1. 1 Simplified Strategies of CR in Low-Resource Settings: Perspectives from ICCPR Sherry L. Grace, PhD Secretary/Treasurer, ICCPR Full Professor, York University Director of Research, Cardiac Rehab University Health Network

2. 2 Disclosure Statement of Financial Interest I, Sherry Grace DO NOT have a financial interest/arrangement or affiliation with any healthcare related companies that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. 3 WHO Global Atlas CVD Prev & Control,2011

4. 4 Availability of CR Globally Adawi et al., (accepted in principle) Nature Reviews: Cardiology

5. Global Availability of CR by Country Income Classification High-income countries: 68.0% ( 51/75 countries ) Middle-income countries: 28.2% ( 29/103 countries ) Low-income countries: 8.3% ( 3/36 countries ) Globally: 38.8% ( 83/214 countries) LMICs: 23.0% 5 Turk-Adawi, K., Sarrafzadegan, N., & Grace, S.L. (accepted in principle). Nature Reviews: Cardiology.

6. 6 21 Associations of the

7. 7 1993

8. 8 “define health system-related opportunities … to access for … rehabilitation … and develop feasible and integrated approaches to apply cost- effective NCD interventions at all levels of health care” 2011; p. 46

9. 9 CR delivery model for low-resource settings: A consensus statement Primary Writing Panel Grace, S.L., Turk-Adawi, K., Contractor, A., Atrey, A., Campbell, N., Derman, W., Ghisi, G.M.G., Hu, D., Lopez, F., Mendis, S.,(WHO) & Sarrafzadegan, N. Secondary Writing Panel Buckley, J., Akinroye, K. (WHF), Mola, A., Neubeck, L., Pogosova, N., & Rivas-Estany, E.

10. 10 Literature Review: Search Strategy 1. Comprehensive search using Medline and Embase a- cardiac diseases b- rehabilitation c- LMICs 2. Grey literature search for reports, guidelines

11. 11 Buckley et al., Heart, 2013

12. 12 Literature Search Results Component# citations CR in LMICs1417 CR models130 Psychological therapy 566 Obesity295 Lipids152 Blood pressure215 Education interventions 318 Smoking cessation 237 Nutrition interventions274

13. Alternative Models of CR Delivery  Low-cost, accessible models: Home-based (Dalal etal., 2010) Community-based (Mandic et al., 2013)  Use of technology (evidence lacking, weak) Internet-based (Munro et al., 2013) telehealth, and mobile (Beatty et al., 2013)

14. 14

15. 15  Developing national policies support CR provision  Randomized controlled trials of CR in LMICs  Provide cost-effectiveness data  CR part of integrated cardiology service  Expanding health human resources & service delivery  Integration of CR in the curricula of medical schools  Training of healthcare professionals (“Task-shifting”)  Increasing the hours of operation of existing programs Implementation Considerations

16. 16 Next Steps Literature review Writing 2ndary Panel review, revision Submission to Nature Reviews: Cardiology WCC 2016 – launch? Field and feasibility testing in low-resource settings

17. 17 Acknowledgments Lit search: Maureen Pakosh, MIst Nizal Sarrafzadegan, MD (co-chair) Contact: sgrace@yorku.ca Funding: