Cardiac rehabilitation delivery in low/middle-income countries

A qualitative study of patient's perceptions of two cardiac rehabilitation models

BACKGROUND

Understanding patients' perceptions about rehabilitation can guide healthcare administrators on modifications of program elements, which can ultimately improve cardiac rehabilitation (CR) use, adherence of heart-health behaviors, and improvements in clinical outcomes.

OBJECTIVE

To examine the perception of patients about their participation in CR.

METHODS

Qualitative study using semi-structured interviews, performed in a public CR center in Brazil. Twenty-eight patients were interviewed 2-years following participation in two CR models: exercise-based and comprehensive CR.

RESULTS

Themes identified included: knowledge acquisition, improvement in functionality, and psychosocial well-being. It appeared that the perceived benefits of CR participation were overall positive and similar between the two models; however, those in the comprehensive CR identified additional subthemes: self-care need and knowledge transfer.

CONCLUSIONS

This study suggested that patients from two different CR models perceived in the long term that the CR participation positively impacted their disease-related knowledge, promoted functional gains, and improved psychosocial well-being. Structured educational interventions seemed to be associated with improved participants' perception about CR, which could contribute to long-term maintenance of heart-health behavior and better outcomes.

Translation, adaptation, and psychometrically validation of an instrument to assess disease-related knowledge in Spanish-speaking cardiac rehabilitation participants: The Spanish CADE-Q SV

OBJECTIVE

To validate the Spanish Coronary Artery Disease Education Questionnaire Short Version(CADE-QSV).

BACKGROUND

Knowledge assessment can tailor patient education strategies in CR.

METHODS

Ten CR experts culturally-adapted the translated tool and 249 CR patients in three countries participated in the psychometrically validation. The internal consistency was assessed using KR-20 and Cronbach's alpha. Distribution- and anchor-based methods were used to estimate the MCID for interpretability analysis. Factor structure, acceptability, floor and ceiling effects and discriminant validity were also assessed.

RESULTS

KR-20 was 0.75.Factor analysis revealed 5 factors, all internally consistent. Discriminant validity was supported by significant differences in educational level and family income at post-CR. Results showed that increases in knowledge can moderately increase mean steps per day, with MCID=3.00. Items were completed by 98% of participants. No evidence for ceiling/floor effects on total score. The area with the highest knowledge was nutrition and the lowest was medical condition.

CONCLUSION

The Spanish CADE-QSV demonstrated preliminary validity and reliability.

Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation

Background

Cardiac rehabilitation (CR) is recommended in clinical practice guidelines for comprehensive secondary prevention. While India has a high burden of cardiovascular diseases (CVD), availability and nature of services delivered there is unknown. In this study, we undertook secondary analysis of the Indian data from the global CR audit and survey, conducted by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR).

Methods

In this cross-sectional study, an online survey was administered to CR programs, identified in India by CR champions and through snowball sampling. CR density was computed using Global Burden of Disease study ischemic heart disease (IHD) incidence estimates.

Results

Twenty-three centres were identified, of which 18 (78.3%) responded, from 3 southern states. There was only one spot for every 360 IHD patients/year, with 3,304,474 more CR spaces needed each year. Most programs accepted guideline-indicated patients, and most of these patients paid out-of-pocket for services. Programs were delivered by a multidisciplinary team, including physicians, physiotherapists, among others. Programs were very comprehensive. Apart from exercise training, which was offered across all centers, some centers also offered yoga therapy. Top barriers to delivery were lack of patient referral and financial resources.

Conclusions

Of all countries in ICCPR's global audit, the greatest need for CR exists in India, particularly in the North. Programs must be financially supported by government, and healthcare providers trained to deliver it to increase capacity. Where CR did exist, it was generally delivered in accordance with guideline recommendations. Tobacco cessation interventions should be universally offered.

Home-Based Cardiac Rehabilitation in Brazil's Public Health Care: Protocol for a Randomized Controlled Trial

Background

Coronary artery disease (CAD) is among the main causes of hospitalization and death worldwide, therefore, the implementation of programs to reduce its impact is necessary. Supervised cardiac rehabilitation has been shown to have positive effects on CAD control. However, there are barriers to patient participation in the traditional, face-to-face cardiac rehabilitation programs, mainly in low-resource environments.

