1. 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

2. 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.

3. 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
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

4. 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.

5. 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.

6. 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
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

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

8. 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

9. 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

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

11. 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.

12. 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.

13. 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.

14. Patients served Current patients/year Potential patients
58/85 (68%) could provide the number
Median 215 (range )
60/85 (71%) could provide the number
Median 200 (range )
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?

15. 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.

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

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

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

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

20. 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

21. 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.

22. 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