. However, keep in mind the 32% of programs whose patients/year is unknown, how is capacity determined?

Knowing program numbers We compared programs that knew their patient numbers and thus service delivery needs and those that did not. There were significant differences in knowledge of patient numbers in programs that identified a resource issue in all areas including budget, personnel, space and equipment issues. It could be concluded that programs that have resources issues are driven by circumstances to audit their programs. However, the logic could also be that programs that don’t audit are unaware that they have resource issues and/or capacity. Regardless, it is difficult to put a successful business case for additional and/or different resources if patient volume is unknown. Furthermore, the basis of a good business case is $ cost/patient and only 2 of 85 programs provided this information.

Limitations Response rate 27% Appropriateness of responder – 78% coordinator Validity – questions pitched to an international audience

Resource barriers to service delivery internationally Finance, staffing and space are barriers across the globe Turk-Adawi, BMC 2015

Patient capacity comparison internationally Programs being at capacity is an issue across the globe

Patient costs internationally Poor national understanding of per person costs in Australia

Conclusions for Australian CR programs Key barriers to service delivery included staffing, equipment and space Program resources may not relate to service delivery needs Not all CR program coordinators could report the key information needed to support business cases for current and ongoing services Potential solution for efficient resource evaluation lies in collaboration across service boundaries e.g. participation in a national minimum data set

The challenge for CR in Australia A national quality assessment process is urgently needed to support programs to understand both individual and national level cardiac rehabilitation delivery, provide benchmarks for improvement and provide an insight into costs. The Australian Cardiovascular Health and Rehabilitation Association (ACRA) must have a key role in this process.

The Global Cardiac Rehabilitation Survey: Program resources and impact in Australia Robyn Gallagher Marta Supervia Karam Turk-Adawi Dion Candelaria Laila Ladak Lis Neubeck Sherry Grace