Objective

This study aimed to verify patient compliance to a home-based cardiac rehabilitation program, which includes unsupervised health education and physical exercises, guided by telephone. Moreover, we compare this new method to the traditional supervised cardiac rehabilitation offered in most hospital centers.

Methods

We present here a two-arm, single-blinded, and randomized controlled design protocol, which compares the traditional cardiac rehabilitation (CenterRehab) with the home-based cardiac rehabilitation (Home-Based) in 72 patients affected by CAD. The primary outcome is the compliance to the cardiac rehabilitation sessions. The secondary outcomes (to evaluate effectiveness) include measurable variables such as functional capacity, CAD risk factors (blood pressure, waist circumference, glycemic, cholesterol levels, depressive symptoms, and the level of physical activity), the patient’s quality of life, the disease knowledge, and the morbidity rate. Parameters such as the program cost and the usability will also be evaluated. The programs will last 12 weeks, with a total of 60 rehabilitation and 6 educational sessions. Patients of the CenterRehab program will participate in 24 supervised sessions and 36 home sessions, while the patients of the Home-Based program will participate in 2 supervised sessions and 58 home sessions, guided by telephone. After the 12-week period all participants will be recommended to continue practicing physical exercises at home or at a community center, and they will be invited for re-evaluation after 3 months. The outcomes will be evaluated at baseline, and after 3 and 6 months.

Results

Participants are currently being recruited for the trial. Data collection is anticipated to be completed by October 2019.

Conclusions

This is the first study in Brazil comparing the traditional cardiac rehabilitation approach with a novel, home-based protocol that uses an accessible and low-cost technology. If positive results are obtained, the study will contribute to establish a new and viable model of cardiac rehabilitation.

Trial Registration

ClinicalTrials.gov NCT03605992; https://clinicaltrials.gov/ct2/show/NCT03605992

International Registered Report Identifier (IRRID)

DERR1-10.2196/13901

Exercise-based rehabilitation for major non-communicable diseases in low-resource settings: a scoping review

INTRODUCTION

While there is substantial evidence for the benefits of exercise-based rehabilitation in the prevention and management of non-communicable disease (NCD) in high-resource settings, it is not evident that these programmes can be effectively implemented in a low-resource setting (LRS). Correspondingly, it is unclear if similar benefits can be obtained. The objective of this scoping review was to summarise existing studies evaluating exercise-based rehabilitation, rehabilitation intervention characteristics and outcomes conducted in an LRS for patients with one (or more) of the major NCDs.

METHODS

The following databases were searched from inception until October 2018: PubMed/Medline, Embase, CINAHL, Cochrane Library, PsycINFO and trial registries. Studies on exercise-based rehabilitation for patients with cardiovascular disease, diabetes, cancer or chronic respiratory disease conducted in an LRS were included. Data were extracted with respect to study design (eg, type, patient sample, context), rehabilitation characteristics (eg, delivery model, programme adaptations) and included outcome measures.

RESULTS

The search yielded 5930 unique citations of which 60 unique studies were included. Study populations included patients with cardiovascular disease (48.3%), diabetes (28.3%), respiratory disease (21.7%) and cancer (1.7%). Adaptations included transition to predominant patient-driven home-based rehabilitation, training of non-conventional health workers, integration of rehabilitation in community health centres, or triage based on contextual or patient factors. Uptake of adapted rehabilitation models was 54%, retention 78% and adherence 89%. The majority of the outcome measures included were related to body function (65.7%).

CONCLUSIONS

The scope of evidence suggests that adapted exercise-based rehabilitation programmes can be implemented in LRS. However, this scope of evidence originated largely from lower middle-income, urban settings and has mostly been conducted in an academic context which may hamper extrapolation of evidence to other LRS. Cost-benefits, impact on activity limitations and participation restrictions, and subsequent mortality and morbidity are grossly understudied.